Ellen Fineout-Overholt

The Evidence‐Based Practice Beliefs and Implementation Scales: Psychometric Properties of Two New Instruments

BACKGROUND Implementation of evidence-based practice (EBP) by health professionals is a key strategy for improving health care quality and patient outcomes as well as increasing professional role satisfaction. However, it is estimated that only a small percentage of nurses and other health care providers are consistently using this approach to clinical practice. AIM The aim of this study was to report on the development and psychometric properties of two new scales: (1) the 16-item EBP Beliefs Scale that allows measurement of a persons beliefs about the value of EBP and the ability to implement it, and (2) the 18-item EBP Implementation Scale that allows measurement of the extent to which EBP is implemented. METHODS Nurses (N= 394) attending continuing education workshops volunteered to complete the scales. Data were analysed to evaluate reliability and validity of both instruments. RESULTS Cronbachs alpha was > .90 for each scale. Principal components analysis indicated that each scale allowed measurement of a unidimensional construct. Strength of EBP beliefs and the extent of EBP implementation increased as educational level increased (p < .001) and as responsibility in the workplace increased (p < .001). CONCLUSION In this study, initial evidence was provided to support the reliability and validity of the EBP Beliefs and Implementation Scales in a heterogeneous sample of practicing nurses. EVIDENCE TO ACTION: Use of the scales in future research could generate evidence to guide EBP implementation strategies in practice and education. Results could establish the extent to which EBP is being implemented and its effect on clinician satisfaction and patient outcomes.

The Establishment of Evidence‐Based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses in Real‐World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs

BACKGROUND Although it is widely known that evidence-based practice (EBP) improves healthcare quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still not the standard of care delivered by practicing clinicians across the globe. Adoption of specific EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health care. AIM The aim of this study was to develop a set of clear EBP competencies for both practicing registered nurses and APNs in clinical settings that can be used by healthcare institutions in their quest to achieve high performing systems that consistently implement and sustain EBP. METHODS Seven national EBP leaders developed an initial set of competencies for practicing registered nurses and APNs through a consensus building process. Next, a Delphi survey was conducted with 80 EBP mentors across the United States to determine consensus and clarity around the competencies. FINDINGS Two rounds of the Delphi survey resulted in total consensus by the EBP mentors, resulting in a final set of 13 competencies for practicing registered nurses and 11 additional competencies for APNs. LINKING EVIDENCE TO ACTION Incorporation of these competencies into healthcare system expectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion processes could drive higher quality, reliability, and consistency of healthcare as well as reduce costs. Research is now needed to develop valid and reliable tools for assessing these competencies as well as linking them to clinician and patient outcomes.Background Although it is widely known that evidence-based practice (EBP) improves healthcare quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still not the standard of care delivered by practicing clinicians across the globe. Adoption of specific EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health care. Aim The aim of this study was to develop a set of clear EBP competencies for both practicing registered nurses and APNs in clinical settings that can be used by healthcare institutions in their quest to achieve high performing systems that consistently implement and sustain EBP. Methods Seven national EBP leaders developed an initial set of competencies for practicing registered nurses and APNs through a consensus building process. Next, a Delphi survey was conducted with 80 EBP mentors across the United States to determine consensus and clarity around the competencies. Findings Two rounds of the Delphi survey resulted in total consensus by the EBP mentors, resulting in a final set of 13 competencies for practicing registered nurses and 11 additional competencies for APNs. Linking Evidence to Action Incorporation of these competencies into healthcare system expectations, orientations, job descriptions, performance appraisals, and clinical ladder promotion processes could drive higher quality, reliability, and consistency of healthcare as well as reduce costs. Research is now needed to develop valid and reliable tools for assessing these competencies as well as linking them to clinician and patient outcomes.

Evidence-based practice, step by step: sustaining evidence-based practice through organizational policies and an innovative model.

The team adopts the Advancing Research and Clinical Practice Through Close Collaboration model.This is the 12th and last article in a series from the Arizona State University College of Nursing and Health Innovations Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When its delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved. The complete EBP series is available as a collection on our Web site; go to www.ajnonline.com and click on Collections.

Consumer preferences and values as an integral key to evidence-based practice.

Although evidence-based practice (EBP) integrates the best evidence from well-designed studies with a clinicians expertise and patient preferences and values, most of what is emphasized in books and reports on EBP is the 5-step EBP process. However, the consideration of patient values and preferences in making clinical decisions is essential to deliver the highest quality of care. This article briefly reviews the status of EBP in the United States, described the ARCC mentorship model, and highlights how to engage consumers in the EBP process.

Getting evidence into practice–understanding knowledge translation to achieve practice change

In 2008, Fineout-Overholt, Stillwell, and Kent commented that educating clinicians and students about evidence-based practice (EBP) can be challenging because, for many, a cognitive paradigm shift is required. Problem solving is commonplace in practice and for the past decade efforts have been made to encourage clinicians to question practice and to base their decisions on a sound evidence base, rather than following traditional practices and relying on rituals. Unfortunately, as Lang et al. (2007) point out, the gap between best evidence and evidence-based practice remains, and patients are still not benefitting from the advances that have been made in the health-related sciences. This column explores the process of transferring knowledge gained from research into effective and sustained changes to clinical practice, policy, or education and highlights why nurse educators have a key role in helping to close the evidence-practice gap. Research utilization (RU), knowledge utilization (KU), research transfer, knowledge transfer, implementation science, knowledge translation (KT), are all terms that have been used to describe the process, or science, behind the transfer of research-based knowledge into a form that can be used to provide effective health services. A useful Web site containing definitions of these terms is the KT Clearinghouse (http://ktclearinghouse.ca/glossary, accessed 26 May 2009). Recently, the Canadian Institutes of Health Research provided a definition that sees KT as a “dynamic and iterative process that includes synthesis, dissemination,exchangeandethicallysoundapplicationof knowledge to improve the health of [Canadians], provide more effective health services and products and strengthen the health care system” (Canadian Institutes of Health Research 2008). These terms are often used interchangeably, which is confusing at times. KT is the term that is currently favored by many implementation scientists and is widely

How systematic reviews can foster evidence-based clinical decisions.

Health care providers increasingly recognize the importance of making decisions based on the best possible evidence. This evidence includes both researchand practice-generated data. Despite substantial financial investment in extensive research (National Institutes of Health 2007), some areas of practice face the problem of having little or no research to guide decision-making, while others are inundated with articles reporting on research developments. Growth in health-related research has led to 20,000–30,000 health and medical journals that annually publish about two million scientific articles and add 500,000 citations to Medline (Pang et al. 2004). On top of keeping up with the sheer volume of reports, other difficulties arise. For example, a multiplicity of methods to summarize and synthesis study results exists, making reliable overall conclusions difficult. This contributes to practitioners, who seek an overall picture of what the best available research supports or refutes, encountering difficulty finding or interpreting existing research. In the next two columns, we will address how to use information from high-quality systematic reviews in making clinical decisions. For a single practitioner to find and organize all that is known about a topic is impossible. Clinicians need a method of gaining a synopsis of what is known about a topic; therefore, organizing and synthesizing these data is imperative. A librarian named Gould painted his vision of such organization and synthesis this way, “I look forward to such an organization of the literary records of medicine that a puzzled worker in any part of the world shall in an hour be able to gain the knowledge pertaining to a subject of the experience of every other person in the world” (Clarke 2005). This vision was described in 1898; however, only recently have the techniques developed that make it possible to both locate the research findings quickly and then make them available to anyone in any part of the world. While the advent of the Internet has made huge amounts of information available, it still must be translated into more user-

A Test of the ARCC© Model Improves Implementation of Evidence‐Based Practice, Healthcare Culture, and Patient Outcomes

Background Although several models of evidence-based practice (EBP) exist, there is a paucity of studies that have been conducted to evaluate their implementation in healthcare settings. Aim The purpose of this study was to examine the impact of the Advancing Research and Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians’ EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the western United States. Design A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up immediately following full implementation of the ARCC Model. Setting and Sample The study was conducted at a 341-bed acute care hospital in the western region of the United States. The sample consisted of 58 interprofessional healthcare professionals. Methods The ARCC Model was implemented in a sequential format over 12 months with the key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare professionals’ EBP beliefs, EBP implementation, and organizational culture were measured with valid and reliable instruments. Patient outcomes were collected in aggregate from the hospitals medical records. Results Findings indicated significant increases in clinicians’ EBP beliefs and EBP implementation along with positive movement toward an organizational EBP culture. Study findings also indicated substantial improvements in several patient outcomes. Linking Evidence to Action Implementation of the ARCC Model in healthcare systems can enhance clinicians’ beliefs and implementation of evidence-based care, improve patient outcomes, and move organizational culture toward EBP.

Evidence-based practice, step by step: evaluating and disseminating the impact of an evidence-based intervention: show and tell.

This is the 11th article in a series from the Arizona State University College of Nursing and Health Innovations Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.The purpose of this series has been to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. The final article in the series will be published in the September issue.

Teaching EBP through Problem‐Based Learning

Problem-based learning (PBL) is a teaching method that was developed in the 1980s to enhance education through nontraditional meth ods. Learners’ involvement, usually in small groups, in resolving aspects of an issue or problem is central to PBL. This column cannot provide all there is to understand and know about PBL; however, the parallels between PBL and the evidence-based practice (EBP) process will be discussed along with the effectiveness of the PBL approach in teaching clinicians. Two systematic reviews were conducted that describe what is known about how PBL influences physicians’, nurses’ and other health care professionals’ competencies in clinical settings (Koh et al. 2008; Williams & Beattie 2008). Koh and colleagues found that across 13 studies evaluating the use of PBL in medical school curricula, this teaching method was particularly effective in enhancing learning within the social dimension. PBL promoted competencies in teamwork and social and emotional aspects as well as ethical and legal aspects of health care. In addition, this style of learning promoted competency in self-care, particularly, the attitudes toward one’s own health and well-being. Williams and Beattie focused on the use of PBL in undergraduate health professions’ clinical practicums and found that although PBL could be used effectively in clinical settings to teach students in the health professions, there were barriers that challenged its efficacy (Table 1). Problem-based learning is not a new method of learning/teaching; however, it has only been recently that research has been conducted on it and theoretical underpinnings articulated (Rideout 2001). Apprentices were taught in this way centuries ago (Bennedsen et al. 2008). The Socratic method, guiding learning with probing or leading questions (Rowles & Brigham 2005), is incorporated into PBL. There have been advances in understanding these methods and how they assist learning. Cognitive apprenticeship is a newer term (Bennedsen et al. 2008) that implies learning through collaboration and interaction is the educational goal, not content memorization. Given that the EBP process is focused on learning, critical thinking, and clinical reasoning, using the PBL approach to teaching

Using Meta‐Synthesis to Facilitate Evidence‐Based Practice

In a previous column, Fineout-Overholt et al. (2008) discussed the use of systematic reviews in decision making for clinical practice, focusing primarily on the quantitative studies, such as randomised controlled trials. Narrative reviews were included but in less detail; this was intentional because the synthesis of qualitative evidence is a complex process and has evoked significant discussion over the past 5 years. Consequently, this column addresses some of the process issues surrounding qualitative evidence synthesis, or meta-synthesis as it is more commonly known, and offers ideas for how evidence arising from these can be used to inform education, teaching, and practice.