Journal of Gerontological Nursing

Evidence-Based Practice: Residency Program in Gerontological Nursing

Jane Hsiao-Chen Tang, MSN, RN; Marita G Titler, PhD, RN, FAAN

Abstract

Evidence-based practice (EBP) is a mechanism to improve patient care with several studies demonstrating benefits of practice based on research evidence (Huber et al., 2000; Le May, Alexander, & Mulhall, 1998; Titler, Mentes, Rakel, Abbott, & Baumler, 1999). Evidencebased practice improves quality care, contains costs, and enhances the professional practice environment (Goode & Piedalue, 1999; Steiler et al., 1998; Titler et al., 2001). Such practices have the potential to affect not only patient and staff outcomes, but also organizational outcomes (Huber et al., 2000). Nursing practice should be based on evidence - preferably research evidence.

Care of older adults requires use of evidence to promote optimal outcomes for patients and their families. Development and dissemination of EBP protocols on health care problems central to elderly individuals are needed. The Research Dissemination Core (RDC) of the Gerontological Nursing Interventions Research Center (GNIRC) develops EBP protocols for a variety of clinical topics. These EBP protocols are designed to assist nurses in practice to improve management of health care problems of older adults (e.g., pain, dehydration, urinary incontinence, acute confusion, delirium).

Development and use of EBP protocols that improve quality care for older adults is important. However, without understanding the process of implementing EBP, availability of the EBP protocols is of little use. Teaching professional nurses how to implement EBP is an important activity of the RDC. The purpose of this article is to share the EBP nursing residency program experiences designed to promote implementation of EBP for care of older adults.

The extent to which program objectives were met are in Table 4. All residents agreed or strongly agreed that the program helped them to infuse EBPs into their organization, critique and use EBP protocols, and implement a new EBP initiative.

Residents rated the usefulness of materials sent to them m preparation for the residency. Example materials included a reading list of EBP literature; a set of the RDC EBP protocols, "Research Utilization: Nursing Clinics of North America," "Critical Care Nursing Clinics of North America: Translating Research Into Practice," and "Research Utilization: A Study Guide;" and "Knowledge for Health Care Practice: A Guide to Using Research Evidence." Residents rated (1 = strongly disagree to 5 = strongly agree) the program materials* helpfulness as follows:

* Using Nursing Research to Improve Nursing Practice, a Guide: CURN (mean = 4.38; SD = .77).

* Research Utilization: A Study Guide (mean = 4.63; SD = .62).

* Research Utilization: Nursing Clinics of North America (mean = 4.4; SD = .73).

* Evidence-Based Protocols (mean = 4.63; SD = 1.03).

Overall, residents strongly agreed that the evidence-based literature was helpful (mean = 4.70; SD = .46).

Lastly, residents rated the helpfulness of the program experts and preceptors (1 = Strongly Disagree to 5 = Strongly Agree). In general, the residents highly valued the program preceptors, with the mean rating of 4.61 (SD = .65).

Strengths and Weaknesses of the Program

Residents also provided written comments and overall review of the residency experience, including strengths of the program and suggestions for improvement. Their comments are summarized below.

Uniqueness. The residency program provides geriatric nurses with a rare opportunity to have hands-on experience learning the research utilization process and enabling them to infuse innovation into their practice settings. The condensed and intense program gives nurses ample opportunities to expand their awareness and understanding of research utilization and EBP from experts and preceptors. It was very helpful when the residents were able to spend time with so many experts and preceptors in the areas of their interests such as falls, depression, and pressure ulcers. Moreover, the program provides flexibility…

Evidence-based practice (EBP) is a mechanism to improve patient care with several studies demonstrating benefits of practice based on research evidence (Huber et al., 2000; Le May, Alexander, & Mulhall, 1998; Titler, Mentes, Rakel, Abbott, & Baumler, 1999). Evidencebased practice improves quality care, contains costs, and enhances the professional practice environment (Goode & Piedalue, 1999; Steiler et al., 1998; Titler et al., 2001). Such practices have the potential to affect not only patient and staff outcomes, but also organizational outcomes (Huber et al., 2000). Nursing practice should be based on evidence - preferably research evidence.

Care of older adults requires use of evidence to promote optimal outcomes for patients and their families. Development and dissemination of EBP protocols on health care problems central to elderly individuals are needed. The Research Dissemination Core (RDC) of the Gerontological Nursing Interventions Research Center (GNIRC) develops EBP protocols for a variety of clinical topics. These EBP protocols are designed to assist nurses in practice to improve management of health care problems of older adults (e.g., pain, dehydration, urinary incontinence, acute confusion, delirium).

Development and use of EBP protocols that improve quality care for older adults is important. However, without understanding the process of implementing EBP, availability of the EBP protocols is of little use. Teaching professional nurses how to implement EBP is an important activity of the RDC. The purpose of this article is to share the EBP nursing residency program experiences designed to promote implementation of EBP for care of older adults.

RESEARCH DISSEMINATION CORE

The GNIRC of the University of Iowa College of Nursing was established in 1994. The center is in the fourth year of a 5-year competing continuation grant from the National Institute for Nursing Research (Grant No. P30 NR 03979, PI Dr. Tripp-Reimer). The primary purpose of the GNIRC is strengthening and expanding intervention focused research in nursing and related fields regarding health care of older adults (Titler & Mentes, 1999). In support of this purpose, the RDC, one of the vital cores of the GNIRC, is responsible for facilitating the transfer of research-based knowledge to clinical practice by:

* Coordinating training on methods of grading and synthesizing evidence for use by health care practitioners.

* Dissemination of scientific information.

* Facilitating the clinical adoption of evidence-based interventions to improve care of older adults.

The functions of the RDC are many, but a major emphasis is on developing and disseminating evidence-based nursing practices for care of older adults to practitioners, scientists, and consumers (Titler, Mentes, Rakel, Abbott, & Baumler, 1999). Developing an EBP protocol requires reviewing relevant literature, critiquing studies, and synthesizing research findings for practice. Nursing's contributions to improving older patients' outcomes can be optimized by the use of EBP protocols (Titler Sc Mentes, 1999). Therefore, the RDC has systematically recruited individual nurses or nurse workgroups to develop EBP protocols within their area of clinical expertise.

Currently, 31 EBP protocols are offered for dissemination through the RDC (Table 1), and 11 protocols are under development (Table 2). Some of the protocols include a quick reference guide for practitioners and a consumer information sheet. The EBP protocols have been abstracted for inclusion in the Agency for Healthcare Research National Guideline Clearinghouse, and more than 20,000 copies of the EBP protocols have been distributed throughout the United States and 20 foreign countries.

Table

TABLE 1LIST OF RESEARCH DISSEMINATION CORE EVIDENCEBASED PRACTICE PROTOCOLS

TABLE 1

LIST OF RESEARCH DISSEMINATION CORE EVIDENCEBASED PRACTICE PROTOCOLS

EVIDENCE-BASED PRACTICE RESIDENCY PROGRAM

Developing EBP protocols is an important step in improving practice through the use of research, but the effort does not guarantee that nurses will automatically adopt the practice. To facilitate the clinical adoption of EBP to improve care of older adults, the RDC offers an EBP residency program to promote use of EBPs by nurses in practice. The program helps nursing residents learn the process of promoting infusion of a clinical innovation into practice, implement an evidencebased protocol from the RDC in the candidate's agency, and submit a manuscript to a specialty journal related to the residency.

The EBP residency program provides 80 hours of paid tuition for nurses who work with older adults. Previously, during the first 4 years of the program, residents spent 80 hours on-site at the University of Iowa Hospitals and Clinics (UIHC) and College of Nursing. Based on the residents' suggestion, in the continuation grant, the RDC modified the program to 40 hours at the UIHC and 40 hours at the resident's home agency implementing the EBP protocol. The 40 hours at UIHC are used to emphasize methods and strategies for implementing clinical innovations m practice. Residents choose an EBP protocol they are interested in implementing at their agency. They are matched with appropriate UIHC researchers and staff, and College of Nursing faculty to learn the protocol and how to implement it.

The residency also consists of assistance in learning electronic literature search techniques for retrieving evidence-based information at the University of Iowa libraries. The residents then spend the subsequent 40 hours of the program in their home agency with protected, non-patient care time to promote adoption of the chosen protocol. The home agency is reimbursed per them (80 hours) for the resident's salary.

Each year, two nurses are selected from a national competitive application process to complete the EBP residency program. The resident criteria include:

* Being an RN who primarily delivers care to the aged population.

* Being employed at least 50% time.

* Having a minimum of a BSN degree, master's preferred.

* Submission of a residency plan to include an evidence-based protocol to be implemented at their home agency, learning objectives, and benefits of residency for self and employing agency.

EVIDENCE-BASED PRACTICE RESIDENCY PROGRAM EVALUATION

The nursing residency in EBP has been offered for 8 years. Evaluation of the program is based on questionnaires completed by the residents (N = 16) at the end of the EBP residency program.

Demographics

Sixteen nurses completed the residency program from 1996 to 2003 (Table 3). All residents were women, the majority of the residents had a master's degree (n - 12), and most were from acute care settings (n = 8). Five were advanced practice nurses, four were staff nurses or care coordinators, four were nurse managers or supervisors, and three were faculty in academic settings.

Residents represented a wide geographic area with nine from the Midwest, two from the South, one from the Mid Atlantic states, and two from Alaska. Two international residents were from Singapore and Canada. The clinical topics of focus were: Prevention of Falls (n = 3), Prevention of Pressure Ulcers (« = 3), Discharger Planning (« = 3), Detection of Depression (n - 3), Acute Confusion (n = 1), Acute Pain Management (n = 1), Management of Diabetes (n = 1), and Medication Management Assessment (n = 1).

Evaluation Results

Residents evaluated the program based on the residency objectives, usefulness of the program materials, and helpfulness of the program experts and preceptors (i.e., individuals meeting with residents from the University of Iowa).

Table

TABLE 2RESEARCH DISSEMINATION CORE EVIDENCE-BASED PRACTICE PROTOCOLS IN DEVELOPMENT

TABLE 2

RESEARCH DISSEMINATION CORE EVIDENCE-BASED PRACTICE PROTOCOLS IN DEVELOPMENT

Table

TABLE 3CHARACTERISTICS OF RESIDENTS ACCEPTED FOR THE EVIDENCE-BASED PRACTICE RESIDENCY (N = 16)

TABLE 3

CHARACTERISTICS OF RESIDENTS ACCEPTED FOR THE EVIDENCE-BASED PRACTICE RESIDENCY (N = 16)

Table

TABLE 4EVALUATION OF EVIDENCE-BASED PRACTICE RESIDENCY PROGRAM OBJECTIVES (N= 16)*

TABLE 4

EVALUATION OF EVIDENCE-BASED PRACTICE RESIDENCY PROGRAM OBJECTIVES (N= 16)*

The extent to which program objectives were met are in Table 4. All residents agreed or strongly agreed that the program helped them to infuse EBPs into their organization, critique and use EBP protocols, and implement a new EBP initiative.

Residents rated the usefulness of materials sent to them m preparation for the residency. Example materials included a reading list of EBP literature; a set of the RDC EBP protocols, "Research Utilization: Nursing Clinics of North America," "Critical Care Nursing Clinics of North America: Translating Research Into Practice," and "Research Utilization: A Study Guide;" and "Knowledge for Health Care Practice: A Guide to Using Research Evidence." Residents rated (1 = strongly disagree to 5 = strongly agree) the program materials* helpfulness as follows:

* Using Nursing Research to Improve Nursing Practice, a Guide: CURN (mean = 4.38; SD = .77).

* Research Utilization: A Study Guide (mean = 4.63; SD = .62).

* Research Utilization: Nursing Clinics of North America (mean = 4.4; SD = .73).

* Evidence-Based Protocols (mean = 4.63; SD = 1.03).

Overall, residents strongly agreed that the evidence-based literature was helpful (mean = 4.70; SD = .46).

Lastly, residents rated the helpfulness of the program experts and preceptors (1 = Strongly Disagree to 5 = Strongly Agree). In general, the residents highly valued the program preceptors, with the mean rating of 4.61 (SD = .65).

Strengths and Weaknesses of the Program

Residents also provided written comments and overall review of the residency experience, including strengths of the program and suggestions for improvement. Their comments are summarized below.

Uniqueness. The residency program provides geriatric nurses with a rare opportunity to have hands-on experience learning the research utilization process and enabling them to infuse innovation into their practice settings. The condensed and intense program gives nurses ample opportunities to expand their awareness and understanding of research utilization and EBP from experts and preceptors. It was very helpful when the residents were able to spend time with so many experts and preceptors in the areas of their interests such as falls, depression, and pressure ulcers. Moreover, the program provides flexibility for the schedule. Not only does the program allow residents to meet people who could help them be successful, but it also incorporates other interests as expressed by the resident. Two residents summed up the residency program experience as follows:

This is a unique program, which is not available anywhere eise that I am aware of. The residency afforded me the information I needed to actually implement the RU process.

Although I had learned the process previously, I hadn't really learned how to implement it.

and:

I thank you so much for the wonderful opportunity and experience I was given with the EBP residency ... In this era of health care chaos, hospital cutbacks, and short staffing, an opportunity like this is a bright light in a sometimes dark tunnel.

Richness. The University of Iowa Hospital and Clinics is nationally known for research utilization and EBP. The RDC director also has a long-standing history of using research in practice to improve patient outcomes. The richness of the EBP environment promotes nursing residents* learning from experts in a university setting. The rich experiences and expertise from experts and preceptors provided great insights and knowledge.

One resident stated, "Everyone on the agenda was very helpful and knowledgeable. There was a good blend of representatives and experts from administration, academia, and clinical areas." Another resident noted "it has been a long time since I have been privileged to gain information and interact with a concentrated group of experts." The experts and preceptors were not only knowledgeable, but also enthusiastic when meeting with the residents. Many residents mentioned the willingness of experts to share knowledge, clinical expertise, resources or materials, and EBP information. As one resident described, "The people I have met have been willing to share not only their triumphs but also their challenges when implementing changes."

Networking. Several residents commented that the EBP program enabled them to meet advanced practice nurses and researchers to share and exchange their experiences and challenges. A resident reported

I feel confident to implement EBP at home, with a whole network of contacts here at U. of Iowa who are interested and supportive. It has been truly wonderful to feel like I'm singing in a choir rather than whistling in the dark.

Another resident agreed by saying

Superb networking opportunity with content experts in the field of administration, library services, research, and nurse practice. Their willingness to assist with advising and providing scientific evidence was pivotal to understand a focused research.

Having an EBP residency program provides practicing nurses great networking to assimilate the information and motivate and encourage them to improve patient care based on evidence.

Suggestions for Improvement. Providing an intensive 40 hours onsite (UIHC) experience presents a great opportunity for residents, but also means some challenges.

Because experts and preceptors are also busy scholars, researchers, and clinicians, it is difficult to schedule a perfect time to accommodate every individual's need. Therefore, several residents have expressed the need to improve schedules. Suggestions include allocating "travel" time for residents from one meeting to another, because of distances around the hospital and campus. Another suggestion is to allow some time in between appointments and meetings so as not to limit or prevent the residents from attending the next meeting, or simply to allow them time to reflect. Other opportunities to improve the program included providing more background information on each of the experts and preceptors. By having the background information, some residents felt they would be better prepared to maximize the discussions with each of the experts.

EFFECT

The program has continued for 8 years and has resulted in several important outcomes. First, the opportunity to learn EBP from the condensed EBP residency program helped geriatric nurses gain knowledge and understanding of the EBP, which resulted in several publications and professional presentations. For instance, one resident successfully published her EBP residency experience in a journal (Holland, 2001). Another resident developed an evidence-based protocol on family bereavement and successfully implemented it in her institution. Her protocol was later accepted in a journal (Davidson, 2003) and presented at two national conferences.

Another resident presented her experiences implementing the EBP protocol in her home agency as part of the annual National EBP conference hosted by UIHC. Other residents are developing evidencebased protocols on topics such as Detection of Depression in Older Adults with Dementia, Discharge Planning, and Medication Management Assessment in the Elderly.

CONCLUSION

Nurses are currently struggling with how to implement EBPs (Barnsteiner & Prevost, 2002). Nursing administrators and educators need to provide strategies to facilitate EBPs so the best patient outcome can be achieved. The RDC has offered a very successful EBP residency program in gerontologicai nursing practice as detailed in this article. The nursing residency program provides a unique experience for nurses to grow professionally. It provides geriatric nurses a great learning environment to enhance their skills toward developing and implementing an EBP protocol to improve care of older adults. Ultimately, it enables health professionals to provide quality health care to older adults. As one resident wrote:

The residency program is a unique, innovative, and valuable link between research and practice that provides the essential tools for successful EBP implementation.

It is hoped that by sharing these experiences, it will help others implement learning strategies to assist nurses in practice to use evidence in delivery of health care to older adults.

FOR FURTHER READING

  • Seeder, C.B. (1992). Nursing research and quality care. In M.J. Johnson (Ed.), The delivery of quality health care: Series on nursing administration (pp. 191-207). St. Louis, MO: Mosby.
  • REFERENCES
  • Barnsteiner, J., & Prevost, S. (2002). How to implement evidence-based practice. Reflection on Nursing Leadership, 28(2), 18-21,45.
  • Davidson, K.M. (2003). Evidence-based protocol: Family bereavement support before and after die death of a nursing home resident Journal of Gerontological Nursing, 29(1), 10-18.
  • Goode, C.J., & Piedalue, F. (1999). Evidencebased clinical practice. Journal of Nursing Administration, 29(6), 15-21.
  • Holland, D.E. (2001). Modeling nursing scientific inquiry: The University of Iowa Hospitals and Clinics Research Utilization Residency Program for geriatric nurse practitioners and gerontological clinical nurse specialists. Journal of Gerontological Nursing, 27(3), 29-33, 54-55.
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  • Le May, A., Alexander, C., & Mulhall, A. (1998). Research utilization in nursing: Barriers and opportunities. Journal of Clinical Effectiveness, 5(2), 59-63.
  • Stetler, C.B., Brunell, M, Giuliano, K.K., Morsi, D., Prince, L., & Newell-Stokes, V. (1998). Evidence-based practice and the role of nursing leadership. Journal of Nursing Administration, 28(7/8), 45-53.
  • Tilter, M.G., & Mentes, J.C. (1999). Research utilization in gerontological nursing practice. Journal of Gerontological Nursing, 25(6), 6-9.
  • Tilter, M.G., Mentes, J.C., Rakel, B.A., Abbott, L., & Baumler, S. (1999). From book to bedside: Putting evidence to use in the care of the elderly. Journal of Quality Improvement, 25(10), 545-556.
  • Tilter, M.G., Steelman, V., Goode, C, Rakel, B., Barry-Walker, J., Small, S. et al. (2001). The Iowa Model of EvidenceBased Practice to promote quality care. Critical Care Clinics of North America, 13(4), 497-509.

TABLE 1

LIST OF RESEARCH DISSEMINATION CORE EVIDENCEBASED PRACTICE PROTOCOLS

TABLE 2

RESEARCH DISSEMINATION CORE EVIDENCE-BASED PRACTICE PROTOCOLS IN DEVELOPMENT

TABLE 3

CHARACTERISTICS OF RESIDENTS ACCEPTED FOR THE EVIDENCE-BASED PRACTICE RESIDENCY (N = 16)

TABLE 4

EVALUATION OF EVIDENCE-BASED PRACTICE RESIDENCY PROGRAM OBJECTIVES (N= 16)*

10.3928/0098-9134-20031101-06

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