Research and the Mandate for Evidence-Based Practice, Quality, and Patient Safety


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RESEARCH AND THE MANDATE FOR EVIDENCE-BASED PRACTICE, QUALITY, AND PATIENT SAFETY


KATHLEEN R. STEVENS


INTRODUCTION


The development of science to guide nursing practice and healthcare is a response to the need for knowledge to improve care and advance the health of the public. Nursing science has the ultimate aim of discovering effective interventions to resolve actual and potential health problems and to point to interventions that reliably produce intended health-related outcomes. Nursing research has been well institutionalized since 1984, with the establishment of the National Institute of Nursing Research (NINR; originally, the National Center for Nursing Research). As a result, nursing science has greatly expanded, providing research results and a foundation for evidence-based practice (EBP); however, it is widely recognized that many years pass before even a small percentage of EBPs are adopted into routine care. The gap between what is known to work and what is practiced is responsible for less-than-possible care quality and patient safety.


There is increased public demand for moving new knowledge into practice to increase care quality and safety and increase the likelihood that our nursing interventions will produce intended health outcomes. The recent past has seen growing emphasis on how to move research findings into everyday practice. Research across all health disciplines is investigating strategies to move evidence into practice through the new field of implementation science. The focus of implementation science is to evaluate strategies that overcome organizational, individual, and policy barriers in adoption of EBP.


During the past 25 years, research has grown the science of quality and safety, providing a foundation for (a) knowing what works in healthcare, as well as (b) how to implement changes in practice. This chapter presents events and findings that influence this scientific interest in healthcare quality and safety. Included are descriptions of the underlying reasons for the emphasis on quality improvement and safety, frameworks for conceptualizing and studying improvement and safety, methods used for such investigations, and new resources and future trends in improvement and safety research. In addition, this chapter explores how EBP achieves quality and safety in healthcare by reflecting nursing theory, research, science, and practice to meet the mandate for improved population health.


To provide a broad context, our discussion first presents an overview of the relationship among research, EBP, quality, and safety, providing a framework through which to view these aspects of healthcare. Sections of the chapter define the relationship among EBP, implementation science, and quality. Additional sections of the chapter are devoted specifically to quality and to safety, highlighting dominant thinking and research advances. Exemplars led by advanced practice nurses illustrate 36their central role in transforming healthcare. The chapter concludes with a look to the future of quality and safety, examining recent advances and suggesting directions in theory, research, and science.


SHIFTS IN NURSING RESEARCH FOCUS


Because of the emphasis on quality improvement in regard to patient safety, the relationship between research and clinical care has changed. In the past, primary research was conducted to test the efficacy of interventions; now, researchers investigate ways to render healthcare systems and processes effective and safe. A number of these approaches involve integrating research into practice—so nurses are called on to be part of the team that transforms research knowledge into clinical practice. Clients demand that healthcare be based on best scientific evidence in combination with client preferences and the clinician’s expertise (the definition of EBP).


This paradigm of EBP has required a shift in thinking about EBP competencies that are needed in clinical care. This is particularly true of competencies at intermediate and advanced levels to promote uptake of evidence into daily care. Prior to the new knowledge forms offered by EBP, educational programs prepared nurses to “conduct” research to discover new knowledge. Although an important function, conducting research is insufficient to achieve evidence-based quality improvement. Increasingly, advance practice nurses assume roles that emphasize evidence-based quality improvement—competencies not widely included in basic and professional development education. These competencies involve managing both the research-based evidence and the organizational activities necessary to translate research into practice (Stevens, 2009). Research has led to identification of these EBP competencies which make clear the distinction between conducting research and translating research into practice. National consensus on 83 EBP competencies (Stevens, 2009) has galvanized changes in nursing practice and in nursing education programs. EBP competencies are being integrated throughout undergraduate, graduate, and professional development education and clinical practice. Additional work identified learning outcomes for quality and safety education (Dolansky & Moore, 2013), which contributed to this growing effort toward a workforce that is prepared to translate research into practice. However, nurses still face significant barriers in employing EBP (Yoder et al., 2014) and it is imperative to continue efforts to embed these competencies into the core of our profession.


CHANGES IN NURSING RESEARCH


Now, over 20 years into the pioneering EBP work in nursing, nurses, managers, and healthcare system leaders are still making the paradigm shift to a system that rapidly adopts best practices; this is owing to the challenge of complex healthcare systems and entire industries. Gains made in the transformation of healthcare to be safe, effective, efficient, equitable, and patient-centered can be accelerated as emphasis on discovery through nursing research is joined by expanding horizons noted in nursing science.


The focus of nursing research has recently expanded to include the study of healthcare delivery systems, quality, and patient safety. In the past, nursing research produced knowledge about individual clients through primary research studies. Research was largely based on designs used to investigate individual client interventions (such as experimental psychology and anthropology). The resulting research reports were found to be difficult to translate into practice. Single research studies were presented in terms of inferential statistics and multiple studies and often produced varying results on the efficacy of a given intervention.


37Today’s healthcare redesign and evidence-based quality initiatives call on nurse scientists and clinicians to embrace what is known about best (effective) practices and system change to support quality healthcare. Prior methods, such as true experiments, and theory are important to our scientific fundamentals. Research designs such as systematic reviews (SR) and new models such as complex adaptive systems (CASs) are being added to place nurses at the cutting edge of advancing the science of improvement. New competencies in translational science have been added to prior investigative competencies to conduct primary research studies. Nurse researchers are realigning previous research approaches and adopting new research designs as members of translational science teams that produce knowledge about effective healthcare and systems.


New fields of study have set about to investigate improvement strategies and to understand factors that facilitate or hinder implementation and adoption of EBP. The aim of implementation and improvement science is to determine which strategies work as we strive to ensure safe and effective care. Improvement and implementation competencies are primarily focused on evolving the healthcare delivery system and microsystem (Berwick, 2008). Implementation science is important to improvement in that it assesses ways to link evidence into practice; it adds to our understanding of the usefulness of strategies to “adopt and integrate evidence-based health interventions and change practice patterns within specific settings” (National Institutes of Health [NIH], 2019). Together, improvement and implementation sciences add to an increased understanding of the system aspects of the care we deliver.


OVERVIEW: RESEARCH, EVIDENCE-BASED PRACTICE, QUALITY, AND SAFETY


Quality, safety, and efficiency are top priorities in contemporary healthcare. The responsibility and accountability for ensuring effective and safe care are inescapable for all health professionals and are a social obligation of every healthcare agency. Delivering the right care at the right time in the right setting is the goal of efforts to advance safety and quality. This challenge requires that well-prepared nurses play key roles in moving research into action to evolve today’s healthcare system. Progress requires competencies at the individual clinician level; in addition, operational leaders and organizational climate must be open to continued learning and change. For nurses to effectively guide the movement for quality and safety, skills and competencies in evidence-based practice (e.g., Stevens, 2013), change management, and organizational development are required. In tandem, organizational leaders must adopt system approaches that reflect improvement principles and principles of high-reliability industries.


The morbidity and mortality toll of both ineffective care and unsafe care requires that all health professionals take a serious look at what must be done to address lapses in quality and to avoid the loss of hundreds of thousands of lives. To meet this challenge, it is vital to ensure that healthcare is error free, that all existing best (research-based) practices are used, and that individual clinicians and organizations implement the highest quality and most reliable processes for every patient. The narrow notion of safety as the absence of medication errors or falls has been broadened. This is the challenge of quality and patient safety in healthcare. The foundation of success is translation of research results into clinical care; the infrastructure of success is conducting research to elucidate change interventions that improve clinical care processes at the individual clinician, organization, system, environment, and policy levels. Thus, translational research is the key to determining clinical effectiveness of care and redesigning healthcare systems that are safe, effective, and efficient.


38 PROBLEMS IN HEALTHCARE QUALITY


Research has built a large body of science about “what works” in healthcare, yet actual care lags behind what has been reported to be effective (Institute of Medicine [IOM], 2008). The end result is healthcare that is ineffective in producing intended patient health outcomes and care that is unsafe. These circumstances are prevalent in nursing and across all health professions, even though massive numbers of research reports provide “best evidence” for care. Healthcare processes and outcomes will be greatly improved when research results are adopted into routine care.


QUALITY AND EVIDENCE-BASED PRACTICE


The quality of healthcare is based on the degree to which decisions about patient care are guided by “conscientious, explicit, and judicious use of current best evidence” (IOM, 2008, p. 3). The following definition of healthcare quality emphasizes this point.


Definition: Quality of Healthcare


Degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.


(IOM, 1990)


This definition makes clear that research evidence is a core element in predictably producing intended health outcomes. Unless patient care is based on the most current and best evidence, it falls short of quality.


The aim of EBP is to standardize healthcare practices using the best scientific base (best evidence) and to reduce illogical variations in care, which lead to uncertainty that clinical interventions will lead to better health outcomes. Development of EBP is fueled by public and professional demand for accountability in safety and quality improvement in healthcare. It is imperative that healthcare is based on current professional knowledge in order to produce the quality necessary for intended patient outcomes.


Leaders in the field have classically defined EBP as the “integration of best research evidence with clinical expertise and patient values” (Sackett et al., 2000, p. ii). Therefore, EBP melds research evidence with clinical expertise and encourages individualization of care through incorporation of patient preferences and the circumstances of the setting.


Just as evidence and quality are linked, so are safety and quality. The ties across safety, errors, quality, and care are explained as concentric circles or subsets of a common flaw (Woolf, 2004). The innermost concentric circle is safety, followed by errors, then quality, and, finally, caring as the outermost circle. The model suggests that safety is a subcategory of healthcare errors. Such errors include mistakes in health promotion and chronic disease management that cost lives but do not affect safety—these are errors of omission. Following this model, errors are a subset of quality lapses, which result from both errors and systemic problems. Systemic problems that reduce quality in healthcare may stem from lack of access, inequity, and flawed system designs. Finally, this model suggests that lapses in quality are a subset of deficient caring; such deficiencies can be seen in lack of access, inequity, and faulty system designs (Woolf, 2004). In nursing research, such a model can serve to frame investigations of healthcare safety and quality.


Healthcare quality and safety have emerged as a principal concern. Multiple reports were produced since 2000 that still guide our national thinking about how to improve our healthcare system 39to impact better population health. In 1990, interprofessional opinion leaders began an intensive initiative to improve the quality of healthcare (IOM, 1990). These leaders proclaimed that there is a chasm between what we know (through research) to be the best healthcare and what we do. In a series of influential reports, these national advisers called for one of our nation’s most far-reaching health reforms, called the IOM Quality Initiative. A series of reports known as the Quality Chasm Series, dissected healthcare problems and recommended fundamental and sweeping changes in healthcare (IOM, 2001). The directions set by the Quality Chasm Series continue to have marked impact on every aspect of healthcare and health professionals, with the “IOM Principles” deeply integrated into requirements in nursing education and practice. Each of the trendsetting IOM reports (2001, IOM 2003a, IOM 2003b, 2004, 2008, 2011a, 2011b) identify EBP as crucial in closing the quality chasm. This movement is likely to continue beyond the next decade. Because of their enduring impact on the transformation of healthcare, we offer the following summary of some of the IOM Chasm reports.


In 2000, the IOM reviewed studies and trends and concluded that 48,000 to 98,000 Americans die annually in hospitals due to medical errors caused by defective systems rather than caregivers themselves. To Err Is Human: Building a Safer Health System (IOM, 2000) offered impressive documentation regarding the severity and pervasive nature of the nation’s overall quality problem. In fact, using statistical approaches, the report showed that more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. In addition to deaths, it was noted that medical errors cause permanent disabilities and unnecessary suffering. This report raised the issue of patient safety to a high priority for every healthcare provider, scientist, agency leader, and policy maker.


The next report in this series further unfolded the story of quality in American healthcare. In Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), healthcare leaders reviewed research that highlighted other widespread defects in our healthcare system. Defects included overuse, misuse, and underuse of healthcare services and described a wide gulf between ideal care (as supported by research) and the reality of the care that many Americans experience. The 2001 Quality Chasm report presented research evidence documenting a lack of quality in healthcare, cost concerns, poor use of information technology, absence of progress in restructuring the healthcare system, and underutilization of resources. Throughout these analyses of healthcare safety and quality, a deep-rooted problem was highlighted: Although health science and technology were advancing at a rapid pace, the healthcare delivery system was failing to deliver high-quality healthcare services (IOM, 2001). The report emphasized that a major part of the problem is that research results are not translated into practice and that practice lags behind research-generated knowledge.


The profession of nursing is central to many of the interprofessional and discipline-specific changes that must be accomplished to provide safe and effective care. The Interdisciplinary Nursing Quality Research Initiative (INQRI, 2013) supported by the Robert Wood Johnson Foundation (RWJF, 2008) funded studies to discover how nurses contribute to and can improve the quality of patient care.


After a series of public input meetings, the IOM issued the 2011 report, The Future of Nursing: Leading Change, Advancing Health. The report identified the 3 million (now 4 million) nurses in the profession as the largest segment of the nation’s healthcare workforce. Among the eight recommendations was urging nurses to lead and manage collaborative efforts within an interdisciplinary team to redesign and improve practice and healthcare systems (IOM, 2011c). Since this publication, a nationwide campaign for action emerged to address the recommendations. Recent assessment of the campaign highlights progress made through nurses’ addressing the areas of healthcare delivery, scope of practice, education, collaboration, leadership, diversity in the nursing profession, and workforce data (Altman et al., 2016). Efforts are underway to update the recommendations and set the course for the Future of Nursing 2020–2030, specifying how nurses might continue to contribute to healthcare quality and safety.


40 NURSING PROGRESSION: RESEARCH UTILIZATION AND EVIDENCE-BASED PRACTICE


Because the purpose of research ultimately is to uncover causal relationships, the primary goal is to determine which interventions are most effective in assisting patients and clients to resolve actual and potential health problems. In other words, research shows us “what works best” to produce the intended health outcome for a given health problem. Knowledge discovered through research is then translated into practice guidelines and ultimately affects health policy through commonly accepted healthcare practices.


In health professions, research is conducted to build a case for specific practices and interventions. The reason for conducting research is to illuminate effective practices, so it follows that the end goal is that research findings be translated into clinical decision-making at the point of care. Although this goal is clear, health professionals have struggled to achieve research utilization since the 1970s.


Nurses, along with other health professionals, have sought ways to move research results into practice; however, early attempts were not fully successful. Barriers to knowledge translation became a crucial topic of investigation in nursing in the early 1990s. A number of research utilization models were developed to explain the barriers and challenges in applying research results in practice. An early program of study established a dissemination model (Funk et al., 1989) and developed a scale with which to quantify nurses’ perceptions of barriers to applying research in practice (Funk et al., 1990). The BARRIERS scale is framed in the old paradigm of research utilization, in which results of a single study were examined for direct application, and clinical nurses were expected to read, critique, and translate primary research reports into point-of-care practice, and to devote time to these activities.


This early work in research utilization resulted in a clearer focus on clinical investigations. Nurse scientists who conducted research, largely in academic settings, were criticized for their shortcomings in making research results clinically meaningful. Such criticism included claims that research did not address pressing clinical problems, results were not expressed in terms understood by clinicians, and clinicians were not in positions to apply the results in care. In tandem, nurse scientists gathered momentum to establish what is today the NINR, dedicated to funding clinical research.


Initial research utilization models were developed prior to the emergence of EBP. The Stetler Model (Stetler, 1994) mapped a step-by-step approach that could be used by individual clinicians to critique research, restate findings, and consider the findings in their own decision-making. The model focuses on a bottom-up approach to change in clinical practice. The Iowa Model outlined a process to guide implementation of research results into clinical practice in the context of provider, patient, and infrastructure (Titler et al., 2001). The Iowa Model gives heavy emphasis to nurse managers as key instruments of change. Both models have moved from their original roots in research utilization to reflect a broader approach used in EBP. These early efforts underscored the importance of moving research into direct patient care.


SHIFT FROM RESEARCH UTILIZATION TO EVIDENCE-BASED PRACTICE


Frequently, research results are either inadequately translated into clinical practice recommendations or applied inconsistently in the delivery of healthcare. Additionally, poor healthcare system design 41contributes to the chasm; healthcare design inadequacies include a lack of interprofessional teams to provide comprehensive and coordinated care and a complex system that is a maze to patients and that fails to provide patients the services from which they would likely benefit (IOM, 2001).


As the EBP movement grew, it became apparent that the hurdles to translating research to practice required complex answers not yet formulated. The EBP movement has provided new scientific means with which to overcome these hurdles (Stevens, 2013).


Until recently, emphasis was placed on designing and conducting research studies to fill knowledge gaps about efficacy of clinical care. While generating this new knowledge is critically important, it falls short of the goal of adopting new knowledge into routine care to improve health and healthcare. The evidence-based practice paradigm and particularly the newer field of implementation science provide foundations for clinicians to spur adoption and sustainment of evidence-based practices. In the EBP approach, emphasis is placed on applying this new knowledge and the steps needed to increase clinical utility and usefulness of the research results. It became clear that knowledge transformation must occur in order for research results to be readily accessible to clinicians and transformed into practice (Stevens, 2015).


As the healthcare quality paradigm expanded to EBP, challenges in transforming research results into common practice became apparent. EBP approaches, derived from clinical epidemiology, provided new insights and changed the approach to moving research into routine care. With the paradigm shift, these two hurdles became apparent: (a) the large volume and complexity of health research literature and (b) the low clinical utility of the form of knowledge that is available to the clinician (Stevens, 2015).


Advancements in the EBP movement produced a number of models and techniques to meet the challenges of adopting research into care to improve care and patient safety (Nilsen, 2020). Nurse scientists contributed a number of models to understand the various aspects of EBP. These models guide implementation approaches intended to strengthen evidence-based decision-making. Forty-seven prominent EBP models identified in the literature were grouped into four thematic areas: “(a) EBP, Research Utilization, and Knowledge Transformation Processes. . ., (b) Strategic/Organizational Change Theory to Promote Uptake and Adoption of New Knowledge. . ., (c) Knowledge Exchange and Synthesis for Application and Inquiry. . ., and (d) Designing and Interpreting Dissemination Research” (Mitchell et al., 2010, pp. 288–289). Listed among models is the widely-adopted Stevens Star Model of Knowledge Transformation (Stevens, 2015). The following discussion expands on the Star Model to frame important aspects of the advance practice nurse’s role in evidence-based quality improvement.


The Star Model addresses two key challenges in moving evidence into action, First, research results from multiple studies must be combined and repackaged to maximize utility for clinical decision-making. Second, systematic facilitation is requisite for successful implementation of the EBP. As depicted in Figure 3.1, the stages represented in the Stevens Star Model are arranged around a 5-point star representing (a) discovery research, (b) evidence summary, (c) translation into clinical guidelines, (d) integration into practice, and (e) evaluation of impact on outcomes (Stevens, 2015).


POINT 1: Discovery Research


As described, the NINR provided great stimulus, resources, and focus for primary nursing research studies. The upshot was that the number of nursing research studies rapidly expanded. However, a large collection of single research studies is not manageable to inform clinical choices at the point of care. Moreover, various studies may show different conclusions about the efficacy of a clinical intervention (e.g., skin-to-skin neonatal care).



42FIGURE 3.1Stevens Star Model of Knowledge Transformation.


Source: Copyright 2015, Kathleen Stevens, EdD, FAAN, RN, ANEF. Used with permission.


POINT 2: Evidence Summary


To overcome the hurdle to clinical application posed by the growing volume of single research studies, a new approach to knowledge management was developed in the mid-1990s. The new approach systematically combined research results from multiple studies and evidence summaries became a key to bridging knowledge to practice. The most rigorous scientific method for synthesizing all research into a single summary is called a systematic review (SR). A SR is defined as a scientific investigation that focuses on a specific question and uses explicitly preplanned scientific methods to identify, select, assess, and summarize similar but separate studies (IOM, 2008).


A SR produces a concise, comprehensive, comprehensible statement about the state of the science regarding clinical effectiveness. It is identified as the cornerstone to understanding whether a clinical intervention works (IOM, 2008, IOM 2011b). Indeed, it is recognized that an evidence summary is requisite to “getting the evidence [about intervention efficacy] straight” (Glasziou & Haynes, 2005). The sobering flip side of this logic is that not conducting an rigorous evidence summary or conducting a non-SR will likely result in not getting the evidence straight, leading to a misinformed clinical decision and poor patient outcomes. Nursing care must be driven by research evidence—not knowing the state of the science about clinical effectiveness results in ineffective, unnecessary, or harmful care. From EBP, we now realize that basing care on results of a single primary research study can lead to the selection of a wrong intervention and produce poor outcomes. With this new realization, we have moved away from using single research studies to change practice to a much more rigorous knowledge form—the evidence summary.



SRs serve two important knowledge functions in selecting high-quality clinical interventions. First, a SR provides evidence about the clinical efficacy of a particular intervention in relation to specified outcomes. Second, a SR provides a view of gaps in the scientific field and points to further research needed to fill these voids. A prime advantage of an evidence summary, such as a SR, 43is that all research results on a given topic are transformed into a single, harmonious statement (Mulrow, 1994).


With a SR, the state of the science on a given topic is placed at the fingertips of the clinician in terms of what is known and what remains to be discovered. SRs are deemed one of the two key ways of knowing what works in healthcare (IOM, 2008, IOM 2011b). With regard to providing evidence-based direction for clinical care, a SR offers other advantages (Mulrow, 1994) as outlined in Box 3.1.


Box 3.2 illustrates a systematic review of a topic of high interest to individual clinicians, healthcare organizations, and patients: falls prevention.



44POINT 3: Translation to Guidelines


The next stage of knowledge transformation is producing evidence-based clinical practice guidelines (CPGs). In the Star Model, CPGs represent the “translation” of the evidence summary into recommendations for clinical practice. Evidence-based CPGs have the potential to reduce illogical variations in practice by encouraging use of clinically effective practices (IOM, 2008, 2011a, 2011b). CPGs articulate the likelihood that a chosen intervention will produce the intended patient outcome, or more succinctly, “what works in healthcare” (IOM, 2008). Importantly, CPGs enhance the uptake of EBP by presenting trustworthy recommendations that are directly related to clinical care. CPGs are “systematically defined statements that are designed to help clinicians and patients make decisions about appropriate healthcare for specific clinical circumstances” (IOM, 1990, p. 38). The current definition is: “CPGs are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” (IOM, 2011a, p. 4). Guidelines can be considered a convenient way of packaging evidence and presenting recommendations to healthcare decision-makers.


The trustworthiness of a CPG is enhanced when it is firmly based on the best evidence relating to clinical effectiveness and cost-effectiveness. Standards for trustworthy CPGs include transparent processes for developing the recommendations and criteria for appraising reliability. Well-developed guidelines include specification and rating of supporting evidence. Defining characteristics of trustworthy guidelines are included in Box 3.3.


An example of nurses engaged in development of guidelines is noted in the U.S. Preventive Services Task Force. This entity is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations (CPGs) about clinical preventive services such as screenings, counseling services, and preventive medications. Table 3.1 presents two examples of “Grade A or B” guidelines (U.S. Preventive Services Task Force, 2020).


When developed in a systematic and transparent way, CPGs are a critical form of knowledge, making evidence far more accessible during clinical decision-making.
















45TABLE 3.1 Two Examples of “Grade A or B” Guidelines


POPULATION


RECOMMENDATION


Pregnant Women


Grade A


“The USPSTF recommends screening for HBV infection in pregnant women at their first prenatal visit.” www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virus-infection-in-pregnant-women-screening


School-aged children and adolescents who have not started to use tobacco


Grade B


“The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.”


www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-and-nicotine-use-prevention-in-children-and-adolescents-primary-care-interventions


HBV, hepatitis B virus; USPSTF, U.S. Preventive Services Task Force.


POINT 4: Integration


Once high quality evidence-based guidelines have been developed, routine practice and clinical decisions must be realigned to these new standards to improve healthcare processes and outcomes. Introduction of EBP into ongoing care is accomplished through change management to promote uptake and sustainment at the individual clinician, organizational, and policy levels. The challenges of changing provider practices within an organizational context are many and complex. New approaches to studying organizational change, CASs, and culture shifts are adding to our understanding of the challenge of integration. Research will fill the gap in what we know about “getting the straight evidence used” (Glasziou & Haynes, 2005) in practice.


Rapid advancement in the new field of implementation science contributes greatly to our growing understanding of changing practice and promoting uptake of EBP. Similar to the development of the field of EBP, this new field has quickly expanded to invent new models, frameworks, methodologies, and metrics. As in most new sciences, the terms, models, and frameworks proliferate. Reviews of the broad scientific field identified more than 100 theories, models, and frameworks (TMFs) (Nilsen, 2020; Tabak et al., 2012). Many grew out of Rogers’s seminal Diffusion of Innovations Theory (Rogers, 2003), describing the ways that innovations diffuse and the elements that speed innovation adoption from scientific research to end users (Nilsen, 2020; Rogers, 2003). Given the advance practice nurse role in improvement, theories are especially useful as practice models for implementing EBP and can lead to successful incorporation of evidence into clinical care.


Other models and frameworks are useful in planning the process of integration in the Star Model Point 4, defining domains that are associated with the adoption, implementation, and maintenance of evidence-based interventions. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) and the i-PARIHS model (Harvey & Kitson, 2015) take into account the importance of “context” or organizational setting of the proposed practice change to explain or predict adoption of evidence into practice. The widely used CFIR model provides a comprehensive framework to systematically identify factors in multi-level contexts that may influence implementation of EBP. In particular, the CFIR model identifies the following characteristics that can help or hinder adoption of the EBP improvement: intervention characteristics; outer setting; inner setting; characteristics of individuals; and process of implementation 46(Damschroder et al., 2009). Similarly, core constructs of the i-PARIHS model are facilitation, innovation, recipients, and context; facilitation is a process that assesses, aligns, and integrates the other three constructs (Harvey & Kitson, 2015). As implementation research provides principles to direct integration into practice, reliable tools are also developed, such as those that assess organizational readiness for change (Weiner et al., 2020).


Applying these theories and tools in practice is useful for maximizing influences of implementation strategies to promote adoption and improve care and patient outcomes and for planning and evaluating implementation efforts. Advanced practice nurses are well-positioned in the healthcare system to outline effective system strategies that promote the integration of EBP into care.


The focus on implementation has grown what is known about successful implementation strategies. Implementation strategies target multiple outcomes, including outcomes related to implementation (e.g., feasibility, fidelity, sustainment); service outcomes (the IOM standards of care—safe, timely, effective, efficient, equitable, and patient centered), and client outcomes (health status and satisfaction; Proctor et al., 2011). To be successful in a complex system, implementation strategies must target a range of stakeholders and multilevel contextual factors across different phases of implementation. For example, strategies may include factors related to patients, providers, organizations, communities, and policy and financing levels.


Implementation strategies are described as those methods and techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice (Proctor et al., 2013). These strategies assist in overcoming barriers to adoption of evidence-based quality improvement changes. Examples of implementation strategies include audit-feedback loops, reminders, decision support, communication technology, incentives, and disincentives. Commonly used strategies include pay-for-performance, professional education, facilitation and championing, opinion leaders, and policy mandates. To date, meta-analyses performed through the Cochrane Collaboration have been performed on seven categories of implementation strategies, showing small effect sizes. The categories are as follows: printed educational materials, educational meetings, educational outreach, local opinion leaders, audit and feedback, computerized reminders, and tailored implementation strategies. A full discussion of effectiveness of implementation strategies is offered by Grimshaw et al. (2012). Strategies vary by their impact and studies continue to evaluate the strategies.


Implementation strategy nomenclature is under development, with a total of 73 implementation strategies identified through expert panels (Powell et al., 2015). This common nomenclature is recommended to guide implementation practice and research. Clinicians can use this foundation to systematically match implementation strategies to the barriers and facilitators for a specific EBP (Powell et al., 2017) in order to maximize success in the practice change and improvement.


An example of an evidence-based program that is packaged for implementation is the program called “Team Training for Enhancement of Performance and Patient Safety” (TeamSTEPPS®). TeamSTEPPS® is a comprehensive evidence-based program aimed at optimizing communication performance in healthcare professionals engaged in team care, reducing adverse events. Although the program is well-developed and includes a full curriculum, implementation guidance, and tools such as posters and flip cards, integrating the program into practice has proven challenging. A recent project used the CFIR model to plan implementation of the TeamSTEPPS® program for school mental health. Implementation challenges were those that are common in implementation projects, including leader and staff turnover, agency policies, and logistical barriers (e.g., securing private space for interviews in schools). This example underscores the importance of considering stakeholder and organizational features within a complex organization to support change management (Wolk et al., 2019).


47Given the neophyte field of implementation science, efforts toward research (e.g., Brownson et al., 2017) have overshadowed the practice of implementation. One resource stands out as a definitive reference for advanced practice nurses who are leading initiatives to implement EBP, rather than studying it. Greenhalgh (2018) offers a clear and comprehensive capture of the scientific principles discovered to date. In her book, she explains how to successfully apply evidence-based healthcare to practice in order to ensure safe and effective practice. Doing so requires mastery of a breadth of skill across a number of factors, including evidence, people, groups and teams, organizations, citizens, patients, technology, policy, networks, and systems (Greenhalgh, 2018). This definitive practice resource includes tools and techniques across each of these factors.


Nurses were significantly involved in “packaging” and creating plans to spread the practices recommended in the Million Hearts Campaign® (Centers for Disease Control and Prevention [CDC], 2018). An all-inclusive tool kit reflects the many elements of successful implementation planning, including multi-level stakeholder engagement, policy impact, and metrics to evaluate success of the national program.


POINT 5: Evaluation


Evaluation is a critical step in the change process as evidence-based practices are implemented. The new quality improvement investigation movement includes estimating costs and savings over time, for the customer and other stakeholders. Once integrated, the practice change is evaluated for its impact on multiple outcomes, including care processes, healthcare services, and patient and population health outcomes. An unresolved issue in implementation science is how to conceptualize and evaluate successful implementation; to that end, conceptual distinctions are made between implementation effectiveness and treatment effectiveness (Proctor et al., 2011). In their seminal discussion, Proctor and her associates list the types of outcomes in implementation research as shown in Table 3.2.


Evaluation of implementation success quantifies the feasibility, fidelity, cost, and sustainment of the evidence-based practice as it moves into care. Improvement in healthcare service can be assessed in terms of safety, timeliness, effectiveness, efficiency, equitability, and patient-centeredness resulting from the change. Client, patient, family, and population outcomes can be evaluated in terms of health status, symptomology, and satisfaction. (Proctor et al., 2011). Building on this conceptual map, implementation scientists have extended the work to develop implementation outcome measures, considered essential for monitoring and evaluating the success of implementation efforts. Consensus and psychometric testing resulted in three noteworthy measures to evaluating three implementation outcomes: Acceptability of Intervention, Intervention Appropriateness, and Feasibility of intervention (Weiner et al., 2017). Table 3.3 further defines each construct.










TABLE 3.2 Types of Implementation Outcomes


Implementation Outcomes


Acceptability


Adoption


Appropriateness


Costs


Feasibility


Fidelity


Penetration Sustainability


Service Outcomes


IOM “STEEEP” Standards of Care


Safety


Timeliness


Effectiveness


Efficiency


Equity


Patient-centeredness


Client Outcomes


Satisfaction


Function


Symptomatology


















48TABLE 3.3 Three Concepts of Fit and Match of an EBP Intervention


CONCEPT DEFINITION


4 LIKERT-TYPE QUESTIONS FOR EACH CONCEPT


Acceptability—Personal views of stakeholder (e.g., clinicians, administrators) perception that a given treatment, service, practice, or evidence-based innovation is agreeable, palatable, or satisfactory


Approval


Appeal


Preference


Openness


Appropriateness—Technical or social views on perceived fit, relevance, or compatibility of the innovation for a given practice setting, provider, consumer for a given problem


Fitting


Suitable


Applicable


Good match


Feasibility—Practical views on the extent to which a new treatment or evidence-based innovation can be successfully used or carried out in a given setting


Implementable


Possible


Doable


Easy to use


Source: Adapted from Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65–76. doi.org/10.1007/s10488-010-0319-7; Weiner, B. J., Lewis, C. C., Stanick, C., Powell, B. J., Dorsey, C. N., Clary, A. S., Boynton, M. H., & Halko, H. (2017). Psychometric assessment of three newly developed implementation outcome measures. Implementation Science, 12(1), 108. doi.org/10.1186/s13012-017-0635-3


One of the most frequently applied implementation evaluation frameworks, the Research-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) framework is useful not only in public health behavior change, but also in clinical settings (Glasgow et al., 2019). RE-AIM identifies metrics for evaluating implementation success: that is, high reach and effectiveness resulting in practice change.


The field of implementation science has greatly advanced and a number of priorities have been identified for continuation. Among these is a call for economic evaluations of implementation strategies (Ovretveit, 2017; Powell et al., 2019). The goal of EBP is to improve healthcare and the cost of the change and maintenance is central in the value equation (Kilbourne et al., 2019). Every practice change requires an up-front investment of time and resources, with the intent of improving patient and service outcomes. Process costs (e.g., clinician orientation to the new practice, supplies) are examined in light of outcomes. Examples of outcomes are shortened length of hospital stay, reduced injurious falls, and avoidance of unplanned re-admissions. Cost analysis is an approach to examine the return on investment of EBP, including implementation. Such analysis often includes determining the costs avoided and cost of implementing the change to estimate the return on investment. Organizational and individual endorsement of the change is enhanced when the benefits of the investment are demonstrated.


NATIONAL COMPETENCIES IN EVIDENCE-BASED QUALITY IMPROVEMENT


Evidence-based quality improvement remains a relatively new field; for the advanced practice nurse, the field brings with it the need for new competencies and skills. Healthcare leaders and organizations have responded to the quality and safety healthcare agenda with unprecedented speed. Few other movements in healthcare have gained such widespread and rapid momentum. 49Nurses have risen to the occasion to lead and join evidence-based quality efforts through improvement activities, development of explanatory models and science of EBP, and educational programs to embed EBP into the profession.


Early in the movement, nurses responded to national urging to integrate EBP into practice and education. Pivotal to building this nursing EBP capacity is the specification of EBP competencies and skills deemed necessary. Along with national experts, Stevens (2009) developed consensus on EBP competencies. This consensus established these competencies to guide the practice of EBP as well as the professional development and preparation of nurses. Because of the breadth of the Stevens Star Model across the knowledge transformation process, the Star Model was used as the framework for organizing the EBP competencies, providing a theory-based, stable foundation as EBP moved forward. The work resulted in consensus on skills that are requisite to employing EBP in a clinical role (Stevens, 2009). Using a systematic process, expert panels generated, validated, endorsed, and disseminated competency statements that guide nursing practice in basic (associate and undergraduate), intermediate (masters), and advanced (doctoral) roles. Between 10 and 32 specific competencies are enumerated for each of four levels of nursing roles/education. This consensus document categorizes requisite skills, including knowledge management, accountability for scientific basis of nursing practice, organizational and policy change, and development of scientific underpinnings for EBP (Stevens, 2013); they are published in Essential Competencies for EBP in Nursing (Stevens, 2009) and are reviewed annually. Table 3.4 displays examples of competencies in each level.


Although EBP competencies are established, health professionals are still in the early adoption stage of fully integrating these into their roles and into healthcare delivery. Individual clinicians face barriers in EBP improvement that include any knowledge deficits including lack of preparation in EBP competencies, lack of experience, and lack of confidence (Saunders et al., 2016). New programs 50have successfully boosted nursing scholarship in clinical settings through EBP internships and fellowship opportunities (e.g., Black et al, 2015; Saunders et al., 2016). These programs increase nurses’ EBP confidence and knowledge, strengthening their EBP readiness at least in the short term.






























TABLE 3.4 Examples of National Consensus Competency Statements for Evidence-Based Quality Improvement


STAR POINT


INTERMEDIATE


(5 OF 32 COMPETENCIES)


ADVANCED


(5 OF 31 COMPETENCIES)


1


Critically appraise original research reports for practice implications in context of EBP using existing standards.


Design primary research to address factors within the system, the microsystem, and the individual that are associated with uptake of evidence-based CPG and quality improvement processes.


2


Interpret statistical analyses commonly used in evidence summaries.


Critically appraise evidence summaries for practice implications in context of EBP and as the basis for proposing primary research studies.


3


Critically appraise CPG in the context of EBP using valid instruments.


As part of planned organizational change, outline systematic approaches to develop evidence-based CPG.


4


Provide leadership for integrating EBP in clinical practice.


Represent nursing in developing interdisciplinary national initiatives to redesign healthcare to infuse quality and safety into healthcare.


5


Interpret analysis of indicators/outcomes in terms of quality of care.


Design processes to determine impact of EBP on multiple outcomes.


CPG, clinical practice guidelines; EBP, evidence-based practice.


Source: From Stevens, K. R. (2009). Essential competencies for evidence-based practice in nursing (2nd ed.). Academic Center for Evidence-Based Practice (ACE), University of Texas Health Science Center.


In tandem, while individual clinicians may possess EBP competencies, they often face organizational obstacles for implementing EBP in the clinical setting. These obstacles include lack of time, lack of facilities or resources, and lack of institutional leadership support (Yoder et al., 2014). One exemplar program housed in a major hospital established dedicated human resources to promote clinical nursing inquiry in evidence-based quality improvement. Key elements of the ongoing program include opportunities to contribute to the science of nursing, culture change for nursing inquiry, institutionalized professional development and mentoring, and bridging between practice and academic sectors (Whalen et al., 2020).


To enable nurses to achieve EBP competencies, leaders have developed, tested, and made available in-depth online learning programs. The web-based Evidence-Based Research (EBR) program incorporates sound instructional design, theoretical basis, including the Stevens Star Model of Knowledge Transformation (Stevens, 2015), and broad EBP skills. The EBR program is usable on multiple devices and is effective in helping interprofessional clinicians acquire skills and tap into important EBP resources. The e-learning strategy places evidence-based resources at the fingertips of users by addressing some of the most commonly cited barriers to research utilization while exposing users to information and online literacy standards of practice, meeting a growing need (Long et al., 2016).


Advancing evidence-based quality improvement, requires that providers, organizational leaders, and the environment continue to support individual clinician and organizational capacity building and infrastructure evolution so that EBP is fully implemented.


Identifying and De-Implementing Low-Value Care: Choosing Wisely® Campaign


In tandem with the nation’s focus on safe, high-quality care, there is grave concern about the overuse of healthcare resources. As much as 30% ($760 billion to $935 billion) of healthcare delivered annually is wasteful and more than half of this is spent on ineffective, inefficient, harmful, duplicative, and unnecessary care; these experts call for wise care decisions (American Board of Internal Medicine [ABIM] Foundation, 2016; Berwick & Hackbarth, 2012; Shrank et al., 2019).


Initially, efforts to improve quality focused on underuse (i.e., not doing the right thing) and misuse (i.e., preventable complications). In 2012, attention was drawn to overuse (i.e., doing too much) amid a growing emphasis on optimizing care value (Schpero, 2014). Value reflects a balance between net clinical benefit and cost. The term low-value care refers to healthcare services with little potential benefit and harm, or for which less expensive alternatives are available. Low-value care includes overtesting and overdiagnosis, leading to overtreatment.


Nurses and nurse leaders have aligned with the NQS to achieve better care for individuals, better health for populations, and greater value (lower per capita costs). Elimination of low-value healthcare services as a cost control strategy has economic appeal because it improves quality while reducing costs (ABIM Foundation, 2016). Unnecessary and ineffective procedures and interventions add to cost while desired health outcomes are not reached, eroding the value of care.


An important strategy is to choose care for which evidence indicates it is nonduplicative, truly necessary, and will cause no harm. In response to cost and overtreatment concerns, the national Choosing Wisely® (CW) campaign was launched by the ABIM Foundation in 2012 with the objective of assisting providers and patients to make informed decisions, to choose wisely among diagnostic and treatment options to avoid overuse, and to avoid “low-value” care (51Wolfson et al., 2014). Over 70 health professional organizations in the nation and multiple countries are currently part of the effort, representing a wide array of disciplines including medicine, nursing, dentistry, and other health professions. Each participating organization has contributed lists of “Things to Question” that providers and patients can use to make wise decisions as they select best care in the individual situation (ABIM Foundation, 2016).


Definition: Overtreatment


The waste that comes from subjecting patients to care that, according to sound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science. Examples include excessive use of antibiotics, use of surgery when watchful waiting is better and unwanted intensive care at the end of life for patients who prefer hospice and home care.


(Berwick & Hackbarth, 2012, p. 1514)


The CW initiative represents what could be called the “flip side” of EBP, that is, removing from practice those approaches for which there is evidence of ineffectiveness, inefficiency, or harm (Stevens, 2019; Woodward et al., 2015). Organizations in the CW campaign generate evidence-based recommendations to help clinicians and consumers engage in conversations to make informed decisions and avoid unnecessary and ineffective care and cost. Such decisions are enacted by the healthcare team, with nurses playing a vital role.


Nurses are represented in the campaign by the nursing organizations convened by the American Academy of Nursing, which was among the first nonphysician organizations to release a CW list in 2014 (Sullivan, 2015). Recommendations are presented as “avoid” or “don’t” statements and are accompanied by background information and reference citations on the website. Two of the 25 recommendations are presented in Exhibit 3.1 (American Academy of Nursing, 2018x).


Additional nursing implications for CW recommendations cross over from medicine. For example, the recommendation to avoid elective labor induction or cesarean birth before 39 weeks from the American College of Obstetricians and Gynecologists is often a highly charged decision for the mother; in this situation, the nurse’s role in wise choices is to support both physician and patient decisions. Whether the nurse is supporting a decision for medical treatment or advocating for a nursing care decision, the trusted voice of the nurse in making wise decisions will help patients navigate the complex health system with evidence-based information.


The removal of wasteful or ineffective practices from our collective thinking and healthcare system is challenging. Many times ineffective clinical approaches are embedded in common practices and held there by multiple factors in the complexity of healthcare and public literacy. While no parallel studies are yet available in nursing, a study in medicine substantiates widespread overuse and variation in overuse in the Medicare population by measure and by geography (Colla et al., 2015). Eleven CW recommendations were tracked to determine the prevalence of the delivery of low-value services (e.g., don’t perform preoperative cardiac tests for cataract surgeries and don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia). The prevalence of low-value services was significant. For example, the prevalence of use of nonrecommended preoperative cardiac testing for low-risk, noncardiac procedures was 46.5% (Colla et al., 2015).


Just as nurse leaders employ principles to promote adoption of best practices, they may also draw on principles to remove useless and harmful practices from daily care. This effort to “de-adopt” low-value interventions requires change management for individual care providers, 52the general public, and healthcare delivery systems. Practical principles can be derived from a number of sources commonly used in promoting adoption of best practices. These include principles of change, team leadership, creating a sense of urgency, and empowering through capacity building (Stevens, 2019). However, actions to remove low-value care are predicated on awareness of nationally-accepted recommendations. Surveys indicate that frontline clinicians were minimally aware of recommendations on low-value care: 21% of RNs and 26% of advanced practice nurses were aware of the AAN Choosing Wisely® recommendations (Stevens, 2019).



EXHIBIT 3.1


EXAMPLES* OF NURSING RECOMMENDATIONS IN THE CHOOSING WISELY CAMPAIGN








Don’t automatically initiate continuous electronic fetal heart rate (FHR) monitoring during labor for women without risk factors; consider intermittent auscultation (IA) first.


As a routine procedure in many hospitals, continuous FHR is associated with increased cesarean or instrument assisted (e.g., forceps) births and do not improve Apgar scores, NICU admission rates, or intrapartum fetal death rates. Advantages of IA is freedom of movement during labor, pain management, shorter first stage of labor and less epidural medication use.


Don’t let older adults lie in bed or only get up to a chair during their hospital stay.


During hospitalization, around 65% of older adults lose their ability to walk. Mobilization during hospital stays maintains functional ability. This in turn reduces length of stay, avoids need for rehabilitation services, reduces risk for falls, and reduces burden on caregivers. Older adults who walk during hospitalization can walk farther at discharge, are discharged sooner, and are able to perform basic activities of daily living.


*Two of 25 recommendations on nursing care


Source: From American Academy of Nursing. (2018). Twenty-five things nurses and patients should question. higherlogicdownload.s3.amazonaws.com/AANNET/c8a8da9e-918c-4dae-b0c6-6d630c46007f/UploadedImages/AAN_Nursing-Choosing-Wisely-List__11_19_18_.pdf

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Oct 17, 2021 | Posted by in NURSING | Comments Off on Research and the Mandate for Evidence-Based Practice, Quality, and Patient Safety
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