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Evidence-based nursing

Evidence-Based Nursing or EBN is a type of evidence-based healthcare, drawing

on some of the traditions ofevidence-based medicine. It involves identifying solid

research findings and implementing them in nursing practices, in order to increasethe quality of patient care. The goal of EBN is to provide the highest quality and

most cost-efficient nursing care possible. EBN is a process founded on the

collection, interpretation, and integration of valid, important, and applicable

research. Some define EBN tightly, considering only the application of the findings

ofrandomized clinical trials, while others also include the use of case reports and

expert opinions.[1] In order to practice evidence based nursing, practitioners must

understand the concept of research and know how to accurately evaluate this

research. These skills are taught in modern nursing education and also as part of

professional training.

The 5 steps of EBN

he first step is to select a topic. Ideas come from different sources but are categorized in twoareas: Problem-focused triggers and Knowledge focused triggers(see below). When selecting atopic, nurses should formulate questions that are likely to gain support from people within theorganization. An interdisciplinary medical team should work together to come up with anagreement about the topic selection. The priority of the topic should be considered as well as theseverity of the problem. Nurses should consider whether the topic would apply to many or fewclinical areas. Also, the availability of solid evidence should be considered because providingproof of the research will increase staffs' willingness to implement into nursing practice.

[edit] Problem & Knowledge Focused Triggers

Problem focused triggers are identified by health care staff through quality improvement, risksurveillance, benchmarking data, financial data, or recurrent clinical problems. Problem focusedtriggers could be clinical problems, or risk management issues.

Knowledge focused triggers are created when health care staff read research, listen to scientificpapers at research conferences or encounter EBP guidelines published by federal agencies ororganizations. Knowledge based triggers could be new research findings that further enhancenursing, or new practice guidelines.

It is important that individuals work closely together to reach the optimum outcome for thechosen topic. Some things that would ensure collaboration are working in groups to reviewperformance improvement data, brainstormingabout ideas, and achieving consensus about thefinal selection.1
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[edit] Form a Team

Some might become overwhelmed when they first learn about EBP and apply it for reasons otherthan improvement of patient care. Forming a team increases the chance of EBP being adopted. Ateam becomes paramount in implementation, and evaluation of the EBP. It is important to have

representatives of the team from authority members of the organization and also grassrootmembers. It is also important to consider interdiscipline involvement to decrease rejection, andfor all to have an understanding of the project. All these individuals have a great impact on thepossibility of successful implementation. Other factors to put into consideration include powerfigures in the organization who may directly or indirectly sabortage the efforts if they are notconsulted, and fully included in EBP implementation. The EBP team should have explanationsthat clearly define the types of patients, setting, outcomes, interventions and exposures. Thisshould be in simplified language that is comprehensible to a lay person.

The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitableand their role becomes pivotal. The approach they adopt and their ability to educate the

coworkers, answer their questions, and clarify any misconceptions greatly improves theoutcomes.

[edit] Evidence Retrieval

One of the most challenging issues in using EBP in the clinical setting is learning how toadequately frame a clinical question so that an appropriate literature review can be performed.When forming a clinical question the following should be included: the disorder or disease of thepatient, the intervention or finding being reviewed, possibly a comparison intervention, and theoutcome.[2] An acronym used to remember this is called the "PICO" model:

P = Who is the Patient Population?

I = What is the potential Intervention or area of Interest?

C = Is there a Comparison intervention or Control group?

O = What is the desired Outcome?

Once the topic is selected, the research relevant to the topic must be reviewed, in addition toother relevant literature. It is important that clinical studies, systematic reviews, (including meta-analyses, metasyntheses and meta-aggregation) and well-known and reliable existing EBPguidelines are accessed in the literature retrieval process. With the internet at ones fingertips, a

plethora of research is just a few clicks away. However, just because you found it in arespectable journal does not signify high quality research. When reviewing any article forevidence retrieval read it very closely. Articles can appear to be precise and factual on thesurface but with further and much closer examination, flaws can be found. The article can beloaded with opinionated and/or biased statements that would clearly taint the findings, thuslowering the creditability and quality of the article. Use of rating systems to determine thequality of the research is crucial to the development of EBP. There are several rating systems
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available online. TheNational Guideline Clearinghouse is a database of published EBP guidelineabstracts.[3]

Time management is crucial to information retrieval. Nurses making their way through the vastamount of research available may find it helpful to read research articles or critical reviews

instead of clinical journals. To maintain high standards for EBP implementation, education inresearch review is necessary to distinguish good research from poorly conducted research.Equally important is that the materials being reviewed, consider if they are current.[

Apply the Evidence

After determining the internal and external validity of the study , a decision is arrived at whetherthe information gathered does apply to your initial question. Its important to address questionsrelated to diagnosis, therapy, harm, and prognosis. The information gathered should beinterpreted according to many criteria and should always be shared with other nurses and/orfellow researchers.[5]

[edit] Qualitative Research Process

One method of research for Evidence based practice in nursing is 'Qualitative Research': "Theword implies a entity and meanings that are not experimentally examined or measured in termsof quantity, amount, frequency, or intensity." With qualitative research, researchers learn aboutpatient experiences through discussions and interviews. The point of qualitative research is to provide beneficial descriptions that allow insight into patient experiences. "Hierarchies ifresearch evidence traditionally categorize evidence from weakest to strongest, with an emphasison support for the effectiveness of interventions. That this perspective tends to dominate theevidence-based practice literature makes the merit of qualitative research unclear;" 1 Some

people view qualitative research as less beneficial and effective, with its lack of numbers, thefact that it is "feeling-based" research, makes the opponents associate it with bias. Nevertheless,the ability to empathetically understand an individual's experience (whether it be with cancer,pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care workersproviding care.

For qualitative research to be reliable, the testing must be unbiased. To achieve this, researchersmust use random and non-random samples to obtain concise information about the topic beingstudied. If available, a control group should be in use, if possible with the qualitative studies thatare done. Evidence should be gathered from every available subject within the sample to createbalance and dissolve any bias. There should also be several researchers doing the interviewing to

obtain different perspectives about the subject. Researchers must also obtain negativeinformation as well as the positive information gathered to support the data. This will help toshow the researchers were unbiased and were not trying to hide negative results from readers,and actually makes it possible to objectively understand the phenomenon under investigation.The inclusion of this negative information will strengthen the researchers initial study, and mayactually work in favor to support the hypothesis. Any data that has been gathered must beappropriately documented. If the data collected was obtained from interviews or observation, itmust all be included. Dates, times and gender of the sample may be needed, providing
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background on subjects, such as breast cancer in women over thirty-five. Any pertinentinformation pertaining to the sample must be included for the reader to judge the study asworthy.

In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that

clinical decision making should be based on the "best evidence" available, preferably thefindings of randomized clinical trials. Within this context qualitative research findings areconsidered to have little value and the old debate in nursing has been re-ignited related as towhether qualitative versus quantitative research findings provides the best empirical evidence fornursing practice. In response to this crisis qualitative scholars have been called upon by leadersin the field to clarify for outsiders what qualitative research is and to be more explicit in pointingout the utility of qualitative research findings. In addition, attention to "quality" in qualitativeresearch has been identified as an area worthy of renewed focus. Within this paper two key problems related to addressing these issues are reviewed: disagreement not only among"outsiders" but also some nursing scholars related to the definition of "qualitative research", anda lack of consensus related how to best address "rigor" in this type of inquiry.

Based on this review a set of standard requirements for qualitative research published in nursingjournals is proposed that reflects a uniform definition of qualitative research and an enlarged yetclearly articulated conceptualization of quality. The approach suggested provides a frameworkfor developing and evaluating qualitative research that would have both defensible scholarlymerit and heuristic value. This will help solidify the argument in favor of incorporatingqualitative research findings as part of the empirical "evidence" upon which evidence-basednursing is founded.

[edit] How to Critique a Research Article

The critiquing process is the building block and foundation for the multiple steps that are tofollow in the successful implementation of EBP. This is so because you must first ensure that thematerial and research that you are trying to convince others to accept is reliable and accurate. Bytaking the time to thoroughly critique a study you can point out both the strengths andweaknesses of the findings and weigh them accordingly. Successful completion of this vital stepwill help "weed out" the material lacking the needed proof of effectiveness, therefore minimizinguseless, or even harmful, implementation of new practices in the healthcare field.

Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) anarticle. In analyzing a research report, the reader must evaluate each step of the research processand ask questions about whether each step of the process meets the criteria. Remember when you

are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique anarticle you must have some knowledge on the subject matter. There is no replacement for readingthe article many times. The reader must search the article for contradictions, illogical statements,and faulty reasoning. It is important to evaluate every section of the research article. Each sectionhas different criteria to meet, in order to be considered a well-written addition to the article.
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[edit] Introduction, Purpose, and Hypothesis

Introductions need to at least include a literature review and a purpose statement, but they mayalso contain a theoretical framework, a research question, and a hypothesis. The researchquestion presents the idea that is to be examined in the study and is the foundation of the

research study. A well-developed research question guides a focused search for scientificevidence about assessing, diagnosing, treating, or assisting patients with understanding of theirprognosis related to a specific health problem. The hypothesis attempts to answer the researchquestion. A hypothesis is a declarative statement about the relationship between two or morevariables that predicts an expected outcome. Characteristics of a hypothesis include arelationship statement, implications regarding testability, and consistency with a defined theorybase. They can be formed by either a directional or nondirectional method. The literature reviewneeds to explain the reason the study was conducted and why it was important for the study to beconducted now. The theoretical framework and the literature review should also work together.The purpose statement needs to explain what the study wants to accomplish. The purpose, aims,or objectives often provide the most information about the intent of the research question and

hypothesis and suggest the level of evidence to be obtained from the findings of the study. Theintroduction should cover these topics, and should not throw in a lot of excess, uselessknowledge. The research question, hypothesis, and the study should all correlate together. Youhave to be careful when critiquing research articles because sometimes researchers will try tocover up a poor study with lots of information that does not belong. It may look good to thereader at first glance so it is always a good idea to reread the articles a few times to fullyunderstand it and to see if there are any discrepancies.

[edit] Methodology

The methodology section must start off by gathering a sample. There are a few definitions you

must understand first. 'Population' is the group that you want you study findings to apply to. A'sample frame' is the target population, in which the study will affect. There are three differentways to select a population. The researchers can choose who they want in the study, theparticipants can choose if they want to be in the study, or it can be a random selection in which

neither the researcher or the participant chooses. The study must either haveexternal validityor

internal validity. If the study has external validity then the study's findings have differentsettings, procedures, and participants. External validity will also question what types of subjects

and conditions in which the same results can be expected to occur. If the study has internal

validity then the findings are held true within the sample. The researchers will rule out factors

or threats as rival explanations of the relationship between the variables that are present. Becareful with internal validity and external validity because there are a number of threats for

both that can affect the outcome of the study. These should be considered by the researchers whoare planning the study and by consumers before implementing the results into practice.

Phenomenological method In qualitative research phenomenological methods are used to learnand construct the meaning of the human experience through intensive dialogue with persons whoare living the experience. The researcher's goal is to explain the meaning of the experience to theparticipant. This is achieved through a dialogic process, which is more than a simple interview.
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[edit] Results and Discussion

The results section puts forth the findings of a study in a clear, logical, and unbiased manner. Itpresents the findings according to the variables studied without extrapolating beyond what thosevariables yielded. Qualitative studies do not contain statistical tests. Therefore, the themes,

concepts, observational or print data are described in the "Methods" or "Data Collection"subtitles and are reported in the "Results" or "Findings" section. A good results section shouldalso make use ofdescriptive statistics. Descriptive statistics are used to summarize, reduce, andorganize the data and characteristics of the data into an easily understood, manageable format.Finding data's mode, median, and mean are three techniques used to easily recognize centraltendency. Techniques such as range and standard deviation are used to measure variability andscatter plots are used to measure correlation. After analyzing the data and finding centraltendency, variability, and correlation, this information should be worked into an easilyunderstood format such as a frequency distribution table, chart, or graph. The reader should beable to easily recognize and interpret the data. However, the reader must be on alert to recognizethat this may yet be another opportunity for the author of the study to make the results appear

more grandiose than they are. Always look at what the actual numbers amount to instead of justlooking at how significant the graph or chart makes the data look. In a good results section, theauthor will not try to make insignificant data look significant, but simply show the results. If thenumerical data of a study does not show the same claims that the researcher stated then this is amajor flaw in the study and raises significant concerns about the study's validity and reliability;therefore, a nurse and other healthcare providers should not only stay current on new researchbut should be able to decipher the research in order to determine its true value to the medicalpractice.

The very last section of a research study is known as the discussion section. Here, theresearchers draw all the pieces from the study together to present the whole picture. The

researchers review the literature and discuss how the results compare and contrast previouslycompleted studies. The researchers often present biased opinions in the discussion section butthese should always be supported by the research and not just the interpretation of theresearchers. This overview of the study serves to make a comparison with the backgroundliterature. The results and discussion sections can sometimes be combined into one by theresearcher, but normally, the researcher will report the findings into separate "results" and"discussion" sections. One way is not better than the other when it comes to combining ordividing the findings into sections. Any new or unexpected results are usually described in thediscussion section as well.

[edit] Evaluating The Conclusion

A conclusion can be identified as paragraphs that state the main claims that came out of thefindings that were read earlier in the article. It should have a summary of the findings (strengthsand weaknesses), status of the hypothesis, limitations, and recommendations, implications, orapplications. In each section the best and worst needs to brought forth. In a quality conclusionsection the author will only state what has been found, or not, without adding anything extra. Thehypothesis will be proven true or false and nothing in between. Limitations will be discussedsuch as the statistical framework or design errors made in the beginning. The researcher should
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also present the limitations or weaknesses of the study. This presentation is important because iteffect's the studies generalizability. The generalizations or inferences about similar findings inother samples also are presented in light of the findings. Recommendations will be few in qualityresearch. If no loop holes or oversights are made at the beginning then these will not have to beexpressed at the end. When all of these come together in a simplified manner then a conclusion

can be considered strong.

A limitation is an admission of how certain aspects of the study, such as the sampling, were notas unbiased as they should have been. This lets the reader know that improvements can be madefrom what was accomplished in the article.

The last thing the conclusion should do is give the reader a recommendation. Thisrecommendation should be derived from the results gathered earlier in the article. Based on theresults, the reader will be able to judge whether the data and hypothesis should be applied tonursing practice.[6]

Barriers to promoting Evidence Based Practice

The use of evidence based practice depends a great deal on the nursing student's proficiency atunderstanding and critiquing the research articles and the associated literature that will bepresented to them in the clinical setting. According to, Blythe Royal, author ofPromotingResearch Utilization in nursing: The Role of the Individual, Organization, and Environment, alarge amount of the preparation requirements of nursing students consists of creating care plansfor patients, covering in depth processes of pathophysiology, and retaining the complexinformation of pharmacology. These are indeed very important for the future of patient care, buttheir knowledge must consist of more when they begin to practice. Evidence based nursing in anattempt to facilitate the management of the growing literature and technology accessible to

healthcare providers that can potentially improve patient care and their outcomes.[7]

NancyDickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change agents increating and implementing community and population-focused health systems."[8] There is also aneed to overcome the barriers to encourage the use of research by new graduates in an attempt toensure familiarity with the process. This will help nurses to feel more confident and be morewilling to engage in evidence based nursing. A survey that was established by the Honor Societyof Nursing and completed by registered nurses proved that 69% have only a low to moderateknowledge of EBP and half of those that responded did not feel sure of the steps in the process.Many responded, "lack of time during their shift is the primary challenge to researching andapplying EBP."[9]There is always and will always be a desire to improve the care of our patients.The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle

in need of evidence based healthcare. The necessity to overcome the current issues is to gainknowledge from a variety of literature not just the basics. There is a definite need for nurses, andall practitioners, to have an open mind when dealing with the modern inventions of the futurebecause these could potentially improve the health of patients.

There are many barriers to promoting evidence based practice. The first of which would be thepractitioner's ability to critically appraise research. This includes having a considerable amountof research evaluation skills, access to journals, and clinic/hospital support to spend time on
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EBN. Time, workload pressures, and competing priorities can impede research and development.The causes of these barriers include nurse's and other professional practitioners lack ofknowledge of research methods, lack of support from professional colleagues and organizations,and lack of confidence and authority in the research arena. [10] Another barrier is that the practiceenvironment can be resistant to changing tried and true conventional methods of practice. This

can be caused because of reluctance to believe results of research study over safe, traditionalpractices, cost of adopting new practices, or gaining momentum to rewrite existing protocols.[11]

It is important to show nurses who may be resistant to changes in nursing practice the benefitsthat nurses, their patients, and their institutions can reap from the implementation of evidence-based nursing practice, which is to provide better nursing care. [12] Values, resources and evidenceare the three factors that influence decision-making with regard to health care. All registerednurses and health care professionals should be taught to read and critically interpret research andknow where to find articles which relate to their field of care. In addition, nurses need to be moreaware of how to assess the information and determine its applicability to their practice.[13]

Another barrier to implementing EBN into practice is lack of continuing education programs. [14]

Practices do not have the means to provide workshops to teach new skills due to lack of funding,staff, and time; therefore, the research may be tossed dismissed. If this occurs, valuabletreatments may never be utilized in patient care. Not only will the patients suffer but the staffwill not have the opportunity to learn a new skill. Also, the practitioners may not be willing toimplement change regardless of the benefits to patient care.

Another barrier to introducing newly learned methods for improving treatments or patients'health is the fear of "stepping on one's toes". New nurses might feel it is not their place tosuggest or even tell a superior nurse that newer, more efficient methods and/or practices areavailable.

The perceived threat to clinical freedom offered by evidence-based practice is neither logical norsurprising. Resistance to change and to authority is part of human nature. When we makedecisions based upon good quality information we are inconsistent and biased. Human natureoffers many challenges to evidence-based practice. Can we do a better job of promotingevidence-based practice? And even if we find and use the evidence, will we make consistentunbiased decisions?

Even if clinicians do act consistently it is possible that their decisions are consistently biased.People put different values on gains and losses. Tversky and Kahneman gave people the twoidentical problems (with the same probabilities of life and death outcomes - see fig 1) but framedthe outcome choices as either lives saved or as deaths.10 Most people wanted to avoid takingrisks with gains which could be safeguarded, but would take risks with losses which might beavoided; this is a framing effect. If people are given identical options but different words areused to emphasize a gain rather than a loss, then a different response is given by a largeproportion of the population under study. Such a change in response appears to be inconsistent
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Implementing Evidence-Based Nursing

Practice

A methodology for establishing and supporting evidence-based nursing practice is examined.Description of a clinical and administrative scenario serves as an example of a systematicappraisal of the relevant literature that had implications for clinical practice.

Abstract

Within the nursing profession, it is expected that new information in the form of researchfindings will be incorporated constantly and knowledgeably into nursing practice. The staff nurseis a critical link in bringing research-based changes into clinical practice. Depending on theenvironment, a health care organization may or may not have the resources to ensure critical,succinct, reasonable evaluation and application of research findings as they relate to the point-of-

care delivery. Health care organizations are beginning to create mechanisms to facilitate theprocess of information translation from the literature to practice.

Introduction

The Purpose of this article is to describe a methodology for establishing and supportingevidence-based nursing practice (EBNP). After establishing the background for this project,authors describe a clinical and administrative scenario in which an issue was identified thatwarranted a systematic appraisal of the relevant literature to inform clinicians. An operationaldefinition for EBNP is presented, and a conceptual framework for translating evidence intopractice is outlined. Next, a case study is presented to describe the process of critically

appraising the evidence and translating the findings into nursing practice, education, andadministration. The clinical and administrative outcomes are highlighted and the roles of EBNPteam members explained.

The hospital described in this article has 205 licensed beds, 15 operating rooms, and a level IIemergency department. Inpatient specialty units include critical and intermediate care as well asseveral medical/surgical units serving various specialties (orthopedics, neurology andneurosurgery, hematology and oncology, bone marrow transplant, solid organ transplant,cardiology, and cardiac surgery). The environment is technology based, with an electronicmedical record for all nursing documentation, telemetry available to each inpatient bed, anepilepsy monitoring unit, electronic supply charging, filmless radiology, wireless phones for

each nurse, and a robotic surgical system. The hospital staff members are registered nursesassisted by patient care assistants. Staff participation in nursing committees is encouraged.Support staff include unit-based educators and specialty-based clinical nurse specialists (CNSs).Participation in nursing and other clinical research studies is encouraged.

In examining the issue of translating research-based evidence into practice, authors focused oncollaboration, service, and integration. Each of these components figures prominently in thework performed at the medical center. The approach selected to use research in practice reflects


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the structure and mission of the organization, which is to provide the best care for the patientusing the three "shields" of practice, education, and research. The themes of collaboration,service, and integration were used to weave together the expertise of library sciences and nursingservices as well as collaboration among the nursing practice subcommittee (NPS), the nursingeducation subcommittee (NES), and the nursing research subcommittee (NRS). This project is an

example of the integration of the work of these three subcommittees that was presented to thenursing staff in an attempt to identify the best possible service for patients.

Nursing Innovations

By David Ollier Weber

A number of initiatives founded by nurses have saved countless lives and millions of dollars.

David Ollier Weber

We all know what nurses do.

Well, to be sure, some fly in helicopters. Some deliver babies. Some sit at the head of anoperating table administering anesthesia. Some oversee the front-line primary care of patients atclinics and neighborhood medical offices. Some teach in colleges and universities. Some serve as

senior executives of hospitals and medical enterprises.

Mostly, though, we think of nurses as tending the sniffles and skinned knees of schoolchildren,staffing physician practices, bustling among the elderly in nursing homes and solicitouslybending over patients in hospital ICUs and medical units. Those really are the settings in whichthe vast majority of registered nurses work. They pop into rooms to deliver medications, changeIVs, re-bandage wounds, check vital signs and, in the process, maybe fluff a pillow, empty abedpan and murmur an encouraging word. They walk on soft soles. They hunch in the dim lightof nursing stations, carefully charting. They speak in low, soothing tones.

Nurses are consistently ranked by respondents to the Gallup Poll as the most trusted, most honest

and ethical of American workers.

Thats no small point of pride to Pat Ford-Roegner, M.S.W., R.N. But as president of theAmerican Academy of Nursing (AAN), she wants the world to know that her profession hasmore to contribute than stereotypical, susurrous bedside TLC.

At a time when the U.S. health care system is displaying all the signs of septic shockinaccessible to many, expensive for most and fragmented for all, the AAN summarizes


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Ford-Roegners organization has launched a campaign, Raise the Voice, to bring nursing intodeliberations over how to resuscitate the failing patient.

Cases in Point

In fact, nurses can already point to dozens of remarkably effective initiatives theyvespearheaded to improve the quality and, concomitantly, the scope, equity, efficiency andeconomy of American health care. Consider these nurse-driven programs and their results:

Evercare. Introduced in 1987 by two Minnesota nurse practitioners, Jeannine Bayard andRuthAnn Jacobson, the Evercare model today serves more than 120,000 people in 35 statesthrough Medicaid, Medicare and private-pay health plans. Evercare was designed to overcomethe fragmentation of resources that drive up medical costs and contribute to poor outcomes forpeople with long-term or advanced illnesses, the elderly and those with disabilities.

The Evercare model places a nurse practitioner or care manager at the center of an integrated

team that includes the enrollees physicians, family members and nursing home staff orrepresentatives from community service agencies. Working with the enrollee and the care teamto develop a personalized plan, the nurse practitioner or care manager coordinates multipleservices, facilitates communication among the various physicians, institutions, patients and theirfamilies, and helps ensure effective integration of treatments.

Where Evercare has been adopted, it has reduced hospitalizations for nursing home residents by45 percent and cut emergency room trips by 50 percent. The state of Texas estimated that itsaved some $123 million in Harris County alone between February 2000 and January 2002 byimplementing this nurse-inspired innovation.

Nurse-Family Partnership. Headquartered in Denver, the Nurse-Family Partnership servesfirst-time mothers in low-income families in more than 280 counties in 23 states across thenation. Under the program, a registered nurse provides in-home advice and care to primiparouswomen through frequent visits14 during pregnancy, 28 during infancy and 22 during thetoddler stageover a two-and-a-half-year period.

The Nurse-Family Partnership has shown dramatic results. Studies indicate pregnancy-inducedhypertension among participating women is reduced by 35 percent, preterm deliveries forwomen who smoke are reduced by 79 percent, child abuse and neglect is reduced by 50 percent,emergency room visits are reduced by 35 percent overall and by 56 percent for accidents andpoisoning, and language delays in children at 21 months of age are down 50 percent. Indeed, the

Washington State Institute for Public Policy found that the program had the highest return oninvestment among all home visiting and child welfare programs evaluated, with a net benefit tosociety of $17,180 (in 2003 dollars) per family served$2.88 saved for every dollar invested.

Family Health and Birth Center. Founded by Ruth Watson Lubic, Ed.D., R.N., and housed ina former supermarket in a low-income section of Washington, D.C., this exemplary facilityprovides modern birthing, comprehensive womens and childrens health care, social support,and early childhood development services in a nurse-driven setting.


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Backed by hospital obstetrical and gynecological consultants, nurse midwives at the FamilyHealth and Birth Center delivered 150 babies in 2006, 25 percent at the facility. After less thansix years of operation, the program in 2005 recorded a 9 percent preterm birthrate as comparedwith 14.2 percent for the District of Columbia overall, a low birth weight incidence of 7 percentcompared with 14.6 percent, and a Caesarean section rate of 15.3 percent versus 29 percent.

Those achievements in a medically underserved community translated to reduced costs for theDistrict of Columbias health care system of at least $1.15 millionmore than the centers totalannual operating budget.

11th Street Family Health Services, Drexel University. This nurse-managed center, founded in1998, brings a full range of primary care, dental, behavioral health, health promotion, anddisease prevention services to residents of four public housing developments and theirsurrounding urban community in Philadelphiawhere 57 percent of patients are covered by thestate Medicaid plan and 33 percent are uninsured.

No one who shows up at 11th Street is turned away. In 2005-06, more than 19,000 visits were

recorded. Not only does the center provide one-stop shopping for health concerns to its largelyAfrican-American clients, it boasts a fitness center, a teaching kitchen, and weekly distributionof fresh fruits and vegetables.

Almost 8,000 primary care visits took place in 2006, with significant documented benefits topatients. Hemoglobin A1C levels among 11th Streets diabetic patients were reduced by 20percent; almost 70 percent of hypertensive program clients now have their blood pressure undercontrol (for African-Americans that far exceeds the nationwide 2010 goal of 50 percent, from a2000 national baseline of 19 percent); immunization rates for adults were increased by 14percent; and sharp improvements were recorded in the number of low birth-weight babies,depression rates in vulnerable adults with chronic illness and breast cancer screening rates.

APN Transitional Care Model. Poor hospital discharge planning and follow-up of elderlypatients frequently results in costly and debilitating readmissions that could have been prevented.Aetna and Kaiser Permanente are now testing a model developed at the University ofPennsylvania School of Nursing under which advanced practice nurses (APNs, all of whom havemasters degrees) establish a relationship with patients and their families soon after hospitaladmission; design the discharge plan in collaboration with the patient, the patients physician andfamily members; and implement the plan in the patients home following discharge, substitutingfor traditional skilled nursing follow-up.

Three clinical trials funded by the National Institute of Nursing Research confirmed that theAPN Transitional Care Model improves quality and substantially decreases health care costs.Compared with standard care there are longer intervals before initial rehospitalizations, fewerrehospitalizations overall, shorter hospital stays and greater patient satisfaction. In a four-yeartrial with a group of elderly patients hospitalized for heart failure, the APN Care Model cutinpatient costs by more than $500,000 compared with a group who received standard careforaverage savings of approximately $5,000 per Medicare patient.

Edge Runners


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Those are just a handful of 35 thoroughly documented innovationsall readily replicable andadaptabledesigned by nurses and outlined on theAAN Web site. Each was formulated by whatthe organization lauds as edge runnersnurses whose ability to think outside conventionalboxes spurred major improvements in local, regional and even national health care delivery.(Each profile also includes the telephone number and e-mail address of a contact person for more

information.)

Funded by the Robert Wood Johnson Foundation, the Raise the Voice campaign kicked off inNovember 2006 to highlight nursings leadership in devising practical solutions to healthcares systemic problems, declares Ford-Roegner. Donna Shalala, president of the University ofMiami and former Secretary of Health & Human Services, chairs its prestigious nationaladvisory board.

Health care reform was a major issue in the 2008 presidential election; it will clearly commandthe attention of legislators, physician organizations, insurers, purchasers, pharmaceutical andmedical technology companies, hospital executives, academics, and consumer groups throughout

the country in the months ahead.

Nurses have ideas and need to be engaged at the highest level of discussion, emphasizes Ford-Roegner.

After all, whether its you whos sick or its your health care system, who are you going to call?

You could do worse than to start with the advice of a nurse.

David Ollier Weberis principal of The Kila Springs Group in Placerville, Calif. He is also a

regular contributor to H&HN Weekly.
http://www.aannet.org/i4a/pages/index.cfm?pageid=3303http://www.aannet.org/i4a/pages/index.cfm?pageid=3303http://www.aannet.org/i4a/pages/index.cfm?pageid=3303

Evidence 03

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