Chapter15 power point july132012

Transitioning Transitioning Evidence to Evidence to

PracticePractice

Evidence Based Practice Evidence Based Practice ModelsModels

Conduct and Utilization of Research in Conduct and Utilization of Research in Nursing (CURN)Nursing (CURN)

Stetler ModelStetler Model Iowa ModelIowa Model

CURN ModelCURN Model

Designed by the Michigan Nurses Designed by the Michigan Nurses Association to develop and test the Association to develop and test the facilitation of scientific nursing facilitation of scientific nursing knowledge in clinical practice settings. knowledge in clinical practice settings.

CURN ModelCURN ModelAssists nurses to incorporate new research into Assists nurses to incorporate new research into

clinical practice: clinical practice:

Identify a patient care problem. Identify a patient care problem. Find and assess research-based knowledge to apply Find and assess research-based knowledge to apply

to the problem. to the problem. Adapt and design a nursing practice innovation from Adapt and design a nursing practice innovation from

the research base. the research base. Decide whether to adopt, alter or reject the Decide whether to adopt, alter or reject the

innovation. innovation. Develop the means to extend the new practice Develop the means to extend the new practice

beyond the trial. beyond the trial. Develop mechanism to maintain the innovation over Develop mechanism to maintain the innovation over

time. time. Retrieved from Retrieved from

www.medicalcityhospital.com/CustomPage.asp?guidCustomContentIDhttp://={ABD30A7E-3A16-424C-A44F-51CCC1B1ED9B After navigating to this site, type in ‘CURN’ in the search box in the upper right corner. After navigating to this site, type in ‘CURN’ in the search box in the upper right corner.

Stetler ModelStetler Model This is a model of research utilization This is a model of research utilization

to facilitate evidence-based practice to facilitate evidence-based practice (EBP).(EBP).

The model formulated a series of The model formulated a series of critical-thinking and decision-making critical-thinking and decision-making steps designed to facilitate safe and steps designed to facilitate safe and effective use of research findings.effective use of research findings.

Resource: Stetler, C.B. (2001). Updating the Stetler model of research utilization to Resource: Stetler, C.B. (2001). Updating the Stetler model of research utilization to facilitate evidence-based practice. facilitate evidence-based practice. Nursing OutlookNursing Outlook, , 4949(6), 272-279(6), 272-279..

Stetler Model of Research Utilization to Facilitate EBP, Part I

Stetler Model, Part II

Stetler Model (Cont.)Stetler Model (Cont.)

Phase I – Preparatory phase – Define Phase I – Preparatory phase – Define the need for clarity of purpose and the need for clarity of purpose and potential significance of internal or potential significance of internal or external factors.external factors. Search, sort and select sources of Search, sort and select sources of

research evidenceresearch evidence Consider influential factorsConsider influential factors Affirm priorityAffirm priority Define purpose and outcomes per issue or Define purpose and outcomes per issue or

catalystcatalyst

Stetler Model (Cont.)Stetler Model (Cont.) Phase II – Validation – Reflect studied Phase II – Validation – Reflect studied

relationships or variables in terms that relationships or variables in terms that could pragmatically be used in daily could pragmatically be used in daily activitiesactivities Perform utilization focused critique & Perform utilization focused critique &

synopsissynopsis Identify and, if applicable, record key study Identify and, if applicable, record key study

details and qualifiersdetails and qualifiers

Stetler Model (Cont.)Stetler Model (Cont.) Phase III – Comparative Phase III – Comparative

Evaluation/Decision Making – Evaluation/Decision Making – Synthesize findings and evaluate per Synthesize findings and evaluate per criteria -criteria - Fit of settingFit of setting FeasibilityFeasibility Current practiceCurrent practice Substantiating evidenceSubstantiating evidence

Decide to use, consider use or not useDecide to use, consider use or not use


Phase IV – Translation/Application – Describes Phase IV – Translation/Application – Describes how to implement findings or recommendations how to implement findings or recommendations –– Confirm type, level and method of applicationConfirm type, level and method of application Use – Review operational details -Use – Review operational details -

Informally – Use in practiceInformally – Use in practice Formally – Identify/design evidence-based documents; Formally – Identify/design evidence-based documents;

package for dissemination; develop EBP change plan, package for dissemination; develop EBP change plan, including evaluationincluding evaluation

Consider UseConsider Use Informally – Obtain targeted practice information; evaluateInformally – Obtain targeted practice information; evaluate Formally – Do formal details as in “Use”; plan and Formally – Do formal details as in “Use”; plan and

implement a pilot project of use, including evaluationimplement a pilot project of use, including evaluation

Decide to accept and extend, with or without Decide to accept and extend, with or without modification or reject and stopmodification or reject and stop


Phase V – Evaluation –Phase V – Evaluation – Evaluate dynamically – Evaluate dynamically –

Identify goal for each useIdentify goal for each use Obtain evidence re: change process and goal-Obtain evidence re: change process and goal-

related progress, as well as end related progress, as well as end result/outcomesresult/outcomes

Use iterative evidence to achieve goalsUse iterative evidence to achieve goals

Evaluate as part of routine practiceEvaluate as part of routine practice

Iowa ModelIowa Model

Provides a guide for clinical decision-Provides a guide for clinical decision-makingmaking

Provides details regarding Provides details regarding implementation of evidence-based implementation of evidence-based practicepractice

It includes both the practitioner and It includes both the practitioner and organizational perspective.organizational perspective.

The Iowa Model of Evidence-Based Practice to Promote Quality Care

The Iowa Model of Evidence-Based The Iowa Model of Evidence-Based Practice to Promote Quality CarePractice to Promote Quality Care

Problem Focused TriggersProblem Focused Triggers Risk Management DataRisk Management Data Process Improvement DataProcess Improvement Data Internal/External Benchmarking DataInternal/External Benchmarking Data Financial DataFinancial Data Identification of Clinical ProblemIdentification of Clinical Problem


Knowledge Focused TriggersKnowledge Focused Triggers New Research or Other LiteratureNew Research or Other Literature National Agencies or other Organizational National Agencies or other Organizational

Standards and GuidelinesStandards and Guidelines Philosophies of CarePhilosophies of Care Questions from Institutional Standards Questions from Institutional Standards

CommitteeCommittee


Is this topic a priority for the Is this topic a priority for the organization?organization? If no, consider other triggersIf no, consider other triggers If yes –If yes –

Form a teamForm a team Assemble relevant research and related Assemble relevant research and related

literatureliterature Critique and synthesize research for use in Critique and synthesize research for use in

practicepractice


Is there a sufficient research base?Is there a sufficient research base? If no:If no:

Conduct researchConduct research Base practice on other types of evidence such as Base practice on other types of evidence such as

case reports, expert opinion, scientific principles or case reports, expert opinion, scientific principles or theorytheory

If yes – Pilot the change in practice:If yes – Pilot the change in practice: Select outcomes to be achievedSelect outcomes to be achieved Collect baseline dataCollect baseline data Design EBP guidelinesDesign EBP guidelines Implement EBP on pilot unitsImplement EBP on pilot units Evaluate process and outcomesEvaluate process and outcomes Modify the practice guidelinesModify the practice guidelines


Is change appropriate for adaptation to Is change appropriate for adaptation to practice?practice? If no – Continue to evaluate quality of care and If no – Continue to evaluate quality of care and

new knowledgenew knowledge If yes – Institute the change in practiceIf yes – Institute the change in practice

Monitor and analyze structure, process and Monitor and analyze structure, process and outcome data, including environment, staff, outcome data, including environment, staff, cost, and effect on patient and familycost, and effect on patient and family

Disseminate ResultsDisseminate ResultsSource: Titler, M.G., Steelman, V.J., Budreau, G., Buckwalter, K.C., Goode, C.J. (2001). The Iowa Model of Source: Titler, M.G., Steelman, V.J., Budreau, G., Buckwalter, K.C., Goode, C.J. (2001). The Iowa Model of

Evidence-Based Practice to Promote Quality Care. Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America.Critical Care Nursing Clinics of North America. 1313(4) (4) 497-508.497-508.

Comparison of the Stetler & Comparison of the Stetler & Iowa ModelsIowa Models

StetlerStetler Focus is on how Focus is on how

individual individual practitioner practitioner implements the implements the researchresearch

Prescriptive (step-Prescriptive (step-by-step) designby-step) design

IowaIowa Explains how Explains how

organizations organizations change practice change practice based on based on researchresearch

Systematic Systematic designdesign

Read, Think, Do Method of Read, Think, Do Method of ImplementationImplementation

Not a model, but is a methodNot a model, but is a method Acknowledges the complexity of Acknowledges the complexity of

problem-solving processes by looking problem-solving processes by looking for –for – The evidenceThe evidence Assessing the value to practiceAssessing the value to practice Addressing the social and cultural milieu Addressing the social and cultural milieu

of the practice setting to ascertain the best of the practice setting to ascertain the best strategies for initiating and sustaining strategies for initiating and sustaining practice changespractice changes

Read, Think, Do Method of Read, Think, Do Method of ImplementationImplementation

Read – Access the breadth of research Read – Access the breadth of research findings that will sufficiently inform the findings that will sufficiently inform the change processchange process

Think – Give critical thought about Think – Give critical thought about applicability to the clinical settingapplicability to the clinical setting

Do – Organize the effective Do – Organize the effective implementation of the practice change implementation of the practice change within a local culturewithin a local culture

Resource: Winch, S., Henderson, A., & Creedy, D.(2005). Read, think, do!: A method for Resource: Winch, S., Henderson, A., & Creedy, D.(2005). Read, think, do!: A method for fitting research evidence into practice. fitting research evidence into practice. Journal of Advanced Nursing, 31Journal of Advanced Nursing, 31(3), pp. 20-(3), pp. 20-26.26.

Barriers to Connecting Research Barriers to Connecting Research and Practiceand Practice

Organizational CultureOrganizational Culture Belief SystemsBelief Systems Research Related BarriersResearch Related Barriers

Perceived Barriers to Research Utilization: Perceived Barriers to Research Utilization: Organizational Culture, Nurses’ Belief Systems and the Organizational Culture, Nurses’ Belief Systems and the

Research-related BarriersResearch-related Barriers

Insufficient time on the job to implement new Insufficient time on the job to implement new ideasideas

Nurses feel they do not have the authority to Nurses feel they do not have the authority to change practicechange practice

Facilities are inadequate for implementationFacilities are inadequate for implementation Statistical analyses are not understandableStatistical analyses are not understandable Insufficient time on the job to read researchInsufficient time on the job to read research

Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Journal of Advanced Journal of Advanced Nursing,Nursing, 31, 31, 599-606.599-606.

Perceived Barriers to Research Utilization: Perceived Barriers to Research Utilization: Organizational Culture, Nurses’ Belief Systems and the Organizational Culture, Nurses’ Belief Systems and the

Research-related BarriersResearch-related Barriers

Physicians will not cooperate with Physicians will not cooperate with implementationimplementation

Nurses are isolated from colleagues with Nurses are isolated from colleagues with whom to discuss research findingswhom to discuss research findings

Nurse does not feel capable of evaluating the Nurse does not feel capable of evaluating the quality of the researchquality of the research

Nurses feel the results cannot be generalized Nurses feel the results cannot be generalized to their settingto their setting

Other staff are not supportive of Other staff are not supportive of implementationimplementation

Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Source: Retsas, A. (2000). Barriers to using research evidence in nursing practice. Journal of Advanced Journal of Advanced Nursing,Nursing, 31,31, 599-606. 599-606.

Strategies Related to Organizational Culture Barriers

To facilitate organizational support of

EBP – Allow time for nurses to conduct activities that

foster EBP such as time for library searches Ensure availability of adequate library resources Start a journal club

Resource: Ciliska, et al. as cited in DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. Mosby, St. Louis, MO. P. 16.

Journal ClubsJournal Clubs

Purpose – Purpose – To help staff stay abreast of clinical researchTo help staff stay abreast of clinical research To improve clinicians’ ability to critically evaluate To improve clinicians’ ability to critically evaluate

published researchpublished research

Process –Process – Develop a format that will entice busy staff to Develop a format that will entice busy staff to

attendattend Select a challenging clinical situation and topicSelect a challenging clinical situation and topic Select a journal articleSelect a journal article Hold the meetingHold the meeting

Journal Club (Continued)Journal Club (Continued)

Sample Guidelines and Format –Sample Guidelines and Format – Purpose –Purpose –

To foster excellence in nursing practice by To foster excellence in nursing practice by promoting evidence-based practicepromoting evidence-based practice

Goals – Goals – Improve nursing knowledge of current research Improve nursing knowledge of current research

findingsfindings Foster the application of clinical research and Foster the application of clinical research and

best practice models to nursing practicebest practice models to nursing practice Provide a means by which to address clinical Provide a means by which to address clinical

issuesissues


Format for meetings and presentations -Format for meetings and presentations - Introduce topic and presenterIntroduce topic and presenter Test baseline knowledge and/or seek Test baseline knowledge and/or seek

opinions, attitudes of audience (optional).opinions, attitudes of audience (optional). Give brief synopsis of following Give brief synopsis of following

parameters –parameters – Title of articleTitle of article Study’s purposeStudy’s purpose SettingSetting PopulationPopulation

Journal Club (Continued)Journal Club (Continued) Discuss major findings of studyDiscuss major findings of study Discuss other relevant research that Discuss other relevant research that

supports or does not support this studysupports or does not support this study Discuss implications of article in terms of Discuss implications of article in terms of

impact on nursing practiceimpact on nursing practice DocumentationDocumentation DelegationDelegation Patient educationPatient education Patient satisfactionPatient satisfaction Patient/Family centered carePatient/Family centered care Interdisciplinary collaborationInterdisciplinary collaboration


What is the relevance of this article to our practice? Should we change our practice based on this information? If yes, then –

Group discussion/Questions Evaluations

Resource: St. Pierre, J. (2005). Changing nursing practice through a nursing journal club. MedicalSurgical Nursing, 14(5). 390 – 392.

Strategies Related to Belief Strategies Related to Belief System BarriersSystem Barriers

Simple dissemination of information is generally ineffective.

Multi-faceted approaches are more likely to succeed. One-to-one sessions between experts such as

nurse facilitators and the staff who will implement changes

Manual and computerized reminders of the change

Educational meetings that are interactive Audit and feedback on a regular basisResource: DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A guide to clinical

practice. St. Louis, MO: Mosby, p. 17.

Strategies Related to Research-Strategies Related to Research-related Barriersrelated Barriers

Research related barriers include nurses’ lack of understanding of how to read and critique research studies Foster nurse researcher positions or nursing

research committees Link staff nurses and advanced practice nurses

with nursing researcher faculty at universities Provide training on how to conduct searches,

read and critique research studies

Resource: Ciliska, et al. as cited in DiCenso, A., Guyatt, G., Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis, MO: Mosby. P. 16.

Making Change HappenMaking Change Happen

What is change?What is change? To give a completely different form or To give a completely different form or

appearance to; transformappearance to; transform

Resource: Resource: The American Heritage® Dictionary of the English Language, The American Heritage® Dictionary of the English Language, Fourth Fourth Edition. Retrieved from Dictionary.com website: Edition. Retrieved from Dictionary.com website: http://dictionary.reference.com/browse/change

Making Change HappenMaking Change Happen

Engaging others to changeEngaging others to change Kotter’s Change ModelKotter’s Change Model

Change has an emotional and a Change has an emotional and a situational componentsituational component

Source: Campbell, R.J. (2008). Change management in health care. Source: Campbell, R.J. (2008). Change management in health care. Health Care ManagerHealth Care Manager. . 2727(1), 23-39.(1), 23-39.

Making Change HappenMaking Change Happen Kotter’s Change ModelKotter’s Change Model Phase 1 - Creating a climate for changePhase 1 - Creating a climate for change

Establish UrgencyEstablish Urgency Create CoalitionCreate Coalition Develop VisionDevelop Vision

Phase 2 - Engaging and enabling the whole Phase 2 - Engaging and enabling the whole organizationorganization Communicate VisionCommunicate Vision Empower ActionEmpower Action Generate short-term winsGenerate short-term wins

Phase 3 - Implementing and sustaining changePhase 3 - Implementing and sustaining change Consolidate Gains/Produce moreConsolidate Gains/Produce more Anchor ApproachesAnchor Approaches

Kotter’s Change ModelKotter’s Change Model

Establish Urgency – “Making sure that Establish Urgency – “Making sure that sufficient people act with sufficient sufficient people act with sufficient urgency – with on your toes behavior urgency – with on your toes behavior that looks for opportunities and that looks for opportunities and problems, that energizes colleagues, problems, that energizes colleagues, that beams a sense of let’s go!”that beams a sense of let’s go!”


Create Coalition – Build a guiding team.Create Coalition – Build a guiding team. Members must –Members must –

Have relevant knowledge about the change.Have relevant knowledge about the change. Be willing to establish credibility with peers.Be willing to establish credibility with peers. Have expertise regarding the inner workings of Have expertise regarding the inner workings of

the organization.the organization. Have formal authority.Have formal authority. Have Leadership skill.Have Leadership skill.


Develop Vision – The vision must be Develop Vision – The vision must be expressed in a clear, concise statement expressed in a clear, concise statement about the direction in which the about the direction in which the organization is headed.organization is headed.

Paint a picture of the future. Paint a picture of the future. Focus on how service will be improved.Focus on how service will be improved. Must call on emotion and motivate to Must call on emotion and motivate to

action.action.


Communicate Vision – Communicate Vision – Develop methods of communication that Develop methods of communication that

address any negative feelings.address any negative feelings. Help employees to think and act in Help employees to think and act in

accordance with the new direction.accordance with the new direction. Identify groups affected by the change and Identify groups affected by the change and

project their needs, concerns and roles.project their needs, concerns and roles. Continuum of feelings: Awareness, Continuum of feelings: Awareness,

Understanding, Collaboration, Understanding, Collaboration, Commitment, Advocacy.Commitment, Advocacy.


Empower Action – Give team the power Empower Action – Give team the power to eliminate barriers such as to eliminate barriers such as supervisors, the system, mental supervisors, the system, mental barriers and lack of information.barriers and lack of information.


Generate short-term wins – Choose and Generate short-term wins – Choose and complete tasks that show the change complete tasks that show the change management project is succeeding.management project is succeeding.

Teams should achieve visible, Teams should achieve visible, meaningful and unambiguous progress meaningful and unambiguous progress quickly.quickly.


Consolidate Gains/Produce More – Consolidate Gains/Produce More – Include ongoing comparison to Include ongoing comparison to competitors to re-energize the change.competitors to re-energize the change.

Anchor approaches – Culture change Anchor approaches – Culture change comes when a new way of operating comes when a new way of operating has been shown to succeed over a has been shown to succeed over a period of time.period of time.

Kotter’s Phases of Change Model Worksheet– Sample Completed Tool

Intervention to be implemented: A distraction-free zone for medication administration will be A distraction-free zone for medication administration will be established.established.

Stakeholders identified:

Nurses, Support staff, Physicians, patients, families.Nurses, Support staff, Physicians, patients, families.

Policy and procedures identified as needed or updated:

Medication Administration policy – Add: Nurses will wear a red vest Medication Administration policy – Add: Nurses will wear a red vest when administering medications. When the vest is on, there may be when administering medications. When the vest is on, there may be no interruptions of the nurse. no interruptions of the nurse.

Kotter’s Phases of Change Model Worksheet– Sample Completed Tool

Project Project NameName

EstablishEstablishUrgencyUrgency

CreateCreateCoalitionCoalition

DevelopDevelopVisionVision

CommunicateCommunicateVisionVision

EmpowerEmpowerActionAction

GenerateGenerateShortShort

termtermWinsWins

ConsolidateConsolidateGainsGainsProduce Produce

MoreMore

AnchorAnchorApproachesApproaches

Pilot - Creating Pilot - Creating a Distraction a Distraction Free Zone Free Zone During Med During Med AdministrationAdministration

Develop Develop Power Point Power Point presentationpresentation – –#1 leading #1 leading cause of med cause of med errors in nation errors in nation & our hospital. & our hospital. Include Include statistics. statistics. Highlight Highlight specific errors.specific errors.

Assemble Assemble TeamTeam – – Director of Director of Nurses, Nurses, Nurse Nurse Manager, Manager, Staff nurse Staff nurse from each from each shift on shift on pilot unitpilot unit

How does How does this affect:this affect: Nurses, Nurses, Support staff, Support staff, Physicians, Physicians, Patients, Patients, Care, Care, Competitors, Competitors, RevenuesRevenuesDevelop Develop vision vision statementstatement

Develop a Develop a Power Point Power Point presentation presentation showing the showing the process of med process of med administration administration in distraction in distraction free zonefree zone

Team Team works 1:1 works 1:1 with staff with staff on first on first day of day of pilot.pilot.Blog set Blog set up where up where staff can staff can anonymously anonymously send send

questions questions or or concerns concerns to team.to team.

Compile Compile and and present present med error med error rates rates monthly monthly and report and report at unit at unit meeting.meeting.Publish Publish article article about pilot about pilot in hospital in hospital newsletter newsletter

Expand pilot Expand pilot to additional to additional units after 3 units after 3 months.months.

Discuss at Discuss at staff meeting staff meeting monthly for monthly for 6 months. 6 months. Team Team conducts conducts audit of audit of implementatiimplementation monthly on monthly by direct by direct observation observation of med pass.of med pass.

Chapter15 power point july132012

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