Evidence, Context, Facilitation: Improving Nurses' Translation of Evidence into Practice

Lima, Sally E.

Much emphasis in undergraduate nursing studies is placed on the development of critical thinking, utilisation of research, and implementation of evidence based practice (EBP), with a view to delivering quality care. Similarly there is increasing recognition of the need to translate evidence into practice (Grimshaw, Eccles, Lavis, Hill & Squires, 2012). Healthcare organisations expect that practice will be based on quality evidence, however they also expect new nurses will ‘hit the floor running’, quickly gaining the clinical knowledge and skills necessary for practice (Wolff, Pesut & Regan, 2010). A number of papers, including a systematic review, have been published that highlight the barriers for nurses to engage in EBP. Various strategies have been proposed to address the barriers to EBP, however to date those papers have been descriptive in nature (Linton& Prasun, 2013).

In 2013, the nursing research team at the Royal Children’s Hospital Melbourne (RCH) undertook an extensive search of the literature to determine whether a validated tool existed that measured nurses’ engagement with generation, utilisation and evaluation of evidence in practice. No suitable tool was found. Preliminary consideration was given to developing such a tool. However, in consultation with an international expert on knowledge translation (Gary Freed, personal communication, October 2013), it was decided that a more meaningful contribution to quality care and understanding of research utilisation, would be to support nurses to identify practice issues, and develop the capacity to address those issues. As such the BEST Practice Program (Building Evidence with Support to Transform Practice) was conceptualised.

The creation of the BEST Practice Program was informed by the literature and investigation of approaches to support generation and translation of evidence into practice. The PARIHS (Promoting Action on Research in Health Services) Framework (Kitson, Harvey & McCormack, 1998) provides the foundation for the program. Taking this approach it is recognised there are three cornerstones to ensuring best evidence informs great care

The nature of the evidence
The way in which the translation of evidence into practice is facilitated
The context into which the evidence is being translated.

In developing the PARIHS Framework, Kitson et al (1998) argue that the successful implementation of evidence into practice is an outcome of the relationship between the level of evidence, and/or style of facilitation and/or nature of the context into which the translation of evidence is being sought. The content of the BEST Practice Program is built around equipping participants to

Gather and review evidence
Develop facilitation skills to translate evidence into practice
Identify and address contextual factors to enable practice change

The BEST Practice Program consists of a series of 9 program days over 6 months with ongoing support from the nursing research team and a commitment of support from the Nurse Managers. A broad overview of the program’s content includes: Day 1: Evidence. Day 2: Gathering Evidence and Facilitation. Day 3: Reviewing Evidence and Context. Day 4: Preparing project plans. Day 5: Context and finalising project plans. Day 6: Data management and analysis. Day 7: Communicating the findings and implementing change. Day 8: Presenting findings to a wider audience. Day 9: Lessons learned and planning for the future.

In August 2014, funding was secured to enable 6 nurses to participate in the BEST Practice Program. Expressions of interest were called for from Nurse Managers to identify the most pressing issues affecting quality care in their units, and the nurses they believed were best situated to lead a change in practice. From 33 submissions, 9 nurses were selected to participate in the program, addressing 8 practice issues. Selection of participants was based on criteria including

Could the issue be addressed at a department level?
Did the issue align to strategic foci of the RCH?
Were there other objectives the issue aligned to?
What was the potential reach of the outcome beyond the department?
Was the description of the issue SMART (Specific, Measurable, Agreed upon, Realistic, Time Frame)?
Would the nurse be supported by the Nurse Manager?

Six nurses from inpatient units are investigating issues through funded positions. Two nurse consultants, who work together, are investigating a shared practice issue with the support of their department head as part of their usual work. One nurse is participating using her allocated professional development leave. The units and practice issues include

Orthopaedics/Plastics/Burns: bedside handover and Central Venous Access Device Competency
Neuroscience/Endocrinology/Gastroenterology: utilisation of treatment rooms for procedures
Short Stay Surgical: administration of oxygen post tonsillectomy
Medical: management of nasopharyngeal airways
Adolescent/Rehabilitation: Cardiac monitoring of patients with anorexia
Mental Health: Identifying triggers that result in an unsafe environment and determining how these can be overcome and re-occurrences prevented
Plastics Department: timely access to outpatient services

The BEST Practice Program is a novel approach that aims to enable nurses to address issues from practice to improve the quality of care. As with all novel approaches, a rigorous evaluation is required to inform the program’s future, and contribute to the evidence regarding processes and programs that support translation of evidence into practice.

To gain insight into the contribution of the BEST Practice Program to the development of nurses’ capacity to gather, review and implement evidence, the participants completed a short questionnaire about competence in evidence based practice at the start of the program. The questionnaire is based on the work of Melnyk, Gallagher-Ford, Long and Fineout-Overholt (2014) who developed a set of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in clinical settings. Given the lack of a validated tool to measure competence in evidence based practice, the facilitators of the BEST Practice Program identified an opportunity to test the competencies developed by Melnyk, Gallagher-Ford, Long and Fineout-Overholt (2014) as a tool for measuring competence. Participants were asked to indicate their perceived level of competence for each statement using a 7 point Likert scale where 1 = novice and 7 = expert. The analysis with the small cohort indicated higher levels of competence with the competencies expected of registered nurses and less competence with competencies expted of advanced practice nurses, relfective of the roles the nurses hold. The questionnaire will be re administered to the participants at the end of the program to determine whether there has been any increase in competence.

To assist the participants gain insight into the context in which they work, the Alberta Context Tool (ACT) was distributed to all nurses in the six inpatient units at the start of the program (n = 280). The ACT was developed by Estabrooks, Squires, Cummings, Birdsell and Norton (2009). The ACT consists of 56 items with each item requiring a response on a 5 point Likert scale. The response rate for the ACT was 69% (n=190) with response rates for individual units ranging from 60% to 75%. The data to arise from the ACT was made available to BEST Practice Program participants and Nurse Managers for them to reflect on the context in which they work, and identify strategies for improvement. The Nurse Managers found the ACT data invaluable, and in conjunction with their BEST Practice Program participants articulated particular foci for ensuring successful translation of individual project outcomes into practice.

Across the course of the program a daily evaluation of the program days has been conducted and the facilitators have maintained field notes to capture the program’s processes and progress as it unfolds. The feedback has been overwhelmingly positive. In particular the participants have commented on the interactive nature of the program with the active support from three facilitators. Camaraderie between the participants has been evident. The establishment of pairs of critical friends between participants has led to shared learning and active challenge and support within the group. This approach has also enabled participants to develop their facilitation skills in a safe, supported environment. Inclusion of the Nurse Managers via individual meetings to discuss the program and their attendance at key sessions throughout the program have ensured their active engagement and interest. One of the key tenets of the approach taken in BEST Practice Program is that the facilitators work ‘with’ the participants and Nurse Managers. The program is not designed for the facilitators to do things ‘to’ or ‘for’. This approach has been appreciated by the participants and the Nurse Managers and has been demonstrated through the motivation and enthusiasm of all involved.

By the end of the fifth day of the BEST Practice Program, the participants had refined a broad practice issue into a question that could be addressed, searched and reviewed the literature, identified gaps, and drafted protocols for submission to ethics. They had also identified strengths in the contexts they were addressing their practice issues in to work with and areas that needed to be addressed. Data collection and analysis will take place throughout February and March 2015, with continued attention to how the findings will be translated into practice. While the final outcomes of the program remain unknown, preliminary evaluation indicate the participants have developed their capacity to gather and review evidence, facilitate engagement and change, and address contextual challenges.