The Iowa Model of Evidence-Based Practice to Promote Quality Care

Energy Through Motion©: An Evidence-Based Exercise Program to Reduce Cancer-Related Fatigue and Improve Quality of Life

BACKGROUND

Evidence supports addressing cancer-related fatigue (CRF) with activity. Activity promotion is feasible during and following cancer treatment and improves patient outcomes.

OBJECTIVES

This project provided an evidence-based activity program for adult cancer survivors after treatment to reduce CRF and improve quality of life.

METHODS

The Iowa Model of Evidence-Based Practice to Promote Quality Care guided development of the activity promotion evidence-based practice project. This included evidence review, creation of an evidence-based activity intervention, and evaluation of the practice change. Two groups participated in the project; one group, the usual care group, provided baseline data and received "usual" instructions for activity, fatigue, and sleep, whereas the Energy Through Motion© (ETM) activity group received a three-month activity intervention with prepackaged ETM kits and follow-up phone calls.

FINDINGS

Patients in the ETM activity group had increased activity levels, whereas those in the usual care group had decreased activity levels. Fatigue levels in the ETM activity group decreased, and quality of life improved. This project supports nurse-led activity promotion as useful in addressing CRF and feasible for use in a busy clinical setting.

Taking Root: a grounded theory on evidence-based nursing implementation in China

BACKGROUND

Evidence-based nursing is widely recognized as the critical foundation for quality care.

AIM

To develop a middle-range theory on the process of evidence-based nursing implementation in Chinese context.

METHODS

A grounded theory study using unstructured in-depth individual interviews was conducted with 56 participants who were involved in 24 evidence-based nursing implementation projects in Mainland China from September 2015 to September 2016.

RESULTS

A middle-range grounded theory of 'Taking Root' was developed. The theory describes the evidence implementation process consisting of four components (driving forces, process, outcome, sustainment/regression), three approaches (top-down, bottom-up and outside-in), four implementation strategies (patient-centred, nurses at the heart of change, reaching agreement, collaboration) and two patterns (transformational and adaptive implementation).

LIMITATIONS

Certain perspectives may have not been captured, as the retrospective nature of the interviewing technique did not allow for 'real-time' assessment of the actual implementation process. The transferability of the findings requires further exploration as few participants with negative experiences were recruited.

CONCLUSION

This is the first study that explored evidence-based implementation process, strategies, approaches and patterns in the Chinese nursing practice context to inform international nursing and health policymaking. The theory of Taking Root described various approaches to evidence implementation and how the implementation can be transformational for the nurses and the setting in which they work.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Nursing educators, managers and researchers should work together to improve nurses' readiness for evidence implementation. Healthcare systems need to optimize internal mechanisms and external collaborations to promote nursing practice in line with evidence and achieve clinical outcomes and sustainability.

Healthy Skin Wins: A Glowing Pressure Ulcer Prevention Program That Can Guide Evidence-Based Practice

BACKGROUND

In 2013, an observational survey was conducted among 242 in-patients in a community hospital with a pressure ulcer (PU) prevalence of 34.3%. An evidence-based pressure ulcer prevention program (PUPP) was then implemented including a staff awareness campaign entitled "Healthy Skin Wins" with an online tutorial about PU prevention.

AIMS

To determine the effectiveness of the PUPP in reducing the prevalence of PUs, to determine the effectiveness of the online tutorial in increasing hospital staff's knowledge level about PU prevention, and to explore frontline staff's perspectives of the PUPP.

METHODS

This was a mixed methods study. A repeat observational survey discerned if the PUPP reduced PU prevalence. A pre-test post-test design was used to determine whether hospital staff's knowledge of PU prevention was enhanced by the online tutorial. Qualitative interviews were conducted with nurses, allied health professionals, and health care aides to explore staff's perspectives of the PUPP.

RESULTS

A comparison of initial and repeat observational surveys (n = 239) identified a statistically significant reduction in the prevalence of PU to 7.53% (p < .001). The online tutorial enhanced staff knowledge level with a statistically significantly higher mean post-test score (n = 80). Thirty-five frontline staff shared their perspectives of the PUPP with "it's definitely a combination of everything" and "there's a disconnect between what's needed and what's available" as the main themes.

CONCLUSIONS

Incorporating evidence-based PU prevention into clinical practice greatly reduced the prevalence of PUs among hospital in-patients. Due to the small sample size for the pre-test post-test component, the effectiveness of the online tutorial in improving the knowledge level of PU prevention among hospital staff requires further research.

LINKING EVIDENCE TO ACTION

Evidence-based PU prevention strategies are facilitated by using a multidisciplinary approach. Educational tools about PU prevention must target all members of the healthcare team including healthcare aides, patients and families.

Changes in nursing students' perceptions of research and evidence-based practice after completing a research course

BACKGROUND

Nurses need a sound education in research and evidence-based practice (EBP) to provide patients with optimal care, but current teaching methods could be more effective.

OBJECTIVES

To evaluate the changes in nursing students 1) perceptions of research and EBP, 2) confidence in research and EBP, and 3) interest in research participation after completing a course in research and EBP.

DESIGN

A pre-post assessment design was utilized to compare changes in students.

SETTINGS

This project was conducted at a small, private liberal arts institution with Bachelor of Science (BSN) students.

PARTICIPANTS

Two cohorts of third-year BSN students (Year 1 N=55, Year 2 N=54) who were taking a required, semester-long Nursing Research and EBP course.

METHODS

Students' perceptions of and confidence in research and EBP were assessed pre- and post-semester using the Confidence in Research and EBP survey, which contained 7 demographic items, 9 Research Perceptions items, and 19 Confidence in Research items (5-point Likert scale; 1=Not at all confident, 5=Extremely confident). Two years of data were collected and analyzed in SPSS v.24.0. Wilcoxon signed-ranks tests and Mann-Whitney-U tests were utilized to examine the data.

RESULTS

Students had significant improvements in perceptions of and confidence in research and EBP (p<0.05). They were more likely to agree to plan to use EBP in the future (p=0.007), yet there were no significant improvements on students' plans to perform research or plans to participate in research in the future.

CONCLUSIONS

A Research and EBP course is an effective way to improve student perceptions of and confidence in research and EBP, increasing the likelihood of applying these skills to future nursing practice.

Advances in Endoscope Reprocessing Technology and Its Impact on Pathogen Transmission

Pathogen transmissions via flexible endoscopes have been documented in the literature and have been historically related to human error or omission of steps in the reprocessing cycle. The 2008 Centers for Disease Control and Prevention report challenged manufacturers of automated endoscope reprocessors to improve and advance technology to automate more of the reprocessing steps. A review and synthesis of the literature following the 2008 Centers for Disease Control and Prevention report was performed to evaluate whether advances in reprocessing technology have occurred and whether these have had an impact on pathogen transmission via flexible endoscopes. The Iowa Model of Evidence-Based Practice to Promote Quality Care was used to guide the project. The literature search regarding pathogen transmission related to flexible endoscopes yielded 10 documents citing infections from 2008 to 2015. A total of 353 patients were identified as having been infected with a contaminated gastroscope, bronchoscope, or duodenoscope. An evaluation of reprocessing technology identified 3 automated endoscope reprocessors with enhanced capabilities and flushing devices intended to automate portions of the manual cleaning step.

Developing a Diary Program to Minimize Patient and Family Post-Intensive Care Syndrome

A series of evidence-based interventions beginning with an intensive care unit diary and a patient/family educational pamphlet were implemented to address the long-term consequences of critical illness after discharge from the intensive care unit, bundled as post-intensive care syndrome and post-intensive care syndrome-family. An extensive literature review and nursing observations of the phenomenon highlighted the potential for this project to have a favorable impact on patients, their families, and the health care team. The goal of this article is to explain the education of all stakeholders; the introduction of the diary, video, and educational pamphlet; and the evaluation of the acceptance of these interventions. This process began with an informal evaluation of the educational products and overall perception of the usefulness of the diary by patients, family members, and staff. The efforts described contribute to the evidence base supporting diaries as an adjunct to intensive care.

Improving the Patient Experience by Implementing an ICU Diary for Those at Risk of Post-intensive Care Syndrome

The critical care literature in the US has recently brought attention to the impact an ICU experience can have long after the patient survives critical illness, particularly if delirium was present. Current recommendations to mitigate post-intensive care syndrome (PICS) are embedded in patient and family-centered care and aim to promote family presence in the ICU, provide support for decision-making, and enhance communication with the health-care team. Evidence-based interventions are few in number but include use of an ICU diary to minimize the psychological and emotional sequelae affecting patients and family members in the months following the ICU stay. In this paper we describe our efforts to implement an ICU diary and solicit feedback on its role in fostering teamwork and communication between patients, family members, and ICU staff. Next steps will involve a PICS follow-up clinic where trained staff will coordinate specialty referrals and perform long-term monitoring of mental health and other quality of life outcomes.

Implementation of a Bowel Management Program in Critical Care

PURPOSE

The purpose of this study was to examine the effectiveness of a unit-based, educational program on implementation of a sustainable bowel management program in a critical care setting.

SUBJECTS AND SETTING

Two hundred thirty nurses in 6 critical care units within a 750-bed level I trauma hospital and 400-bed university academic teaching hospital participated in the study.

METHODS

Data collection and analysis were guided by a quasi-experimental pre-/postdesign. An evidence-based, interactive Web-based education program was developed. The education program consisted of 3 components: (1) knowledge acquisition (Web-based education module), (2) skill acquisition (unit-based skill session performance and competency), and (3) mastery experiences (self-efficacy). Data collected included pre- and posteducation module test scores, skill-acquisition competency, and self-efficacy scores.

RESULTS

The Web-based education module pre- and posttest scores for 225 participants showed significant (P < .001) improvement in knowledge scores. All participants (100%) completed the skill acquisition sessions successfully during the unit-based performance session. Nurses' self-efficacy scores significantly improved (P < .001) over the course of this study period. Eighty-six percent (n = 125) of critical care nurses reported enhanced collaboration with the WOC nurses and clinical nurse specialists.

CONCLUSION

Study findings support the use of a structured, evidence-based educational program incorporating a multimethod approach to implement practice change for critical care.

Evidence-Based Practice and School Nursing

School nurses need to demonstrate that their practice is based on the best evidence available, which is usually data obtained from research. Evidence-based practice involves combining the best evidence available with nursing expertise and patient and family preferences to determine optimum care. Evidence-based practice guidelines are developed by carefully reviewing the available evidence on a topic and synthesizing this information into recommendations for practice. This article defines evidence-based practice and best evidence, describes the development of evidence-based practice guidelines, discusses factors that affect the use of research and evidence-based practice guidelines in school nursing, and reviews current sources of evidence-based practice guidelines for school nurses. Strategies that school nurses can use to incorporate evidence into their practice are discussed. One recommendation is that school nurses partner with nurse leaders and nurse researchers to develop evidence-based practice guidelines relevant to school nurse practice.

Health Behavior Theory for Pressure Ulcer Prevention: Root-Cause Analysis Project in Critical Care Nursing

The purpose of this project was to use a behavioral theory to examine pressure ulcer prevention by nurses in a critical care setting. A root-cause analysis approach was used, including an integrative literature review, operationalization of behavioral constructs into a survey, and root-cause analysis application in a cardiovascular intensive care unit. This article highlights an innovative approach to quality improvement in critical care.

How to understand and conduct evidence-based medicine

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions regarding the care of individual patients. This concept has gained popularity recently, and its applications have been steadily expanding. Nowadays, the term "evidence-based" is used in numerous situations and conditions, such as evidence-based medicine, evidence-based practice, evidence-based health care, evidence-based social work, evidence-based policy, and evidence-based education. However, many anesthesiologists and their colleagues have not previously been accustomed to utilizing EBM, and they have experienced difficulty in understanding and applying the techniques of EBM to their practice. In this article, the author discusses the brief history, definition, methods, and limitations of EBM. As EBM also involves making use of the best available information to answer questions in clinical practice, the author emphasizes the process of performing evidence-based medicine: generate the clinical question, find the best evidence, perform critical appraisal, apply the evidence, and then evaluate. Levels of evidence and strength of recommendation were also explained. The author expects that this article may be of assistance to readers in understanding, conducting, and evaluating EBM.

Medical device-related hospital-acquired pressure ulcers: development of an evidence-based position statement

Hospital-acquired pressure ulcers (HAPUs) are a problem in the acute care setting causing pain, loss of function, infection, extended hospital stay, and increased costs. In spite of best practice strategies, occurrences of pressure ulcers continue. Many of these HAPUs are related to a medical device. Correct assessment and reporting of device-related HAPUs were identified as an important issue in our organization. Following the Iowa Model for Evidence-Based Practice to Promote Quality Care, a task force was created, a thorough review of current evidence and clinical practice recommendations was performed, and a definition for medical device-related HAPU and an evidence-based position statement were developed. Content of the statement was reviewed by experts and appropriate revisions were made. This position statement provides guidance and structure to accurately identify and report device-related HAPU across our 18 healthcare facilities. Through the intentional focus on pressure ulcer prevention and evidence-based practice in our organization and the use of this position statement, identification and reporting of device-related HAPUs have improved with a decrease in overall HAPU rates of 33% from 2011 and 2012. This article describes the development and implementation of this device-related HAPU position statement within our organization.

An Evidence-Based Template for Implementation of Multidisciplinary Evidence-Based Practices in a Tertiary Hospital Setting

Public demand for higher quality and lower cost, evolving pay-for-performance initiatives from payors, and the growing volume of quality "report cards" are driving health care organizations to develop evidence-based practice (EBP) guidelines. Hospitals will be expected to provide the infrastructure and resources needed to support these care processes. Published best practices for implementing EBPs are rooted in organizational and behavioral change theories. Some provide a framework for implementation but lack specific steps to be followed. Others provide process detail, but their focus is too narrow to address the breadth of interdisciplinary care for defined populations. The Saint Vincent Guide for Evidence-Based Practice Implementation is a 4-phase, "fill-in-the-blank" template, road map, and time line for creating interdisciplinary, diagnosis-specific, evidence-based practices to "hard wire" the care delivery process. It is a result of our experiences with and a literature review of EBP implementation best practices that, taken together, substantiate the steps prescribed by the Guide.

Development and Use of Gerontological Evidence-Based Practice Guidelines

Evidence-based practice (EBP) is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making and the achievement of optimal patient outcomes and quality of life. Since 1994, The University of Iowa College of Nursing and its partner, University of Iowa Hospitals and Clinics Department of Nursing Services and Patient Care, has been at the forefront of making gerontological nursing EBP a reality. Every 4 months since 2007, the Journal of Gerontological Nursing (JGN) has published an EBP article focusing on a specific situation or problem associated with the care of older adults based on an EBP guideline developed and published by the University of Iowa College of Nursing. The current article provides background for the development of EBP in general and the specific development, processes, and components of the EBP guidelines published in this section of JGN. [Journal of Gerontological Nursing, 42 (7), 25-32.].

Women's Voices in Maternity Care: The Triad of Shared Decision Making, Informed Consent, and Evidence-Based Practices

The United States is the only industrialized nation that has experienced dramatic increases in the use of maternity interventions resulting in poor birth outcomes. It is speculated that the increased rates of maternal mortality and other outcomes are attributed to the current maternity model of care focused on the overuse of interventions, such as induction of labor, in otherwise healthy pregnant women. The overuse of induction of labor to artificially speed up the birth process has been linked to an increase in preterm and cesarean births. The cost of these interventions and poor outcomes has been substantial. The purpose of this article is to present concepts that demonstrate the challenges and value of informed, shared decision making, informed consent, and women's use of evidence within the context of maternity care. To highlight these important concepts, this article presents original findings from a secondary analysis of data on induction of labor. Findings from this analysis further highlight the importance of including women as part of informed, shared decision making in models of maternity care.

Implementing Clinical Practice Changes: A Practical Approach

Implementing changes in clinical practice is critical for insuring the highest quality patient care. Ideally, changes in clinical practice should be based upon high-quality research findings or so-called evidence-based medicine. The increase in health care expenditures and data on the variance in clinical practices are exerting external pressures on professionals to justify practice patterns and are now tightly linked to reimbursement. As these factors fuel tensions between quality practice and care on one hand and cost on the other, clinicians must increasingly be prepared to justify the processes and resources used to deliver the required care to produce optimal patient outcomes. Continuously monitoring the clinical literature and implementing clinical practice changes, when a sufficient body of evidence exists, will contribute to improved patient outcomes. This involves three practical steps: (a) examining and evaluating the research, (b) gauging the likelihood of success, and (c) recommending and implementing a clinical practice change.

Colonoscopy Comfort: An Evidence-Based Practice Project

Decreased discomfort after colonoscopy is a high priority for patients. Typically, air is used to insufflate the bowel during colonoscopy, but emerging literature shows that carbon dioxide insufflation decreases postoperative discomfort and flatus. An evidence-based practice project was developed and implemented by a surgical department at a community hospital. The Director of Surgical Services brought the evidence to the staff, secured agreement from a physician champion, and the new process was quickly adopted. Patients experienced less discomfort and flatus postprocedure with carbon dioxide insufflation, and were able to be discharged expediently. These patient outcomes validated the literature and confirmed the success of the practice change.

Outcomes of Implementing an Evidence-Based Hypertension Clinical Guideline in an Academic Nurse Managed Health Center

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Educational Intervention for an Evidence-Based Nursing Practice of Skin-to-Skin Contact at Birth

This article presents the development and evaluation of an educational intervention aiming at an evidence-based practice of skin-to-skin contact at birth among nurses of a maternity care unit. Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care, four educational sessions were developed according to an active-learning pedagogy. Even if the nurses' practice did not fully meet the recommendations for skin-to-skin contact, a pre- and postintervention evaluation showed some positive results, such as a longer duration of skin-to-skin contact immediately after birth, delivery of some routine care directly on mothers' chest, and improved parent education. The educational intervention seems to have enacted some evidence-based nursing practice changes regarding skin-to-skin contact at birth.

Psychometric Testing of the Health Care Evidence-Based Practice Assessment Tool

BACKGROUND AND PURPOSE

Evidence-based practice (EBP) is essential to optimal health care outcomes. Interventions to improve use of evidence depend on accurate assessments from reliable, valid, and user-friendly tools. This study reports psychometric analyses from a modified version of a widely used EBP questionnaire, the information literacy for nursing practice (ILNP).

METHODS

After content validity assessments by nurse researchers, a convenience sample of 2,439 nurses completed the revised 23-item questionnaire. We examined internal consistency and used factor analyses to assess the factor structure.

RESULTS

A modified 4-factor model demonstrated adequate fit to the data. Cronbach's alpha was .80-.92 for the subscales.

CONCLUSIONS

The shortened ILNP (renamed Healthcare EBP Assessment Tool or HEAT) demonstrated adequate content validity, construct validity, and reliability.

Current state of evidence-based practice education for undergraduate nursing students in Taiwan: A questionnaire study

BACKGROUND

Evidence-based practice (EBP) has been emphasized as the core competency of undergraduate nursing students and must be cultivated before graduation. However, there is limited information of EBP education for undergraduate nursing students in Taiwan.

OBJECTIVES

The purpose of this study was to investigate the current state of EBP education for undergraduate nursing students in Taiwan.

DESIGN

A self-developed questionnaire, validated by experienced educators, was designed to explore curriculum design, teaching resources, qualification of teachers, and barriers regarding EBP education.

PARTICIPANTS

A total of 21 nursing schools and colleges participated. The chair of each recommended a faculty member involved in teaching EBP as the school's representative to fill out the questionnaire.

RESULTS

Among the 21 nursing schools and colleges, 18 (85.7%) had implemented EBP education in the curriculum. Among these schools, 22.2% conducted an independent EBP course, 50% incorporated EBP concepts into other courses, and the remainder offered both kinds of EBP courses. Multiple strategies were incorporated to teach the EBP. Less than 35% of the schools had designed or adopted standardized teaching materials and evaluated students' learning outcomes. Although 55.6% of the schools reimbursed faculty for participation in EBP training, 39% of their faculty members who taught EBP did not receive any EBP training. Shortage of qualified faculty and limited opportunity to involve students in evidence-based applications were reported as major obstacles to teaching EBP.

CONCLUSIONS

EBP education has already gained the attention of nursing schools in Taiwan. However, lack of comprehensive EBP training among teachers and the difficulty of teaching clinical application of EBP require special consideration. In order to promote EBP education in undergraduate nursing curriculums, we suggest that nursing schools reinforce and support faculty to participate in formal EBP training. Also needed is a systematic curriculum design with multiple teaching strategies and links with clinical practicum.

Implementing the Mother-Baby Model of Nursing Care Using Models and Quality Improvement Tools

As family-centered care has become the expected standard, many facilities follow the mother-baby model, in which care is provided to both a woman and her newborn in the same room by the same nurse. My facility employed a traditional model of nursing care, which was not evidence-based or financially sustainable. After implementing the mother-baby model, we experienced an increase in exclusive breastfeeding rates at hospital discharge, increased patient satisfaction, improved staff productivity and decreased salary costs, all while the number of births increased. Our change was successful because it was guided by the use of quality improvement tools, change theory and evidence-based practice models.

Evidence-Based Protocols to Guide Pulse Oximetry and Oxygen Weaning in Inpatient Children with Asthma and Bronchiolitis: A Pilot Project

Nurses', respiratory therapists' (RTs), and physicians' concerns about oxygen weaning practices and pulse oximetry use in healthy children during inpatient admissions prompted this multidisciplinary evidence-based project. A nurse-led inter-professional team found lack of consistent oxygen weaning practices and lack of guidelines for nurses or RTs regarding pulse oximetry use with children admitted for acute respiratory illness. The team created and piloted evidence-based oxygen weaning and pulse oximetry protocols. After a 6 month pilot, children in the pilot had shorter length of stay, time on oxygen, and time on continuous pulse oximetry. Protocols improved patient outcomes and decreased associated charges.

Evidence-Based Practice in the United States: Challenges, Progress, and Future Directions

Scientific literature demonstrates that advances in evidence-based nursing have improved systems of care and women's health outcomes. Experts agree that nurses worldwide can play a key role in building such evidence and working with interdisciplinary health care teams and systems to accelerate its implementation.

Graduating baccalaureate students' evidence-based practice knowledge, readiness, and implementation

With evidence-based practice (EBP) as an expected core competency for all health care professionals and the integration of EBP competencies in nursing curricula, the process of translating EBP knowledge to EBP implementation behaviors among graduating baccalaureate nursing students was examined. A sample of 174 students in four states participated in this online survey. Results showed students scored low on their EBP knowledge test and engagement in EBP implementation behaviors. However, students were moderately confident in their EBP readiness. EBP readiness was a significant mediator between knowledge and engagement in implementation behaviors. Nursing education should focus on increasing students' self-confidence in their EBP competencies to support engagement in EBP implementation behaviors. A nursing workforce ready to deliver care using an evidence-based approach has the potential of improving patient outcomes.

Clinical nurse specialists lead teams to impact glycemic control after cardiac surgery

PURPOSE

The purpose of this evidence-based practice improvement project was to improve patients' blood glucose control after cardiac surgery, specifically aiming to keep blood glucose levels less than 200 mg/dL.

BACKGROUND/RATIONALE

Glycemic control is essential for wound healing and infection prevention. Multiple factors including the use of corticosteroids and the stress of critical illness put cardiac surgery patients at greater risk for elevated blood glucose levels postoperatively. A Surgical Care Improvement Project measure related to infection prevention calls for the morning blood glucose level (closest to 6:00 AM) to be less than 200 mg/dL on postoperative days 0 to 2. Patients on our cardiothoracic surgery unit were experiencing blood glucose levels greater than benchmark goals.

DESCRIPTION

A practice improvement effort was designed to decrease the number of blood glucose results greater than 200 mg/dL after cardiac surgery. The clinical nurse specialists for diabetes and cardiac surgery worked with nursing staff and the interdisciplinary team to implement a 4-pronged approach to improve efficiency in care processes: (1) increase frequency of glucose monitoring, (2) improve accessibility of insulin orders, (3) develop delegation protocol to facilitate nurse-initiated insulin infusion, and (4) implement revised insulin infusion protocol.

OUTCOMES

Hyperglycemia was identified more quickly, and a nurse-initiated protocol prompted more timely use of revised insulin infusion orders and involvement of the diabetes specialty team. Clinically significant improvement in postoperative glycemic control was achieved.

CONCLUSIONS

Empowering nurses to initiate hyperglycemia treatment and consultation by diabetes specialists may greatly improve efficiency in care processes and clinical outcomes for cardiac surgery patients.

IMPLICATIONS

Clinical nurse specialists are well positioned to plan and implement interventions that facilitate an evidence-based approach to glycemic management after cardiac surgery.

Critical examination of knowledge to action models and implications for promoting health equity

Introduction

Knowledge and effective interventions exist to address many current global health inequities. However, there is limited awareness, uptake, and use of knowledge to inform action to improve the health of disadvantaged populations. The gap between knowledge and action to improve health equity is of concern to health researchers and practitioners. This study identifies and critically examines the usefulness of existing knowledge to action models or frameworks for promoting health equity.

Methods

We conducted a scoping review of existing literature to identify knowledge to action (KTA) models or frameworks and critiqued the models using a health equity support rubric.

Results

We identified forty-eight knowledge to action models or frameworks. Six models scored between eight and ten of a maximum 12 points on the health equity support rubric. These high scoring models or frameworks all mentioned equity-related concepts. Attention to multisectoral approaches was the factor most often lacking in the low scoring models. The concepts of knowledge brokering, integrative processes, such as those in some indigenous health research, and Ecohealth applied to KTA all emerged as promising areas.

Conclusions

Existing knowledge to action models or frameworks can help guide knowledge translation to support action on the social determinants of health and health equity. There is a need to further test existing models or frameworks. This process should be informed by participatory and integrative research. There is room to develop more robust equity supporting models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-015-0178-7) contains supplementary material, which is available to authorized users.

Hiding in plain sight: communication theory in implementation science

Background

Poor communication among healthcare professionals is a pressing problem, contributing to widespread barriers to patient safety. The word “communication” means to share or make common. In the literature, two communication paradigms dominate: (1) communication as a transactional process responsible for information exchange, and (2) communication as a transformational process responsible for causing change. Implementation science has focused on information exchange attributes while largely ignoring transformational attributes of communication. In this paper, we debate the merits of encompassing both paradigms.

Discussion

We conducted a two-staged literature review searching for the concept of communication in implementation science to understand how communication is conceptualized. Twenty-seven theories, models, or frameworks were identified; only Rogers’ Diffusion of Innovations theory provides a definition of communication and includes both communication paradigms. Most models (notable exceptions include Diffusion of Innovations, The Ottawa Model of Research Use, and Normalization Process Theory) describe communication as a transactional process. But thinking of communication solely as information transfer or exchange misrepresents reality. We recommend that implementation science theories (1) propose and test the concept of shared understanding when describing communication, (2) acknowledge that communication is multi-layered, identify at least a few layers, and posit how identified layers might affect the development of shared understanding, (3) acknowledge that communication occurs in a social context, providing a frame of reference for both individuals and groups, (4) acknowledge the unpredictability of communication (and healthcare processes in general), and (5) engage with and draw on work done by communication theorists.

Summary

Implementation science literature has conceptualized communication as a transactional process (when communication has been mentioned at all), thereby ignoring a key contributor to implementation intervention success. When conceptualized as a transformational process, the focus of communication moves to shared understanding and is grounded in human interactions and the way we go about constructing knowledge. Instead of hiding in plain sight, we suggest explicitly acknowledging the role that communication plays in our implementation efforts. By using both paradigms, we can investigate when communication facilitates implementation, when it does not, and how to improve it so that our implementation and clinical interventions are embraced by clinicians and patients alike.

Making sense of implementation theories, models and frameworks

BACKGROUND

Implementation science has progressed towards increased use of theoretical approaches to provide better understanding and explanation of how and why implementation succeeds or fails. The aim of this article is to propose a taxonomy that distinguishes between different categories of theories, models and frameworks in implementation science, to facilitate appropriate selection and application of relevant approaches in implementation research and practice and to foster cross-disciplinary dialogue among implementation researchers.

DISCUSSION

Theoretical approaches used in implementation science have three overarching aims: describing and/or guiding the process of translating research into practice (process models); understanding and/or explaining what influences implementation outcomes (determinant frameworks, classic theories, implementation theories); and evaluating implementation (evaluation frameworks). This article proposes five categories of theoretical approaches to achieve three overarching aims. These categories are not always recognized as separate types of approaches in the literature. While there is overlap between some of the theories, models and frameworks, awareness of the differences is important to facilitate the selection of relevant approaches. Most determinant frameworks provide limited "how-to" support for carrying out implementation endeavours since the determinants usually are too generic to provide sufficient detail for guiding an implementation process. And while the relevance of addressing barriers and enablers to translating research into practice is mentioned in many process models, these models do not identify or systematically structure specific determinants associated with implementation success. Furthermore, process models recognize a temporal sequence of implementation endeavours, whereas determinant frameworks do not explicitly take a process perspective of implementation.

Identifying and applying a targeted evidence-based practice change in the maternal/child health inpatient setting

As the literature on implementation research continues to expand, it's important to address the unique aspects and challenges of research dissemination and implementation in maternal/child health settings. This article describes a nurse-initiated evidence-based practice (EBP) study on urinary catheterization at a labor and delivery unit in the southwestern United States. It describes successful strategies for implementing EBP, as well as barriers encountered, and provides recommendations for the facilitation of EBP in the maternal/child inpatient setting.

Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model

BACKGROUND

In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link.

DISCUSSION

Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model's ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve.

CONCLUSIONS

In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process.