CONTINUING EDUCATION
Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
www.aorn.org/CE
SHAWNA WHITE, MSN, RN, CNOR; LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #15525 Session: #0001 Fee: Members $10.40, Nonmembers $20.80 The CE contact hours for this article expire July 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to implementing clinical practice guidelines using the Iowa Model of Evidence-Based Practice for Perioperative Nursing Leaders.
Objectives 1. Describe barriers that affect how staff nurses practice. 2. Discuss how surgical site infections (SSIs) result in poor outcomes. 3. Describe an example of using clinical guidelines to reduce the incidence of SSIs. 4. Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). 5. Explain use of the Iowa Model.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Ms White and Dr Spruce have no declared affiliation that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2015.04.001 ª AORN, Inc, 2015
50 j AORN Journal
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Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
www.aorn.org/CE
SHAWNA WHITE, MSN, RN, CNOR; LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP
ABSTRACT Many health care organizations, nursing leaders, and individual clinicians are not providing care consistently based on evidence and many are not aware of the evidence that is available. Preventable complications have an adverse effect on hospital reimbursement and the burden is placed on hospital personnel and nursing leaders to use current evidence to improve care and prevent complications, such as surgical site infections. Using AORN resources, leadership involvement and ownership, and implementing a theoretical model will contribute to implementing daily evidence-based practice and help to decrease the chasm between research and practice. AORN J 102 (July 2015) 51-56. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.04.001 Key words: evidence-based practice, EBP, clinical practice, guidelines, AORN.
E
vidence-based practice (EBP) should be the standard of care in all perioperative facilities. However, care is not always provided based on evidence, and often perioperative leaders are unaware of the evidence that is available. Research has shown variation in the quality of care throughout the United States and within individual facilities.1 Preventable complications have an effect on hospital reimbursement and the burden is placed on hospital personnel and nursing leaders to use current evidence to improve care.2
Perioperative nursing leaders, including executives, managers, and educators, must recognize that variability in care has the potential to affect outcomes, safety, and health care costs. Failure to align care with the patient’s need and support that care with evidence may prove to be costly to facility resources and pose a threat to patient safety.3 Research has found that most staff nurses practice based on how they were taught by senior
nurses and not based on what has been proven to work.4 When making clinical decisions, nurses use other sources of evidence, such as reflection on their own experiences, rather than EBP.5 Time constraints, lack of skill, and knowledge deficits have been found to be barriers to providing EBP. Perioperative nursing leaders are in the perfect position to integrate best evidence into clinical practice by developing skills, becoming EBP champions, overcoming barriers, and supporting EBP among health care team members.6 Clinical practice guidelines, such as AORN’s Guidelines for Perioperative Practice,7 can help perioperative nursing leaders by translating the abundance of literature related to EBP into clear recommendations for patient care. Clinical practice guidelines promote a more consistent, safe, and cost-effective approach to patient care through the application of EBP.8
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EXAMPLE OF A COSTLY CLINICAL PROBLEM An example of a serious perioperative patient problem, surgical site infections (SSIs), can demonstrate how implementing clinical practice guidelines can improve patient care and is cost-effective. Surgical site infections can result in poor outcomes such as increased patient pain and suffering, higher morbidity and mortality, longer length of stay, and higher costs of care. A report by the Centers for Disease Control and Prevention found that SSIs are the health care-associated infection (HAI) that generate the largest cost, with costs for SSIs in US hospitals ranging from $3.5 billion to $10 billion annually.9 Additionally, a 2014 study found that on any given day, approximately one of every 25 inpatients in US acute-care hospitals had at least one HAI, with pneumonia and SSIs being the most common.10 Perioperative nursing leaders can greatly reduce the incidence of SSIs and the cost of care by implementing clinical practice guidelines. AORN’s “Guidelines for hand hygiene in the perioperative setting”11 and the American Society of Health-System Pharmacists (ASHP) “Clinical practice guidelines for antimicrobial prophylaxis in surgery” are examples of guidelines that could be implemented to reduce SSIs.12 Hand hygiene has been recognized as a primary method of decreasing HAIs. Hand hygiene, hand washing, and surgical hand scrubs are the most effective way to prevent and control infections and represent the least expensive means of achieving both.11 In addition, a standardized approach to the rational, safe, and effective use of antimicrobial agents has been found effective in the prevention of SSIs. Of importance in antimicrobial prophylaxis is the timing of the preoperative dose of antibioticsdwithin 60 minutes before surgical incision for most antibiotics except for fluoroquinolones and vancomycin, which are administered 120 minutes before surgical incision, rather than the previous recommended time at induction of anesthesia.12
IMPLEMENTATION MODELS For perioperative nursing leaders to implement clinical practice guidelines and improve patient care, all professionals must embrace a culture of best practice. Researching and developing the tools, resources, and mentor relationships needed to sustain practice change is the responsibility of every nursing leader.13 Being able to contribute, effectively use, and communicate EBP knowledge to nurses, the perioperative team, and policy makers is a crucial responsibility of all perioperative nursing leaders.14 Several theoretical models have been developed that can be used to guide clinical decision making and EBP implementation from both the practitioner and organizational perspectives. 52 j AORN Journal
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Examples of theoretical models include the Iowa Model of Evidence-Based Practice to Improve Quality of Care,15 Johns Hopkins Nursing Evidence-Based Practice Model,16 Stetler Model of Research Utilization,17 ACE Star Model of Knowledge Transformation,18 and the ARCC Model: Advancing Research and Clinical Practice Through Close Collaboration Model.19 These models provide step-by-step guides on how to take a clinical problem, such as SSIs, and match it with an intervention based on research to make an organizational or departmental change to practice. Using a model for EBP change also can assist nursing personnel in better focusing their limited fiscal and personnel resources on critical EBP activities.20
THE IOWA MODEL For the purposes of this discussion, the Iowa Model of Evidenced-Based Practice to Promote Quality Care (Figure 1) is reviewed as an example of how using a theoretical model can help focus on the process of implementing evidence-based changes.15 The Iowa Model was selected because nurses find it intuitively understandable and it has been used in numerous academic settings and health care organizations.20 The Iowa Model focuses on organization and collaboration, allowing nurses to target knowledge- and problem-focused triggers, encouraging personnel to question current nursing practices and determine whether care can be improved by using current research findings.21 Perioperative nursing leaders can use the Iowa Model in providing an organized conceptual framework to guide implementation and ensure that changes are sustainable to achieve quality outcomes in their organization. The first step in the Iowa Model is selecting a topic. Selection of the topic can stem from problem-focused triggers such as risk management data, process improvement data, internal/external benchmarking data, financial data, or an identified clinical problem.15 In addition, selection of the topic can be derived from knowledge-focused triggers such as new research or other literature, national agencies or organizational standards and guidelines, philosophies of care, and questions from institutional standards committees.15 Using the previous example of SSIs, the topic could be a clinical problemefocused trigger as well as a national agency or guideline knowledgeefocused trigger. The next step is to form a team responsible for evaluating the selected problem or topic and developing and implementing a solution.22 The composition of the team is directed by the topic selected and should include interested interdisciplinary stakeholders. For example, a team focusing on the problem of SSIs ideally would be composed of perioperative nurses, scrub
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Implementing Clinical Practice Guidelines
The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers
Knowledge Focused Triggers
1. 2. 3. 4. 5.
1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee
Risk Management Data Process Improvement Data Internal/External Benchmarking Data Financial Data Identification of Clinical Problem
Consider Other Triggers
Is this Topic a Priority For the Organization?
No
Yes Form a Team
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
Yes
Is There a Sufficient Research Base?
Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline
Base Practice on Other Types of Evidence: 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory
No
Continue to Evaluate Quality of Care and New Knowledge
Disseminate Results
= a decision point
No
Is Change Appropriate for Adoption in Practice?
Yes
Institute the Change in Practice
Monitor and Analyze Structure, Process, and Outcome Data • Environment • Staff • Cost • Patient and Family
Titler, M.G., C., Steelman, V.J., Rakel., B. A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa Model Of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
DO NOT REPRODUCE WITHOUT PERMISSION
Conduct Research
REQUESTS TO: Department of Nursing University of Iowa Hospitals and Clinics Iowa City, IA 52242-1009 Revised April 1998
©
UIHC
Figure 1. The Iowa Model. (Used/reprinted with permission from the University of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN, FAAN. Copyright 1998.)
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Figure 2. Implementation strategies. (Used/reprinted with permission from the University of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN, FAAN. Copyright 1998.) 54 j AORN Journal
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personnel, surgeons, and infection prevention personnel. It is important to remember that including representatives for all personnel involved is the most successful approach to implementing EBP because change is more successful when initiated by the personnel affected, rather than imposed by management personnel.23 After the team has been formed and they have selected a topic, they should hold a brainstorming session to identify available sources and key terms to guide the search for and retrieval of evidence. This is where clinical practice guidelines can help the team find clinical practices that are based on the best available evidence. Clinical practice guidelines are patient-focused as well as scientifically sound, clinically useful, and informative for nursing leaders, health care professionals, physicians, policy makers, and the public. Using clinical practice guidelines ensures that the evidence has been reviewed by multidisciplinary panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. When used appropriately, clinical practice guidelines can facilitate shared decision making for the EBP team, as well as identify gaps in knowledge.24 When the team has reviewed and discussed the guidelines, they must decide on recommendations for practice to pilot the change. Piloting the change involves
selecting the outcomes to be achieved, collecting baseline data, developing a written EBP guideline, testing the guideline on one or more units or with a small number of patients, evaluating the process and outcomes of the trial, and modifying the guideline based on process and outcome data.15 To support these changes, clinicians and organizational and nursing leaders must interact directly throughout the process. The perioperative nursing leader is essential in communicating the evidence via inservice education programs, audits, and feedback provided by team members.25 The Iowa Model’s Implementation Guide (Figure 2) suggests the following implementation strategies:
create awareness and interest, build knowledge and commitment, promote action and adoption, and pursue integration and sustained use.21
The perioperative nursing leader cannot underestimate the importance of using implementation strategies in helping to create acceptance and sustained use of the new EBP guideline
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Implementing Clinical Practice Guidelines
across the organization. Nursing leaders can begin by communicating the new EBP guideline at every level in the organization using multiple mediums. Posters are not enough; the nursing leader should consider using e-mails, departmental meetings, brown-bag luncheons, newsletters, mobile road shows, pocket guides, tip sheets, and videos. Next, the leader should emphasize the advantages and anticipated patient effect to create awareness and excitement and rally support for implementation. Last, the leader should work with managers related to determining how the new EBP guideline will affect the daily workflow of the department’s personnel, identifying a process to ensure skill competency, discussing how to troubleshoot implementation issues at the bedside, and allowing personnel to provide input in the entire process. These implementation strategies can be used to connect clinicians, organizational leaders, and key stakeholders as well as build organizational system support. Overall, the implementation strategies must support EBP with the goal of delivering high-quality cost-effective care and increasing patient statisfaction.26 When implemented, evaluation is essential to identify the significance and contribution of putting the evidence into practice. Leaders must ensure that preimplementation baseline data are compared with postimplementation data so that key stakeholders see how the evidence contributed to patient care.
CONCLUSION Providing high-quality cost-effective care based on best practices is the responsibility of all nursing leaders. Evidenced-based care is associated with higher quality health care and decreased costs. In today’s changing health care environment, it has never been more important to implement care based on evidence to prevent adverse events and decrease costs. Perioperative nursing leaders must actively engage in reading, critiquing, and grading the evidence to continually challenge and change nursing practice. By changing practice, perioperative nursing leaders can provide measureable care and outcomes of the highest standards in an evidenced-based manner. Leaders must be involved and “own” the clinical practice guidelines that resulted in changes in practice. AORN’s perioperative practice guidelines and theoretical models such as the Iowa Model can help perioperative nursing leaders implement clinical practice guidelines in daily practice and decrease the gap between research and practice.
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References
15. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa Model of Evidenced-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509. 16. Dearholt S, Dang D. Johns Hopkins Evidence Based Practice: Models and Guidelines. 2nd ed. Indianapolis, IN: Sigma Theta Tau International; 2012. 17. Romp CR, Kiehl E. Applying the Stetler model of research utilization in staff development: revitalizing a preceptor program. J Nurses Staff Dev. 2009;25(6):278-284. 18. Stevens KR. ACE Star Model of EBP: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. www.acestar.uthscsa.edu. Accessed February 3, 2015. 19. Melnyk BM, Fineout-Overholt E. Evidenced Based Practice in Nursing and Healthcare. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014. 20. Gawlinski A, Rutledge D. Selecting a model for evidence-based practice changes: a practical approach. AACN Adv Crit Care. 2008;19(3):291-300. 21. LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 8th ed. St Louis, MO: Elsevier; 2014. 22. Cullen L, Adams SL. Planning for implementation of evidencebased practice. J Nurs Adm. 2012;42(4):222-230. 23. Doody CM, Doody O. Introducing evidence into practice: using IOWA model. Br J Nurs. 2011;20(11):661-664. 24. Hollon S, Arean PA, Craske MG, et al. Development of clinical practice guidelines. Annu Rev Clin Psychol. 2014;10:213-241. 25. Johansson B, Fogelberg-Dahm M, Wadensten B. Evidence-based practice: the importance of education and leadership. J Nurs Manag. 2010;18(1):70-77. 26. Tucker SJ, Olson ME, Frusti D. Evidenced-Based Practice Selfefficacy Scale: preliminary reliability and validity. Clin Nurse Spec. 2009;23(4):207-215.
1. Stone PW, Pogorzelska-Maziarz M, Herzig CT, et al. State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control. 2014;42(2):94-99. 2. Hauck S, Winsett RP, Kuric J. Leadership facilitation strategies to establish evidence-based practice in acute care hospital. J Adv Nurs. 2013;69(3):664-674. 3. Crosby E. Review article: the role of practice guidelines and evidence-based medicine in perioperative patient safety. Can J Anaesth. 2013;60(2):143-151. 4. Yip WK, Zubaidah SM, Shen L, Ang EN, Zhang X, Majid S. Nurses’ perception towards evidence-based practice: a descriptive study. Singapore Nurs J. 2013;40(1):34-41. 5. Rolfe G, Segrott J, Jordan S. Tensions and contradictions in nurses’ perspectives of evidence-based practice. J Nurs Manag. 2008;16(4):440-451. 6. Melnyk BM, Ford LG, Troseth M, Wyngarden K. Leveraging EBP e Advisory Report. A national survey & forum for nurse executives: leveraging evidence-based practice to enhance healthcare quality reliability, patient outcomes and cost containment. Center for Transdisciplinary Evidence-Based Practice. https://ctep-ebp.com/ leveraging-ebp-advisory-report. Accessed February 3, 2015. 7. Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015. 8. Leach MJ, Segal L. Are clinical practical guidelines (CPGs) useful for health services and health workforce planning? A critique of diabetes CPGs. Diabet Med. 2010;27(5):570-577. 9. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention. http://www.cdc.gov/hai/pdfs/hai/ scott_costpaper.pdf. Accessed February 3, 2015. 10. Magill SS, Edwards JR, Stat M, et alEmerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13): 1198-1208. 11. Guidelines for hand hygiene in the perioperative setting. In: Guidelines for Perioperative Practices. Denver, CO: AORN, Inc; 2015:31-42. 12. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. http://www.ashp.org/DocLibrary/ BestPractices/TGSurgery.aspx. Accessed February 3, 2015. 13. Wallen GR, Mitchell SA, Melnyk B, et al. Implementing evidencebased practice: effectiveness of a structured multifaceted mentorship programme. J Adv Nurs. 2010;66(12):2761-2771. 14. Hanrahan K, Marlow KL, Aldrich C, Hiatt AM. Dissemination of Nursing Knowledge: Tips and Resources. Iowa City, IA: The University of Iowa College of Nursing; 2012.
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Shawna White, MSN, RN, CNOR, is the perioperative informatics coordinator at Banner Health, Loveland, CO. Ms White has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP, is the director of Evidence-based Perioperative Practice at AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge specific to implementing clinical practice guidelines using the Iowa Model of Evidence-Based Practice for perioperative nursing leaders.
OBJECTIVES 1. 2. 3. 4. 5.
Describe barriers that affect how staff nurses practice. Discuss how surgical site infections (SSIs) result in poor outcomes. Describe an example of using clinical guidelines to reduce the incidence of SSIs. Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). Explain use of the Iowa Model.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1. Research has found that most staff nurses practice based on a. how they were taught by senior nurses. b. what has been proven to work. c. experiential learning from mistakes they have made. 2. Barriers to providing EBP include 1. knowledge deficits. 2. lack of skill. 3. time constraints. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 3. Surgical site infections can result in poor outcomes such as
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1. 2. 3. 4.
higher cost of care. higher morbidity and mortality. increased patient pain and suffering. longer length of stay. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
4. A report by the Centers for Disease Control and Prevention found that the cost of SSIs in US hospitals ranges from ____________ billion annually. a. $2 to $7 b. $2.5 to $8 c. $3.5 to $10 d. $4 to $11 5. The American Society of Health-System Pharmacists (ASHP) “Clinical practice guidelines for antimicrobial prophylaxis in surgery” provide a standardized approach
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to the rational, safe, and effective use of antimicrobial agents in the prevention of SSIs, which indicates that the preoperative dose of antibiotics should be administered at induction of anesthesia. a. true b. false 6. Examples of theoretical models that can be used to guide clinical decision making and EBP implementation from both the practitioner and organizational perspectives include the 1. ACE Star Model of Knowledge Transformation. 2. ARCC Model: Advancing Research and Clinical Practice Through Close Collaboration Model. 3. Iowa Model of Evidence-Based Practice to Improve Quality of Care. 4. Johns Hopkins Nursing Evidence-Based Practice Model. 5. Stetler Model of Research Utilization. 6. Benner’s Novice to Expert model. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6 7. Perioperative nursing leaders can use the Iowa Model in providing an organized conceptual framework to guide implementation and ensure that changes are sustainable to achieve quality outcomes in their organization. a. true b. false
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8. The first step in the Iowa Model is to a. hold a brainstorming session to guide the search for and retrieval of evidence. b. select a topic from problem-focused or knowledgefocused triggers. c. form a team responsible for development, implementation, and evaluation. d. form recommendations for practice to pilot the change. 9. The Iowa Model’s Implementation Guide suggests the following implementation strategies: 1. build knowledge and commitment. 2. create awareness and interest. 3. promote action and adoption. 4. pursue integration and sustained use. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 10. When implemented, evaluation is essential to 1. gain acceptance of the guideline. 2. identify the significance and contribution of putting the evidence into practice. 3. compare preimplementation baseline data with postimplementation data so key stakeholders can see how the evidence contributed to patient care. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe barriers that affect how staff nurses practice. Low 1. 2. 3. 4. 5. High 2.
Discuss how surgical site infections (SSIs) result in poor outcomes. Low 1. 2. 3. 4. 5. High
3.
Describe an example of using clinical guidelines to reduce the incidence of SSIs. Low 1. 2. 3. 4. 5. High
4.
Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). Low 1. 2. 3. 4. 5. High
5.
Explain use of the Iowa Model. Low 1. 2. 3. 4. 5.
8.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
9.
Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)
9A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
9B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
10.
Our accrediting body requires that we verify the time you needed to complete the 1.3 continuing education contact hour (78-minute) program: _________________________________
High
CONTENT 6.
7.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
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SHAWNA WHITE, MSN, RN, CNOR; LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #15525 Session: #0001 Fee: Members $10.40, Nonmembers $20.80 The CE contact hours for this article expire July 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to implementing clinical practice guidelines using the Iowa Model of Evidence-Based Practice for Perioperative Nursing Leaders.
Objectives 1. Describe barriers that affect how staff nurses practice. 2. Discuss how surgical site infections (SSIs) result in poor outcomes. 3. Describe an example of using clinical guidelines to reduce the incidence of SSIs. 4. Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). 5. Explain use of the Iowa Model.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict-of-Interest Disclosures Ms White and Dr Spruce have no declared affiliation that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. http://dx.doi.org/10.1016/j.aorn.2015.04.001 ª AORN, Inc, 2015
50 j AORN Journal
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Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
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SHAWNA WHITE, MSN, RN, CNOR; LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP
ABSTRACT Many health care organizations, nursing leaders, and individual clinicians are not providing care consistently based on evidence and many are not aware of the evidence that is available. Preventable complications have an adverse effect on hospital reimbursement and the burden is placed on hospital personnel and nursing leaders to use current evidence to improve care and prevent complications, such as surgical site infections. Using AORN resources, leadership involvement and ownership, and implementing a theoretical model will contribute to implementing daily evidence-based practice and help to decrease the chasm between research and practice. AORN J 102 (July 2015) 51-56. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.04.001 Key words: evidence-based practice, EBP, clinical practice, guidelines, AORN.
E
vidence-based practice (EBP) should be the standard of care in all perioperative facilities. However, care is not always provided based on evidence, and often perioperative leaders are unaware of the evidence that is available. Research has shown variation in the quality of care throughout the United States and within individual facilities.1 Preventable complications have an effect on hospital reimbursement and the burden is placed on hospital personnel and nursing leaders to use current evidence to improve care.2
Perioperative nursing leaders, including executives, managers, and educators, must recognize that variability in care has the potential to affect outcomes, safety, and health care costs. Failure to align care with the patient’s need and support that care with evidence may prove to be costly to facility resources and pose a threat to patient safety.3 Research has found that most staff nurses practice based on how they were taught by senior
nurses and not based on what has been proven to work.4 When making clinical decisions, nurses use other sources of evidence, such as reflection on their own experiences, rather than EBP.5 Time constraints, lack of skill, and knowledge deficits have been found to be barriers to providing EBP. Perioperative nursing leaders are in the perfect position to integrate best evidence into clinical practice by developing skills, becoming EBP champions, overcoming barriers, and supporting EBP among health care team members.6 Clinical practice guidelines, such as AORN’s Guidelines for Perioperative Practice,7 can help perioperative nursing leaders by translating the abundance of literature related to EBP into clear recommendations for patient care. Clinical practice guidelines promote a more consistent, safe, and cost-effective approach to patient care through the application of EBP.8
http://dx.doi.org/10.1016/j.aorn.2015.04.001 ª AORN, Inc, 2015
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EXAMPLE OF A COSTLY CLINICAL PROBLEM An example of a serious perioperative patient problem, surgical site infections (SSIs), can demonstrate how implementing clinical practice guidelines can improve patient care and is cost-effective. Surgical site infections can result in poor outcomes such as increased patient pain and suffering, higher morbidity and mortality, longer length of stay, and higher costs of care. A report by the Centers for Disease Control and Prevention found that SSIs are the health care-associated infection (HAI) that generate the largest cost, with costs for SSIs in US hospitals ranging from $3.5 billion to $10 billion annually.9 Additionally, a 2014 study found that on any given day, approximately one of every 25 inpatients in US acute-care hospitals had at least one HAI, with pneumonia and SSIs being the most common.10 Perioperative nursing leaders can greatly reduce the incidence of SSIs and the cost of care by implementing clinical practice guidelines. AORN’s “Guidelines for hand hygiene in the perioperative setting”11 and the American Society of Health-System Pharmacists (ASHP) “Clinical practice guidelines for antimicrobial prophylaxis in surgery” are examples of guidelines that could be implemented to reduce SSIs.12 Hand hygiene has been recognized as a primary method of decreasing HAIs. Hand hygiene, hand washing, and surgical hand scrubs are the most effective way to prevent and control infections and represent the least expensive means of achieving both.11 In addition, a standardized approach to the rational, safe, and effective use of antimicrobial agents has been found effective in the prevention of SSIs. Of importance in antimicrobial prophylaxis is the timing of the preoperative dose of antibioticsdwithin 60 minutes before surgical incision for most antibiotics except for fluoroquinolones and vancomycin, which are administered 120 minutes before surgical incision, rather than the previous recommended time at induction of anesthesia.12
IMPLEMENTATION MODELS For perioperative nursing leaders to implement clinical practice guidelines and improve patient care, all professionals must embrace a culture of best practice. Researching and developing the tools, resources, and mentor relationships needed to sustain practice change is the responsibility of every nursing leader.13 Being able to contribute, effectively use, and communicate EBP knowledge to nurses, the perioperative team, and policy makers is a crucial responsibility of all perioperative nursing leaders.14 Several theoretical models have been developed that can be used to guide clinical decision making and EBP implementation from both the practitioner and organizational perspectives. 52 j AORN Journal
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Examples of theoretical models include the Iowa Model of Evidence-Based Practice to Improve Quality of Care,15 Johns Hopkins Nursing Evidence-Based Practice Model,16 Stetler Model of Research Utilization,17 ACE Star Model of Knowledge Transformation,18 and the ARCC Model: Advancing Research and Clinical Practice Through Close Collaboration Model.19 These models provide step-by-step guides on how to take a clinical problem, such as SSIs, and match it with an intervention based on research to make an organizational or departmental change to practice. Using a model for EBP change also can assist nursing personnel in better focusing their limited fiscal and personnel resources on critical EBP activities.20
THE IOWA MODEL For the purposes of this discussion, the Iowa Model of Evidenced-Based Practice to Promote Quality Care (Figure 1) is reviewed as an example of how using a theoretical model can help focus on the process of implementing evidence-based changes.15 The Iowa Model was selected because nurses find it intuitively understandable and it has been used in numerous academic settings and health care organizations.20 The Iowa Model focuses on organization and collaboration, allowing nurses to target knowledge- and problem-focused triggers, encouraging personnel to question current nursing practices and determine whether care can be improved by using current research findings.21 Perioperative nursing leaders can use the Iowa Model in providing an organized conceptual framework to guide implementation and ensure that changes are sustainable to achieve quality outcomes in their organization. The first step in the Iowa Model is selecting a topic. Selection of the topic can stem from problem-focused triggers such as risk management data, process improvement data, internal/external benchmarking data, financial data, or an identified clinical problem.15 In addition, selection of the topic can be derived from knowledge-focused triggers such as new research or other literature, national agencies or organizational standards and guidelines, philosophies of care, and questions from institutional standards committees.15 Using the previous example of SSIs, the topic could be a clinical problemefocused trigger as well as a national agency or guideline knowledgeefocused trigger. The next step is to form a team responsible for evaluating the selected problem or topic and developing and implementing a solution.22 The composition of the team is directed by the topic selected and should include interested interdisciplinary stakeholders. For example, a team focusing on the problem of SSIs ideally would be composed of perioperative nurses, scrub
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Implementing Clinical Practice Guidelines
The Iowa Model of Evidence-Based Practice to Promote Quality Care Problem Focused Triggers
Knowledge Focused Triggers
1. 2. 3. 4. 5.
1. New Research or Other Literature 2. National Agencies or Organizational Standards & Guidelines 3. Philosophies of Care 4. Questions from Institutional Standards Committee
Risk Management Data Process Improvement Data Internal/External Benchmarking Data Financial Data Identification of Clinical Problem
Consider Other Triggers
Is this Topic a Priority For the Organization?
No
Yes Form a Team
Assemble Relevant Research & Related Literature
Critique & Synthesize Research for Use in Practice
Yes
Is There a Sufficient Research Base?
Pilot the Change in Practice 1. Select Outcomes to be Achieved 2. Collect Baseline Data 3. Design Evidence-Based Practice (EBP) Guideline(s) 4. Implement EBP on Pilot Units 5. Evaluate Process & Outcomes 6. Modify the Practice Guideline
Base Practice on Other Types of Evidence: 1. Case Reports 2. Expert Opinion 3. Scientific Principles 4. Theory
No
Continue to Evaluate Quality of Care and New Knowledge
Disseminate Results
= a decision point
No
Is Change Appropriate for Adoption in Practice?
Yes
Institute the Change in Practice
Monitor and Analyze Structure, Process, and Outcome Data • Environment • Staff • Cost • Patient and Family
Titler, M.G., C., Steelman, V.J., Rakel., B. A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp-Reimer, T., & Goode C. (2001). The Iowa Model Of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
DO NOT REPRODUCE WITHOUT PERMISSION
Conduct Research
REQUESTS TO: Department of Nursing University of Iowa Hospitals and Clinics Iowa City, IA 52242-1009 Revised April 1998
©
UIHC
Figure 1. The Iowa Model. (Used/reprinted with permission from the University of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN, FAAN. Copyright 1998.)
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Figure 2. Implementation strategies. (Used/reprinted with permission from the University of Iowa Hospitals and Clinics and Marita G. Titler, PhD, RN, FAAN. Copyright 1998.) 54 j AORN Journal
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personnel, surgeons, and infection prevention personnel. It is important to remember that including representatives for all personnel involved is the most successful approach to implementing EBP because change is more successful when initiated by the personnel affected, rather than imposed by management personnel.23 After the team has been formed and they have selected a topic, they should hold a brainstorming session to identify available sources and key terms to guide the search for and retrieval of evidence. This is where clinical practice guidelines can help the team find clinical practices that are based on the best available evidence. Clinical practice guidelines are patient-focused as well as scientifically sound, clinically useful, and informative for nursing leaders, health care professionals, physicians, policy makers, and the public. Using clinical practice guidelines ensures that the evidence has been reviewed by multidisciplinary panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. When used appropriately, clinical practice guidelines can facilitate shared decision making for the EBP team, as well as identify gaps in knowledge.24 When the team has reviewed and discussed the guidelines, they must decide on recommendations for practice to pilot the change. Piloting the change involves
selecting the outcomes to be achieved, collecting baseline data, developing a written EBP guideline, testing the guideline on one or more units or with a small number of patients, evaluating the process and outcomes of the trial, and modifying the guideline based on process and outcome data.15 To support these changes, clinicians and organizational and nursing leaders must interact directly throughout the process. The perioperative nursing leader is essential in communicating the evidence via inservice education programs, audits, and feedback provided by team members.25 The Iowa Model’s Implementation Guide (Figure 2) suggests the following implementation strategies:
create awareness and interest, build knowledge and commitment, promote action and adoption, and pursue integration and sustained use.21
The perioperative nursing leader cannot underestimate the importance of using implementation strategies in helping to create acceptance and sustained use of the new EBP guideline
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across the organization. Nursing leaders can begin by communicating the new EBP guideline at every level in the organization using multiple mediums. Posters are not enough; the nursing leader should consider using e-mails, departmental meetings, brown-bag luncheons, newsletters, mobile road shows, pocket guides, tip sheets, and videos. Next, the leader should emphasize the advantages and anticipated patient effect to create awareness and excitement and rally support for implementation. Last, the leader should work with managers related to determining how the new EBP guideline will affect the daily workflow of the department’s personnel, identifying a process to ensure skill competency, discussing how to troubleshoot implementation issues at the bedside, and allowing personnel to provide input in the entire process. These implementation strategies can be used to connect clinicians, organizational leaders, and key stakeholders as well as build organizational system support. Overall, the implementation strategies must support EBP with the goal of delivering high-quality cost-effective care and increasing patient statisfaction.26 When implemented, evaluation is essential to identify the significance and contribution of putting the evidence into practice. Leaders must ensure that preimplementation baseline data are compared with postimplementation data so that key stakeholders see how the evidence contributed to patient care.
CONCLUSION Providing high-quality cost-effective care based on best practices is the responsibility of all nursing leaders. Evidenced-based care is associated with higher quality health care and decreased costs. In today’s changing health care environment, it has never been more important to implement care based on evidence to prevent adverse events and decrease costs. Perioperative nursing leaders must actively engage in reading, critiquing, and grading the evidence to continually challenge and change nursing practice. By changing practice, perioperative nursing leaders can provide measureable care and outcomes of the highest standards in an evidenced-based manner. Leaders must be involved and “own” the clinical practice guidelines that resulted in changes in practice. AORN’s perioperative practice guidelines and theoretical models such as the Iowa Model can help perioperative nursing leaders implement clinical practice guidelines in daily practice and decrease the gap between research and practice.
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References
15. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa Model of Evidenced-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509. 16. Dearholt S, Dang D. Johns Hopkins Evidence Based Practice: Models and Guidelines. 2nd ed. Indianapolis, IN: Sigma Theta Tau International; 2012. 17. Romp CR, Kiehl E. Applying the Stetler model of research utilization in staff development: revitalizing a preceptor program. J Nurses Staff Dev. 2009;25(6):278-284. 18. Stevens KR. ACE Star Model of EBP: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. www.acestar.uthscsa.edu. Accessed February 3, 2015. 19. Melnyk BM, Fineout-Overholt E. Evidenced Based Practice in Nursing and Healthcare. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014. 20. Gawlinski A, Rutledge D. Selecting a model for evidence-based practice changes: a practical approach. AACN Adv Crit Care. 2008;19(3):291-300. 21. LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 8th ed. St Louis, MO: Elsevier; 2014. 22. Cullen L, Adams SL. Planning for implementation of evidencebased practice. J Nurs Adm. 2012;42(4):222-230. 23. Doody CM, Doody O. Introducing evidence into practice: using IOWA model. Br J Nurs. 2011;20(11):661-664. 24. Hollon S, Arean PA, Craske MG, et al. Development of clinical practice guidelines. Annu Rev Clin Psychol. 2014;10:213-241. 25. Johansson B, Fogelberg-Dahm M, Wadensten B. Evidence-based practice: the importance of education and leadership. J Nurs Manag. 2010;18(1):70-77. 26. Tucker SJ, Olson ME, Frusti D. Evidenced-Based Practice Selfefficacy Scale: preliminary reliability and validity. Clin Nurse Spec. 2009;23(4):207-215.
1. Stone PW, Pogorzelska-Maziarz M, Herzig CT, et al. State of infection prevention in US hospitals enrolled in the National Health and Safety Network. Am J Infect Control. 2014;42(2):94-99. 2. Hauck S, Winsett RP, Kuric J. Leadership facilitation strategies to establish evidence-based practice in acute care hospital. J Adv Nurs. 2013;69(3):664-674. 3. Crosby E. Review article: the role of practice guidelines and evidence-based medicine in perioperative patient safety. Can J Anaesth. 2013;60(2):143-151. 4. Yip WK, Zubaidah SM, Shen L, Ang EN, Zhang X, Majid S. Nurses’ perception towards evidence-based practice: a descriptive study. Singapore Nurs J. 2013;40(1):34-41. 5. Rolfe G, Segrott J, Jordan S. Tensions and contradictions in nurses’ perspectives of evidence-based practice. J Nurs Manag. 2008;16(4):440-451. 6. Melnyk BM, Ford LG, Troseth M, Wyngarden K. Leveraging EBP e Advisory Report. A national survey & forum for nurse executives: leveraging evidence-based practice to enhance healthcare quality reliability, patient outcomes and cost containment. Center for Transdisciplinary Evidence-Based Practice. https://ctep-ebp.com/ leveraging-ebp-advisory-report. Accessed February 3, 2015. 7. Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015. 8. Leach MJ, Segal L. Are clinical practical guidelines (CPGs) useful for health services and health workforce planning? A critique of diabetes CPGs. Diabet Med. 2010;27(5):570-577. 9. Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention. http://www.cdc.gov/hai/pdfs/hai/ scott_costpaper.pdf. Accessed February 3, 2015. 10. Magill SS, Edwards JR, Stat M, et alEmerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13): 1198-1208. 11. Guidelines for hand hygiene in the perioperative setting. In: Guidelines for Perioperative Practices. Denver, CO: AORN, Inc; 2015:31-42. 12. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. http://www.ashp.org/DocLibrary/ BestPractices/TGSurgery.aspx. Accessed February 3, 2015. 13. Wallen GR, Mitchell SA, Melnyk B, et al. Implementing evidencebased practice: effectiveness of a structured multifaceted mentorship programme. J Adv Nurs. 2010;66(12):2761-2771. 14. Hanrahan K, Marlow KL, Aldrich C, Hiatt AM. Dissemination of Nursing Knowledge: Tips and Resources. Iowa City, IA: The University of Iowa College of Nursing; 2012.
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Shawna White, MSN, RN, CNOR, is the perioperative informatics coordinator at Banner Health, Loveland, CO. Ms White has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, CNS-CP, is the director of Evidence-based Perioperative Practice at AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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EXAMINATION
Continuing Education: Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
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PURPOSE/GOAL To provide the learner with knowledge specific to implementing clinical practice guidelines using the Iowa Model of Evidence-Based Practice for perioperative nursing leaders.
OBJECTIVES 1. 2. 3. 4. 5.
Describe barriers that affect how staff nurses practice. Discuss how surgical site infections (SSIs) result in poor outcomes. Describe an example of using clinical guidelines to reduce the incidence of SSIs. Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). Explain use of the Iowa Model.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1. Research has found that most staff nurses practice based on a. how they were taught by senior nurses. b. what has been proven to work. c. experiential learning from mistakes they have made. 2. Barriers to providing EBP include 1. knowledge deficits. 2. lack of skill. 3. time constraints. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3 3. Surgical site infections can result in poor outcomes such as
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1. 2. 3. 4.
higher cost of care. higher morbidity and mortality. increased patient pain and suffering. longer length of stay. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4
4. A report by the Centers for Disease Control and Prevention found that the cost of SSIs in US hospitals ranges from ____________ billion annually. a. $2 to $7 b. $2.5 to $8 c. $3.5 to $10 d. $4 to $11 5. The American Society of Health-System Pharmacists (ASHP) “Clinical practice guidelines for antimicrobial prophylaxis in surgery” provide a standardized approach
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to the rational, safe, and effective use of antimicrobial agents in the prevention of SSIs, which indicates that the preoperative dose of antibiotics should be administered at induction of anesthesia. a. true b. false 6. Examples of theoretical models that can be used to guide clinical decision making and EBP implementation from both the practitioner and organizational perspectives include the 1. ACE Star Model of Knowledge Transformation. 2. ARCC Model: Advancing Research and Clinical Practice Through Close Collaboration Model. 3. Iowa Model of Evidence-Based Practice to Improve Quality of Care. 4. Johns Hopkins Nursing Evidence-Based Practice Model. 5. Stetler Model of Research Utilization. 6. Benner’s Novice to Expert model. a. 1, 3, and 5 b. 2, 4, and 6 c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6 7. Perioperative nursing leaders can use the Iowa Model in providing an organized conceptual framework to guide implementation and ensure that changes are sustainable to achieve quality outcomes in their organization. a. true b. false
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8. The first step in the Iowa Model is to a. hold a brainstorming session to guide the search for and retrieval of evidence. b. select a topic from problem-focused or knowledgefocused triggers. c. form a team responsible for development, implementation, and evaluation. d. form recommendations for practice to pilot the change. 9. The Iowa Model’s Implementation Guide suggests the following implementation strategies: 1. build knowledge and commitment. 2. create awareness and interest. 3. promote action and adoption. 4. pursue integration and sustained use. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 10. When implemented, evaluation is essential to 1. gain acceptance of the guideline. 2. identify the significance and contribution of putting the evidence into practice. 3. compare preimplementation baseline data with postimplementation data so key stakeholders can see how the evidence contributed to patient care. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Perioperative Nursing Leaders Implement Clinical Practice Guidelines Using the Iowa Model of Evidence-Based Practice 1.3
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T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe barriers that affect how staff nurses practice. Low 1. 2. 3. 4. 5. High 2.
Discuss how surgical site infections (SSIs) result in poor outcomes. Low 1. 2. 3. 4. 5. High
3.
Describe an example of using clinical guidelines to reduce the incidence of SSIs. Low 1. 2. 3. 4. 5. High
4.
Identify theoretical models that can be used to guide clinical decision making and evidence-based practice (EBP). Low 1. 2. 3. 4. 5. High
5.
Explain use of the Iowa Model. Low 1. 2. 3. 4. 5.
8.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
9.
Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.)
9A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
9B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
10.
Our accrediting body requires that we verify the time you needed to complete the 1.3 continuing education contact hour (78-minute) program: _________________________________
High
CONTENT 6.
7.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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