Laura Cullen, DNP, RN, FAAN 15 6/3/2019

Laura Cullen, DNP, RN, FAAN 15th Annual Methodist Research Day6/3/2019

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Evidence-Based Healthcare – Creating and Sustaining it with the Interprofessional Team

15th Annual Methodist Research Day

Laura Cullen, DNP, RN, FAANEBP ScientistOffice of Nursing Research & EBPDepartment of Nursing Services and Patient CareUniversity of Iowa Hospitals and Clinics

Greetings from Iowa and University of Iowa Hospitals and Clinics

[email protected]

https://uihc.org/nursing-iowa

Disclosure

Financial disclosure: 3M


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ObjectivesTeams are intended to “get everyone on the same page”

Discuss strategies for positive team functioning to promote evidence-based practice (EBP)

Describe team roles that support provision of evidence-based healthcare

Current state of healthcareThe pace of practice and change will continue

Pain Medication Administration Upon Admission after TKR

Cullen, Pennathur, Onsongo, Tripp Reimer, Farrington, Rakel, Herr, Strabala, Schomberg


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Organizational Leader’s RoleLeaders have responsibility to create the foundation

Big C’s FrameworkCommunication is foundational to quality healthcare

Communication

Coordination

Collaboration

Climate

Competence

Coordination


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Teams - OrganizationalBroadly reflect the stakeholders across clinical areas and roles. Be inclusive.

EVIDENCE-BASED PRACTICE IN ACTION

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EBP Project Director

Lead/Facilitate project Oversee process Collaborate with team Clinical expert Utilize experts Problem solve Establish meeting schedule Set agenda and run

meetings Determine timeline with

group Delegate work assignments

Keep team moving forward

Work closely with project practice mentor

Keep advisor and stakeholders well informed

Team meetingsEstablish working process decisions and ground rules early

Clear purpose and objectives

Identified process (establish the method to be followed)

Provide agendas

Chose a standing meeting time- cancel as needed

Use the action plan

Keep moving forward despite challenges

Seize opportunities

Look for easy solutions first

Report progress


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Team Rules

Active participation is expected

Everyone’s time is respected

Questioning is valued

Decisions are made by team consensus

Meetings generate action steps

Keep an open mind and let evidence lead to a solution


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EBP Project TimelineSteady progress toward the goal


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Benefits of Using Action Plans

Outlines steps in the EBP process

Identifies responsibility/accountability

Divides work

Sets goals by providing a timeline

Communicates work accomplished

Assists with review of next steps

Keeps projects moving forward


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EBP Action PlanFacilitates team work

Key Step or Objective

Specific Activity to Meet the Objective

Person Responsible

Resources Needed

Timeline Evaluation


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Project Director (name): Team:

Purpose

Reminders about Action PlanProvides solid ground for stable and strategic planning

Fluid and dynamic; not too rigid

Adjusted over time to meet project purpose and goals

Application-oriented

Identify next key steps or objectives

Breakdown into action steps

Delegate and collaborate

Collaboration


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Patient at the Center

LeadershipLeadership is a key to success and the role has not been well described

“Look for helpers. You will always find people who are helpers.”

-Mr. Rogers


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Teams – Unit/clinic SpecificCore groups expand the influence to reach each clinician team member

Cullen, L., Hanrahan, K., Farrington, M., DeBerg, J. Tucker, S., & Kleiber, C. (2018). Evidence-based practice in action: Comprehensive strategies, tools and tips from the University of Iowa Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau International.


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Change Agent Roles

Change Champion

Core Group

EBP Facilitator

Opinion Leader

Knowledge Broker


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EBP Facilitator/Mentor

Guide others through EBP process

Provide access to resources

Assist with most difficult steps Evidence Finding, appraising, and synthesis

Local data

Design and format the practice change

Developing implementation plan

Developing an evaluation plan

Anticipate and troubleshoot challenges

Keep project on track

Assure approvals are in orderEVIDENCE-BASED

PRACTICE IN ACTION

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Identifying an Opinion LeaderCredible, trusted, informal leader whose ideas and behaviors are a model for peers


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Opinion Leader


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Identifying EBP Change ChampionsCharacteristics of emerging leaders to consider for future opportunities


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EBP Change ChampionExpand the sphere of influence

Abdullah, Rossy, Ploeg, Davies, Higuchi, Sikora, & Stacey, 2014; Fleuren, Van Dommelen, & Dunnink, 2015; Greenhalgh, 2018; Hauck, Winsett, & Kuric, 2013; Kaasalainen, Ploeg, Donald, Coker, Brazil, Martin-Misener, Dicenso, Hadjistavropoulos, 2015; Ploeg, Skelly, Rowan, Edwards, Davies, Grinspun, Bajnok, & Downey, 2010; Titler, 2008; Rogers, 2003


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Unit/clinic Leaders Role

Unit/Clinic Leader Role in EBPKey role in success

Set expectations on unit

Facilitate work time

Discuss project with nursing staff & other disciplines

Cheerleading project importance

Track progress

Maneuvering in the system (key players, committees, etc.)


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Every Clinician is a Leaders

Climate

You want me to do what?Design the EBP intervention so it will work for the majority of patients and within the work flow


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TroubleshootEvery patient is unique and has unique characteristics to address

Design the practice change to meet the majority of most typical patients

Avoid delays from attempting to meet every patients needs

Retain core elements – required for desired outcome

Requires access to experts

Apply the best evidence

Clinician InputBring the perspective of stakeholders to the planning table

Listen to clinician questions

Select influential core group members

Use Precision Implementation Approach

Keep moving forward

Clinician TrainingClinicians have a role in keeping practice current and provision of EBP


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Be AdaptiveAnticipate that midstream corrections will be needed from lessons learned

vs.

PersistPersistence and keeping the end in mind will help you pervail

Begin by asking “how can we make this work”?

Build each initiative using a stepwise approach, linked to the goals

Never quit – do the right thing

“If not now, when? If not you, who”?

Track and Celebrate SuccessCelebration sets the bar so all will better understand expectations


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Competence

Evidence-Based Practice

Evidence-based practice is the process of shared decision-making between practitioner, patient and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information (STTI, 2008)

Integration of best research evidence with clinical expertise and patient values (Sackett et al, 2000)

Process/methodsIdentify the process or methods to be used early in team development

Iowa Model Collaborative, 2017, Worldviews on Evidence-Based Nursing


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Diffusion Model: Innovation-Decision Process

I.Knowledge

II.Persuasion

III.Decision

IV.Implementation

V.Confirmation

AwarenessAwareness, Attitude

& Behavior Change

Awareness &

Attitude Change

Passive Active Interactive

(Grol, Wensing & Eccles, 2005; Logan & Graham, 1998; Rogers, 2003; Veniegas, Kao, Rosales, & Arellanes, 2009)

I.Creating

Awareness & Interest

II.Building

Knowledge & Commitment

III.Promoting Action & Adoption

IV.Pursuing

Integration & Sustained Use

ImplementationMany decisions involved in implementation planning

Cullen, L. & Adams, S. (2012). Planning for Implementation of Evidence-Based Practice. Journal of Nursing Administration, 42(4), 222-230.

Leadership lessons TED talk

Phased Approach

EBP Implementation GuideImplementation planning is not linear and there are many options from which to choose

(Cullen & Adams, 2012)


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(Cullen & Adams, 2012)

Implementation Target

*Strategies with the strongest evidence base

Update Team for Sustaining the ChangeIntegrating the practice change requires build it into the system

Unit QI Coordinator Include in annual unit QI goals

Divisional QI Coordinator Report results on QM report form

Nurse Educator Orientation checklist

Competency assurance

Nursing Informatics

EBP Examples

Interprofessional Teams Improving Quality Healthcare


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Sample EBP initiatives and teamsTeam membership reflects the stakeholders

Oral mucositis during treatment for head and neck cancers Nurse-led

College of Dentistry; radiation technicians; MA; physicians; front desk personnel; hospital dentistry; OT; Oral pathologists; volunteers

Patient/family input

OR smoke plume evacuation Nurse-led

Surgeons; anesthesia; surgical technicians; supply chain

ICU early mobility Nurse-led

PT/OT; RT; physicians; LIP; NA; ergonomics specialist

Impact: WorkloadTeamwork – when done well, optimizes everyone’s strengths and reduces critical clinician workload

Big C’s FrameworkStrength of an organization is the people

Communication

CoordinationTeam work

Action planning

Collaboration

Patient

Leadership

Change Agent Roles

Climate

Troubleshooting

Clinician involvement

Adaptive

CompetenceEBP methods

Implementation science


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What I Need from You

Use 1-2-4-All• Silent self-reflection

- What are my needs- What are my challenges- What are my opportunities

• Share with your partner(s)- Discuss - Generate actionable requests

• Share with a foursome- What ideas stood out as most important

• Report two most important requests for your success in your clinical area(s)

http://www.liberatingstructures.com/7-15-solutions/

ConclusionWait! There is an “I” in team!

“There is no “I” in team, but there is in win.”-Michael Jordan

Questions &

Ideas

[email protected]

Thank you for promoting evidence-based healthcare


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Select References - Team

• AHRQ (2014). TeamSTEPPS 2.0 Essentials Course. Content last reviewed March 2019. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/teamstepps/instructor/index.html

• Almost, J., Wolff, A. C., Stewart‐Pyne, A., McCormick, L. G., Strachan, D., & D'Souza, C. (2016). Managing and mitigating conflict in healthcare teams: an integrative review. Journal of Advanced Nursing (John Wiley & Sons, Inc.), 72(7), 1490-1505.

• Baik, D., & Zierler, B. (2019). Clinical nurses' experiences and perceptions after the implementation of an interprofessional team intervention: A qualitative study. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 28(3/4), 430-443.

• Cullen, L., Hanrahan, K., Farrington, M., DeBerg, J., Tucker, S., & Kleiber, C. (2018). Evidence-Based Practice in Action: Comprehensive Strategies, Tools and Tips from the University of Iowa Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau International.

• Körner, M., Bütof, S., Müller, C., Zimmermann, L., Becker, S., & Bengel, J. (2016). Interprofessional teamwork and team interventions in chronic care: A systematic review. Journal of Interprofessional Care, 30(1), 15-28.

• Iowa Model Collaborative (2017). Iowa Model of Evidence-Based Practice: Revisions and Validation. Worldviews on Evidence Based Nursing, 14(3), 175-182. doi: 10.1111/wvn.12223.

• Miller, C., Kim, B., Silverman, A., Bauer, M. (2018). A systematic review of team-building interventions in non-acute healthcare settings. BMC Health Services Research, 18:146. https://doi.org/10.1186/s12913-018-2961-9

• Patterson, M. E., Bogart, M. S., & Starr, K. R. (2015). Associations between perceived crisis mode work climate and poor information exchange within hospitals. Journal of Hospital Medicine, 10(3), 152-159.

• Petit Dit Dariel, O., & Cristofalo, P. (2018). A meta-ethnographic review of interprofessional teamwork in hospitals: what it is and why it doesn't happen more often. Journal of Health Services Research and Policy, 23(4), 272-279.

• Salas, E., Wilson, K. A., Murphy, C. E., King, H., & Salisbury, M. (2008). Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Joint Commission Journal on Quality & Patient Safety, 34(6), 333-341.

• Sargeant, J., Loney, E., & Murphy, G. (2008). Effective interprofessional teams: 'contact is not enough' to build a team. Journal of Continuing Education in the Health Professions, 28(4), 228-234.

Select References –Change Champions• Abdullah, G., Rossy, D., Ploeg, J., Davies, B., Higuchi, K., Sikora, L., & Stacey, D. (2014). Measuring the

effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: A systematic review. Worldviews on Evidence-Based Nursing, 11(5), 284-300. doi: 10.1111/wvn.12060

• Fleuren, M. A., van Dommelen, P., & Dunnink, T. (2015). A systematic approach to implementing and evaluating clinical guidelines: The results of fifteen years of preventive child health care guidelines in the Netherlands. Social Science & Medicine, 136-137,35-43. doi:10.1016/j.socscimed.2015.05.001

• Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Quarterly, 82(4), 581-629. doi: 10.1111/j.0887-378X.2004.00325.x

• Hauck, S., Winsett, R. P., & Kuric, J. (2013). Leadership facilitation strategies to establish evidence-based practice in an acute care hospital. Journal of Advanced Nursing, 69(3), 664-674. doi: 10.1111/j.1365-2648.2012.06053.x

• Kaasalainen, S., Ploeg, J., Donald, F., Coker, E., Brazil, K., Martin-Misener, R., . . . Hadjistavropoulos, T. (2015). Positioning clinical nurse specialists and nurse practitioners as change champions to implement a pain protocol in long-term care. Pain Management Nursing, 16(2), 78-88. doi: 10.1016/j.pmn.2014.04.002

• Ploeg, J., Skelly, J., Rowan, M., Edwards, N., Davies, B., Grinspun, D., . . . Downey, A. (2010). The role of nursing best practice champions in diffusing practice guidelines: A mixed methods study. Worldviews on Evidence-Based Nursing, 7(4), 238-251. doi: 10.1111/j.1741-6787.2010.00202.x

• Titler, M.G. (2008). The evidence for evidence-based practice implementation. In R. Hughes (Ed.), Patient safety & quality - An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Available from: http://www.ahrq.gov/qual/nurseshdbk/

• Rogers, E. (2003). Diffusion of Innovation (5th ed.). New York: Free Press.

Select References – Opinion Leaders

• Anderson, C., & Titler, M. (2014). Development and verification of an agent-based model of opinion leadership. Implementation Science, 27;9:136. doi: 10.1186/s13012-014-0136-6.

• Breimaier, H., Halfens, R., Wilborn, D., Meesterberends, E., Haase Nielsen, G., Lohrmann, C. (2013). Implementation Interventions Used in Nursing Homes and Hospitals: A Descriptive, Comparative Study between Austria, Germany, and the Netherlands. International Scholarly Research Notices, 14,http://dx.doi.org/10.1155/2013/706054

• Carpenter, C.R., Sherbino, J. (2010). How does an "opinion leader" influence my practice? CJEM, 12(5), 431-4. • Farley, K., Hanbury, A., Thompson, C. (2014). Gathering opinion leader data for a tailored implementation

intervention in secondary healthcare: a randomised trial. BMC Medical Research Methodology. 10;14:38. doi: 10.1186/1471-2288-14-38.

• Flodgren, G, Parmelli, E., Doumit, G., Gattellari, M., O'Brien, M.A., Grimshaw, J., Eccles, M.P. (2011). Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Systematic Reviews, 10;(8):CD000125. doi: 10.1002/14651858.CD000125.pub4.

• Lugtenberg, M., Burgers, J., Han, D., Westert, G. (2014). General preferences for interventions to improve guideline adherence. Journal of Evaluation in Clinical Practice, 20(6). 820-6. doi: 10.1111/jep.12209.

• Miech, E. (2016). Inside Help: A Systematic Review of Champions in Healthcare-Related Implementation. QUERI Implementation Network. Retrieved July 27, 2016, from: http://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=1160

• Rogers, E. (2003). Diffusion of Innovation (5th edition). New York: Free Press. • Rosen, B.L., Goodson, P., Thompson, B., Wilson ,K.L. (2015). School nurses' knowledge, attitudes, perceptions of

role as opinion leader, and professional practice regarding human papillomavirus vaccine for youth. Journal of School Health. 85(2):73-81. doi: 10.1111/josh.12229.

Laura Cullen, DNP, RN, FAAN 15 6/3/2019

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