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Promoting Evidence-Based Practice

Internship program enables RNs to create their own protocols of care.

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So much to read, so little time.

That's the oft-heard lament of book lovers: subtract the hours spent working, raising kids, cooking, cleaning and other imperatives, and the cruel arithmetic of modern life leaves little time to immerse oneself in Stephen King or Jane Austen.

Nurses face the same predicament. Every day, scores of clinical trials, research papers and meta-analyses appear in print or electronic form. But what nurse who serves on a super-busy staff, manages a floor of needy patients, and charts diligently and thoroughly - what nurse, however dedicated, has time to ingest even a fraction of all that knowledge?

Answer: A staff nurse at the University of Iowa (UI) Hospitals and Clinics, in Iowa City.

Since 2000, UI has offered a formal internship program that allows its nurses to take time off their regular duties and investigate how to solve some problem of care that intrigues them.

First, a UI nurse plunges into a thorough review of existing literature about the problem. Then she leads an effort to institute a protocol to eliminate the problem, resulting in improved patient care and potential financial savings for UI long-term.

To secure one of these mini-sabbaticals, a nurse "has got to be passionate about a topic," said Laura Cullen, MA, RN, FAAN, who coordinates UI's internship program. "And you want to pick topics that can be win-wins, that don't have a lot of land mines."

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'Triggers' of Change

In the parlance of the day, these topics are called "triggers" of change, a term derived from the Iowa Model of Evidence-Based Practice (EBP) to Promote Quality Care.

And nurses are a fountain of ideas for triggers, Cullen noted, because they work so closely with patients.

"They come up with phenomenal questions about practice issues that are not working well either for patients or for staff," Cullen explained. "They ask: how can we do this better? We've had topics that reflect the huge variety in patient needs: pet visitation, saline irrigation, hypothermia for neonates and adult trauma patients, control of dermatitis. It's really the full range across the spectrum."

Once she identifies a trigger, the staff nurse approaches his or her manager, who pulls in a clinical nurse specialist to help, or a nurse with mentoring skills. Additionally, a librarian joins the team to help with Web searches.

"In the end, the staff nurse and a clinical nurse specialist are responsible for working through the evidence and coming up with recommended practices," Cullen said. "In the example of pet visitations, we had to examine safety considerations such as possible infections patients might contract from pets. Once we know the practice recommendations and 'trial' the change, then we follow our path for building it into the system."

Early Mobility, Decreased Aspiration

As an intern in UI's EBP program in 2009-10, Sandra Hess, BSN, RN, CCRN, MICU nurse, amassed convincing evidence that early mobility is safe and feasible for patients on mechanical ventilation (MV).

Hess designed a set of teaching powerpoints to cover the adverse effects of extended bed rest on the body, the benefits of continuous lateral rotation on the lungs and the steps to safe upright mobility. She also designed an algorithm, wrote a protocol and formed a team to teach the entire nursing staff about early mobility in MV.

"I have always been an advocate of getting ICU patients up and moving," Hess told ADVANCE, "but until I formally researched the subject I didn't have a real appreciation for how deleterious bed rest is for the body and how the relatively simple act of getting people moving can pay off in profoundly beneficial ways."

UI nurse Amy Bowman, BSN, RN, tackled a similar topic: assessing ways to decrease the risk of aspiration in patients with nasogastric tubes.

Her literature review indicated supine positioning and use of paralytics increased aspiration risk.

"Nurses are often hesitant to move patients for several hours after intubation," Bowman noted. "We think, 'This patient is too sick to move.' After my project, my response became, 'This patient is too sick to not move into a position that decreases additional risk of aspiration.'"

Encouraged by mentors and peers, Bowman documented her work in poster presentations and publications. By making her work public, Bowman may impact patient outcomes in hospitals far beyond her immediate vicinity.

Postop Pain, Other Projects

As a UI recovery room nurse, Diana Besler, BSN, RN, saw several patients with uncontrolled postoperative pain unrelated to their surgeries. The culprit: undertreated or unrecognized neuropathic pain.

Better screening for this problem, she reasoned, could reduce delays in discharging postop patients.

Using the EBP process, Besler implemented the self-reported Leeds Assessment of Neuropathic Symptoms and Signs, a reliable tool to screen patients preoperatively for chronic neuropathic pain.

"Just because we learned how to do a procedure a certain way," Besler explained, capturing the essence of IU's nurse internship program perfectly, "doesn't mean it is still the best way."

Other EBP-related nurse internships at UI have resulted in:

  • changing sedation management in the MICU, which has reduced vent time and saved $1.9 million within the first 26 months of implementation;

  • consolidating a variety of products to control incontinence-associated dermatitis down to one product, saving $13,000 a year;

  • improving preop patient teaching, and,

  • reducing needlestick injuries and upgrading hand hygiene products in the operating room, two moves that were, in Cullen's words, "real satisfiers for the staff."

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Financial Commitment

Of course, none of these nurse-led initiatives would be possible without a financial commitment from UI administration.

"Nurses will feel guilty being away from their units," Cullen observed. "They'll say, 'What if I'm doing this project when my colleagues are working hard?' But we were able to secure paid release time for staff nurse, and fix their schedules so they couldn't get pulled into staffing."

UI provides enough money to cover a dozen 8-hour work days for each nurse who participates in the internship. "To budget for something like this, an organization needs to look at their upper classification in salary range for staff nurses," Cullen said. "Then they need to have a program coordinator - my role - which equates in our case to 25 percent to 50 percent of an FTE."

Material costs are quite small, though. "Some specific small-budget items might include posters, CD players for music therapy, stamps for mailing patient questionnaires, or purchasing a mailing list," she said.

Cullen herself is now leading an EBP project to implement the most effective pain assessment tools for older adult patients. The trigger: some patients with dementia have trouble responding to the standard 0-to-10 scale. Nurses may need to adopt a variety of scales for pain and not rely solely on 0-to-10.

"It's really early. I'm trying to collect our pre-data," she explained. "I expect to be piloting a change in the spring, evaluating it by early summer and rolling it out housewide this fall."

Michael Gibbons is an editor with ADVANCE.




     

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