The elements in the definition emphasize knowledge produced through rigorous and systematic inquiry; the experience of the clinician; and the values of the patient, providing an enduring and encompassing definition of EBP. The entry of EBP onto the healthcare improvement scene constituted a major paradigm shift. The EBP process has been highly applied, going beyond any applied research efforts previously made in healthcare and nursing.
This shift was apparent in the way nurses began to think about research results, the way nurses framed the context for improvement, and the way nurses employed change to transform healthcare.
In this wide-ranging effort, another significant player was added…the policymaker. For EBP to be successfully adopted and sustained, nurses and other healthcare professionals recognized that it must be adopted by individual care providers, microsystem and system leaders, as well as policy makers. Federal, state, local, and other regulatory and recognition actions are necessary for EBP adoption.
A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice. In spite of many significant advances, nurses still have more to do to achieve EBP across the board. One example of implementation of EBP points to the challenges of change.
Yet, because of the change necessary to fully implement and sustain the program across the system supported by organizational culture, a sophisticated implementation plan is required before the evidence-based intervention is adopted across an institution.
Forty-seven prominent EBP models can be identified in the literature. These frameworks guide the design and implementation of approaches intended to strengthen evidence-based decision making. The ACE Star Model of Knowledge Transformation Stevens, was developed to offer a simple yet comprehensive approach to translate evidence into practice.
As explained in the ACE Star Model, one approach to understanding the use of EBP in nursing is to consider the nature of knowledge and knowledge transformation necessary for utility and relevance in clinical decision making.
Rather than having clinicians submersed in the volume of research reports, a more efficient approach is for the clinician to access a summary of all that is known on the topic. Likewise, rather than requiring frontline providers to master the technical expertise needed in scientific critique, their point-of-care decisions would be better supported by evidence-based recommendations in the form of clinical practice guidelines.
The model explains how various stages of knowledge transformation reduce the volume of scientific literature and provide forms of knowledge that can be directly incorporated in care and decision making.
The ACE Star Model emphasizes crucial steps to convert one form of knowledge to the next and incorporate best research evidence with clinical expertise and patient preferences thereby achieving EBP. Depicted in Figure 1 , the model is a five-point star, defining the following forms of knowledge: Point 1 Discovery, representing primary research studies; Point 2 Evidence Summary, which is the synthesis of all available knowledge compiled into a single harmonious statement, such as a systematic review; Point 3 Translation into action, often referred to as evidence-based clinical practice guidelines, combining the evidential base and expertise to extend recommendations; Point 4 Integration into practice is evidence-in-action, in which practice is aligned to reflect best evidence; and Point 5 Evaluation, which is an inclusive view of the impact that the evidence-based practice has on patient health outcomes; satisfaction; efficacy and efficiency of care; and health policy.
Quality improvement of healthcare processes and outcomes is the goal of knowledge transformation. Important new knowledge resources have been developed and advanced owing to the EBP movement.
Likewise, the function of clinical practice guidelines is to guide practice IOM, While resources were available for Point 1, only recently have resources been developed for the knowledge forms on Point 2, 3, 4, and 5 of the Model. These resources are outlined in Table 1. Table 1. Resources for Forms of Knowledge in the Star Model. Cochrane Collaboration Database of Systematic Reviews-provides reports of rigorous systematic reviews on clinical topics.
See www. National Guidelines Clearinghouse-sponsored by AHRQ, provides online access to evidence-based clinical practice guidelines. AHRQ Health Care Innovations Exchange-sponsored by AHRQ, provides profiles of innovations, and tools for improving care processes, including adoption guidelines and information to contact the innovator.
Following the influential Crossing the Quality Chasm report IOM, , experts emphasized that the preparation of health professionals was crucial to bridging the chasm IOM, The Health Professions Education report IOM, declared that current educational programs do not adequately prepare nurses, physicians, pharmacists or other health professionals to provide the highest quality and safest health care possible.
This overhaul would require changing way that health professionals are educated, in both academic and practice settings. Programs for basic preparation of health professionals were to undergo curriculum revision in order to focus on evidence-based quality improvement processes. Also, professional development programs would need to become widely available to update skills of those professionals who were already in practice.
Leaders in all health disciplines were urged to come together in an effort for clinical education reform that addresses five core competencies essential in bridging the quality chasm: All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team emphasizing evidence-based practice, quality improvement approaches, and informatics IOM, Table 4 presents details of each competency.
From this core set, IOM urged each profession to develop details and strategies for integrating these new competencies into education. With a focus on employing evidence-based practice, nurses established national consensus on competencies for EBP in nursing in and extended these in Stevens, Through multiple iterations, an expert panel generated, validated, and endorsed competency statements to guide education programs at the basic associate and undergraduate , intermediate masters , and doctoral advanced levels in nursing.
Between 10 and 32 specific competencies are enumerated for each of four levels of nursing education which were published in Essential Competencies for EBP in Nursing Stevens, These competencies address fundamental skills of knowledge management, accountability for scientific basis of nursing practice; organizational and policy change; and development of scientific underpinnings for EBP Stevens, These resources have also been incorporated into educational settings as programs are revised to include EBP skills.
Curricular efforts were also underway. To stimulate curricular reform and faculty development, the IOM suggested that oversight processes such as accreditation be used to encourage adoption of the five core competencies. Initiatives that followed included the new program standards established by the American Association of Colleges of Nursing, crossing undergraduate, masters, and doctoral levels of education AACN, The AACN standards underscored the necessity for nurses to focus on the systems of care as well on the evidence for clinical decisions.
This systems thinking is crucial to effect the changes that are part of employing EBP. Through multiple phases, this project developed a website that serves as a central repository of information on core QSEN competencies, knowledge, skill, attitudes, teaching strategies, and faculty development resources designed to prepare nurses to engage in quality and safety. While the materials presented were in existence in other professional literature, the book added great value by synthesizing what was known into one publication.
This resource was accessible to every faculty member offering teaching strategies and learning resources for incorporating the IOM competencies into curricula across the nation. This close alignment reflects the appreciation that nursing must be part of this solution to effect the desired changes; and remaining in the mainstream with other health professions rather than splintering providers into discipline-centric paradigms.
Nascent fields are emerging to understand how to increase effectiveness, efficiency, safety, and timeliness of healthcare; how to improve health service delivery systems; and how to spur performance improvement. Nursing research has been impacted by recent far-reaching changes in the healthcare research enterprise. These emerging fields include translational and improvement science, implementation research, and health delivery systems science.
Investigation into uptake of evidence-based practice is one of the fields that has deeply affected the paradigm shift and is woven into each of the other fields.
Several notable federal grant programs have evolved to foster research that produces the evidential foundation for effective strategies in employing EBP. When the public cry for improved care escalated, rapid movement of results into care was brought into sharper focus in healthcare research.
Nurses are involved in each of the 60 CTSAs that were funded across the nation Nurse scientists have been significant leaders in the CTSA program, conducting translational research across these two areas. Nurses are involved in each of the 60 CTSAs that were funded across the nation, contributing from small roles and large roles, ranging from advisor and collaborator to principal investigator.
As part of the CTSAs, nurse scientists conduct basic research and applied research, adding significantly to the interprofessional perspectives of the science. As evidence mounted on standard medical metrics Another recent and swooping change in healthcare research emerged with a focus on patient-centered outcomes research PCOR.
As evidence mounted on standard medical metrics mortality and morbidity , it was noted that metrics and outcomes of particular interest to patients and families such as quality of life were understudied. In , attention was drawn to the need to produce evidence on patient-centered outcomes from the perspective of the patient. These calls encourage early and meaningful engagement of patients and other stakeholders in stating the research question, conducting the study, and interpreting results AHRQ, Two additional federal initiatives exemplify what may be called the next big ideas in EBP—each underscoring evidence-based quality improvement.
The initiatives call for better use of the knowledge that may be gained from quality improvement efforts. Both initiatives emanate from the NIH and both focus on generating evidence needed to make systems improvements and transform healthcare. A call for increased emphasis on implementation of evidence-based practices brought forth a federal funding program. Because of the central role that nurses play across all healthcare settings and clinical microsystems, research in this field is highly relevant to the profession.
This field of science moves beyond the individual provider as the unit of analysis and focuses on groups, health systems, and the community. For example, one emphasis in the field is discovering and applying the evidence for the most effective ways to speed adoption of evidence-based guidelines across all health care professionals in the clinical unit and in the agency.
The overriding goal of improvement science is to ensure that quality improvement efforts are based as much on evidence as the best practices they seek to implement. In many instances, studies about single innovations on Star Point 4 were often not rigorous or broad enough to produce credible and generalizable knowledge Berwick, As a new field, improvement science focuses on generating evidence about employing evidence-based practice , providing research evidence to guide management decisions in evidence-based quality improvement.
Recognizing that pockets of excellence in safety and effectiveness exist, there is concern that local cases of success in translating research into practice are often difficult to replicate or sustain over time. Factors that make a change improvement work in one setting versus another are largely unknown. The ISRN is an open research network for the study of improvement strategies in healthcare. The national network offers a virtual collaboratory in which to study systems improvements in such a way that lessons learned from innovations and quality improvement efforts can be spread for uptake in other settings.
The ISRN supports rigorous testing of improvement strategies to determine whether, how, and where an intervention for change is effective.
The following shortcomings in research regarding improvement change strategies have been noted: studies do not yield generalizable information because they are performed in a single setting; the improvement intervention is inadequately described and impact imprecisely measures; information about sustainability of change is not produced; contexts of implementation are not accounted for; cost or value is not estimated; and such research is seldom systematically planned IOM, b.
The primary goal of the network is to determine which improvement strategies work as we strive to assure effective and safe patient care. Through this national research collaborative, rigorous studies are designed and conducted through investigative teams. Foundational to the network is the virtual collaboratory, fashioned to conduct multi-site studies and designed around interprofessional academic-practice partnerships in research.
The ISRN offers scientists and clinicians from across the nation opportunities to directly engage in conducting studies. ISRN Research Priorities were developed via stakeholder and expert panel consensus and are organized into four broad categories: transitions in care; high performing clinical microsystems; evidence-based quality improvement; and organizational culture ISRN, The research collaboratory concept has proven its capacity to conduct multi-site studies and is open to any investigator or collaborator in the field.
These will provide the scientific foundation for the rapidly expanding efforts to make healthcare better. Nurses will take advantage of these EBP advances to address opportunities and challenges. Much has been done to make an impact; much remains to be accomplished. From this admittedly selective overview of EBP, it is seen that the story of EBP in nursing is now long, with many successes, contributors, leaders, scientists, and enthusiasts.
Opportunities and challenges exist for clinicians, educators, and scientists. Those leading clinical practice have willing partners from the academy for discovering what works to improve health care. Such evidence to guide clinical management decisions is long overdue Yoder-Wise, While there are benefits to both as the evidence is gathered and applied, the true benefit goes to the patient.
Clinical leaders have unprecedented opportunity to step forward to transform healthcare from a systems perspective, focusing on EBP for clinical effectiveness, patient engagement, and patient safety. Those leading education have great advantages offered from a wide variety of educational resources for EBP.
The rich resources offer students a chance to meaningfully connect their emerging competencies with clinical needs for best practices in clinical and microsystem changes.
Those leading nursing science have access to new funding opportunities to develop innovative programs of research in evidence-based quality improvement, implementation of EBP, and the science of improvement. Readiness of the clinical setting for academic-practice research partnerships brings with it advantageous access to clinical populations and settings and an eagerness for utilization of the research results.
The challenges for moving EBP forward spring from two sources: nurses becoming powerful leaders in interprofessional groups and nurses becoming powerful influencers of change. Therefore, adopting the following habits hold promise for moving us ahead:. The nursing profession remains central to the interdisciplinary and discipline-specific changes necessary to achieve care that is effective, safe, and efficient.
New in our vernacular and skill set are systems thinking, microsystems change, high reliability organizations, team-based care, transparency, innovation, translational and implementation science, and, yes, still evidence-based practice. Let us move swiftly to make these new ideas and skills commonplace. On September 3, , the Acknowledgment was modified from the original publication date of May 31, Additional information has been added at the request of the author.
Kathleen R. Her multi-site research on team collaboration and frontline engagement in quality improvement is conducted through the national collaboratory, the ISRN. Funding and grants. Retrieved from: www. All of these dynamics impact how satisfied patients are with their experience of what they encounter in healthcare.
Their satisfaction may or may not actually be related to whether they received quality care or whether they had good clinical outcomes. Patient satisfaction and reimbursement.
Johnston expressed concerns about the utilization of patient satisfaction scores to judge the performance of physicians or its use as a metric for reimbursing physicians for care. Johnston described an encounter with a patient receiving palliative care where the patient and the physician had different approaches and expectations about facing end of life. These differences led to a less than satisfactory experience on the part of the patient, even though the physician used an evidence-based approach.
The experience of this patient was very different from his expectation and equally distressing for the physician. Neither were very satisfied. Johnston also suggested that linking patient satisfaction to physician payment creates a dilemma for the provider who knows that a particular treatment may not lead to a satisfied patient or family.
The opposite view was reported by Riskind, Fossey, and Brill based on their belief that patient satisfaction, while time consuming, can have a positive effect on the success of a medical practice.
Their premise was that increased patient satisfaction, and the ability to measure those results, created a climate where providers began to understand that a successful medical practice was influenced by how satisfied their patients were. Benchmarking patient satisfaction goals to physician accountability enabled this practice to directly educate providers on the correlation among higher patient satisfaction and profitability, increased market share, employee and physician productivity, retention, and reduction of malpractice lawsuits.
Evaluate patient experience to determine patient satisfaction. The list of criticisms included such ideas as:. Price et al. Experiences that providers and patients have during a healthcare encounter seem to capture not just the clinical aspects of care, but many other non-clinical aspects that further illustrate the complexity of measurement of these concepts. What are those conditions within a healthcare encounter, particularly within a hospital environment, that may impact the patient experience and, therefore, his or her satisfaction?
Examples of these may include: predictors of patient satisfaction, patient perception, and health related failures; the relationship between nurse burnout and patient satisfaction; and patient safety perceptions and patient satisfaction. Each of these conditions is discussed briefly below in the context of selected research studies.
Predictors of patient satisfaction, patient perception and health related failures. Jackson, Chamberlin, and Kroenke examined the predictors of patient satisfaction in a general medical clinic. The authors utilized a satisfaction survey with eight predictors of satisfaction.
At subsequent intervals, the patients completed a different questionnaire with one overall satisfaction question. The authors found a high correlation between the overall satisfaction scores and their responses to the eight specific satisfaction questions. Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication in this study the providers were all physicians , and symptom outcomes.
Specific satisfaction items that correlated positively with the overall satisfaction score included functional status, unmet expectations, provider-patient communication A study by Gadalean, Cheptea, and Constantin examined factors that had the potential to impact patient satisfaction scores.
This international study examined 39 factors related to satisfaction or dissatisfaction. The sample was patients within an intensive care unit in a National Cancer Center in Romania. Factors that positively impacted satisfaction scores included: proper treatment; compassionate treatment; clear explanations about treatment; no pain; demonstration of proper concern; adequate contact with family; prompt resolution of requests; rest; quality and quantity of food; and properly addressing the patient.
However, the only factors significantly related to satisfaction scores included compassionate treatment and prompt resolution of requests. Factors significant for dissatisfaction included facilities and accommodations; lack of privacy; room temperature; medical staff not present; nurse attention focused on devices rather than patients; no explanation about treatments; regarding patience as objects; noise; and lack of sleep.
The study also examined patient factors such as education level and diagnosis. The authors reviewed events that caused significantly poor outcomes in each of the triple aim categories. They provided examples of six clinical care and or health related failures that negatively impacted the quality of care, the patient experience, and the cost of the care. These events included unplanned hospital readmission within 30 days, nursing home admission, inappropriate initiation of hemodialysis, wrong-site surgery, intentional injury or maltreatment of a child, and overly invasive treatment of a preference-sensitive condition.
The authors developed an approach to identifying populations by risk of experiencing these failures and taking a preventive approach to avoiding the outcomes.
For example, patient satisfaction was negatively impacted by the loss of independence as the result of a nursing home admission, or invasive treatment Lewis et al. Nurse burnout and patient satisfaction. This study was conducted during a time when a national nurse shortage was raising concerns about nurse burnout and stressed nurse work environments.
The authors used cross-sectional surveys of nurses and patients across 20 urban U. They reported that patients cared for by nurses who were in a work environment with adequate staffing, good administrative support, and positive relations between physicians and nurses reported higher satisfaction with their care.
Safety and patient satisfaction. The authors studied these relationships across three hospitals in acute care in-patient environments. One of their interests was the role that patients themselves play in improving patient safety and that patient perception and understanding of safety may influence better safety outcomes.
They were also interested in the types of experiences within hospital settings that may be predictive of satisfaction on the part of patients. The study conceptual framework, attribution theory, postulated that service quality impacted safety perceptions which in turn influenced patient satisfaction. The study findings from a sample of acute care patients across the three hospitals suggested that patient safety did mediate the relationship between quality and satisfaction and that as patients became more satisfied with service quality they reported more positive experience with safety related activities and procedures.
Even the brief review of the literature above demonstrates the inconsistent terminology and multitude of contributing factors that provide challenges for accurate measurement of the patient experience and its contribution to patient satisfaction, or vice versa. The complexity of this task can be daunting, but health systems have both acknowledged and have come to value the importance of the potential knowledge gained as it impacts patient care and outcomes.
The next section will discuss several examples from clinical practice innovations or processes that have contributed to positive results. How have health systems, particularly nursing leaders, responded to both the demands of the regulatory environment i. Examples from clinical practice described below demonstrate how the implementation of technology, the influence of a positive work environment, and the process of care coordination can contribute to improved patient experiences and better patient satisfaction.
Implementation of Technology. Weston and Roberts examined this question through the lens of three nursing leaders from the perspective of leading clinical care in their large health systems Department of Veterans Affairs, Kaiser Permanente, and Ascension Health. They offer several specific examples of process implementations in clinical practice. For example, the Department of Veterans Affairs utilized technology to create a portal for patients to access their personal health records.
The primary purpose of this feature was to engage patients in their care. Kaiser Permanente created a roadmap to a system of alerts to support nurse decision making and to enhance best practices such as prevention of pressure ulcers and falls. Positive work environment. Relationships have been noted between patient satisfaction and work environments where nurses thrive.
A study by Kutney-Lee et al. Three of the subscales in the Practice Environment Scale of the Nursing Work Index measured the nurse work environment.
Measures of the quality of the work environment and staffing ratios were significantly associated with measures of patient satisfaction. Care coordination. The researchers reported a positive association between care coordination and patient satisfaction with care that was focused on chronic disease management.
With the current emphasis on care coordination, further research as to the impact of this coordination on patient satisfaction can help us to direct these initiatives. There is much to appreciate from this brief glimpse at some of the knowledge generated about the dynamic of patient experience and patient satisfaction. And yet, there is much still unknown. For clinical nurses and nursing leaders within healthcare systems and for policy makers who help to design the regulatory environment of healthcare, it is essential that we continue to explore this dynamic in greater detail.
As patients, families, and providers collectively and collaboratively experience a healthcare encounter, we want to better understand the dynamic that brings together such factors as the expertise of the nurse, the support of the environment, organizational leadership, and the vast environmental, social, and cultural influences that contribute to patient satisfaction.
Her areas of expertise and research include public health systems and health equity. Berwick, D. The triple aim: Care, health, and cost. Health Affairs , 27 3 , Centers for Medicare and Medicaid Services. CMS quality strategy — beyond. CMS Center for Medicare. Federal Register. Medicaid program: Initial core set of health quality measures for Medicaid-eligible adults. Evaluation of patient satisfaction. Applied Medical Informatics , 29 4 , Hospital consumer assessment of healthcare providers and systems.
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