Describing the Problem for an Evidence-Based Practice Improvement Project: A Missing Ingredient

Abstract

Co-authoring this issue's evidence-based practice (EBP) column is particularly exciting for me because I am co-authoring it with one of my Doctor of Nursing Practice (DNP) students. This is a first because Pace just began its DNP program in fall 2008. Robert is a member of the first cohort. He and I have been dialoguing from his first semester in the program about EBP. At first he was reluctant to completely embrace this model of clinical decision making because he felt that it lacked elements of patient-centered care. After much conversation, reading, and reflection, his beliefs evolved and he began to see the interconnectedness of EBP, primary health care, and cultural competence (which happen to be the 3 Pillars for Pace's DNP Program). Readers of this column in RTNP may have realized how my thinking about the paradigm has been evolving over the past few years. Previous columns in RTNP such as EBP by Any Other Name is Still a Rose ( Levin, 2008 ) and Walk Before You Run ( Levin, 2009 )-were instrumental in helping me hone my thinking into what has become the Evidence-Based Practice Improvement (EBPI) Model ( Levin et al., 2010 ), a model that merges the best of and performance improvement (PI) into a simple and relevant model that may guide improvement efforts. EBPI was originally introduced as the model that students would use for their EBPI doctoral projects. After two semesters in which we were immersed in EBPI as a model for DNP projects, and after a course in evaluation in which the importance of stakeholder involvement in any organizational initiative was stressed, Robert came up with the idea that we need to include stakeholder interview data as an important component of problem description. Although the importance of stakeholder involvement has been emphasized in primary health care ( World Health Organization, 1978 ), public health initiatives (Centers for Disease Control, 1999), PI ( Langley et al., 2009 ), and evaluation ( Patton, 2008 ) literature, it has not become part and parcel of an or EBPI framework. This column explores the notion of including stakeholder involvement as a stated and important component of any organizational improvement effort. Inspiration for practice improvement comes in many forms. Can you remember the last time you went to a conference or network meeting and learned about exciting innovations that incorporate in a new and unique way? These moments energize us and often times motivate us to implement similar changes in our own agencies. Getting from that initial spark, the initial idea, to the implementation and dissemination of best practices may seem like a daunting task, but when approached in a systematic way, will yield promising outcomes. Levin et al. (2010) discuss the first step in the EBPI Model as the description of the problem . Accordingly, clinical problems are uncovered by reviewing external literature and internal data sources. External data, or background literature, is needed to put the clinical problem in a larger societal/health care context, whereas internal agency data identify if an EBPI topic has support for change within a specific agency or organization. Internal evidence includes both quantitative and qualitative evidence within an agency. Quantitative internal evidence can include PI information, continuous quality improvement (CQI) information (for example, Press-Ganey reports), or any other systematic data an agency collects and uses to gauge whether or not they are reaching their benchmarks. Qualitative internal evidence includes a stakeholder analysis, and is central to the entire EBPI process. A stakeholder is any individual, group, or organization who has a vested interest in the process and/or outcomes of an EBPI project ( Patton, 2008 ). Patients, community groups, health care providers, staff, administrators, and other stakeholders have unique and essential experiences and views that inform any improvement effort, including those that are specifically aimed at enhancing patient care services. …