Strategies for Infusing Evidence-Based Practice
Presented by Victoria M. Steelman, PhD, RN, CNOR, FAAN and Sonya Osborne, PhD, RN
AORN Global Surgical Conference and Expo, Boston, MA – Apr 4, 2017
Attended and reviewed by Anne C. Jones, MA, BSN, RN, NE-BC
I know what you’re thinking—BORING! What would make me pick a topic with that title? Well, besides the fact that I love this stuff, haven’t you ever wondered just a little bit, why it is that even when we know what is the right thing to do – we have the data, we have the resources, we have the training, we have the guidelines, we have the policy – even with all that, it’s so darn hard to get everybody to do it?! How long did it take to implement the Universal Protocol for procedure verification, OR attire standards, medication labeling, and I could go on…
Among the many practice changes and improvements in which I participated over the years at the University Hospital, the elimination of straight-edge razors for hair removal remains perhaps the most confounding. We have known for decades that shaving the surgical site with razors causes micro-abrasions in the skin which can become colonized with bacteria which then increase the risk of a surgical site infection. We know that we should use clippers, not razors, and perform hair removal outside the OR suite as close to the time of surgery as possible, and remove hair near the incision only if it will interfere with the procedure.
I was a staff nurse, a clinical nurse educator, and a nurse manager at an academic medical center, for over 35 years, where we dealt with surgeons who had trained in a variety of different programs and who were all sure that their preferences were based on solid scientific rationale – not personal preference or folklore. I clearly remember this being part of my training as a floor nurse on a surgical unit back in the early ‘70s, and then again as a OR nurse in the early ‘80s.
Use of straight-edge razors hung on forever. It seemed that every time we set out to make a practice change and eliminate those razors, once and for all, we would be sabotaged. We had support from the surgeons on the OR committee, the infection control department, the staff, the supply area. They’re gone from the inventory. Yay!
Eventually, we even had support from the big guns in the American College of Surgeons (ACS) with SCIP – Surgical Care Improvement Project protocols. SCIP grew out of a collaboration between the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC). I thought this was it – the capper – no more room for argument. We buy the right equipment, inform and train the staff, stock the clipper heads, provide chargers, include clip-not-shave in the pre-op skin prep procedure. We write the policy and procedure, orient the staff, change all the preference cards, set a start date for the new practice. This will be a piece of cake, right?
Well, not all surgeons belong to the ACS. Every surgical specialty has its own national organization. And every specialty at the U has its own chair with separate channels of communication. The Infection Control Department works for the hospital, not the U of M, or the surgical services departments. The OR Committee was supposed to help with standardizing processes and protocols.
And you’d think that the CDC and CMS would outrank all of them. Wouldn’t you?
Now, since this article is true confessions, let me share with you a thought that intrudes into my consciousness in moments of greatest frustration. How is it that every surgeon wants the latest and greatest gadget that they saw at the most recent conference, or got from some product rep, whether or not it’s on the list from the supply chain controllers, yet they cannot handle a “change” in practice that is evidence-based, organizationally supported, and easily accomplished with the supplies at hand? How is that? I am reminded of a phrase in an article by Dr. Atul Gawande, a surgeon who wrote Checklist and Being Mortal, in addition to numerous pieces for The New Yorker. He said that change in health care happens “at a glacial pace.” This is a small comfort, given the speed and volume of the information for which we are responsible in the era of information technology.
All of this is prelude to the reason for my interest in this topic. Most professionals in clinical practice today would agree that we are in the era of evidence-based practice. We believe in the primacy of data and science over “the way we’ve always done it.” So, why is the focus on implementation? According to the presenters, Steelman and Osborne, “Studies estimate an average of 17 years for new knowledge from randomized controlled trials to be incorporated into practice.” They call this the “Evidence-Practice Gap.” I’ve certainly experienced it. Implementation of new practices range from very to somewhat to not very successful, even when the practice is well-supported and critical to patient care.
So, in addition to the science embedded in a particular clinical practice change, leaders and staff need to take into account something called “Implementation Science”, to help us “understand the behavior of the healthcare professionals and all of the stakeholders as key variables in the sustainable uptake, adoption, and uptake of evidence-based interventions.” “Implementation science provides a systematic set of principles and methods to identifying and addressing barriers and facilitators to system change.”
Changing behavior involves understanding capability, motivation, and opportunity. Never underestimate the tendency to revert to the familiar.
Key factors to consider are the innovation, the people, the context, and the process. Six reasons that implementation fails are:
- Lack of clarity in the aim or the innovation.
- Not including people in the plan/planning.
- Lack of understanding of the context.
- Bad planning.
- Measuring nothing or measuring everything.
- Failing to build support to sustain, scale up, or spread.
While it sounds obvious, assure that all stakeholders are in agreement and hold a shared view of the evidence. Changes in practice are often not optional but it can be helpful to engage early adopters, build success with smaller pilot projects to remove barriers and make it easier to do the right thing than the wrong thing, adjust processes as needed, report progress and outcomes to everyone involved. Expand and sustain the change in a planned way and monitor for success.
Key messages from the presentation:
- Patients who receive evidence-based care have better outcomes.
- Good evidence does not guarantee uptake in practice.
- Consideration of not only the what, but also the why and how is important for successful, effective, and sustainable implementation of evidence-based practices.
- It is imperative to continually evaluate practice in the light of new and emerging evidence.
Effective implementation is as important as evidence-based practice.
So, what about those darn razors? Years, and I mean years, after we implemented clippers in the OR at the U, I was doing a case with one of our more senior GYN staff surgeons. She asked for a razor to shave above the pubis before the skin prep and I said we didn’t have them anymore. I offered her the electric clipper. She went to the drawer in the supply cupboard and pulled out a razor. I asked the GYN room nurse how those happened to be in the drawer. She shrugged. The surgeon said she didn’t buy that stuff about razors. Surgeons believe in science and data. I wondered to myself do we have to wait for them to retire or die to get some of these changes to be made? Perhaps I would have been better equipped had I understood more about implementation science.
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