By Bernadette Mazurek Melnyk and Ellen Fineout-Overholt
 |
Bernadette Mazurek Melnyk |
 |
Ellen Fineout-Overholt |
Evidence-based practice (EBP) is a problem-solving approach to delivery of health care that combines the best evidence from well-designed studies with a clinician’s expertise and a patient’s preferences and/or values (Melnyk & Fineout-Overholt, 2005; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). When EBP is provided in a context of caring, it leads to the best clinical decision-making and outcomes for patients and their families (Melnyk & Fineout-Overholt, 2005).
It currently takes an average of 17 years to translate research findings into clinical practice (Balas & Boren, 2000). For this lead time to become shorter, federal agencies, national professional organizations, the Institute of Medicine and leading health care experts have stated that clinical practice and health care education must incorporate evidence-based practice. However, only a small percentage of nurses deliver this type of care.
Findings from a recent survey of 1,097 randomly selected nurses by the Nursing Informatics Expert Panel of the American Academy of Nursing indicated that: 1) Almost half were not familiar with the term “EBP”; 2) more than half reported that they did not believe their colleagues use research findings in practice; 3) only 27 percent of the respondents had been taught how to use electronic databases; and 4) most do not search information databases such as Medline and CINAHL to gather practice information. Those who do use these resources do not believe they have adequate searching skills (Pravikoff, Pierce, & Tanner, 2005).
A statewide EBP consortium
Intensive interdisciplinary efforts are necessary if EBP is to become routine culture in health care institutions. To improve clinical practice and patient outcomes in the state of Arizona, the United States’ first statewide consortium for EBP was formed in the spring of 2005 as an initial step toward addressing the need for a national research and EBP network. Formation of this consortium, known as the Arizona Consortium for the Advancement of Evidence-based Practice [AZCAEP]), was spearheaded by the Center for Advancement of EBP (CAEP) at the Arizona State University (ASU) College of Nursing in Tempe. The vision and mission of the consortium were communicated to directors and heads of hospitals, health care agencies and educational institutions throughout the state of Arizona in a letter announcing the date and time of the first consortium meeting.
Interdisciplinary representatives from more than 50 institutions gathered for that meeting in April 2005. These institutions included large tertiary care hospitals, small rural health care agencies, professional organizations such as the Arizona Nurses Association and Arizona Health & Hospital Association, and educational institutions across the state of Arizona.
Priorities established
During the first three meetings of AZCAEP, priorities for the consortium were established. Assessment of the status of EBP in Arizona was identified as the first important step for gaining an understanding of how AZCAEP could facilitate advancement of EBP. Mentorship was determined to be the second highest priority. Participating agencies began working together to establish a formal mentoring mechanism for clinicians that would promote EBP. In addition, the CAEP at Arizona State University College of Nursing began to offer full-week, ongoing EBP mentorship immersion programs in December 2005, along with EBP workshops throughout the state. The third priority was establishing vision and leadership for the consortium, including its structure, bylaws and funding.
Strategies that worked
A major key to launching the consortium was leadership from the CAEP at the ASU College of Nursing & Healthcare Innovation. CAEP faculty members wrote a strategic plan, which was conveyed to attendees at the initial meeting, and sought consensus for advancing the plan. Belief in the viability of the consortium and frequent communication of that belief were central elements to AZCAEP’s initial and sustained success.
One person was responsible for providing mechanisms for effective communication, and a listserv was developed to facilitate exchange of information between AZCAEP members. Obtaining input from constituents was critical to the consortium’s success. Regularly scheduled meetings with formal agendas were held across the state. Alternating the location and sponsorship of the meetings helped overcome distance barriers. Funded meetings provided opportunities for participating agencies to invest in AZCAEP outcomes. For example, meetings were held early in the day, between 8 and 10 am, and breakfast was served by the sponsoring agency.
A common Web site was developed to serve as a teaching tool and resource for AZCAEP members. This site facilitates sharing of existing resources, such as policies and procedures, protocols and educational plans to reduce work required by individual agencies.
AZCAEP at one year
AZCAEP’s momentum is strong after its first year of implementation. The consortium has lengthened the time of its meetings to now include an educational component in which one of the members presents a successful EBP implementation project. An awards committee also has been formed to recognize successes in EBP on a routine basis. Current foci of AZCAEP task forces include: 1) Assessment of the status of EBP in Arizona, 2) mentorship, 3) vision and leadership, 4) education, and 5) awards and recognition.
The assessment task force is planning a random-sample EBP survey of health care providers in all participating institutions. The mentorship task force is developing a grant application for funding a statewide EBP mentorship initiative. The vision and leadership group continues to hone bylaws and plan strategic initiatives, including funding, for the organization. The education task force is planning to develop training that provides continuing education credit. Finally, the awards and recognition task force has established mechanisms to recognize EBP accomplishments through awards—for example, the EBP innovations award—that will be presented for the first time this year.
AZCAEP also is co-sponsoring the 8th Annual Evidence-Based Practice Conference, “Translating Evidence into Best Practice with Vulnerable Populations.” The conference will be held Feb. 22-23 in Phoenix, Ariz.
Looking ahead
Balancing the initial vision of the consortium with constituent-driven desires and initiatives is an ongoing challenge. Keeping the vision fresh for AZCAEP members helps their initiatives remain congruent with the consortium’s direction and goals. Establishing a formal structure for the organization that includes leadership from all sections of the state and all types of institutions is important. Funding is a continuing challenge that requires grappling with member investment (dues) and the benefits of membership, as well as intensive grant-writing efforts if new initiatives are to be successfully launched.
The first U.S. Leadership EBP Summit was held in 2004, in conjunction with the 5th Annual EBP Conference to: 1) evaluate the current state of EBP in the United States, 2) set national priorities for advancing EBP and 3) establish action strategies for implementing those priorities (Melnyk, Fineout-Overholt, Stetler, & Allan, 2005).
Summit leaders recommended three top priorities for advancing EBP: 1) Form a national EBP/research consortium or network of institutions to advance EBP and to facilitate the conduct of efficacy and effectiveness studies; 2) implement a national EBP mentorship program and 3) develop standards to integrate EBP at all educational levels.
Following up on these recommendations, the CAEP at Arizona State University created a national weeklong mentorship immersion workshop, which occurs twice a year. The first workshop in December 2005 attracted 40 people from across the United States, who returned to their health care institutions to begin system-wide implementation strategies to advance EBP. Three of these people negotiated positions as EBP mentors, i.e., nurses with advanced practice degrees whose roles are specifically to advance EBP in their institutions (Melnyk & Fineout-Overholt, 2005).
EBP mentors are key to the advancement and sustainability of EBP in institutions, as first proposed in the ARCC (Advancing Research and Clinical practice through close Collaboration) model (Melnyk & Fineout-Overholt, 2002). Research indicates that nurses who are mentored by colleagues with expertise in EBP come to believe in EBP, gain confidence in it and, as a result, help promote its implementation (Melnyk et al., 2004). Studies also indicate that clinicians who implement EBP have greater satisfaction with their roles than those who do not (Tranmer, Kisilevsky, & Muir, 1995; Seeman, Soukup, & Adams, 2000).
AZCAEP began as an initial step toward addressing the recommendation, put forth at the 2004 summit, that a national research and EBP network be established. Other statewide consortiums now are being planned, some spearheaded by attendees of the first EBP mentorship workshop at Arizona State University. In addition, others are attempting to establish regional EBP consortia. These initiatives are laying the foundation for a national research and EBP network.
Another step toward fulfilling this objective is establishment of a national EBP consortium in child and adolescent health. A pediatric EBP summit that will bring together health care leaders from pediatric institutions across the United States will be conducted in conjunction with the 8th Annual EBP National Conference to be held in Phoenix.
The final recommendation from the 2004 summit was to establish EBP standards for all levels of students. This initiative calls for EBP experts across the United States to combine their expertise to assist faculty and students in integrating EBP into curricula that are already quite full. To achieve the requisite paradigm changes, faculty members need time to dialogue and think about the implications of shifting to an evidence-user focus. Educators will also need ready-made, easy-to-use EBP teaching resources.
To be effective, EBP must be integrated into clinical courses, so that students do not consider these concepts as merely an academic exercise. Through careful consideration of the program’s objectives and integration of evidence-based practice into curricula, students will learn that EBP is an effective means for focusing daily on achieving best patient outcomes through application of evidence.
Conclusion
If a paradigm shift toward EBP is to accelerate and become standard culture for achieving highest quality care and patient outcomes, silo-based initiatives in practice, education, and research must cease and be replaced by interdisciplinary, statewide, regional and national consortiums.
Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP, is dean and Distinguished Foundation Professor in Nursing at Arizona State University College of Nursing in Tempe, and associate editor of Worldviews on Evidence-Based Nursing, published by the Honor Society of Nursing, Sigma Theta Tau International.
Ellen Fineout-Overholt, RN, PhD, is director of the Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing in Tempe.
References
Balas, E.A, & Boren, S.A. (2000). Managing clinical knowledge for healthcare improvements. In V. Schattauer (Ed.), Yearbook of medical informatics (pp. 65-70). Stuttgart, Germany: Schattauer Publishing.
Melnyk, B., & Fineout-Overholt, E. (2002). Putting research into practice. Reflections on Nursing Leadership, 28(2), 22-25.
Melnyk, B.M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
Melnyk, B.M., Fineout-Overholt, E., Feinstein, N., Li, H.S., Small, L., Wilcox, L., & Kraus, R. (2004). Nurses’ perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: Implications for accelerating the paradigm shift. Worldviews on Evidence-based Nursing, 1(3), 185-193.
Melnyk, B.M., Fineout-Overholt, E., Stetler, C., & Allan, J. (2005). Outcomes and implementation strategies from the first U.S. evidence-based leadership summit. Worldviews on Evidence-Based Nursing, 2(3), 113-121.
Pravikoff, D.S., Pierce, S.T., & Tanner, A. (2005). Evidence-based practice readiness study supported by academy nursing informatics expert panel. Nursing Outlook, 53, 49-50.
Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (2000). Evidence-based medicine: How to practice and teach EBM. London: Churchill Livingstone.
Seeman, S., Soukup, S.M., & Adams, P. (2000). Hospital-wide intravenous initiative. Nursing Clinics of North America, 35(2), 361-373.
Tranmer, J.E., Kisilevsky, B.S., & Muir, D.W. (1995). A nursing research utilization strategy for staff nurses in the acute care setting. Journal of Nursing Administration, 25(4), 21-29.
Reproduced from Second Qtr. 2006 issue of Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International. Used with permission.
