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Spirit of Curiosity:The Time is Now

Mary Beth Flynn Makic PhD CCNS CCRN-K FAAN FNAP FCNSProfessor

University of Colorado, College of Nursing

Disclosures•Elsevier, Editor for Nursing textbooks and

editorial board for Elsevier journal

• Past Board of Director American Association of Critical Care Nurses

•Co-Chair, American Association of Critical Care Nurses, Clinical Advisory Work Group

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Greetings from Denver!

University of Colorado Anschutz Medical Campus

Closing the GAP…

http://media.execunet.com/m/closing-gap-Kristine-Gunn.jpg

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http://www.mnwc.org/the-power-of-questions/

Clinical Inquiry

Why…and Why Not

Crossing theQuality Chasm

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Health Care Reform

Improved

Access

Health Care ReformComplicated by Challenges

Staffing Challenges:

All Clinical Roles

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“all great changes are preceded by chaos”Deepak Chopra

Photo by Anna Tarazevich: https://www.pexels.com/photo/opportunity-lettering-text-on-black-background-5598297/

Florence Nightingale used evidence

to demonstrate the impact of nursing

care~

She also was an innovator…

Challenged ‘norms’ by asking

questions and seeking answers ….

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https://blog.soliant.com/wp-

content/uploads/nursing_history_lessons_learn

ed_soliant.jpg

Nursing Knowledge:

⮚ Empirical⮚ Esthetic⮚ Personal⮚ Ethical

Carper, 1978

So what if we changed our focus from Never Events to Always Events through EBP?

Always Events® Getting Started Kit. Cambridge, MA: Institute for Healthcare Improvement; 2014.

Returning to

Foundations of Practice

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Evidence-Based Practice

Adoption

Improved Nursing Practice and

Patient Outcomes

Research• Infrastructure

for EBP• New questions

raised from practice not answered by EBP

Quality Improvement• Evaluating

process to use evidence in practice

Program Evaluation• Evaluation of

programs to guide practice based on evidence

Evidence-Based Practice • Framework to

guide practice

Makic, 2018

Research: intent is to generate NEW knowledge

EBP: intent is to apply current knowledge/research/best evidence to practice to improve patient outcomes

QI/PE: intent is to improve a process that leads to better outcomes in efficiency and/or patient outcomes

The INTENT drives the method

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Research is conducted to produce knowledge that can be ‘generalized’ to a larger population/setting⮚Research methods allow knowledge generated to be generalized⮚But RCT is not the only research methodology to answer clinical

questions⮚Critically appraise, quality of study, SYNTHESIZE the body of evidence

EBP, QI, and PE projects cannot be generalized as dynamics of the unit where the project was implemented impacts uptake/practice change success

Driving Practice Excellence

EBP Defined

Evidence-based practice is both a process of inquiry and a way of providing quality patient care in ever more complex healthcare environments. EBP uses a problem solving approach to clinical practice that integrates the best research evidence with clinical expertise and patient preferences and values to facilitate clinical decision making. (AACN 2011)

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Evidence-Based Practice

Patient preference

Evidence

(research and other forms)

Clinical expertise

Context of care

EBP

Barker, 2014

Evidence-Based Practice

Patient preference

Evidence(research and other forms)

Clinical expertise

Context of care

EBP

https://resources.workable.com/nurse-interview-questions

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The 5 A’s Model of Evidence

Based Practice; (Richardson, 2005)

EBP ModelsProvide Road Maps

Common language for framing opportunity to identify and move evidence into practice

https://wiki.openstreetmap.org/w/images/thumb/a/a4/Roundabout_Maps_9_aaronsta.png/637px-Roundabout_Maps_9_aaronsta.png

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Quality Improvement Models

Evaluates and Improves Processes so that best evidence can be effectively implemented

http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx

TWO KEY VARIABLES FOR EBP SUCCESS

NURSING LEADERSHIP

MENTORSHIP

https://cf.ltkcdn.net/feng-shui/images/std/215850-342x342-Lotus-

Yin-Yang.jpg

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Leaders and Mentors

⮚ Prioritizes quality and safety in a meaningful way

⮚ Lead at the micro (person/unit) and macro (team, upper leadership) set the tone

⮚ Mentors guide, support, facilitate, innovate

⮚ Ask Why and Why not

⮚ Promote growth

Leaders and Mentors = YOUKnickman & Kovner 2015

Ubbink et al, 2013

Schaefer & Welton 2018

Challenges

We know the challenges….

▪ Time: Workload▪ Staff/leadership resistance to change Lack of resources▪ Lack of authority to implement EBP▪ Professional culture resistant to change

Build solutions to challenges into the EBP

process for success

Williams et al., 2015

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Opportunities

Time: EBP is ‘how you practice’ not something additional to ‘do’

Best Practice vs Traditions: Challenge the status quo

Empowerment comes doing the ‘right thing’ for patient safety

WHY and WHY NOT are good questions

◦ Professional culture of inquiry is welcomed

Build solutions to challenges into the EBP process for success

Williams et al., 2015

• Empower Staff• “Challenge

Norms”• Develop EBP

competency/skills• Systematically

Measure Outcomes

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Positive Deviance

http://www.life-savers.com/www/img/home_showcase_gummy_yellow_big.png

What’s YOUR practice base on?

Tradition Best Evidence

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Summary Practice Habits: Decade Long Journey

Makic & Rauen, CCN 2016, 36(2): 1-6

When things are unknown (i.e. pandemic)…

stop, ask questions, look to the evidence….

Then innovate!

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Best Practice Guidelines Challenge

http://blog.gravity-lifestyle.com/wp-content/uploads/2017/03/challenge.jpg

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De-Implementation….“divesting from ineffective and [possibly] harmful practices”

(Prasad & Ioannidis 2014)

• Embracing questions

• Seeking answers

• Focus on value of care

Change requires healthcare [system] behavior modification (not just healthcare professionals)

Niven, D. J., et al.

(2015). Towards

understanding the de-

adoption of low-value

clinical practices: a

scoping review.

BMC medicine, 13(1), 1-21.

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Evidence-Based De-Implementation

http://www.choosingwisely.org/wp-

content/uploads/2015/02/AANursing-Choosing-Wisely-List.pdf

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De-Implementation and Implementation Science✔Explores ways to move EBP into practice and sustain practice change

✔Challenges us to look at habits in practiceIdentify and prioritize ‘low value’ clinical practices that do not provide meaningful outcomes and may cause harm

✔Context of practice environments

Requires embracing Change

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De-implementing practices reflects a recommitment to evidence-based healthcare

Prasad & Ioannidid 2014

PatientEBP HealthCare

System

Culture

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Ultimate Goal

Translation of scientific and other forms of evidence into practice and eventually adoption of the evidence as the practice norm to improve patient outcomes

Complexity ScienceSuccessful Translation of Evidence

Into Practice▪ Complex

▪ Multi-factorial

▪ Not a singular event

▪ Adaptive

▪ Practice is not linear

Plsek et al, 2001; Titler 2004; Rycroft-Malone 2010

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Partnerships for Implementation Science

The scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice and hence to improve the quality and effectiveness of health services

Bauer et al. 2015

▪ Partner academia and practice to develop insightful sound approaches to evidence translation

▪ Involve patients

▪ Be rigorous; strive for sustainability;

▪ Consider cost-effectiveness

▪ Be mindful of the workforce and opportunities

Van Achterberg 2013

Work Smarter – Not Harder

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https://www.google.com/search?site=&tbm=isch&source=hp&biw=1280&bih=899&q=head+in+sand+picture

Asking questions…..

Patients

http://www.allwhitebackground.com/images/3/3818.jpg

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✔For EBP to Become Embedded into Everyday Practice, All Healthcare professionals and Organizational Leaders Must Create a Culture of Clinical Inquiry, Curiosity & Continual Learning

✔Practice Standards, Policies & Practice Guidelines Must Incorporate Current Best Evidence to Guide Practice

✔Access to New Evidence and Confidence to Critique and Apply Evidence in Practice

✔Willingness to ask questions…and then seek answers to those questions

Schulman, 2008; Solomons et al, 2011

The Path To Excellence

“Being successful with change means being open to learning”

Kevin Cashman 2017

Leadership from the Inside Out

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Rogers’ Diffusion of Innovation: Change Model. 1995

Where are YOU on this curve of

translating evidence into practice?

Will you “follow” practice habits…..

Or choose to “lead” practice based on

current best evidence

http://www.cutestpaw.com/wp-content/uploads/2014/05/Follow-the-leader.jpeg

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https://www.google.com/search?q=thomas+paine+quotes

http://www.lovethispic.com/image/50995/you-can-make-a-

difference

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I AM an

Evidence-Based Clinician

Will you join me?

Thank you~

marybeth.makic@cuanschutz.edu

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Selected ReferencesOster CA, Braaten JA. (2016). High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality. Indianapolis, IN: Sigma Theta Tau International.

Prasad V Ioannidis J (2014) Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implementation Science, 9:1. https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-9-1

Orr P, Davenport D (2015) Embracing change. Nurs Clin N Am 50, 1018

Pronovost PJ, Austin JM, Cassel Ck, et al. (2016). Fostering transparency in outcomes, quality, safety, and costs: A vital direction for health and health care. National Academy of Medicine. https://nam.edu/wp-content/uploads/2016/09/Fostering-Transparency-in-Outcomes-Quality-Safety-and-Costs.pdf

Ghaferi AA, Myers CG, Sutcliffe KM, et al. (Aug 8, 2016). The next wave of hospital innovation to make patients safer. Harvard Business Review.

Krein SL, Fowler KE, Ratz D, et al., (2015). Preventing device-associated infections in US hospitals: national surveys from 2005-2013. BMJ Qual Saf 24, 385-392.

Makic, MBF, Granger B (2019). De-implemtation in clinical practice: What are we waiting for? AACN Adv Crit Care, 30(3), 282-286.

Makic MBF, Rauen CA. Maintaining your momentum: Moving evidence into practice. Crit Care Nurse, 2016; 36(2): 13-18.

Gerrish K, Nolan M, McDonnell A, et al. Factors influencing advanced practice nurses’ ability to promote evidence-based nurses’ ability to promoted evidence-based practice among frontline nurses. Worldviews on Evidence-Based Nursing, 2011; 9(1): 30-39.

Melnyk B M (2012). Achieving a high-reliability organization through implementation of the ARCC model for system-wide sustainability of evidence-based practice. Nurs Admin Q 36(2), 127-135.

National Quality Forum (NQF). Safe Practices for Better Healthcare-2010 Update: A Consensus Report. Washington, DC: NQF, 2010.

American Association of Critical Care Nurses. Evidence-based resources. Available at: http://www.aacn.org/WD/Practice/Content/ebp.content?menu=Practice&lastmenu.

Cashman, K. (2017). Leadership from the inside out. Oakland, CA. Berrett-Koehler Publishers.

Warren, J.I. (2016). The strengths and challenges of implementing EBP in healthcare systems. Worldviews on Evidence-Based Nursing, 13(1): 15-24.

Stevens K.R. et al. (2017). Operational failures detected by frontline acute care nurses. Research in Nursing & Health. DOI: 10.1002/nur.21791

Dolansky M A , Schexnayder J., Patrician, P et al. (2017). Implementation science: New approaches to integrating quality and safety education for nurses competencies in Nursing Education. Nurse Education ,4 2(55), 512-517.

Selected ReferencesPeterson MH, Barnason S, Donnelly B., et al. Choosing the best evidence to guide clinical practice: Application of AACN levels of evidence. Critical Care Nurse. 2014; 34(2): 58-68.

Rauen CA, Chulay M, Bridges E, et al. Seven evidence-based practice habits: Putting some sacred cows out to pasture. Crit Care Nurse, 2008; 28: 98-123.

Rauen CA, Makic MBF, Bridges E. Evidence-based practice habits: Transforming research into bedside practice. Crit Care Nurse, 2009; 29: 46-59.

Makic MBF, VonRueden KT, Rauen CA et al. Evidence-based habits: Putting more sacred cows out to pasture. Crit Care Nurse, 2011; 31: 38-62.

Makic MBF, Martin SA, Burns S, et al. Putting evidence into nursing practice: four traditional practices not supported by the evidence. Crit Care Nurse, 2013; 33: 28-42.

Makic MBF, Rauen CA, Watson R, et al. Examining the evidence to guide practice: Challenging practice habits. Crit Care Nurse, 2014; 34: 28-45.

Makic MBF, Rauen CA, Jones K, Fisk, AC. Continuing to challenge practice to be evidence-based. Crit Care Nurse, 2015; 35(2): 39-50.

Makic MBF, Rauen CA. Maintaining your momentum: Moving evidence into practice. Crit Care Nurse, 2016; 36(2): 13-18.

Gerrish K, Nolan M, McDonnell A, et al. Factors influencing advanced practice nurses’ ability to promote evidence-based nurses’ ability to promoted evidence-based practice among frontline nurses. Worldviews on Evidence-Based Nursing, 2011; 9(1): 30-39.

Melnyk, B.M. (2013). Disguising the preparation and roles of doctor of philosophy and doctor of nursing practice graduates: National implications of r academic curricula and health care systems. J Nurs Edcu 52(8): 442-228.

Bauer M., et al. (2015). An introduction to implementation science for the non-specialist. BMC Psychology, 3:32.

Carper, B.A. (1978). Fundamental patterns of knowing in nursing. ANS 1(1): 13-24.

Porter S (2010). Fundamental patterns of knowing in nursing: The challenge of EBP. ANS, 33(1): 3-14

Titler M. et al, (1994). Infusing research into practice to promote quality care. Nursing Research 43, 307-313.

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Selected ReferencesEdwards J. et al. (2016). Strategic innovation between PhD and DNP programs: Collaboration, collegiality, and shared resoruces. Nursing Outlook. 64(4): 312-320.

Ubbink, D.T. et al. (2013). Framework of policy recommendations for implementation of evidence-based practice: a systemic scoping review. BMJ Open. 3:e001881

Trautman D.E. (2016). Collaboration: the key to healthcare transformation. American Nurse Today. 1197): 10-13

Hanrahan, K. et al. (2015) Sacred cow gone to pasture: a systematic evaluation and integration of evidence-based practice. Worldviews on evidence-based Nursing. 12(1): 3-11.

Stevens, K.R. (2013). The impact of evidence-based practice in nursing the next big ideas. OJIN 18(2).

Schaefer J. Welton, J. (2018). Evidence based practice readiness: a concept analysis. J Nurs Manag , 1-9.

Prasad V, et al. (2014) Evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices. Implementation science, 9:1

Williams B et al. (2015). What are the factors of organizational culture in healthcare settings that act as barriers to the implementation of evidence-based practice? A scoping review. Nurse Education Today 35: e34-341.

Levinson W., et al. (2015). Choosing Wisely: A growing international campaign. BMJ Qual Saf, 24: 167-174.

Montini T, Graham, I. (2015). Entrenched practices and other biases: unpacking the historical, economic, professional, and social resistance to de-implementation. Implementation Science, 10;24.

Newhouse, R. et al. (2013). Methodology issues in implementation science. Medical Care, 51(4): S32-S40

Ubbink D. T. et al. (2011). Implementation of evidence-based practice: outside the box throughout the hospital. The Netherlands Journal of Medicine, 69(2): 87-93.

vanAchterberg, T (2013). Nursing implementation science: 10 ways forward. International J of Nursing Studies. 50: 445-447

Ingersoll GL (2000) Evidence-based nursing: What it is and what it isn’t. Nursing Outlook, 48, 151-152.

Beyea S.C. et al. (2013). Historical perspectives on EBN. Nursing Science Quarterly 26(2), 152-155.