Institutionalizing evidence-based practice: an organizational case study using a model of strategic change.

BACKGROUND: There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. METHODS: A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. RESULTS: The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP-related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. CONCLUSION: Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively.

A collaborative approach to building the capacity for research and evidence-based practice in community hospitals.

The use of best evidence to support nursing practice and the generation of new knowledge to use in practice are hallmarks of excellence. Nurses at the bedside, however, often lack the resources and knowledge necessary to change the traditional nursing culture to one in which the use of evidence is incorporated into daily care. This article describes the experience in two hospitals using a program designed to give nurses the skills needed to engage in evidence-based care.

Development and implementation of an inductive model for evidence-based practice: A grassroots approach for building evidence-based practice capacity in staff nurses.

Evidence-based practice (EBP) is an essential component of the development of nursing science and has importance for today's clinical nurses. It benefits patients, organizations, and the nursing discipline, as well as having personal and professional benefits for individual clinicians. As interest in EBP has grown, so has the need for educational programs designed to develop the scholarly skills of the nursing workforce. The Clinical Scholar Model is one grassroots approach to developing a cadre of clinical nurses who have the EBP and research skills necessary in today's demanding health care delivery environments.

Evaluating the effectiveness of gel pillows for reducing bilateral head flattening in preterm infants: a randomized controlled pilot study.

This study evaluated the effectiveness of gel pillows for reducing bilateral head molding (plagiocephaly) in preterm infants, as determined by the cephalic index (CI). Eighty-one infants weighing <1,500 g were randomly assigned at birth to usual care on a standard mattress (n = 40) or to placement on a gel pillow (n = 41). The CI was measured with a digimatic caliper upon entry and weekly thereafter, until infants had been transferred or discharged. Repeated measures analysis of variance revealed no statistically significant differences in the CI between subjects upon entry, at 5 weeks postintervention, or at 10 weeks postintervention. The trend was toward less molding over time for smaller infants on gel pillows who were hospitalized longer; however, the sample size was too small to detect statistical significance.

Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters.

Approximately 150 million peripheral intravenous (PIV) catheters are inserted annually in the United States, with a 5% incidence rate of phlebitis as an acceptable benchmark. In 2002, the Centers for Disease Control and Prevention recommended that PIV sites and administration sets be changed at least every 96 hours, yet clinical practice supported that at least 25% of PIV catheters showed no signs of phlebitis at 96 hours' dwell time. This study reports the assessment results of 850 PIV catheters over the indwelling life of the catheter, using the Visual Infusion Phlebitis scale as the measure determining when a PIV should be removed.

Reducing pain in ED patients during lumbar puncture: the efficacy and feasibility of iontophoresis, collaborative approach.

INTRODUCTION: This study examined the efficacy and feasibility of a collaborative iontophoresis procedure for dermal anesthesia prior to lumbar puncture (LP) in adult ED patients. METHODS: Patients were randomized to receive lidocaine by iontophoresis or needle infiltration. Emergency nurses and physicians completed a collaborative LP procedure in those randomized to iontophoresis. Usual care was provided for needle infiltration subjects. Pain was assessed at 3 points using an 11-point numeric rating scale to measure pain, and provider satisfaction was recorded. RESULTS: Ninety subjects completed the protocol: infiltration group (n = 48) and iontophoresis group (n = 42). Subjects in the lidocaine infiltration group reported significantly more pain (mean, 4.1A+/-2.6) than subjects in the iontophoresis group (mean, 0.9A+/-1.6) ( t82 = 1.26, P =.000). There was no significant difference between the pain experienced during the lumbar puncture by both groups. Mean pain score during LP was 3.7 (+/-2.7) for iontophoresis compared to 3.4 (+/-2.9) for infiltration. More iontophoresis subjects (18 or 43.9%) required "rescue" lidocaine than infiltration subjects (12 or 24.5%) (chi-square 1 =3.79, P =.0515). Providers reported greater satisfaction with the collaborative procedure compared to physician administered lidocaine infiltration and anecdotally reported that iontophoretic anesthesia administration does not obscure anatomical landmarks, as needle infiltration can. Time for completion of dermal anesthesia using the iontophoretic procedure was longer than time for completion of dermal anesthesia using the lidocaine infiltration procedure (12A+/-12 min vs 2A+/-1.7 min); however, no statistically significant difference in total LP time or ED length of stay was found. NURSING IMPLICATIONS: Dermal anesthesia by lidocaine iontophoresis in patients undergoing an LP with emergency nurses and physicians working in collaboration during the procedure takes longer, but decreases the pain of administering anesthesia, increases provider satisfaction, and fosters collaborative practice in the emergency setting. Iontophoretic administration of anesthesia for LP is now an option for dermal anesthesia in our emergency department.

Role of research in reconstructing global healthcare for the 21st century.

Nursing as the largest healthcare discipline is central within every healthcare system worldwide. This centrality provides the unique opportunity and the express responsibility for the creation of new knowledge through research in reconstructing global healthcare in the 21st century. International nursing research requires collaboration among culturally diverse team members and data collection with multilingual participants. The critical role of ethical research is exemplified by the diverse cultural norms. Language translation of not only the words but also their meanings is paramount to the relevant application of the study results. Institutions and schools of nursing in developed countries must acknowledge and act on the opportunities available and necessary for global collaboration afforded through the technological resources of the 21st century. Clinical nursing scholars who are the expert care providers must be involved in the conduct and application of research if any reconstruction of global healthcare is to succeed.

Healthy Hands: Use of alcohol gel as an adjunct to handwashing in elementary school children.

Elementary school-age children are particularly vulnerable to infections. While handwashing is the best method of preventing infections, many elementary schools are housed in buildings that have barriers to effective hand hygiene. The purpose of this study was to determine the effectiveness of an alcohol gel as an adjunct to handwashing in reducing absenteeism secondary to infectious illness. Two-hundred and fifty-three elementary school children were randomized by classroom into an experimental or control group. With a crossover design, all children participated in both groups, with a one-week washout period between phases. A 45-minute "Germ Unit" was taught to all children as they started the experimental phase and a standard unit on hand hygiene was taught as they started the control phase. Sixty-nine children were absent due to illness while in the control group. Thirty-nine children became ill while in the experimental group. Alcohol gel as an adjunct to handwashing was shown to be effective in reducing absenteeism due to infectious illness by 43%.

Comparison of acupressure bands and droperidol for reducing post-operative nausea and vomiting in gynecologic surgery patients.

The purpose of this study was to evaluate the effectiveness of acupressure bands, droperidol, and the combined modalities, administered preoperatively, in reducing PONV in inpatient gynecologic patients. One hundred and forty-three patients were randomized to one of four groups: droperidol and acupressure bands, droperidol and placebo bands, placebo drug and acupressure bands, or placebo drug and placebo bands. Overall, during their hospital stay, 69% of the women experienced PONV and 45% experienced vomiting at some time. Although droperidol was most effective the day of surgery, neither acupressure bands or droperidol were effective in reducing PONV.

Safety, tolerability, and efficacy of iontophoresis with lidocaine for dermal anesthesia in ED pediatric patients.

INTRODUCTION: This study examined the safety, tolerability, and efficacy of iontophoresis with 30 mA of lidocaine for dermal anesthesia in children younger than 84 months in the emergency department and the usefulness of a modified version of the Pre-verbal, Early Verbal Pediatric Pain Scale (M-PEPPS). METHODS: Three expert nurses completed the protocol for iontophoresis and inserted an intravenous catheter. Parents scored pain by using the 10-cm visual analogue scale, nurses used the M-PEPPS, and children, if able, self-reported pain during the procedure and at needle stick. RESULTS: Serum lidocaine levels were within the normal laboratory reference range. Adverse effects were minor and disappeared prior to discharge from the emergency department. Eighty-five percent of the children had M-PEPPS scores < or=6 during the iontophoresis procedure; 42% had scores of < or =6 at needle stick. Eighty-two percent of the parents marked the vas as < or =30 during the procedure; 65% indicated scores of < or =30 at needle stick. Four children self-reported "a lot of pain" at needle stick. Although low to moderate, M-PEPPS scores and parental pain ratings were significantly correlated at both points in time. DISCUSSION: Iontophoresis with lidocaine is safe for use in young children. It does not create any long-term untoward effects and is quite well tolerated. It is not clear if the higher pain scores at needle stick reflect anxiety and fear of a needle or a painful experience.

Comparison of normal saline and heparinized saline for patency of IV locks in neonates.

In this randomized double-blind experiment of 49 neonatal intensive care unit patients, probable time to catheter failure was significantly longer (p =.0358) for catheters flushed with heparinized saline (median = 127) compared with those flushed with normal saline (median = 39). This is in contrast to the nonsignificant difference (p =.841) in mean scores for six heparin-flushed catheters (M = 41.5 hours, SD = 44.0) compared with 18 saline-flushed catheters (M = 30.4 hours, SD = 20.8) discontinued for reasons other than completion of treatment. We concluded that survival time analysis is necessary when evaluating results of time-dependent studies in which the end point may not be elective.