Melnyk, Bernadette, PhD, RN, CPNP/PMHNP, FAAN, FNAP, FAAN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Transcending Boundaries to Transform Healthcare through Intervention Research and Evidence-based Practice  Bernadette Mazurek Melnyk, PhD, CPNP/PMHNP, FAANP, FAAN  Associate Vice President for Health Promotion    University Chief Wellness Officer  Dean and Professor, College of Nursing Professor of Pediatrics & Psychiatry, College of Medicine Editor, Worldviews on Evidence-Based Nursing     In God We Trust,  Everyone Else Must  Bring Data!  The State of U.S. Healthcare and Health   There are up to 200,000 unintended patient deaths per year (more than auto accidents & breast cancer)  Patients only receive about 55% of the care that they should when entering the healthcare system  Poor quality healthcare costs the United States about 720 billion dollars every year   The U.S. healthcare system could reduce its healthcare spending by 30% if patients receive evidence-based healthcare  One in 2 Americans have a chronic condition and 1 in 4                               have multiple chronic conditions  One in 4 Americans have a mental health disorder     Current State of Health in Nurses   What Will the Last 10 Years of YOUR Life Look Like?     Every day, we make behavioral choices that influence our health and wellness outcomes               Based on Evidence What Do We Know? People who have the following behaviors have 66% less diabetes, 45% less heart disease; 45% less back pain, 93% less depression,  and 74% less stress • Physical activity- 30 minutes 5 days per week • Healthy eating- 5 fruits and vegetables per day • No smoking • Alcohol in moderation- 1 drink per day for women,  2 drinks per day for men Kaylin’s Story: Australian Dream Trip Turned Nightmare        From Melnyk, B.M.,  & Fineout-Overholt, E. (2011).  Implementing EBP: Real World Success Stories  The Merging of Science and Art: EBP within a  Context of Caring & EBP Culture and Environment Results in the  Highest Quality of Patient Care Clinical Decision-making  Quality Patient  Outcomes Research Evidence & Evidence-based Theories  Clinical Expertise and Evidence from assessment of the patient’s history and condition as well as healthcare resources  Patient  Preferences  and Values   © Melnyk & Fineout-Overholt, 2003 EBP Culture & Environment Acting on the Evidence •  Strength of the Evidence + Quality of the Evidence = Confidence to Act! Annual Guide to Clinical  Preventive Services  Evidence-based gold standard recommendations adapted for a pocket-sized book    Formatted for clinicians to consult for clinical guidance in their daily practice    Recommendations are presented in an indexed, easy-to-use format with at-a-glance charts  Patient Outcomes With and Without  Evidence-Based Practice 010203040TraditionalPracticeEvidence-BasedPractice Despite an aggressive research movement, the majority of findings from research often  are not integrated into practice to improve outcomes  ● The gap between the translation of research into practice and policy is huge; It often takes decades to translate research findings into practice and policy     Why Must We Accelerate EBP?  ● Practices routed in tradition are often outdated and do not lead to the best patient outcomes Daily changing of IV dressings Mayonnaise for head lice  Sugar paste for pressure ulcers Albuterol delivery with nebulizers Checking placement of NG tubes with air Vital signs every 2 or 4 hours 12 Hour Shifts for Nurses    Why Must We Accelerate EBP? Why Must We Accelerate EBP?  Tongue Patch for Weight Loss The Steps of EBP • Cultivate a Spirit of Inquiry & EBP Culture Step 0:  • Ask the PICO(T) Question Step 1: • Search for the Best Evidence Step 2:  • Critically Appraise the Evidence Step 3:  • Integrate the Evidence with Your Clinical Expertise and Patient Preferences to Make the Best Clinical Decision   Step 4:  • Evaluate the Outcome(s) of the EBP Practice Change Step 5:  • Disseminate the Outcome(s) Step 6:  Clinical Inquiry Formulate a Searchable, Answerable Question (PICOT)  Search for the Best Evidence  Rapid Critical Appraisal, Evaluation, and Synthesis of Evidence  Integrate the Evidence  with Clinical Expertise and  Patient Preference(s) Generate  Evidence  Internal: QI External: Research Evaluate Outcomes based on Evidence  © Melnyk, Fineout-Overholt 2010 Disseminate the Outcome(s)       Descriptive Research    Predictive Research The Typical Progression of Research  Qualitative --Research Experimental Research Two Group Randomized Controlled Trial with Pre-test/Post-test Design and Structurally equivalent comparison group                     R   O1   X1   O2                    R   O1   X2   O2       Advantages  Strongest design for testing cause and effect  Comparison intervention controls for time spent with         experimental group  Pre-test may sensitize subjects to testing Disadvantages  Expensive and time consuming        The Strongest  Experimental Design   Determining effects of interventions is currently a top research priority  Only approximately 20-25% of studies test interventions  Common problems in intervention studies oLack of a theoretical framework to guide interventions oLack of sufficient power to detect differences between    study groups oLack of an appropriate attention control intervention oFailure to limit sources of error  The State of Intervention Studies The Role of DNPs and PhDs in Generating External and Internal Evidence   PhDs should be the best generators of “external evidence” from rigorous research   DNPs should be the best generators of “internal evidence” from quality improvement, outcomes management and evidence-based practice projects               Over 1000 randomly sampled nurses from the American Nurses Association   The more years in practice, the less nurses were interested in and felt it was important to gain more       knowledge and skills in EBP Findings from our EBP Survey  with U.S. Nurses                        (Melnyk et al., 2012, JONA      Percent of Respondents from the ANA Survey Who Agreed or Strongly Agreed with the Following Statements                                         % EBP is consistently implemented in my healthcare system  53.6 My colleagues consistently implement EBP with their patients  34.5 Findings from research studies are consistently implemented in my institution to improve patient outcomes  46.4 EBP mentors are available in my healthcare system to help me with EBP  32.5 It is important for me to receive more education and skills building in EBP  76.2 The One Thing That Prevents You From Implementing EBP   Total Responses 1.  Time 151 2.  Organizational culture, including policies and procedures,    politics, and a philosophy of “that is the way we have always done it here.” 123 3.  Lack of EBP knowledge/education 61 4.  Lack of access to evidence/information 55 5.   Manager/leader resistance  51 6.   Workload/staffing, including patient ratios 48 7.    Nursing (staff) resistance 46 8.    Physician resistance 34 9.    Budget/payors 24 10.   Lack of resources 20 • 93% currently in the CNO role  • Ages ranged from 32-68 (M= 55 years) • Years in practice ranged from 8-47 (M=31 years) • Years as a CNO ranged from <1- 32 (M= 9 years) • 92% female; 94% White • 6% bachelor’s degree; 69% master’s degree;  • 8% PhD prepared; 10% DNP prepared  • 45 States and DC represented • 18% work in Magnet facilities • 55% reported having clinical ladder systems • 47% had no ongoing nursing research projects      Chief Nurse Survey Demographics What % of your annual operating budget do you spend on building and sustaining EBP in your organization? Frequency Percent % 0 41 15% 1 to 10 162 59% 11 to 25 49 18% 26 to 50 15   5% 51 to 100 6   2% Organization Related Questions 0%10%20%30%40%50%60%Falls Falls withInjuryPressureUlcersPressureUlcers (Stage2 and above)Restraints Nursing CareHoursRN Education RNCertificationBelow benchmarkAt benchmarkExceeding benchmarkNDNQI Metrics  Performance Metrics 0%10%20%30%40%50%60%CatheterAssociated UrinaryTract InfectionsPressure Ulcers(Stage 3 and 4)Vascular CatheterAssociatedInfectionsFalls and Trauma Manifestations ofPoor GlycemicControlCore Measures Below National RateSame as National RateAbove National Rate Performance Metrics  EBP Priorities 0%10%20%30%40%50%60%70%80%90%0 = Not at all Important 1 2 3 4 = Extremely ImportantHow important is itfor you to build &sustain a culture ofEBP?How important is itfor your organizationto build & sustain aculture of EBP? EBP Priorities 0%10%20%30%40%50%60%70%80%90%100%0 = Not at all 1 2 3 4 = A great dealHow much do you believe implementation of EBP improves quality & patient outcomes? EBP Beliefs, EBP Implementation, EBP Culture  CNOs EBP Beliefs 0%5%10%15%20%25%30%35%40%45%1 = Strongly Disagree 2 3 = NeitherAgree/Disagree4 5 = Strongly AgreeI am sure that I can implement EBP  CNOs EBP Beliefs 0%5%10%15%20%25%30%35%1 = Strongly Disagree 2 3 = NeitherAgree/Disagree4 5 = Strongly AgreeI am sure about how to measure the outcomes of services provided to patients  Organizational  Readiness for EBP  0%5%10%15%20%25%30%35%40%45%1 = Not at all 2 3 = Somewhat 4 5 = Very MuchTo what extent do you believe that EBP is practiced in your organization?  Organizational  Readiness  0%5%10%15%20%25%30%35%1 = Not at all 2 3 = Somewhat 4 5 = Very MuchIn your organization, to what extent is there a critical mass of nurses who have strong EBP knowledge & skills? Creating a Culture and  Environment to  Sustain EBP What Works The only person that likes a change is  a baby with a wet diaper!                A Vision with Specific Written Goals                  We must begin with the end in mind An Essential Element Required  for a Successful Change to System-wide EBP SHOCK!  “You are asking me to implement EBP on top of everything else that I do?” Critical Components  of an EBP Culture   • there must be commitment to advance EBP across the organization as evidenced in orientation, clinical ladders, evaluations A Philosophy, Mission and Commitment to EBP: • health professionals are encouraged to continuously ask questions, review and analyze practices to improve patient outcomes A Spirit of  Inquiry: • who have in depth knowledge and skills in EBP, mentoring others, and overcoming barriers to individual and organizational change EBP Mentors: Critical Components  of an EBP Culture • leaders who value and model EBP as well as provide the needed resources to sustain it Administrative Role Modeling and Support: • tools and resources that enhance EBP across the organization; computers for searching, up to date data bases, library resources Infrastructure: • individuals and units are rewarded regularly for EBP Recognition: EBP Competencies for Practicing Nurses and Advanced Practice Nurses 2014 Download free at: http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787/homepage/MostCited.html Making Use of the Competencies The new EBP competencies should be integrated into healthcare system orientation programs, clinical ladders, and performance appraisals  Incorporating the competencies into real world practice settings will assist healthcare systems in improving quality, safety, and patient outcomes as well as reducing costs!  Return on Investment with EBP  It is critical to establish ROI with EBP projects ROI helps with sustainability of EBP  We must measure quality indicators, which include: • hospital-acquired conditions (HACs) declared by the Centers for Medicare and Medicaid (CMS) as preventable unless present upon admission to the hospital (Centers for Medicare & Medicaid Services (CMS), 2014); or   • those included in the scoring for the value-based purchasing program (VBP) that CMS began in 2013, whereby incentive payments will be distributed across all hospitals performing in the top 50% on selected quality indicators. These incentive payments are based on how closely hospitals follow best clinical practices and how well they enhance patients’ experiences of care (CMS, 2012). Melnyk & Fineout-Overholt’s ARCC (Advancing Research and Clinical practice through close Collaboration) Model Evidence to Support ARCC  Study #1: Descriptive correlational study with 160 nurses  Study #2: A psychometric study of the EBP beliefs and EBP implementation scales with 360 nurses  Study #3: A randomized controlled pilot study with 47 nurses in the VNS  Study #4: A quasi-experimental study with 159 nurses in a clinical research medical center environment  Study #5: A pre-experimental study with 52 clinicians at WHHS   Outcomes of Implementing the ARCC Model  at Washington Hospital Healthcare System    Early ambulation in the ICU resulted in a reduction in ventilator days from 11.6 to 8.9 days and no VAP  Pressure ulcer rates were reduced from 6.07% to .62% on a medical-surgical unit  Education of CHF patients led to a 14.7% reduction in hospital readmissions   75% of parents perceived the overall quality of care as excellent after implementation of family centered care compared to 22.2% pre-implementation     The simple provision of resources and dissemination of information alone will not lead to uptake of EBP     A multi-component active  strategy is necessary, including behavior and organizational change strategies   Early Adopters 13.5% Early Majority 34% Late Majority 34% Laggards  16%  Innovators 2.5%  Culture shift Diffusion of Innovation  A key ingredient for success is persistence as there will be  many “character-building” experiences along the way!! “At least I have found 9000 ways that it won’t work."     Thomas Edison  Editor  Bernadette Melnyk, PhD, CNPN/PMHNP, FAANP, FAAN   Gives readers methods to apply best evidence to  practice  Global coverage of practice, policy, education   and management  From a source you can trust, the Honor Society of  Nursing, Sigma Theta Tau International www.blackwellpublishing.com/wvn     Worldviews on Evidence-Based Nursing™    Linking Evidence to Action Ask yourself:   •What will you do if  you know                you can not fail in the next  2 to 5           years?                                        • What is the smallest  EBP change that              you can make  tomorrow that  would                           have the largest  positive  impact for your  patients’ outcomes? “…because we’ve always  done it that way.” ? ? ? ? ?        Greatest Hitter in the World        Nothing Happens Unless First a Dream!                                                       Carl Sandburg The Next 2-5 Years What can we do together in the next 2 to 5 years if we know that we cannot fail?  Let’s shoot for the moon, even if we miss, we will land amongst the stars                                                             -Les Brown             There Is A Magic In Thinking Big! Copyright, 2015 Bernadette Mazurek Melnyk  melnyk.15@osu.edu 614-292-4844 Follow me on Twitter @bernmelnyk  Contact Information 

Transcending Boundaries to Transform Healthcare Through Intervention Research and Evidence-Based Practice

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Transcending Boundaries to Transform Healthcare Through Intervention Research and Evidence-Based Practice

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