Evidence-based Practice Strategies Research Articles

Using Organizational Theory to Explain ‘How’ EBP Implementation Occurs in HCOs

Despite increasing use of theory in the field of implementation science over the past decade, the literature has largely focused on using deterministic frameworks to retrospectively understand ‘what’ factors are essential for effective implementation of evidence-based practices (EBPs). On the other hand, gaps remain in using organizational theory to prospectively understand ‘how’ successful EBP implementation occurs in healthcare organizations (HCOs). This paper discusses the theoretical and empirical contributions of two selected recent exploratory research works, which provide a starting point for addressing the identified gaps in the literature, with the purpose of deriving implications for theory, practice, and research in implementation science. The selected works used the theory of ‘effective knowledge sharing network structures in professional complex systems (PCS),’ developed through an integration of organizational theories, to design prospective interventions for enabling EBP implementation in HCOs. In doing so, these studies have helped explain ‘how’ inter-professional knowledge exchange and collective learning occurred, to enable successful EBP implementation in HCOs. Correspondingly, the selected works have served a dual purpose in 1) identifying evidence-based management practice strategies for successful EBP implementation, while 2) further developing the theoretical literature on ‘effective knowledge sharing networks in PCS.’ Importantly, by addressing the identified gaps in the literature, the selected works serve to either complement or supplement existing theoretical approaches in implementation science. To this effect, they provide unique insights for theory, practice, and research in implementation science, including insights into a potential ‘dual-role’ for the future implementation researcher—one of advancing implementation science, while working to strengthen implementation practice. Based on these contributions, it could be argued that the selected works provide a starting point for a new research stream that has potential to occupy a distinct position in the taxonomy of theoretical approaches used in implementation science.

Therapist-Observer Concordance in Ratings of EBP Strategy Delivery: Challenges and Targeted Directions in Pursuing Pragmatic Measurement in Children's Mental Health Services.

Pragmatic measures of therapist delivery of evidence-based practice (EBP) are critical to assessing the impact of large-scale, multiple EBP implementation efforts. As an initial step in the development of pragmatic measurement, the current study examined the concordance between therapist and observer ratings of items assessing delivery of EBP strategies considered essential for common child EBP targets. Possible EBP-, session-, and therapist-levels factors associated with concordance were also explored. Therapists and independent observers rated the extensiveness of therapist (n = 103) EBP strategy delivery in 680 community psychotherapy sessions in which six EBPs were used. Concordance between therapist- and observer-report of the extensiveness of therapist EBP strategy use was at least fair (ICC ≥ .40) for approximately half of the items. Greater therapist-observer concordance was observed in sessions where a structured EBP was delivered and in sessions where therapists reported being able to carry out planned activities. Findings highlighted conditions that may improve or hinder therapists' ability to report on their own EBP strategy delivery in a way that is consistent with independent observers. These results can help inform the development of pragmatic therapist-report measures of EBP strategy delivery and implementation efforts more broadly.

Writing intervention: A comprehensive program for primary school children

AbstractThis article describes an intervention program to improve writing skills, intended to be a useful tool for everyday remedial work in primary school. The design was based on an initial review of the approaches most often used for writing intervention and identification of the main concerns for such intervention; namely, the use of direct and explicit instructions, the importance of feedback, recommended levels of intervention, the main content to consider, and use of motivating activities to get the student engaged or even to enjoy the intervention. All these considerations guided decision making about the appropriate features that would ensure an effective intervention in children with general and specific writing difficulties. The intervention program follows evidence-based practice strategies and may be useful for educational professionals in primary school, acknowledging that the program needs to be experimentally evaluated.

Duration of antibiotic therapy in critically ill patients: a randomized controlled trial of a clinical and C-reactive protein-based protocol versus an evidence-based best practice strategy without biomarkers

BackgroundThe rational use of antibiotics is one of the main strategies to limit the development of bacterial resistance. We therefore sought to evaluate the effectiveness of a C-reactive protein-based protocol in reducing antibiotic treatment time in critically ill patients.MethodsA randomized, open-label, controlled clinical trial conducted in two intensive care units of a university hospital in Brazil. Critically ill infected adult patients were randomly allocated to (i) intervention to receive antibiotics guided by daily monitoring of CRP levels and (ii) control to receive antibiotics according to the best practices for rational use of antibiotics.ResultsOne hundred thirty patients were included in the CRP (n = 64) and control (n = 66) groups. In the intention-to-treat analysis, the median duration of antibiotic therapy for the index infectious episode was 7.0 (5.0–8.8) days in the CRP and 7.0 (7.0–11.3) days in the control (p = 0.011) groups. A significant difference in the treatment time between the two groups was identified in the curve of cumulative suspension of antibiotics, with less exposure in the CRP group only for the index infection episode (p = 0.007). In the per protocol analysis, involving 59 patients in each group, the median duration of antibiotic treatment was 6.0 (5.0–8.0) days for the CRP and 7.0 (7.0–10.0) days for the control (p = 0.011) groups. There was no between-group difference regarding the total days of antibiotic exposure and antibiotic-free days.ConclusionsDaily monitoring of CRP levels may allow early interruption of antibiotic therapy in a higher proportion of patients, without an effect on total antibiotic consumption. The clinical and microbiological relevance of this finding remains to be demonstrated.Trial registryClinicalTrials.gov Identifier: NCT02987790. Registered 09 December 2016.

Exploring the prevalence and management of wounds for people with dementia in long-term care.

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Implementation of a Central Line Maintenance Bundle for Dislodgement and Infection Prevention in the NICU.

Infants in the newborn intensive care unit (NICU) often receive medications or nutritional support for extended periods. Due to the fragility of veins, central lines are often used. Adverse outcomes from central lines such as infections and line dislodgements, where the line terminates in a peripheral vessel rather than centrally, can drastically increase infant morbidity and mortality. Although evidence exists addressing the specialized needs of premature or smaller infants, there is far less evidence regarding infants that are larger, more physiologically complex, and have longer stays. Using evidence-based practice strategies, we examined the literature for central line maintenance practices specific to the NICU population and created a care maintenance bundle to reduce infection and line dislodgement rates. Furthermore, we examined implementation of this bundle. A systematic search of PubMed, Cochrane Library, and CINAHL provided evidence for a practice change for central line maintenance for our nontunneled central lines. During project implementation, infection and dislodgement rates for both tunneled and nontunneled lines were examined in order have a control and intervention group. Prior to central line maintenance bundle implementation, there were 19 total incidences of central line dislodgements and 5 central line infections (14 dislodgements and 4 infections were from nontunneled lines, 5 dislodgements and 1 infection from a tunneled line). Postintervention there were 1 total dislodgement and 4 central line infections (the dislodgement was from a nontunneled line and all infections were from tunneled lines). Although research has shown frequent, scheduled dressing changes using the chlorhexidine patch decreases infection rates, the risk of dislodgement and skin breakdown for NICU infants outweighs the potential benefit of decreased infection. Further research is needed to determine whether this central line maintenance bundle would be beneficial for tunneled central lines.

Exploring, defining, and illustrating a concept: Structural and psychological empowerment in the workplace.

The aim of this concept analysis is to clarify the meaning and relationship of psychological and structural empowerment. Empowerment is linked to positive organizational and individual constructs and outcomes. Improving the work environment may assist in sustaining a fragile and essential workforce. Walker and Avant's method was used to guide an analysis of this concept. Resources published from 1970 to 2018 were identified via electronic databases, empirical works, and modern operational usage of the terms. A literature review and search for concept maps were completed and analyzed to identify uses and definitions of the concept: attributes, antecedents, consequences, and empirical referents. It also includes identifying model, borderline, and contrary cases to differentiate empowerment from other related concepts. A comprehensive, inclusive review of empowerment must include both constructs, structural and psychological. A conceptual map of these akin constructs illustrates their syndication. The concept of examining empowerment from both constructs, structural and psychological, is necessary to develop evidence-based practice strategies and improve the work environment and workforce.

Practice of and Barriers to Prevention by Secondary School Athletic Trainers

Purpose: Prevention is a key aspect of care from athletic trainers. There is limited research on the practice strategies employed to prevent injury by secondary school athletic trainers (SSATs). The purpose of this study was to describe the prevention practice strategies and barriers faced by secondary school athletic trainers. Methods: Athletic trainers (n=3010) were recruited from secondary schools through e-mails provided by the national professional organization database. Secondary school athletic trainers were surveyed on their self-reported prevention practices and barriers using a web-based survey platform. Respondents were 28±3 years, predominantly female (n=260/359, 72.4%), with about 5 years (±2yrs) of clinical experience. The survey contained prevention strategies items with tasks from Domain 1 of the Board of Certification Role Delineation Study (6th ed.) that relates to athletic training clinical practice. Barrier items were developed from previous literature about implementing evidence-based practice strategies. Partial data (completion rate=359/473, 75.9%) was used for the analyses. Data were analyzed by using frequencies, medians with percentiles, means, and standard deviations. Results: The least frequently practiced environmental illness monitoring techniques and addressing patient-specific nutritional needs were identified. In contrast, secondary school athletic trainers most frequently practiced compliance for both equipment maintenance and maintaining a clean facility. The most common ‘always practiced’ skills align with Task 102, 103, and 104 in Domain 1 of the Board of Certification Role Delineation Study. These include pre-participation and screening, personal protective equipment, and maintaining treatment and rehabilitation areas through regulatory standards. A lack of time, workload, player compliance, available space, and coach support were the most commonly cited barriers to prevention practice. Conclusions: Overall, secondary school athletic trainers engaged in prevention strategies frequently, yet external factors were barriers to implementation. The consistent and continual practice of prevention skills are essential to risk mitigation. As a result, always practicing the skill is essential and should not be completed as an occasional duty of the athletic training. As many prevention strategies are required for all patient encounters, the frequency of task performance must improve for clinical practice.

Fidelity and Outcome of Implementation Strategies for Evidence-Based Practice in Four Trauma Settings

To evaluate the fidelity and outcomes of four implementation strategies.

Using the Evidence-Based Practice Service Nursing Bundle to Increase Patient Satisfaction

AbstractIntroductionPatient satisfaction and patient experience goals are often linked to financial consequences. Although the link does exist, the bottom line is not only about money; it’s about providing a quality experience for ED patients and creating an environment that engages staff. Evidence-based practice (EBP) strategies that have positive impact on patient perceptions of their ED care and increased satisfaction ratings include AIDET, Hourly Rounding, and Bedside Shift Report, which incorporate updates of test results and explanations of events occurring during a patient’s visit. In addition to these outcomes, Hourly Rounding and Bedside Shift Report have been linked to patient safety improvements. Combining these strategies, our team created and implemented the service nursing bundle as a quality improvement (QI) initiative, with the goal of having a positive effect on patient experiences in emergency departments, represented by at least a 5% increase in overall quality-of-care ranking and ratings. MethodsThis QI project involved comparing professional research consultant (PRC) patient- satisfaction phone survey ratings from patients before and after ED staff members completed a 1-hour service nursing bundle class. In addition to the patient-satisfaction ratings, 1,104 audits evaluating staff use of the service bundle implementation were collected over an 8-week period.reading document: ResultsThe random observational audits showed the adoption of the service nursing bundle as staff compliance started at 65% in week 1 compared with 100% by week 8. Before intervention (July 2015): 50% of patients rated their overall quality of care as excellent, yielding a benchmark ranking of 42.5 percentile. Postservice bundle education implementation (September 2015): 60% of patients rated their overall quality of care as excellent, increasing our ranking to the 85.5 percentile. The postservice bundle group was 1.5 times more likely to respond “excellent” to all 5 survey questions, which was statistically significant (z =2.82, P = 0.004). The patients’ perceptions of total time spent in the emergency department and ratings of “excellent” revealed a significant statistical difference (before: 35.0%, after: 49.5%, X2 (1) = 4.24, P < 0.05). DiscussionWith the implementation of the bundle, our emergency department experienced an 11.8% increase in the number of patients rating their overall quality of care as excellent. This upsurge resulted in a 40% increase in overall quality of care, propelling our emergency department’s ranking to the 85th percentile.Image 1

Pharmacotherapy of personality disorders: what we know and what we have to search for

Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.

Stakeholder Education for Community-Wide Health Initiatives: A Focus on Teen Pregnancy Prevention.

Teen pregnancies and births continue to decline due in part to implementation of evidence-based interventions and clinical strategies. While local stakeholder education is also thought to be critical to this success, little is known about what types of strategies work best to engage stakeholders. With the goal of identifying and describing evidence-based or best practice strategies for stakeholder education in community-based public health initiatives, we conducted a systematic literature review of strategies used for effective stakeholder education. Over 400 articles were initially retrieved; 59 articles met inclusion criteria. Strategies were grouped into four steps that communities can use to support stakeholder education efforts: identify stakeholder needs and resources, develop a plan, develop tailored and compelling messaging, and use implementation strategies. These strategies lay a framework for high-quality stakeholder education. In future research, it is important to prioritize evaluating specific activities taken to raise awareness, educate, and engage a community in community-wide public health efforts.

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making.

Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.

Central Line-Associated Bloodstream Infection Prevention: Standardizing Practice Focused on Evidence-Based Guidelines.

Central venous access devices (CVADs) are integral to the treatment and provision of supportive care for many patients with cancer. Central venous catheters are the most frequent cause of healthcare-associated bloodstream infections. Healthcare-associated bloodstream infections can be prevented when evidence-based practices are followed consistently over time. Establishing nursing best practice with CVADs in the ambulatory setting presents additional challenges because of multiple providers, caregivers, and policies. This article identifies evidence-based practice strategies implemented at a comprehensive ambulatory cancer center to standardize best nursing practice for central lines. .

Strategies for teaching evidence-based practice to undergraduate health students: a systematic review protocol

Review question/objective The objective of this review is to find, critically appraise and synthesize the available quantitative evidence on the effectiveness of interventions that promote successful teaching of the evidence-based practice process in undergraduate health students, in preparation for them to become professional evidence-based practitioners. More specifically, the question that this review seeks to answer is: What is the effectiveness of teaching strategies for evidence-based practice for undergraduate health students? Inclusion criteria Types of participants This review will consider studies that include undergraduate health students from any undergraduate health discipline, including but not limited to medicine, nursing and allied health. Post graduate and post-registration students will not be included. Types of interventions This review will consider studies that evaluate strategies or interventions aimed at teaching any or all of the five steps of evidence-based practice, namely asking a structured clinical question; collecting the best evidence available; critically appraising the evidence to ensure validity, relevance and applicability; applying or integrating the results into clinical practice, and evaluating outcomes. The strategy may take place solely within a tertiary education environment or may be combined with a clinical setting. Types of outcomes This review will consider studies that include the following outcome measures: evidence-based practice behavior, knowledge, skills, attitudes, self-efficacy (or self-confidence), beliefs, values, intention to use evidence-based practice (future use) and confidence levels. Tools used to measure these outcomes will be assessed for reported validity, reliability and generalizability. Outcomes will be measured during the student’s education period up to graduation. If studies are conducted across different year levels this will be taken into account during analysis and reported accordingly.

Identification of Pediatric Oral Health Core Competencies through Interprofessional Education and Practice.

Over the past seven years, the Department of Pediatric Dentistry at New York University College of Dentistry (NYUCD) and the Advanced Practice: Pediatrics and the Pediatric Nurse Practitioner (PNP) program at New York University College of Nursing (NYUCN) have engaged in a program of formal educational activities with the specific goals of advancing interprofessional education, evidence-based practice, and interprofessional strategies to improve the oral-systemic health of infants and young children. Mentoring interprofessional students in all health care professions to collaboratively assess, analyze, and care-manage patients demands that faculty reflect on current practices and determine ways to enhance the curriculum to include evidence-based scholarly activities, opportunities for interprofessional education and practice, and interprofessional socialization. Through the processes of interprofessional education and practice, the pediatric nursing and dental faculty identified interprofessional performance and affective oral health core competencies for all dental and pediatric primary care providers. Students demonstrated achievement of interprofessional core competencies, after completing the interprofessional educational clinical practice activities at Head Start programs that included interprofessional evidence-based collaborative practice, case analyses, and presentations with scholarly discussions that explored ways to improve the oral health of diverse pediatric populations. The goal of improving the oral health of all children begins with interprofessional education that lays the foundations for interprofessional practice.

Utilization of evidence-based practice knowledge, attitude, and skill of clinical nurses in the planning of professional development programming.

This collaborative study explored nurses' knowledge, attitudes, and skills related to the evidence-based practice (EBP) process. It also explored the nurses' perceptions of the barriers and facilitators that they face related to fully using EBP in the workplace. Findings will afford the healthcare system the information to develop, plan, and restructure the educational services to meet the demand of enhancing EBP strategies and utilization.

Using a Critical Appraisal Assignment to Infuse Evidence-Based Practice into a Therapeutic Modality Course

Context It is the responsibility of athletic training educators, through curriculum and clinical experiences, to engage students towards adopting evidence-based practice (EBP) into their practice. The initial task of implementing EBP into a curriculum or course can seem like a large task for educators and students. As a way to start scaffolding EBP concepts across the curriculum, a modified critical appraisal assignment was developed to teach therapeutic modality concepts. Objective The purpose of this action research project was to demonstrate how a modified critical appraisal assignment can be used to introduce the process and aspects of critical appraisal and begin scaffolding the development of critical appraisal skills over time. The objectives of this study were to evaluate the students' ability to (1) successfully locate relevant research needed to answer clinical questions and (2) successfully appraise the literature according to basic EBP strategy. From a program perspective, the modified critical appraisal assignment was a starting point from which to include EBP principles into didactic coursework. Design Seventeen athletic training students completed 3 modified critical appraisal assignments pertaining to the use of therapeutic modalities. Each paper included 5 sections: (1) clinical question, (2) key clinical findings, (3) clinical applicability based on information from the appraisal and significance of results, (4) article comparison table, and (5) implications for clinical practice, patient education, and future research. The instructor evaluated the assignments blind. Conclusions Students were generally able to complete the critical appraisal assignment; however, students had difficulty locating research that answered the clinical question. Students struggled to relate the key clinical findings of the research articles and implications for clinical practice to the given clinical question. Findings from this study have informed faculty teaching, including introducing EBP skills earlier in the curriculum and inserting assignments that stress various aspects of the critical appraisal process.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Relationships between evidence-based practice, quality improvement and clinical error experience of nurses in Korean hospitals.

This study investigated individual and work-related factors associated with nurses' perceptions of evidence-based practice (EBP) and quality improvement (QI), and the relationships between evidence-based practice, quality improvement and clinical errors. Understanding the factors affecting evidence-based practice and quality improvement activities and their relationships with clinical errors is important for designing strategies to promote evidence-based practice, quality improvement and patient safety. A cross-sectional survey was conducted with 594 nurses in two Korean teaching hospitals using the evidence-based practice Questionnaire and quality improvement scale developed in this study. Four hundred and forty-three nurses (74.6%) returned the completed survey. Nurses' ages and educational levels were significantly associated with evidence-based practice scores whereas age and job position were associated with quality improvement scores. There were positive, moderate correlations between evidence-based practice and quality improvement scores. Nurses who had not made any clinical errors during the past 12months had significantly higher quality improvement skills scores than those who had. The findings indicated the necessity of educational support regarding evidence-based practice and quality improvement for younger staff nurses who have no master degrees. Enhancing quality improvement skills may reduce clinical errors. Nurse managers should consider the characteristics of their staff when implementing educational and clinical strategies for evidence-based practice and quality improvement.