NR 451 Week 1 Discussion Types Of Nursing Models And Frameworks Of EBP

NR 451 Week 1 Discussion Types of Nursing Models and Frameworks of EBP Recent

Types of Nursing Models and Frameworks of EBP

What are some of the models and frameworks of EBP currently in use? How does the strength of the evidence determine translation into practice? Why is it important to integrate both evidence-based practice and patient and family preferences? What is the nurse’s responsibility when EBP and patient and family practice do not match?

Professor I agree with your post.  I finished my LPN in 2009. I do not remember learning anything about EBP.  I received my ADN in 2013.  I may remember my professor mentioning EBP but not in detail.  I was thinking that it only came about in the last 2 years.  To read in this post that it arrived before I was born is new news to me.  While obtaining this degree I have learned to evaluate research and evidence.  This has helped me to understand EBP and its importance.  “EBP is important because it aims to provide the most effective care that is available, with the aim of improving patient outcomes.  Patients expect to receive the most effective care based on the best available evidence.  EBP promotes an attitude of inquiry in health professionals and starts us thinking about: Why am I doing this in this way?”  “EBP is important because it aims to provide the most effective care that is available, with the aim of improving patient outcomes.  Patients expect to receive the most effective care based on the best available evidence.”

http://canberra.libguides.com/evidence

I agree that each patient is different and we should use the best practice depending on that patient. Sometimes as nurses we may struggle at times on how to find the right practice for a patient. The patients beliefs may interfere with the best practice. You are correct when you say the patient preference is the “trump card”. In the nursing home with new regulations it is very important to follow what the residents like. For instance if the resident is a pureed diet for swallowing reason, but they say I want a hamburger with fries we have to honor that! The state says they have the right to eat what they want even if it goes against safety reasons.

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Great discussion this week. I agree with you that EBP is not a new concept and started with Florence Nightingale. Also the importance of using the models to develop different approaches for nurses giving care to patients. Your explanation about rating EBP is great and something that was I unaware of. Also using the nursing process to prove the EBP is important as well. I also agree that is of the greatest importance that the patient is willing to be a part of the EBP if the research is still being completed, or even when the research is completed, and the EBP is placed into practice. According to Veterans Health Administration Office of Nursing Services (2017), “Evidence isn’t actionable without the patient. In EBP, patient preferences are the “trump card”. Patients can’t have a preference if they don’t have (or aren’t given) a choice; and, patients can’t have a choice if they aren’t truly informed of all options.” Again great post.

Reference:

Veterans Health Administration Office of Nursing Services. (2017). Evidence-Based Practice Curriculum: Patient Preferences. Received from https://www.va.gov/nursing/ebp/docs/DefiningPatientPreferencesCurriculum_www.pdf

There are many different models and frameworks that are currently used for evidence based practice. One includes the ACE Star Model of Knowledge. This nursing model of EBP is a good starting for place for nurses as it incorporates five points to help the nurse integrate new practice. “The model of evidence translation that will prove most useful depends on the type of practice, the setting, and the practitioner’s needs(Houser,2018, p.468). The stronger the research the more informative a nurse can be about translating it into their practice. While implementing the evidence nurse have to take the patient into consideration as they may not agree with the new practices.

As nurses, we are taught to respect the patient and the family preferences to make sure the patient receives the best care possible. If the patient and family does not agree with EBP the nurse can try to educate the patient and family. If at the end of the education they still do not agree respect the wishes of the patient and family, and take care of the patient with other methods that they wish to be taken care of. As nurses, we are taught to critically think, and adjust our practices to individualize for each patient that we meet. “EBP is aimed at hardwiring current knowledge into common care decision to improve care processes and patient outcomes”(Steven, 2013, p.2)

Lesson Week 1

Houser, J. (2018). Nursing research: Reading, using, and creating evidence (4th ed.).Sudbury, MA: Jones and Bartlett.

Stevens, K. R. (2013). The impact of evidence-based practice in nursing and the next     big ideas. Online Journal of Issues in Nursing, 18(2), manuscript 4.doi:10.3912/OJIN.Vol18No02Man04.

I enjoyed reading your post. It sometimes seems that we are caught in situations where we must make judgment calls and our own ethics play a role. It is often difficult to step back and allow the patient’s wishes to “trump” what we know is best from a medical point of view. Emotions play a large role in why each person makes the decision he / she does. I often have to remind myself that what is physically best for the patient is not what may be emotionally best for him / her.

Good post. I enjoyed reading your response. I agree with you, The ACE star model of knowledge is a great starting point for nurses. According to Bonis (2007), the model is used to convert knowledge to outcomes through evidence based practice which is now being implemented into nursing programs because the overall passing standards for becoming a nurse has increased. When patients and family members do not agree with the practice or care, strong research is how we can support our EBP in nursing. We must also allow them to make their own decisions, but we must educate them and allow them to be informed of care and the situation of the patient. We must not become biased and allow the patient and family to make their own choices whether we agree with them or not. I like you statement that “we must adjust our practices for each patient we meet”. 

Reference:

Bonis, S., Taft, L., & Wendler, M. (2007). Strategies to promote success on the NCLEX-RN: an evidence-based approach using the ACE Star Model of Knowledge Transformation. Nursing Education Perspectives (National League For Nursing), 28(2), 82-87.

This week’s lesson listed five different EBP models (CCN, 2017):

  The John’s Hopkins Nursing Evidence-Based Practice Model (JHNNEBP)

The Stetler Model
The Advancing Research and Clinical Practice through Close Collaboration Model (ARCC)
The Iowa EBP Model
The Promoting Action on Research Implementation in Health Service Framework (PARIHS)

This all took place several years back, never labeled as EBP. I now know the painstaking time and energy that went into all of these algorithm changes. It did create an uproar and we were wondering, “Why can’t we just do what we have always done”? Many of the changes came with the care of pregnant hypertensive patients and hyperemetic patients. It all made sense after our organization provided us with an in-service and support. But, today we still have some who just can’t see past the old ways. The introduction of EBP has made caring for the patient much more efficient and prevents unnecessary interventions and reduces costs.

  As stated by Houser (2018, p. 25), “Based on the strength of the evidence and the preponderance of benefit or harm, recommendations are generated that are classified as strongly recommended, optional, or recommended.  Evidence collected by research studies are graded based on the strength. Vigilant evaluation of specific characteristics matched with an assessment of the credibility and validity of the studies is essential before carrying out changes. Evidence that supports better patient outcomes, efficient, effective care and reduction in errors is what gets translated to practice.

  When we integrate EBP with patient and family preferences, it allows us to design and develop appropriate and acceptable interventions tailored to that patient/family unit. By doing so we are implementing PFCC and allowing the patient/family to be active participants.  As nurses, we provide the knowledge, resources, and support each patient needs to be involved in informed decision making processes and assume important aspects of self-care (Hood, 2014, p. 408). The patient is not exclusive in PFCC as most people are part of a family. Personal preferences, values, family dynamics, religious and cultural traditions must all be taken into consideration.

  Healthcare providers and patients approach clinical care and treatment differently. First and foremost, it is my obligation and duty to uphold the patient and or family’s preferences.  We have a duty to care according to the patient’s wishes. So it is inevitable that there will be a time when EBP and the patient and family practice are at odds and don’t agree. There will always be these dilemmas. According to Siminoff (2013), PFCC increases treatment adherence and better outcomes. The family influence has a significant impact on health care decisions. Working with the patient and family and understanding their approach and decisions is important. Understanding that illness is not just a biological process but also a social process. Open commination and actively listening to the patient/family to make sure there is no misunderstandings about the EBP practice chosen is important.

The decision to be an active participant is the patient’s to make, not ours. Increased patient involvement is an important part of quality improvement because it is associated with improved health outcomes (Say & Thompson, 2003). With that being said, we must abide by our patients wishes. Several years back I can remember taking care a very sick hyperemesis patient who was Orthodox Jew. She was to be started on a sq Ondansetron pump, but because it was religious fast day, Yom Kippur, we could not start her until the fast was completed. I was so upset as this woman was already very sick and not eating or starting her therapy meant even more insult to her already depleted condition. After talking with her and listening, I understood the importance of this religious day and nothing I could say would change her mind. I did more research myself and came to realize the significance of this day for her. Cleary, compromise and allowing the patient to be the driver in her care was the best approach to take.

  References,

Chamberlain College of Nursing. (2107) NR451 Week   online lesson. Collaborative Healthcare: Chamberlain College of Nursing. Downers Grove Il

Siminoff L. Incorporating patient and family preferences into evidence-based medicine. BMC Medical Informatics And Decision Making [serial online]. 2013;13 Suppl 3:S6. Available from: MEDLINE Complete, Ipswich, MA. Accessed August 23, 2017.

Say, R. E., & Thomson, R. (2003). The importance of patient preferences in treatment decisions-challenges for doctors. BMJ: British Medical Journal, 327(7414),542. doi:http://dx.doi.org.proxy.chamberlain.edu:8080/10.1136/bmj.327.7414.542

 thank you for this weeks’ insight. Thank you for sharing a part of your own practice experience as well as your personal growth. In our textbook, (ANA,2015,pg.12) , there is a section on caring. It states caring is

* grounded in ethics, beginning with respect for the autonomy of the care recipient.

* grounded, as a science, in nursing, but not limited to nursing

* an attribute that may be taught, modeled, learned, mastered

* Capable of being measured and analyzed scientifically

* The subject of study within caring science institute/academic        worldwide

*Central to relationships that lead to effective haling cure, and/or actualization of human potential

As many of you have discussed, our own values, beliefs and preference, even knowledge does not supersede those of our patients. As with this patient, medically the intervention was necessary and important, however, to the patient her loyalty, her “faith” of what/who she believed her hope was in, was of a spiritual nature first, then the physical. As nurses we must care for the physical, the emotional and the spiritual part of our patients despite our own beliefs.  As patients face physical and emotional distress they also frequently experience spiritual unrest. As the patient advocate and caretaker ,it is often the nurse that can comfort and connect with the patient to enable them to confide their most inner fears and thoughts. As a NICU nurse, I have been asked to join hands and pray, participate in the baptism of an infant that is near death. This total care approach can often be uncomfortable. It is important to have working knowledge of major religions, as society, culture and religion is often interweaved. One article, Religion in Nursing, states,” there is  strength in a diverse yet united approach to the challenge of spiritual care in nursing practice.  

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author

(2017).Religion in Nursing retrieved from http://www.NursingLinks to an external site. School Hub.com    

  I agree, the spiritual part of the patients beliefs can be uncomfortable at times especially if it is in direct conflict with our own spiritual beliefs.  Setting aside our own beliefs and honoring those of the patient can be a nurses biggest challenges in practice.

As a human factor, nurses may know what they believe to be best in medical care and want to force this onto a patient. The doctor-patient relationship is important in influencing a patients beliefs or attitude toward medicine (Clyne, 2017).  The stronger the relationship the better the influence. Nurses have relationships with patients that may not be as respected as the doctors. If a doctor’s and a nurse’s values disassociate with each other, added challenges may exist to promoting change.

     The power of spiritual beliefs is a true challenge to changing a patient’s perspective to change in medical care. If there is a mismatch of beliefs it could severely impact what is the best therapy. A nurse has an added responsibility to have knowledge not only of EBP, but what beliefs a patient may have to encourage change. 

Clyne, B., Cooper, J. A., Boland, F., Hughes, C. M., Fahey, T., & Smith, S. M. (2017). Beliefs about prescribed medication among older patients with polypharmacy: a mixed methods study in primary care. The British Journal Of General Practice: The Journal Of The Royal College Of General Practitioners, 67(660), e507-e518. doi:10.3399/bjgp17X691073

What are the best ways to bring EBP to the bedside or to your individual practice?  How do you integrate the patient and family into these practices?  Which practice do you decide upon to integrate into your practice?

Professor and class,

This week’s lesson listed five different EBP models (CCN, 2017):

  The John’s Hopkins Nursing Evidence-Based Practice Model (JHNNEBP)

The Stetler Model
The Advancing Research and Clinical Practice through Close Collaboration Model (ARCC)
The Iowa EBP Model
The Promoting Action on Research Implementation in Health Service Framework (PARIHS)

  These models provide the direction or roadmap to guide new strategies for care when new research has been identified. When a problem has been identified, you must first collect internal data to support the problems exists. The next step is find data to determine the magnitude of the problem, along with its causes. The final step is to analyze your findings. Not all nursing models of EBP will fit all organizations (CCN, 2017). Prior to the last class, EBP NR439, I really wasn’t too familiar with the term EBP. As I reflect and have more knowledge, I know see the Iowa EBP Model was and is used in my current practice to most of our daily care. This all took place several years back, never labeled as EBP. I now know the painstaking time and energy that went into all of these algorithm changes. It did create an uproar and we were wondering, “Why can’t we just do what we have always done”? Many of the changes came with the care of pregnant hypertensive patients and hyperemetic patients. It all made sense after our organization provided us with an in-service and support. But, today we still have some who just can’t see past the old ways. The introduction of EBP has made caring for the patient much more efficient and prevents unnecessary interventions and reduces costs.

  References,

Chamberlain College of Nursing. (2107) NR451 Week   online lesson. Collaborative Healthcare: Chamberlain College of Nursing. Downers Grove Il

* grounded in ethics, beginning with respect for the autonomy of the care recipient.

* grounded, as a science, in nursing, but not limited to nursing

* an attribute that may be taught, modeled, learned, mastered

* Capable of being measured and analyzed scientifically

* The subject of study within caring science institute/academic        worldwide

*Central to relationships that lead to effective haling cure, and/or actualization of human potential

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author

(2017).Religion in Nursing retrieved from http://www.NursingLinks to an external site. School Hub.com    

  Does anyone in the class remember asking in nursing school “why” something is done and the answer was “because it has always been done that way”  When I went to nursing school (for the first round) Evidence based practice was not heard of.  We did things because it was tradition, or that is how we do it here, or that is how I was taught to do it.  Outcomes were really not thought of.  There was no evidence to back our interventions.  Now we have change models and research models and a body of evidence to bring positive outcomes to our patients.   

What are the best ways to bring EBP to the bedside or to your individual practice?  How do you integrate the patient and family into these practices?  Which practice do you decide upon to integrate into your practice?

I have always been one of those people who constantly ask why. I feel that knowing why I do a skill or why I give a medication is important. More importantly, I hate not having a consistent and steadfast reason when a patient asks why I am doing a skill a certain way or giving a medication. After reading your post, I was inspired to research the case of Lorenza Somera. Somera was a new graduate nurse in Manila in the Philippines. The doctor ordered cocaine injections for a tonsillectomy patient. Somera followed those orders and subsequently, the patient died. The order should have been for procaine injections. The courts found the doctor not guilty and ruled that Somera should have questioned the physician’s order. The courts charged Somera with manslaughter. It is appalling that a new graduate nurse was charged with manslaughter for following a physician’s order. Nurses now are taught to question any orders that do not feel comfortable executing. In 1929, that was not the case. Nurses at that time were educated that allegiance to the doctor meant that the patient was better served. “The Somera case sparked worldwide protests from nurses and served to push nursing toward independent practice and accountability” (Mason, et. al., 2016, p. 31).

After the Somera case, nurses began to continuously pursue new guidelines for practice. Autonomy and patient advocacy were the forefront for this protest. Even with this push for independence and patient advocacy, it wasn’t until 1978 that the ANA code of Ethics announced that “In the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical or illegal practice(s) by any member of the health care team or the health care system itself, or any action on the part of others that is prejudicial to the client’s best interest” (Mason, et. al., 2016, p. 32).

The Somera case brought to light many issues regarding the patriarchal relationship between nurses and doctors. It is unfortunate that Somera was charged with manslaughter but, the circumstances surrounding Somera’s involvement brought about changes that were drastically needed in nursing. If this case would have never happened, where would we be now?  We would not be discussing evidence-based practice from a nursing standpoint.

One of the most common ways that nurses utilize evidence-based practice is with patient safety. Per Titler, “Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions” (Titler, 2008, p. 113). It is vital to involve the patient and his / her family in the plan of care for the best conceivable outcomes. The patient must be aware of all possible choices and options related to care before deciding which route to take.

To choose the best possible evidence-based practice for my unit, I should do more research. I must read the articles because none seem to relate to an adult only ED except maybe hospital readmissions. I look forward to learning new information as I research the topics.

References:

Mason, D. J., Gardner, D. B., Outlaw, F. H., & O’Grady, E. T. (Eds). (2016). Policy & politics in nursing and healthcare (7th ed.). Retrieved from https://books.google.com/books?id=NGGuLinks to an external site.CAAAQBAJ&pg=PA31&lpg =PA31&dq=1929+nurse+in+philippines+ charged +with+manslaughter &source=bl&ots=57JsKKMO-K&sig=qzyQExee8go9sy 0ZYA5rv_CICro&hl =en&sa=X&ved=0ah UKEwjiioaynfzVAhXK4CYKHcu9Dcw Q6AEILTAB#v =onepage&q=1929%20nurse%20in%20philippines%20charged%20with%20manslaughter&f=false

Titler MG. The Evidence for Evidence-Based Practice Implementation. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 7.Available from: https://www.ncbi.nlm.nih.gov/books/NBK2659/Links to an external site.

Yes it is unfortunate that it took something like the tragedy of the Somera case to bring about change and it is something we as nurses should think about moving forward.  We should always be advocates for our patients and use the best EBP to care for our patients.  Which model do you think is the easiest and most appropriate for use in nursing practice?  It there a model that you or your organization uses already?

I believe the Johns Hopkins Nursing Evidence-Based Practice Model is the easiest and most appropriate model. “The strength of the Johns Hopkins model is its reliance on a strong academic–clinical collaboration as a foundation for mutual benefit” (Houser, 2018, p. 470).This model only has three phases, but has multiple steps within each phase. Each step is clearly defined and gives exact instructions on how to move forward. For a novice in evidence-based practice, this model would give me all the checks and balances needed to ensure I wasn’t overlooking crucial information. I do not know which model my facility utilizes but I do know that the supporting frameworks used at my facility are patient-centered care and shared decision-making.

Reference:

Houser, J. (2018). Nursing research: Reading, using, and creating evidence (4th ed.). Sudbury, MA: Jones & Bartlett.

I also found that the “PET” tool designed and used by Johns Hopkins appeared to be more user friendly.  I also like the part where the research goes into actions and therefore we can develop a process or modify as it seen necessary.

My present job I am a Quality Improvement Analyst and work with a team of non-clinical staff and developing processes is our business.  However, in a bedside clinical practice ACE: Evidence-Based Practice model would be a better tool to use.  I am grateful that there is more than enough models to chose from.

  When I was in nursing (which was not long ago) the professors asked the students the question why. Why are we doing it this? I remember being in clinical giving a medication and my clinical instructor sending me out because I did not have the correct diagnoses the patient was receiving the medication for. That has stuck with me. I am in wound care now, and started the job with no experience with 2 days of training! I have to look up the best researcher to prevent wounds and also how to take care of the wounds. Educating myself and the family to these new practices is very important. The best way to bring it to the beside is to practice what you have learned.

How do you know what is the “best” practice?  How do you decipher from all the research?  Which research is considered most correct?

I have always been taught that it depends on your patient or resident for the best practice. Individualize care is what it is about. What may work for one person may not work for the other. A good way to determine best research is the most current, and depending on the ending of the website such as org or edu.

I would have to agree that individualized care or patient centered care is the way to go. I also believe that as healthcare has shifted to  this approach ,the input of patients and their families are vital in determining best practice.  As nurses we are to educate on options, support decision,and facilitate intervention for positive outcome. Thanks for this weeks’ insight.

I have always wanted to know the “why” behind everything. I remember asking this question a lot as a child and getting the answer, “just because”. Unfortunately, I still hear this answer today in my nursing practice, along with “because this is how we’ve always done it”. Another response that I hear when a practice change is suggested is “why do we need to change?” or “there’s nothing wrong with the way we do it now.” People are always going to be resistant change because of fear of the unknown. If evidence-based practice (EBP) is implemented correctly, this can help decrease that fear and open people up to change.

Evidence-based practice means utilizing the best clinical evidence to make sound patient-care decisions. By using EBP, nursing rituals and traditions can be examined and determine if they need to be replaced with practices founded by scientific research. To use EBP one must know how to obtain, interpret, and integrate it into nursing practice. I found six steps that can help make EBP a reality at the bedside. Step 1 is to identify a clinical practice problem in the unit or an idea from a research article. Step 2 is to create a team with varied clinical and research skills to evaluate the evidence. Step 3 is to develop a plan of action. Step 4 is to implement and promote the plan. Staff education is vital in this step. Step 5 is to evaluate the results. Outcome measurements should be gather over 6 to 12 months to adequately evaluate the effectiveness of the new nursing intervention. Step 6 is to share the results. It is important to continually share the results with staff to maintain forward movement with the new intervention (Lawson, 2005). Following these steps will help to successfully implement EBP at the bedside and decrease resistance from staff that fear change.

The best way to integrate patient and family into evidence-based practice is by involving them in the process. It is important, as I talked about in my original post, for the patient and family to be well informed about all options as to make informed decisions.

The practice that I would decide to integrate into my practice is one that shows strong evidence for a practice change. It can’t just be based on popular opinion or on how things have always been done. Sound research that shows positive patients outcomes is needed to change practice.

Reference

Lawson, P. (2005). Doing it better: putting research into practice. How to bring evidence-based practice to the bedside. Nursing, 35(3), 18-19.

I really enjoyed reading your post. I have always heard the why, it’s something behind every why after research. A few years ago at a facility I worked at, had the staff look at a video who move my cheese,  because so many were resistant to change,  and it’s always good to change if it’s no longer working,  just like medications, in any growing industry a person must be willing to be flexible in order for growth, and a positive outcome   especially when dealing with patients and their families.

 Professor, when I went to nursing school 34 years ago, “Evidence based practice” in the same sentence was not heard of either.  However, Florence Nightingale was my roommate (lol if it is allowed).  I began to learn about research in the 80’s when bedside care and nurses began to have a voice and a mind of there on.  We began to ask questions and comparing notes on patient care and what worked best in our monthly nurse’s meeting.  I remember questioning a physician regarding treatment of a patient with high risk of skin breakdown.  I explained to him that several patients on another unit were placed on a low-flow mattress, with a noted decrease in skin breakdown.  He agreed with my suggestion and ordered the mattress. At a monthly nurses meeting, we established a wound care committee and began creating policy and procedures for skin care integrity. There are many hospitals and Long-Term Care facilities today continue to use wound care committees and developing policies and procedures to which I am proud to say I played my part.

  Yes we all had to find our way back in the 80s to provide the best care we knew how to our patients.  I think of some of the wound care protocols we used back then and cringe because now we know so much more because of research.  Change even now for many is difficult and requires proof that a change is needed.  In education, I ask many times “why are we still teaching this? It is not done like this anymore in real world nursing”  but until I can provide solid proof that times have changed, there will be no change. 

I can relate to not knowing about evidence based practice when I went to nursing school also.  Using evidence to support the best practice instead of just relying on existing practices, nursing care keeps up to date on the newest technological developments (Youngblut, J.M. 2001). I also have worked in wound care and I questioned the doctor about certain treatments that I didn’t agree with.  Usually with my rational & me treating the patients on a daily basis, the wound care doctor would often agree with me. At the facility that I did wound care at, we also used wound care committees and developed policies & procedures and I too had input on some of them.  It is a great feeling to be a part of that and you should always be proud of your contributions.  

I enjoyed reading your post, thanks for sharing.

Reference:

Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11759419