Reducing Wait Time in The Healthcare Facility

Developing an Evidence-Based Practice Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 2 Research utilization Evidence-based practice encompasses research utilization but also case reports and expert opinion Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 3 Multifaceted, systemic process of promoting adoption of evidence-based practices in delivery of health care services that goes beyond dissemination of evidence-based guideline Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 4 Dissemination: publications, conferences, consultations, and training programs Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Reducing Wait Time in The Healthcare Facility

5 Validates current practice, changes in practice, cost-effectiveness, and quality of care High-quality Cost-effective Outcomes Research Conduct Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. Research Utilization 6 Questions about current nursing practice Literature review Need for investigation Clinical research Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 7 Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 8 Develop and implement improved practice Other types of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 9 Priority is given to projects in which a high proportion of practice is guided by research evidence. If a practice change is warranted, changes are implemented using a process of planned change. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 10 EBP is refined based on evaluation data. Outcomes are monitored. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 11 Selecting a topic Problem-focused triggers ➢ Quality improvement data ➢ Risk-surveillance data ➢ Benchmarking data ➢ Financial data ➢ Recurrent clinical problems Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 12 Selecting a topic Knowledge-focused triggers ➢ Reading research ➢ Listening to scientific papers at research conferences ➢ Reviewing EBP guidelines published by federal agencies or specialty organizations Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 13 Critical that staff members: ➢ Be involved in selecting the topic ➢ View the potential practice as contributing significantly to patient care Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 14 Forming a team ➢ Composition of the team ➢ Key stakeholders identified Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 15 Identification of key stakeholders: ➢ How are decisions made? ➢ What types of changes will be needed? ➢ Who is involved in decision-making? ➢ Who is likely to lead and champion implementation? ➢ Who can influence the decisions? ➢ What type of cooperation is needed? Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 16 Question clearly defined: ➢ Types of people and patients ➢ Interventions or exposures ➢ Outcomes ➢ Relevant study designs Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 17 Consider using PICO ➢ Patient, population, or problem ➢ Intervention or treatment ➢ Comparison intervention or treatment ➢ Outcomes Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 18 Evidence examined should include: ➢ Clinical studies, meta-analyses, integrative literature reviews, and existing EBP guidelines Identify key search terms Use the expertise of health science librarians 19 Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. It is helpful to categorize articles and read in this order: ➢ Clinical (nonresearch) ➢ Theory articles ➢ Integrative and systematic reviews ➢ Synthesis reports ➢ EBP guidelines ➢ Research articles ➢ Meta-analyses Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 20 There are many grading schemas available but all address: ➢ Quality of the individual research ➢ Strength of the body of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 21 Before reviewi ng the literature, it is imperative that the team agree on: ➢ Methods for categorizing the type of research Reducing Wait Time in The Healthcare Facility

➢ Rating the quality of individual articles ➢ Grading the strength of the body of evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 22 Date of publication or release Authors of the guideline Endorsement of the guideline Clear purpose of what the guideline covers and the patient groups for which it was designed Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 23 Types of evidence (research, nonresearch) used in formulating the guideline Types of research included in formulating the guideline Description of the methods used in grading the evidence Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 24 Search terms and retrieval methods used to acquire research and nonresearch evidence used in the guideline Well-referenced statements regarding practice Comprehensive reference list Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 25 Review of the guideline by experts Whether the guideline has been used or tested in practice and, if so, with what types of patients and in what types of settings Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 26 Best as a group project ➢ Journal club ➢ Novice and expert ➢ Assistance from students ➢ Use graduate students ➢ Class project Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 27 Use summary tables to synthesize information and include: ➢ Study purpose ➢ Research questions and hypotheses ➢ Variables studied ➢ Description of sample and setting ➢ Research design ➢ Methods used to measure each variable ➢ Description of the intervention tested ➢ Findings Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 28 Practice changes based on evidence Consider: ➢ Relevance ➢ Consistency ➢ Sample characteristics ➢ Feasibility ➢ Risk-benefit ratio Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 29 Put in writing the evidence base of the practice. Clinicians need to know: ➢ That recommended practices are based on evidence ➢ The type of evidence (e.g., randomized clinical trial, expert opinion) used in developing the EBP standard Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 30 Implementing the practice change ➢ Rogers’ model on diffusion of innovations ▪ Nature of the innovation ▪ Manner in which it is communicated Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 31 Characteristics of innovations that influence adoption: ➢ Advantage ➢ Compatibility ➢ Complexity Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 32 Strategies to promote adoption: Reducing Wait Time in The Healthcare Facility

➢ Reinvention of the EBP guideline to fit the local context ➢ Use of quick reference guides and decision aids ➢ Use of clinical reminders Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 33 Methods of communicating change: ➢ Mass media ➢ Educational strategies ➢ Opinion leaders ➢ Change champions ➢ Core groups ➢ Educational outreach ➢ Performance gap assessment ➢ Audit and feedback Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 34 Social context and change ➢ Strong leadership ➢ Clear strategic vision ➢ Good managerial relations ➢ Visionary staff in key positions ➢ A climate conducive to experimentation and risk taking ➢ Effective data capture systems ➢ Available resources to support change Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 35 Goal is to collect and analyze data with regard to use of a new EBP and then to modify the practice as necessary. Evaluation should include both: ➢ Process measures ➢ Outcome evaluation Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 36 Findings must be provided to clinicians to: ➢ Reinforce the impact of the change in practice ➢ Ensure that they are incorporated into quality improvement programs Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 37 Education must include knowledge and skills in the use of research evidence in practice. Communicate and integrate EBP into nursing profession. Professional responsibility of all nurses to read and use research in their practice and to communicate with nurse scientists the many and varied clinical problems for which we do not yet have a scientific base. Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 38 A. The researcher B. A direct care provider C. The hospital administrator or CEO D. The head nurse or CNO E. A mixture of management and direct care providers Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 39 A. Education specialist B. Information technologist C. Opinion leader D. Risk manager Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 40 A. Strong leadership B. Clear strategic vision C. Reducing Wait Time in The Healthcare Facility

Visionary staff in key positions D. A climate conducive to experimentation and risk taking E. All of the above Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 41 A. Patient outcomes B. Cost savings C. Who is successfully using it D. Barriers overcome Copyright © 2014, 2010, 2006, 2002, 1998, 1994, 1990, 1986 by Mosby, an imprint of Elsevier Inc. 42 THE NIGHTINGALE LEGACY CHILD HEALTH 2000 International Pediatric Nursing Conference Friday, June 2, 1995 Heather F. Clarke, RN, PhD Nursing Research Consultant Registered Nurses Association of British Columbia, Vancouver, B.C., Canada 1 INTRODUCTION “The time has come the walrus said to talk of many things, of sailing ships and sealing wax and cabbages and kings”. Indeed the time has come – and its a time of reform – not just a tinkering around the edges – but of rule breaking; not just reducing/maintaining costs but of reengineering – doing more with less; not just developing new technologies but of their creative use. Albert Einstein’s wisdom is as relevant today as it was decades ago “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” The clues that it is a time for calling in the chits include: – evidence-based practice is “in” – ritual and intuition are “out” – inappropriate/ineffective diagnostic and therapeutic interventions are not being tolerated – evidence-based tools for decision-making in practice (e.g. CPGs, Care Maps, Critical Paths) are proliferating and being made widely accessible (e.g. on-line, internet) accountability for outcomes is demanded of each and every health care profession – the “lone ranger” practitioner is neither effective nor tolerated – “collaborative” practice is taking on many shapes and sizes – consumer participation in decision making is not an option – the medical model (paradigm) has been replaced (by many if not most) by the consumer model (paradigm) In this era of shared responsibility and cost-consciousness, patient preferences are a key element of health care decisions and should be considered in the development of practice guidelines. How come it is taking us so long to recognize these clues – to re-conceptualize our world of professional nursing – to clearly demonstrate how nursing care makes a difference – how health care resources and therapeutic nursing interventions are effectively and efficiently utilized 2 to improve the health status of clients of our health care system? Clearly, there is a need to improve the research and evidence bases of our practice. This is the Nightingale Legacy Research and Practice. In Nightingale’s view, nursing should be a search for truth. She held that the ability to collect accurate information and make correct observations is essential. “If you cannot get the habit of observation one way or other, you had better give up being a nurse, for it is not your calling, however kind and anxious you might be”

(1) However, promoting and implementing research-based practice is not a simple task; nor is it solely reliant upon nurses in clinical practice. There are forces affecting the advancement of research-based practice within both the health care and nursing systems. I know Dr. Ritchie is going to address this as well, so I am going to focus more on some “how come” questions related to research-based nursing practice and discuss two interrelated processes which must be attended to if the “how come” questions are to be turned into “why not” questions – or “just do it” approaches. And I am going to address this with particular emphasis on research utilization. HOW COME? How come there is a gap between knowledge generation and application? Is it that research is not seen to be relevant to practice? If so, how come we aren’t getting the relevant research done? Are we not asking the right or relevant questions? We know nurs es have questions – consider those generated through the provincial Agency Challenge and agency dinosaur and sacred cow challenges. There are relevant questions. So – How come they are not being explored? Are researchers not listening to those questions? And even if they are to some 3 extent – Reducing Wait Time in The Healthcare Facility

How come clinicians are not more engaged in answering those questions? Furthermore sometimes there are answers to the practice relevant questions. How come we’re not using the research? Example: Internet – IM Injection Sites In the clinical arena the challenges of promoting research-based practice require a different view of our world – they require us to create a new future. How we shape our future will depend to great extent on how we perceive the clues I mentioned earlier – do we see them as threats? or opportunities? do we see this as a loss? or a gain? I believe it is time to turn our nursing system upside down: From one that is currently unstable  poorly balanced  difficult for responsive decision-making  inappropriate for knowledge diffusion and distillation (promotes evaporation instead)  not strategically situated to meet today’s challenges to one that is  firmly grounded on evidence and research-based knowledge  stable  encourages diffusion and distillation of knowledge 4  maximizes the potential of each resource (clinicians, educators, administrators and researchers) Let’s go back to one of the “how come” questions. How come we’re not using the research-based knowledge that we have in our practice?  are we unaware of the difference it would make – or do we either not believe the research findings – or not believe that we have “permission” to use them?  Nurses tend to be perfectionists, looking for absolute proof of all facts before a piece of research is deemed usable(2)  do we not value this aspect of our responsibilities?  do we lack the infrastructure and/or competencies to support such activity?  is there a lack of incentive to do so?  are we unaware of frameworks available to assist us in the process? In this section of the presentation I will focus on two processes – diffusion and adoption of innovations and use of research utilization models/frameworks – processes that have the potential to facilitate the use of research in nursing. I will tell you a couple of success stories to illustrate my point. We know that neither the mere existence or dissemination of knowledge nor enforced behavior change ensure that attitudes, values and behaviors will change (3). Using research findings in nursing practice can be thought of as adoption of an innovation – a complex process which involves several stages. 5 Rogers'(4) (1983) theory of diffusion of innovations with its four successive stages is a good place to start. The first stage – knowledge – occurs as nurses become aware of the innovation. Next, in the persuasion stage, they form a favorable or unfavorable attitude toward the innovation. Thirdly, nurses make decisions to adopt or reject the innovation, at least on a trial basis. If a new practice is mandated without practitioners moving through these appropriate stages, it is unlikely that the innovation w ill be implemented consistently or as intended. Consistent application with evaluation occurs in the fourth confirmation stage – if progress has been successful through the previous stages. A number of researchers have found that the source for new knowledge influences the rate at which individuals pass through the first stage. Print-media and interpersonal contacts (research-oriented conferences and inservice programs and role models) are most influential in solving clinical problems and adopting innovations (Brett(5), Coyle and Sokop(6), Means(7), Salasin and Cedar(8), Stinson and Mueller(9)). Reducing Wait Time in The Healthcare Facility

Although educational programs are suggested as important methods of research dissemination, few studies have examined the extent to which research findings are incorporated into nursing curricula. In 1995, Barta(10) reported on a study that investigated pediatric nurse educators’ inclusion of evidence-based pain management techniques in the curriculum. Practices most highly diffused among pediatric nurse educators were use of pain scales, providing sensory information and teaching self-comforting strategies. However, only the use of pain scales was in the “include always” range. The least diffused innovation in this sample was the use of TENS (transcutaneous electrical nerve stimulation). It’s interesting to note that at the 1992 International Pediatric Nursing Conference at Child Health 2000, Dr. Leora Kutner11 spoke about desirability 6 (in fact predicted) that physical methods to ease pain would become more commonplace including therapeutic touch, massage and TENS – and that this would reflect the growing appreciation of the research that shows that pain can …