The need for Evidenced Based Practice (EBP) in healthcare settings is imperative for quality outcomes today. With the advent of the Institute of Medicine competencies for health professionals, nursing programs are reviewing and revising curriculum to ensure that EBP is incorporated and prominent. Through real-life "burning questions" brought forth from hospital nurses and nurse leaders, students in a Baccalaureate program engage in a semester long in-depth journey to identify the latest evidence on the selected topics. Through analysis, student teams determine if current research and EBP standards merit a change in practice or the need for further research. The team recommendations are presented in a full-day EBP Symposium where students share their findings through podium and poster presentations. The most recent annual symposium attracted over four hundred faculty, students, and practicing nurses from collaborative hospitals. Post-symposium, both the Proceedings Booklet and PowerPoint slides are accessible through the College of Nursing website thus allowing for world-wide dissemination of the findings. In addition, the posters travel to regional hospitals. Through this innovative model of EBP collaboration, changes in practice and implementation of new processes have emerged, thus yielding positive advances toward evolving collaborative efforts with our partnering organizations.
Throughout the world of healthcare, the impetus to engage in best practices using the latest evidence is paramount. With the Institute of Medicine report "Crossing the Quality Chasm", the need for a health care system that is "safe, effective, patient centered, timely, efficient, and equitable" is vital (IOM, 2001, p. 5-6). To achieve optimal patient outcomes, and ultimately obtain reimbursement for care, strategies to implement Evidenced Based Practices (EBP) in health care settings are occurring at rapid speed. While the interdisciplinary team model is important in management of patient care today, the role of the nurse is pivotal to achieve these aims. Educating the nurse while still in their nursing program, and throughout the entire curriculum, is an approach to make the use of EBP a routine practice, not a periodic occurrence.
EBP is seldom thought of as a set of skills that requires one to retrieve information to determine what evidence is generalizable, superimposed with the clinical experience that prompts the 'identification of clinically relevant questions' (de Cordova et al, 2008, p. 242). In "Health Professions Education: A Bridge to Quality", this basis of knowledge and inquiry to "integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible" is what defines Evidenced Based Practice (Institute of Medicine, 2003, p. 4).
Nine years ago, an exemplar model of EBP collaboration was developed through a partnership between the University of Oklahoma College of Nursing and acute care hospitals in the region. The collaborative partnership has created a vital link between the classroom and practice, as well as served as the impetus for 'real' changes in practice. Senior baccalaureate nursing students, working in teams, share discoveries from semester-long EBP projects during an annual EBP Symposium, co-provided by the college and hospitals partners. Each year, the EBP Symposium continues to draw a larger statewide audience; last year over 425 nursing students and faculty, as well as nurses from acute care and community practice attended the full-day event.
The college's BSN program consists of four different student types enrolling in coursework simultaneously: Traditional, Accelerated (ABSN), LPN-BSN, and RN-BSN. For the students in the traditional and ABSN program, EBP is integrated in all four semesters of study; integration of EBP occurs in both semesters of full-time study for LPN-BSN and RN-BSN students.
According to the American Academy of Colleges of Nursing (AACN), Essential #3 - Scholarship for Evidenced Based Practice – notes that:
"professional nursing practice is grounded in the translation of current evidence into practice.....As practitioners at the point of care, baccalaureate nurses are uniquely positioned to monitor patient outcomes and identify practice issues" (2008, p. 15).
The AACN notes nine components that ever y baccalaureate level nursing graduate should be skilled in, but three components are prominent in our EBP program.
The baccalaureate program prepares the graduate to: i) participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes ii) Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care, and iii) collaborate in the collection, documentation, and dissemination of evidence. (AACN, 2008, p. 16)
Likewise, the National League for Nursing (NLN) cites in their Education Competency Model, four overarching competencies for graduates of nursing programs (2010, Version A_047b). The competency, Professional Identity, invokes the graduate to have a commitment to EBP while the second competency, a Spirit of Inquiry, engages the graduate as:
"an evolving scholar who contributes to the development of the science of nursing practice by identifying questions in need of study, critiquing published research, and using available evidence as a foundation to propose creative, innovative, or evidence-based solutions to clinical practice problems" (NLN, 2010, para.4).
It is with standards from these prominent accrediting bodies for baccalaureate education that our EBP program continues to energize and propel the graduating baccalaureate student to be proponents of the EBP process.
In the very first introduction to professional nursing course, students are given an explanation of EBP, an in-depth orientation on how to search the literature, and the different levels of evidence. They are then assigned to work in teams to formulate a PICO-T (Population, Intervention, Comparison, Outcome, and Time) question based on a health question or problem they have experienced or have encountered in the clinical setting. As they process the question, students do a cursory review of the literature so that each team member can locate one pertinent research article to critique.
In the next two semesters, EBP is presented in all other coursework and integrated in the clinical courses. When students incorporate EBP interventions for patients in the clinical setting, they are able to see application to real patients. In the final semester Leadership course, the integration of EBP culminates into a semester-long project. The course content includes a greater in-depth overview of EBP, critiquing the literature, and the linkage to standards of practice, quality improvement, staff and patient satisfaction (i.e. HCAHPS), environmental impact, and financial outcomes.
Prior to the Leadership course in the final semester, the lead EBP faculty puts out a 'call for burning questions' to the regional collaborative hospitals. The request goes to the Directors of Education, who in turn route the request to the Nurse Managers seeking input from nursing staff. Up to this point, only acute care facilities have been queried, although a future plan to engage the community agencies is being reviewed.
Once the 'burning questions' have been received, a master listing is given to the students early on in the semester. Students self-select student teams of three to five students per team. Each team then indicates their first, second and third choices from the master listing. The lead EBP faculty reviews the student selections and then assigns students their topic. Once the student topics are known, the listing goes out to the faculty where they also choose their first and second topic selection, based on interest and familiarity. Faculty are then paired with the student teams as a mentor for the entire semester.
Each team selects a team leader, who is the primary contact for the faculty mentor. Each student team has a minimum of three to four consultations with their faculty mentor throughout the semester. A descriptive outline of benchmarks to achieve by each consultation is given to the student teams. Additional on-line resources are available to each team/faculty mentor. The goal for each team is to synthesize the literature on their particular topic to develop a practice recommendation, including a change in practice or not. Additional components to address in their project is: feasibility of the change, what levels of the organization need to be involved, readiness level of those involved, what resources are needed to complete the change, what change theories could be used to guide strategy, anticipated barriers and facilitators, ways to communicate the change, evaluating the practice change and sustainability.
As the student progresses to project completion, the final consultation involves the faculty mentor and students performing a final run-through and edit of the student podium presentation and poster display. On the day of presentation, the students are graded by a faculty team and are also peer-evaluated. In addition, for those symposium participants requesting continuing education hours, evaluation feedback is also obtained.
Dissemination of students' findings is published annually in a Proceeding Booklet (The University of Oklahoma College of Nursing, 2011). Abstracts and Matrices, an overview of current relevant research and practice standards, are included in the booklet. With growth of the symposium and mindfulness of the environment, the Proceedings Booklet has evolved from a 'paper' to an online publication with world-wide dissemination through the college's website: (http://nursing.ouhsc.edu/Research/ebp.cfm) (The University of Oklahoma College of Nursing, 2011). With online dissemination, the powerpoint slides from the students' podium presentations have also been included. The posters that are created by the students for the symposium are collected and delivered to regional collaborative partners as a 'traveling road show'. For some of the more outlying organizations, this method of delivery and presentation is time efficient and informative for all practicing nurses.
For the past nine years, the nursing students have investigated the 'burning questions' coming from the collaborative partners. Some of the most current examples of successfully completed EBP projects by the BSN graduates have included the following.
A strong feature of the EBP projects is the student groups focusing on ways to find the latest evidence to answer the questions. An example of this occurred recently in which an EBP group studied whether eight hour versus 12 hours shifts for nurses had an effect on patient care outcomes. They were able to incorporate findings from the Joint Commission on Accrediting Healthcare Organizations (JCAHO) that had just been released 4 months prior, making it 'hot off the press' information. From this perspective, the agencies have had a plethora of information to help address current problems or issues in the clinical practice setting.
The linkages formed with the collaborative partners have been crucial to the growth and success of the EBP Symposium. With the initial Symposium in 2004, two special features have been maintained each year: the event is provided free-of-charge and continuing education contact hours are given to registered nurses in attendance. In addition, the collaborative partners have been supporting the symposium with financial gifts and/or in-kind services, thus making the 'annual' symposium a reality.
Implementing the first Symposium in 2004, OUCN in collaboration with three local hospitals presented a half day event of six to seven student teams. Fast-forward to 2012, it has been seen that the collaborative hospitals have tripled and there is now a total of 36 student teams presenting (See Appendix A). The first EBP Symposium began as a one-room venue seating 75-80 persons on the campus. As evident with increased numbers of students and participants, one of the collaborative partners volunteered to provide the larger venue and support for the EBP Symposium for the next two years. Again, with continued growth, the EBP Symposium moved back to the campus in a new Learning Center on OU-Tulsa campus with presentations held in seven classrooms for all-day concurrent sessions. Invited keynote speakers have been from practice as well as academia.
Appendix A
As the Symposium audiences grew, so did the interest from other nursing programs; many area faculty requiring their students to attend the event. In fall 2009, nursing faculty with another university, in the region, inquired about the possibility of their RN to BSN nursing students conducting similar semester-long EBP projects and actively participating in the podium and poster presentations at the annual Symposium. A meeting was held between lead EBP faculty at both universities to begin dialogue about a collaborative endeavor. Utilizing the EBP project course content and materials for the Leadership course, students from a second university joined in presenting poster and podium presentations related to semester-long EBP projects they had conducted.
At the conclusion of each Symposium the posters of students' EBP projects travel, for the next six to nine months, throughout northeastern Oklahoma for display at the collaborative hospitals. The posters have served as a focus for annual nurses' week events and educational offerings at the hospitals. Response has been resoundingly positive, with students receiving high praise for their work and dissemination of findings. Because not all nurses from the collaborating hospitals can attend the annual Symposium, on occasion, some student teams have presented their powerpoint slides to nurses on units which submitted the team's 'burning question'. Nurses are also encouraged to access the College's website to view the Proceedings Booklet and powerpoints for all of the podium presentation.
While EBP is integrated throughout the students' entire curriculum and culminates with the EBP Symposium project, the longer-lasting effects of participating in this process have been evident by some of the outcomes from the graduates. One example of this is a student group who took their 'burning question' and ultimately created a screening tool based on the topic. The screening tool was presented to the hospital practice council with positive feedback. Although not yet adopted by the organization, there has been an increased interest and awareness of the issue. The students’ efforts were then rechanneled into a publication that disseminated their findings, yet one more component of the research process.
Two other alumni have taken on leadership roles that incorporate EBP as a model of practice. The first alumni participated in the first EBP Symposium process. Since that time, she has achieved an advanced nursing degree in education, continuing to highlight the EBP process in her staff development position through her involvement with Research Roundtables. Working with practicing nurses not familiar with the EBP process, she has worked diligently to make staff nurses more comfortable with the process of searching for the best evidence to solve problems impacting their respective clinical units. In the Research Roundtables, more recent graduates from the program readily step up to the plate to assist those staff nurses with less familiarity with the EBP process.
The second alumnus is practicing at the CNS level and continues to use EBP in daily practice through the review of best practices on the neonatal unit. Role modeling behaviors using EBP in clinical practice settings, even five years after graduating from the nursing program, has become habit, thus foundational for continued use of EBP as standard practice. Through EBP classes created by the alumnus for bedside nurses not familiar with the EBP process, the rigor of newly implemented journal clubs has increased (L. Green, personal communication, June 26, 2012). In addition, at an annual research day, bedside nurses utilize EBP knowledge in completing a variety of research projects including focused literature reviews requiring critical appraisal of at least a level five or higher of evidence, and an EBP comprehensive literature review to answer a PICO question (L. Green, personal communication, June 26, 2012). Reflecting on her initial nursing preparation, she states "my nursing program helped me realize how important it is to answer those burning clinical issues and questions and feels that ‘my foundational knowledge of EBP is solid because of my exposure and experiences to EBP in my baccalaureate program" (L. Green, personal communication, June 26, 2012).
These are just but a few of the examples of the EBP continuing on past the graduates nursing baccalaureate program. It is hoped that a new paradigm may be forming in nursing practice, one which "envisions students not merely as the recipients of education in EBP but also as active enablers who promote EBP within clinical settings by forming partnerships with practicing nurses" (Moch, Cronje, & Branson, 2010, pg. 11).
Integrating EBP from an academic setting to clinical practice is a continual evolving process. In reflection of the past nine years, the model of including EBP into the curriculum has gone from a semester-long project to infusion of EBP throughout the entire four-semester curriculum. But where do we go from here?
Ideas for future directions include inviting nurses, who submit a team's 'burning question', to participate in consultations throughout the semester with the faculty mentor and students. The nurse's expertise would enhance the potential for development of realistic implementation strategies and actualization of a change in practice, if indicated.
Extending an invitation to other baccalaureate nursing programs to join the two current universities and collaborative hospitals in this endeavor have also been discussed. By engaging additional nursing students, a greater number of nurses well prepared in EBP would be created for the job market. Thus, the number of new nurses, as well as experienced nurses (completing a BSN), who could champion EBP in their practice settings would be significantly increased.
Taking EBP to another level would be the inclusion of graduate nursing students, particularly students in the Clinical Nurse Specialist (CNS) program. As envisioned, CNS students could assist faculty mentors with facilitation of the student teams and enhance the bond with collaborative hospitals.
It is hoped that being immersed in EBP throughout the curriculum as students, the new practicing BSN's will have a greater understanding of EBP. It is postulated that this increased understanding will enhance the likelihood of incorporating EBP as a part of their daily nursing practice, thus advancing the IOM's aims for care that is 'safe, effective, patient centered, timely, efficient, and equitable' (2001, p. 5- 6). It is through these linkages between the classroom and practice to strengthen EBP that better patient outcomes, including a more satisfied patient, will result.