Levels of knowledge usability in evidence-based clinical

As part of their efforts to more systematically implement EBP, healthcare organizations worldwide aim at boosting the use of CPGs in order to standardize clinical practices and to move best evidence that has been summarized and translated into recommendation form into daily practice, to achieve more consistent care delivery. The primary underlying assumption for these efforts is that improved clinical care processes, quality of care, and

patient outcomes occur when care is based on summarized and translated best evidence, i.e., when CPGs are integrated into daily practice (Grimshaw et al. 2006, Thomas et al. 2009, Harrison & Graham 2012). However, even though healthcare organizations have invested a lot of resources, particularly over the last couple of decades, to implement CPGs in patient care, a considerable chasm still exists between what we know and what we actually do in clinical care delivery regarding consistent integration of best evidence into practice (IOM 2001, Wallen et al. 2010, Matthew-Maich et al. 2013, Stevens 2013).

Evidence-based CPGs, which have been developed through using the KT process to translate evidence summaries into practice recommendation form, represent a significant step forward in transforming best evidence into more practical and usable formats to assist with the integration of research-based evidence into clinical decision-making at the point-of-care (Edwards et al. 2005). However, findings from previous studies indicate that evidence-based CPGs are nevertheless not systematically implemented in clinical practice (Bennett et al. 2003, Meline & Paradiso 2003, Fink et al. 2008, Wallen et al. 2010, Melnyk et al. 2012), partially due to nurse clinicians’ lack a sufficient understanding on how to consistently adopt and integrate CPGs into daily care delivery (Eccles et al. 2005, Grimshaw et al. 2006, Bick & Rycroft-Malone 2010). In addition, complicating CPG adoption is the wide variation in their quality, particularly in relation to how the guidelines were developed and to the group or body that developed them (Graham & Harrison 2005).

However, publication of high-quality, evidence-based CPGs from credible international and national bodies, such as the Agency for Health Care Research and Quality (AHRQ), the Royal College of Nursing (RCN), as well as the Finnish national Käypä hoito (Duodecim)- and nursing CPGs (Hotus), along with the development of several coherent EBP models to guide their implementation, have helped facilitate the efforts of many healthcare organizations globally in using evidence-based CPGs to improve the quality and consistency of care delivery as well as patient outcomes (Harrison and Graham 2012, Matthew-Maich et al. 2013).

Another reason why nurse clinicians do not consistently implement evidence-based

CPGs in clinical practice is because CPGs frequently are not in a readily usable format for clinical practice, which prevents them to be easily integrated into daily care delivery.

Although many CPGs comprise robust evidence summaries in recommendation form, at several pages long, they often are far too lengthy, contain far too complex a structure or language, and fail to incorporate local evidence or circumstances, to be readily integrated into daily clinical decision-making (Harrison & Graham 2012, Korhonen et al. 2012, Saunders 2015). In order to implement EBP in daily clinical care delivery, the translated best evidence should be packaged into a concise and user-friendly format that is readily accessible and relevant in the local context, such as clinical care bundles and LOAs, which consist of 3-5 practical and actionable core clinical interventions that have been adapted to the local circumstances (IHI 2012a, b, c, d, Resar et al. 2012). This will enable nurse clinicians to integrate the translated best evidence in these formats into their daily practice much more easily than most CPGs. The KT process for translating best evidence from evidence summaries to these formats is illustrated by the levels of knowledge usability in evidence-based clinical practice (Figure 2). Usability refers to the format of the translated best evidence that from the clinical practitioner’s viewpoint is pragmatic, concise, relevant, and actionable in daily practice in the local setting as basis for clinical decision-making related to patient care.

An important aspect improving usability of translated best evidence is the integration of local knowledge, including data from local studies and about the local population (e.g., needs and environmental assessments, and prevalence studies of the clinical problem or issue of interest), as well as patient assessment data, outcomes management data, and quality improvement data (i.e., internal evidence) (Melnyk et al. 2014). It is essential to also evaluate the local circumstances and context, including how they affect CPG implementation e.g., the local care delivery model and any local gaps or variations in

practice related to the clinical problem or issue of interest, because it is usually not possible to adopt a CPG ‘as is’ in daily practice but instead, the CPGs need to be tailored to the local circumstances to allow their integration into daily practice (Harrison & Graham 2012, Singer & Vogus 2013). Thus, the levels of knowledge usability in clinical practice outlined in Figure 2 provide a summary of the different formats of translated best evidence related to their usability in clinical practice, which may help frontline nurses integrate EBP into daily care delivery.

Figure 2.Levels of knowledge usability in evidence-based clinical practice (Saunders 2015).

Reprinted with the kind permission of Wiley-Blackwell.

2.2.2 EBP implementation models in this study

2.2.2.1 The Stevens Model of Knowledge Transformation©

In the last few years, many EBP models and frameworks have been published in the literature to understand various aspects of EBP implementation and to guide integration of best evidence into clinical practice, some of which have been summarized by Ciliska et al.

(2010) and by Rycroft-Malone & Bucknell (2010). However, one of the earlier EBP implementation models, the Stevens Star Model of Knowledge Transformation© (Stevens 2004), also known as the ACE Star Model of Knowledge Transformation©, the origins and premises of which have previously been described by Mitchell et al. (2010), was selected as one of the relevant frameworks to be used as theoretical basis for this study. The Star Model was selected because it not only helps identify the specific EBP knowledge, skills, attitudes, beliefs and abilities, i.e., EBP competencies, requisite to frontline nurses’ employment of EBP in clinical decision-making, it also emphasizes the importance of using knowledge translation to transform the best available evidence into forms of knowledge that are more relevant, practical, and usable for frontline nurses in daily care delivery.

The knowledge transformation (KT) process, defined as the conversion of best available evidence from primary research studies through a series of stages and forms, into formats that are more readily usable in practice to support clinical decision-making and thus better

able impact on patient outcomes and care quality, is regarded as essential for EBP.

Consequently, the KT process is central to the Star Model, in addition to the process of BP implementation. According to the KT process, it would be more useful to provide frontline nurses with evidence summaries, such as systematic reviews, rather than have them searching for the best available knowledge amongst large volumes of research literature.

Similarly, rather than requiring frontline nurses to master the technical research skills of locating and critically appraising research literature, their clinical decision-making related to patient care would be better supported by CPGs and clinical care bundles. The Star Model therefore illustrates how the sequential stages of the KT process reduce the volume of knowledge available through summarizing and synthesizing best evidence, as well as provide forms of knowledge that are more readily usable in clinical decision-making (Stevens 2013). The Star Model also highlights the key steps for translating each form of knowledge into the next (e.g., translating evidence summaries into CPGs), with each stage getting closer to more pragmatic and readily usable formats for integration into clinical practice, thus aligning with the classic definition of EBP by Sackett et al. (1996, 2000), as well as with the more recent interpretation of EBP by Melnyk et al. (2012).

There are five stages in the Star Model which are illustrated by a five-point star.

According to the Model, the knowledge to be transformed in the KT process will circulate through all the Star points as it is translated from one form to the next, beginning with: 1) Star Point 1 or Discovery, representing primary research studies; 2) Star Point 2 or Evidence Summary, during which all available knowledge is synthesized into a harmonious statement, such as a systematic review; 3) Star Point 3 or Translation of the knowledge into action, during which the the evidence base and expertise are combined to make recommendations, such as evidence-based clinical practice guidelines (CPGs); 4) Star Point 4 or Integration of the knowledge into practice, during which evidence is moved into action and practice is aligned to reflect best evidence; and 5) Star Point 5 or Evaluation, during which the EBP outcomes on patient outcomes and care quality and consistency are assessed. In other words, during the five successive stages of the KT process in the Star Model, the key forms of knowledge (e.g., systematic reviews and CPGs) are sequentially translated into more usable formats in clinical practice, to help attain the goal of improving care quality and patient outcomes.

Figure 3. Stevens Star Model of Knowledge Transformation© (Stevens 2004) with 5 Star points.

Reprinted with explicit permission.

The Star Points of the Star Model also illustrate the KT and EBP processes and how these processes gradually advance through the levels of knowledge usability in clinical practice.

Specifically, best evidence from primary research studies is translated via the KT process into evidence summaries, such as systematic reviews, and further into practice recommendations, such as CPGs. During the EBP process, the translated best evidence is combined with the clinician’s expertise and the patient’s preferences and values, integrated into practice (i.e., practice is changed to reflect translated best evidence), and the practice change is evaluated for impact. In other words, the Star Model provides a practical roadmap for systematically integrating translated best evidence via the KT and EBP processes into clinical practice.

The goal of knowledge translation is evidence-based quality improvement, in order to improve the consistency and quality of clinical care delivery. Summarizing and synthesizing evidence into rigorous systematic reviews (i.e., Star Point 2 of the Star Model) is crucially important, in order to link best translated evidence with clinical decision-making (IOM 2008). As the KT process progresses, the summarized best evidence is translated one step further from systematic reviews into even more usable formats in clinical practice as CPGs (i.e., Star Point 3) to facilitate the integration of evidence into clinical care delivery. Several Institute of Medicine (IOM) reports and announcements (IOM 2001, IOM 2008a & b, IOM 2011a, b, & c, IOM 2013) have emphasized the significance of the evidence-based quality improvement process for improving patient outcomes and care consistency. However, it is important to keep in mind that although bibliographic databases have been available for over six decades for primary research studies (i.e., Star Point 1 of the Star Model), resources for the evidence forms on Star Points 2, 3, 4, and 5 have been developed only in the last few years., The forms of knowledge resources have been outlined in Table 2, which was first published in a concise table format in an article by Stevens (2013) and reprinted with explicit permission here.

Table 2. Resources for forms of knowledge in the Stevens Star Model of Knowledge Transformation© (Stevens 2013). Reprinted with explicit permission.

Form of Knowledge at Star Point Description of Knowledge Resources

Star Point 1 – Discovery Research Bibliographic Databases (e.g., CINAHL) provide single research reports

Star Point 2 – Evidence Summary Databases of Systematic Reviews (e.g., Cochrane Collaboration Database of Systematic Reviews) provide reports of rigorous systematic reviews on clinical topics, http://www.cochrane.org/

Star Point 3 – Translation into Guidelines Databases of Guidelines (e.g., National Guidelines Clearinghouse sponsored by the Agency for Healthcare Research and Quality (AHRQ)) provide online access to evidence-based CPGs, http://www.guideline.gov Star Point 4 – Practice Integration

Innovations Exchanges (e.g., Health Care Innovations

Exchange sponsored by AHRQ) provide profiles of innovations and tools fro improving care processes, http://innovations.ahrq.gov/

Star Point 5 – Evaluation of Impact Databases of Quality Measures (e.g., National Quality Measures Clearinghouse sponsored by AHRQ) provide detailed information on quality measures and measure sets, http://qualitymeasures.ahrq.gov/

2.2.2.2 The Advancing Research and Clinical practice through close Collaboration (ARCC) Model

Nurse mentorship differs from simply providing continuing education to nurses or developing the practice of others in that it requires development of a coaching, guiding relationship of mutual trust and support between the mentor and the mentee. EBP mentorship differs from what is traditionally understood by nurse mentorship in that it is clinical mentorship related to strengthening frontline nurses’ EBP readiness, i.e., it focuses on advancing nurses’ clinical competencies related to EBP implementation. A number of clinical mentor models, which in effect are EBP mentorship models in the clinical practice setting, have been published to guide the advancement of frontline nurses’ clinical competencies related to EBP implementation in clinical practice settings, such as the Clinical Mentor Model (Burritt et al. 2006), the Clinical Nurse Scholar Model (Schultz 2005), and the Advancing Research and Clinical Practice through Close Collaboration Model (ARCC) (Melnyk & Fineout-Overholt 2002). Clinical Mentors and Clinical Scholars are bedside nurse clinicians who become proficient in EBP implementation and mentor their peers in the direct care setting to deliver clinical care based on translated best evidence.

They are role models, clinical coaches, advisors, and teachers to their frontline nurse peers in clinical patient care units who help ensure that frontline nurses use translated best evidence as basis for their clinical decision-making and integrate it into their daily clinical practice. Clinical Mentors and Clinical Scholars are themselves mentored by a Masters-prepared APN or a doctorally-Masters-prepared Clinical Nurse Scientist in the application to clinical practice of the steps of the EBP implementation process through close collaboration and consultation. APNs are Registered Nurses (RNs) who have completed at least Masters- degree -level nursing education, passed a national certification exam for APNs, maintain continued competence as evidenced by recertification as APNs, and are licensed to practice specifically as APNs (ANA 2010).

The centrality of the EBP mentor role to advancing EBP integration into clinical care delivery was first proposed in the Advancing Research and Clinical practice through close Collaboration (ARCC) Model (Melnyk & Fineout-Overholt 2002). The ARCC Model was selected for the theoretical basis of this study because of the essential role of the EBP mentor in the Model. Specifically, APNs as EBP mentors strengthen frontline nurses’ beliefs in the value of EBP and in their ability to implement the EBP process. This in turn promotes frontline nurses’ EBP implementation, increases their job satisfaction and group cohesion, and ultimately improves care quality and patient outcomes, while at the same time, decreases nurse turnover, intent to leave the nursing profession, and hospital costs (Melnyk

& Fineout-Overholt 2001, Levin et al. 2011). Because of the centrality of the EBP mentor role in the ARCC Model (Figure 4), it was a useful framework for this study and an ‘excellent fit’ particularly for sub-study 3, which was an RCT for testing and evaluating the effectiveness of EBP education program and booster EBP mentoring interventions delivered by an APN serving as an EBP mentor, and designed to strengthen frontline RNs’ readiness for EBP, i.e., their EBP competencies, at one unversity hospital.

In the ARCC Model, EBP mentors are APNs, i.e., nurse experts with in-depth EBP competencies, as well as clinical leadership, collaboration, knowledge translation, change management, and outcomes evaluation skills (Melnyk & Fineout-Overholt 2002). APNs as EBP mentors have a crucially important, key role in creating an EBP-infused professional practice environment and in sustaining an organizational culture supportive of EBP. As clinical leaders and experts with advanced knowledge and skills in EBP, APNs are in an ideal position to advance EBP implementation among clinical nurses through employing evidence-based clinical strategies, such as journal clubs, clinical rounds, and development of EBP champions, through using effective educational interventions for frontline nurses focusing on the application of EBP into clinical care delivery. The mutual trust and support between the EBP mentor and the mentee (e.g., a frontline nurse) in a mentoring relationship

is important in advancing frontline nurses’ EBP competencies, i.e., their EBP knowledge, skills, attitudes, and beliefs, as well as strengthening their confidence in their own abilities to integrate EBP into daily patient care. Further, EBP mentors are in a key role in helping frontline nurses systematically implement EBP and in enabling EBP implementation to be sustained at hectic care delivery settings, where competing priorities frequently place challenges on frontline nurses’ ability to consistently implement EBP. However, few research studies have thus far focused on evaluating the impact of APNs on promoting EBP among frontline nurses (Varnell et al. 2008, LaSala et al. 2011, Levin et al. 2011, Muller et al.

2011, Moseley 2012), although prior studies have indicated that the presence of APNs as EBP mentors in healthcare organizations leads to stronger EBP beliefs in nurses, including stronger confidence in their ability to implement EBP, which in turn leads to greater EBP implementation (Burritt et al. 2007, Melnyk 2007, Hart et al. 2008, Melnyk et al. 2008b, Varnell et al. 2008, Wallen et al. 2010, Melnyk et al. 2012), and that the development and availability of EBP mentors is key to implementing and sustaining an EBP-infused organizational culture at healthcare organizations (Fineout-Overholt et al. 2005, Melnyk 2007, Walker et al. 2009, Aitken et al. 2011). In addition, the findings of a randomized controlled pilot study indicated that frontline nurses who were mentored in EBP by an APN, exhibited stronger EBP beliefs and group cohesion as well as greater EBP implementation, in comparison to frontline nurses who received mentoring in physical assessment skills (Levin 2011).

Figure 4. The Advancing Research & Clinical practice with close Collaboration (ARCC) Model©

(Melnyk & Fineout-Overholt, 2005). Reprinted with explicit permission.

2.2.2.3 The Action Model of Expertise in Nursing

The National Nursing Action Plan for the years 2009-2011, published by the Finnish Ministry of Social Affairs and Health (2009), aimed at increasing the effectiveness and attraction of nursing by outlining a national strategy for the development and management of nursing expertise in Finland. The National Nursing Action Plan also contained the Action Model of Expertise (AME), the primary purpose of which was to facilitate EBP

implementation in nursing. For the first time in the context of Finnish nursing workforce, the AME Model aimed to describe and differentiate the four primary professional nursing roles in terms of their levels of clinical expertise, characterized by the general clinical competencies in each role. In addition, the AME Model outlined the general emphasis in the clinical competencies of each primary nursing role, as well as gave examples of the types of general clinical tasks related to EBP implementation. The general emphasis of the competencies in the Nurses in clinical care- and the Specialized nurses in clinical care – primary nursing roles related to EBP implementation in the AME Model was on the patient sphere of influence, i.e., on clinical nurses employing EBP in direct patient care. The general emphasis of the APNs, i.e., the Clinical Nurses Specialist- and the Specialists in clinical nursing science – primary nursing roles related to EBP implementation in the AME Model, was on nurse/nursing and organization/system -spheres of influence, i.e., disseminating evidence-based knowledge, facilitating EBP implementation in clinical care delivery, and development of clinical care processes. Thus, the AME Model is essentially a EBP

implementation in nursing. For the first time in the context of Finnish nursing workforce, the AME Model aimed to describe and differentiate the four primary professional nursing roles in terms of their levels of clinical expertise, characterized by the general clinical competencies in each role. In addition, the AME Model outlined the general emphasis in the clinical competencies of each primary nursing role, as well as gave examples of the types of general clinical tasks related to EBP implementation. The general emphasis of the competencies in the Nurses in clinical care- and the Specialized nurses in clinical care – primary nursing roles related to EBP implementation in the AME Model was on the patient sphere of influence, i.e., on clinical nurses employing EBP in direct patient care. The general emphasis of the APNs, i.e., the Clinical Nurses Specialist- and the Specialists in clinical nursing science – primary nursing roles related to EBP implementation in the AME Model, was on nurse/nursing and organization/system -spheres of influence, i.e., disseminating evidence-based knowledge, facilitating EBP implementation in clinical care delivery, and development of clinical care processes. Thus, the AME Model is essentially a EBP