The purpose of this study was to explore factors influencing the use of tradition-based practices and create a model of de-implementation processes to facilitate adoption of evidence-based practice in the critical care setting. This presentation is aligned with the conference objective of discussing research strategies to promote evidence-based teaching and learning influencing interprofessional environments.
Evidence-based practice is an expected standard of clinical practice as the means for optimizing patient outcomes and minimizing cost. Nursing research has focused its attention on the implementation of evidence-based practices without considering de-implementation of existing entrenched, routine practice, also known as tradition-based practice. Tradition-based practices may be devoid of adequate empirical evidence (Prasad & Ioannidis, 2014) and some are described as low-value care (van Bodegom-Vos, Davidoff, & Marang-van de Mheen, 2016). Since tradition-based practices may be potentially harmful or ineffective, de-implementation is necessary to optimize patient outcomes and/or resources (Flynn Makic, Rauen, Watson, & Poteet, 2014). De-implementation or termination of these tradition-based practices is a relatively new approach to changing practice and is necessary to facilitate evidence-based practices in the clinical setting (Montini & Graham, 2015; Prasad & Ioannidis, 2014). Our novel study was the first that we are aware of to study de-implementation of tradition-based practices by critical care nurses.
The research question was: What are the factors and processes necessary for de-implementation of tradition-based practices by critical care nurses to facilitate implementation of evidence-based practices? Specific aims included 1) explore factors that influence the continued use of tradition-based practices by critical care nurses and barriers to stopping these practices, and 2) identify processes that facilitate de-implementation of tradition-based practices.
Qualitative, descriptive inquiry using semi-structured interviews were used to collect data. Critical care nurses from an acute care hospital in Central Florida were recruited for the study. University and hospital institutional review boards granted ethical approval. A series of demographic and interview questions were asked. Interview questions inquired about practice changes, including roles, facilitators and barriers, processes, and tradition-based practices. Questions evolved based on participant data and interviews ceased when data saturation was reached. Thematic content analysis was used to code and categorize interview data in two phases (Miles, Huberman & Saldaña, 2014). Two researchers reached consensus on coding and derived categories and themes. HyperResearch software was utilized to manage and code data.
The sample consisted of 22 critical care nurses; 4 of the participants were in formal leadership roles and 18 were staff nurses. Nursing experience ranged from 1-39 years (M=10) and 17/22 (77%) of participants held a BSN or higher degree. The major theme that emerged during secondary data analysis was uncertainty of the scientific underpinnings of clinical nursing practice. Participants were unsure if their practices were based solely on tradition, evidence, or a combination of sources and most were unable to define and/or identify a tradition-based practice. Uncertainty then became the core concept in our new model for practice change. “Desire to know” was the primary mediator between uncertainty and de-implementation of tradition-based practices and implementation of evidence-based practices. Sources of information to satisfy desire to know and relieve uncertainty included professional organizations, nursing leadership at the unit level including the Unit Practice Council, and previous knowledge acquired from formal nursing education. Additional mediators to de-implementation of tradition-based practices were identified as secondary facilitators and barriers. These facilitators, such as use of a Gemba visual management board and identified barriers to practice change, influenced both de-implementation and implementation processes.
The inclusion of tradition-based practices in this new model for clinical practice changes may facilitate de-implementation of tradition-based practices and enhance the evidence-based practice process. More research is necessary to explore factors associated with uncertainty of the scientific underpinnings of clinical nursing practice. This model will need to be tested in the local critical care setting with consideration to the environment and cultural context. Nurse educators and leaders may play an active role to assist students and nurses to become aware of tradition-based practices and determine methods to de-implement these practices. Additionally, Gemba boards may be a useful tool to identify tradition-based practices and begin discussions about de-implementation. Further research on the effectiveness of Gemba boards in nursing is also warranted.