In 2010, the Robert Wood Johnson Foundation's Future of Nursing initiative called for nurses to practice to the full extent of their education and training. It recommended hospitals expand the opportunities for nurses to lead and diffuse collaborative improvement efforts.1 That includes implementing evidenced-based practice (EBP) into all levels of nursing care.
In nursing, implementing EBP creates new, state-of-the-science knowledge, summarized and clarified for translation into best practice for clinical policy. 2 EBP is used at all levels of nursing in the acute care setting. It is used by staff nurses on inpatient units, maternal/child health, mental health, surgical, critical care, leadership - the list goes on.
Implementing EBP in nursing helps to facilitate a culture of safety for patients and staff, and it can improve the healthcare system by facilitating consistent decision making and advancing cost-effectiveness.3 EBP keeps nurses up to date on the latest technology and advances in patient care as well. Nurses who are involved in EBP have been found to express a sense of professionalism and growth, which can also contribute to their professional identity.3
Many acute care facilities are striving for the American Nurses Credentialing Center's Magnet Status, widely held as the industry's most prestigious peer reviewed designation. A primary requirement in achieving Magnet recognition is to disseminate best practices in nursing. Toward that end, we chose to establish an Evidence-Based Nursing Team, an idea we believe will assist any facility seeking Magnet status.
The Journey Begins
In 2006, I took on a new role as a unit-based clinical nurse educator. This was a new role for me, along with the institution.
In creating this role, it was evident that the idea of evidenced-based practice was not understood at many levels in the facility. While the nurse incorporated evidence-based changes in to everyday practice, changes were being made at the leadership level and brought then to the bedside.
Nurses often asked questions such as, "Why do we do it this way?" but would not go the next step to research and find the evidence for themselves. The staff nurses would reach out to leadership and education to supply them with the answers, after the educators and leadership performed the literature search for the evidence.
With the focus of Magnet status on bringing evidence and power to the staff nurse, I, along with nursing leadership decided it was the perfect opportunity to implement an evidenced-based nursing team.
Group of Seven
In 2006 and early 2007, myself and a central-based educator brought together a small group of staff nurses, seven in all, to implement the team.
In the early stages, the discussion focused on research, and the staff nurses wanting to implement and perform research, but having no knowledge base of nursing research. The nurses held associate, bachelor's and/or master's level degrees. In each of these groups there is a varying degree to the knowledge of EBP.
Starting from the ground up, the chairs decided education on the definition of EBP was needed. The team was supplied with a nursing research text, and articles explaining EBP.
We discussed over the next few meetings and came to a consensus that this team was going to be evidenced based nursing focused and not research. This was a long process, getting the staff nurses to grasp the difference between performing nursing research and using existing evidence to implement a change. We had a high turnover of nurses during this phase, as the decision was to not do research.
The team developed a mission and vision to help define its purpose.
Once we had a solid team, of seven nurses, we did some site visits to various acute care hospitals that had been successful in implementing an EBNP team/council.
One site visit was to a small community facility which had not yet achieved Magnet status. Another site visit was to a community hospital with magnet status. Our last visit was to a large city acute care facility, associated with our facility and had achieved Magnet status.
The members all sat in on one meeting at each of these facilities. The purpose of the visits was to gather information on adapting an EBP model, structure of the committee, and interview members on the journey to implementing their team.
After attending the meetings, and obtaining permission, the Iowa Model was adapted. The team then split out into ad hoc groups of 2-3 members and created a definition for evidenced based nursing practice for this facility.
A mission and values statement was created and adopted. A logo was also created. This process took a period of 6 months to finalize each of these documents. After working this out, this structure was presented to leadership to raise awareness and increase membership.
The vision was defined as: "To Promote the utilization and application of evidence-based nursing practice to improve patient satisfaction and outcomes."
The mission was defined as: "Through the utilization of the most current research, nursing expertise and patient preference, we empower nurses to provide the highest quality of care through evidenced based nursing practice."
The ultimate purpose/goal was defined as follows:
- To promote the professionalism and satisfaction of our nursing staff through the application of evidence based research.
- To facilitate evidence based projects on the patient care units
The team was comprised of nurses from two separate campuses. We proposed and accepted to start advertising our team, now that a definition, mission and values were defined.
The chairs and members created posters to display in the cafeteria on each campus. Members of the team and a chair were present with the poster to answer questions and hand out flyers about the team with contact information.
A website was created by a few of the team members and is accessed via the hospitals intranet patient care services page. An email broadcast has been sent out at various times throughout the past few years, defining the team and membership.
Identifying & Overcoming Barriers
One of the biggest barriers to overcome was defining evidence-based practice for this team. After a series of meetings, and an all day retreat, the team agreed on the following definition:"Evidence Based Nursing Practice is the use of the best available research by which nurses can make clinical decisions utilizing their expertise while respecting the patient's individuality."
Another barrier is attendance and sustaining membership for the team. The meeting was opened to any staff nurse interested in joining. No approval from management was required, but was highly encouraged so as to be allotted the time to attend meetings and perform work outside of team meetings.
Practices and cultures vary from each campus. On one campus, nurses were given the time to attend during work hours. On the other campus, nurses chose to attend on their day off from the unit. This was the preference for this group of nurses.
Over the course of the years, I presented three different presentations to the nursing leadership team, a presentation on current membership status, team progress, and need for approval for time to be allotted for members to attend meetings.
One campus continued to allow members to attend during scheduled work time. This time was dedicated as "class time, management time, or meeting time" to allow for the staff nurse to be free of a patient care assignment. This does work, to the most part. But during high patient volume, the member could be pulled to take a patient care assignment.
The other campus continued to allow staff to attend and get paid for time over and above their scheduled hours. This worked as well, but it was clear up front that it was not expected that members would be required to attend meetings on their time off. Administrative/Leadership support is the first and foremost important support needed to sustain this team.
A continuing barrier is setting up a scheduled date and time for the team to meet. The staff nurses worked all three shifts, each from 8 to 12 hours, and came from different departments. Each year we changed the times and days of our meetings, and because of this continued to lose members. But we were always able to keep our core group of the seven dedicated nurses.
These nurses still remain on the team today. It is evident that they are dedicated to sustaining this team. The time that worked best was 8 a.m. on a Tuesday morning. This was the day and time, over the years, which we saw the most members attend and participate.
Another significant barrier identified was time allotted for performing literature searches. As the team began to familiarize themselves with research and evidence based practice, the chairs advised the team do literature searches and start critiquing articles to find best evidence.
As previously mentioned, time was a factor, but also knowledge on how to perform a literature search. A member we identified as a key member to add to the team was our librarian. Having her as a member, allowed for the staff to become familiar with searching databases, identifying keywords for searching, and critiquing the evidence. The librarian also assisted us in our literature searches and serves as a key member on our team.
Another important barrier to mention was lack of knowledge within the team on data entry and analysis. With the support of leadership, the team was provided with a data analyst from the quality department, to assist with future projects. This would be another key member to bring into your team at the beginning of your journey.
The final barrier to mention is collaboration with other councils and teams within the organization. Communication between councils is important to keep up to date on projects implemented in various departments within your organization.4
The EBP team identified a project to implement, but also needed to reach out to other councils/teams to assure the team was not duplicating another project. Identifying a key council was important.
The organization has a council, the Nursing Professional Practice Council, which consists of representation from all areas of the patient care services, including but not limited to, pharmacy, leadership, education, radiology, surgical services, maternal child health, psychiatric health.
The EBP team was able to connect with the council and will be reporting progress on projects this council on an ad hoc basis. Any changes in practice will be presented to the Nursing Practice Council, upon completion of any EBP project for approval to move forward with a change in practice or policy. The change is then forwarded to leadership for approval. After approval from both councils, the change is implemented on each unit with support from the manager and educator and nursing staff of each unit.
Sustaining the Team
As with any nursing team/council, the key to sustaining is leadership support.5 But the other major component for sustaining this team was hope. We never gave up hope that we could bring change to the bedside to improve patient outcome and promote professionalism among nursing staff.
At some meetings there would only be three of us. They did not let this get them down and continued to attend each meeting and show enthusiasm. After getting to the above mentioned point of having a solid team of seven and leadership support, this team has completed its first evidenced based project and has implemented an institution wide change in nursing practice, supported by evidence and data collection.
The change occurred after 2 years of researching the evidence, collecting and analyzing data, surveying nursing staff, and obtaining support for the change with leadership, and physician approval. This project is in it final stages of sustaining the change and a data reanalysis will then be performed.
The team is already looking on to its next project, with feedback from peers. The membership has increased to 12 members. At our meetings we now have 75 percent attendance rate.
This is all from leadership support, not giving up hope, and publicizing the team within the facilities. The team has proved itself over the past 6 years and completed its first project and implemented a significant change in practice based on the results of this project.
This team did not give up. Leadership was continually approached and updated over the course of the 5 years. The team educated itself on implementing a team and implementing a change in practice. With the support from each and every one of the members, this team has advanced on to a council and is recognized in all areas of the facility including physicians, dietary, laboratory and pharmacy staff.
I was blessed to work with this team over the past 5 years, and looks forward to continuing to implement evidence based care to promote patient safety and patient centered excellent care.
References for this article can be accessed here.
Kimberly Foisy is assistant professor for an accelerated baccalaureate nursing program in Boston and per-diem clinical educator / administrative nursing supervisor at North of Boston Acute Care Hospital.