Background
Study purpose and framework
Methods
Sampling and recruitment
Sites
Characteristic | Role model site | Beginner site |
---|---|---|
Bed size | Over 350 | Approximately 400 |
In-patient units | 20 | 24 |
Type of hospital | Academic medical center | Community hospital (With multiple nursing school affiliations) |
Chief nursing officer authority | Full administrative authority, with financial resources control | Full administrative authority, with financial resources control |
Chief nursing officer type of position | A vice president of patient services in general, with responsibilities beyond nursing | A vice president of patient services in general, with responsibilities beyond nursing |
Magnet status | Magnet designated hospital | Magnet application hospital |
Other status | Non-Union | Non-Union |
Self-perceived EBP status upon selection | More than three-fourths progress* along the scale toward full EBP integration Also self-reported: 'an intense focus on EBP' | Not even one-fifth progress along the scale* toward full EBP integration: Also self-reported: 'implemented some EBP initiatives... basic, nothing high level' |
Case mix index, all payors | At the time of their site visit, both hospitals reported case mix indices in the low to medium intensity of resource use, with the role model site** reporting lower resource needs more similar to that of community hospitals, and the beginner site experiencing resource use suggesting moderate needs, higher than most community hospitals but lower than tertiary medical centers. | |
Nursing education mix | The role model site had a very high proportion of BSN nurses, virtually double that of the beginner site. | |
Hours per patient day (HPPD) | ▪ Critical care: Last quarter (Jan-Mar 07) 19.8 | ▪ Critical care: 14.62 |
▪ Med-surg: 9.92 | ▪ Med-surg: 5.22 |
Site participants
Data collection methods
Analysis
Qualitative data analysis
Pettigrew et al. elements[34] | Study definition and observations |
---|---|
Change agenda and its locale | The element's focus is on the fit between the agenda and factors in the local, external environment that might influence internal change efforts. |
Cooperative inter-organizational networks | Development and management of links with other agencies, e.g., through boundary spanners. |
(Long term) Environmental pressure | The intensity and scale of pressures from influential agents external to the organization. |
Key people leading change | • Defined by the team in terms of roles in which an individual influences others, more specifically, in terms of strategic versus operational influence, i.e., influencing others to behave in certain ways toward preconceived group goals (Schein) ___ in this case EBP in a department of nursing. |
• Types of roles were defined as formal, or managerial and related to positions of authority at all levels; or informal. Informal leaders included both clinical support personnel, such as APNs (Advance Practice Nurses) and special types of staff or EBP roles, either formal or informal. | |
Quality and coherence of policy | • The meaning of policy is broad, e.g., in the form of a broad vision, and not specifically about local policies and procedures. |
• More focused on strategic decisions relative to change, with quality referring to the related evidence base, related conceptual thinking about such decisions, and eventual buy-in | |
• Coherence reflects initial exploration of a vision's congruence among related 'goals'; attention to politics and needed negotiation with key stakeholders; feasibility; and skill in terms of how the targeted strategic change was managed. In this study such congruence was defined as not only including development/refinement of organizational components on paper but the actual operationalization of such infrastructures for EBP; i.e., organizational structures, systems, roles, processes, relations, alignments, and capabilities. | |
Managerial-clinical relations | The quality of the interface between staff and management. |
Simplicity and clarity of goals | • The ability 'to narrow the change agenda down into a set of key priorities, and to insulate this core from the constantly shifting short-term pressures' [34]. |
• Demonstrates managerial '... persistence and patience in pursuit of objectives over a long period' [34]. | |
Supportive organizational culture | Defined by the study team as the way things are done in an organization that is supported by its values, norms and expectations. Such forces in an organizational social system affect behavior of individuals. |
Culture can be characterized as strong or weak. In an organization with a strong culture there is high agreement among individuals regarding expectations and values, whereas the level of agreement regarding values and expectations is low or highly variable in a weak culture. | |
Regarding EBP, values and expectations regarding use of evidence are direct aspects of a culture supporting evidence based practice. Related characteristics of a culture, such as values supporting collaboration and teamwork, are expected to support EBP. |
Triangulation
Quantitative data analysis
Results
Sampling
SOURCES OF DATA
|
ROLE MODEL SITE N/TYPE PARTICIPANT
|
BEGINNER SITE N/TYPE PARTICIPANT
|
---|---|---|
FOCUS GROUPS: on three units per case | Focus Group interviews = 9 | Focus Group interviews = 5 |
• General med/surg unit; specialty unit; and a critical care unit. | Total staff nurse participants, multiple shifts = 27 | Total staff nurse participants, multiple shifts = 14 |
• All staff, per unit, invited to one of several sessions. | ||
LEADERSHIP INTERVIEWS: | Total leadership interviews = 30 | Total leadership interviews = 29 |
• Primarily formal leaders within nursing but also physicians, allied health and non-nursing top leaders. | Number of individual leaders = 26 | Number of individual leaders = 28 |
• Informal leaders, primarily nursing | • FORMAL: 14 | • FORMAL: 14 |
- Top organizational leaders, e.g., chief nurse; her 'supervisor'; and chief MD | - Top organizational leaders, e.g., chief nurse; her 'supervisor'; and chief MD | |
- Nursing clinical directors and nurse managers; and non-nurse clinical director and non-nurse manager, e.g., allied health | - Nursing clinical directors and nurse managers; and non-nurse clinical director and program leader, e.g., allied health | |
- Nursing support or clinical resource services manager and non-nurse support service director | - Nursing support or clinical resource services manager and non-nurse support service director | |
- Some also chairs of EBP-related committees/groups | - Some also chairs of EBP-related committees/groups | |
• INFORMAL: 12 | • INFORMAL: 14 | |
- Nursing support or clinical resource staff, such as researchers, APNs, or other various specialists relevant to EBP | - Nursing support or clinical resource staff, such as researcher or APN | |
• Special staff nurse roles relevant to EBP on non-embedded units such as champion/facilitators or data/outcome specialists; some were also charge nurses | - Other various specialists relevant to EBP either within or outside of nursing, such as condition-specific educator or data/outcome specialists | |
• Staff nurses involved in a special project or governance-related group; and an expert nurse | ||
GROUP OBSERVATIONS
| Groups = 5; Total participants = 74 | Groups = 3; Total participants = 16 |
• Policy/procedure-related and inter-disciplinary | • Policy/procedure and inter-disciplinary | |
• Interdisciplinary clinical group | • Special QI group | |
• Two special EBP groups, one interdisciplinary | • Nursing leadership group | |
• Shared governance (PI invited) | ||
EBP-RELATED DOCUMENTS
| • A multiplicity related to infrastructures, including, e.g., | • Some related to infrastructures, including, e.g., |
- Philosophy and mission | - Philosophy | |
- More than a dozen on role descriptions and appraisal; clear focus in career ladder program | - A few nursing role descriptions; roles in QI department; included in career ladder program | |
- Materials and minutes from multiple committees and interest groups heavily focused or specifically focused on EBP, some present for over five years | - A research group with materials, minutes and reference to EBP; QI groups, some clearly evidence-focused | |
- Descriptions of governance groups, with EBP included in the expectations or activities of the majority | - Descriptions of governance groups, with EBP or data included in the expectations or activities of most | |
- Educational and orientation materials, including EBP-related tools, presentations, skill sets | - Journal club material, PowerPoint presentation, and orientation description (e.g., re: library services) | |
- Policy/procedure algorithm, researcher audit of related EBP status, and multiple Ps seen linked to evidence; clinical forms for documentation said to be E-B | - Policy/procedure algorithm, and Ps seen being linked to evidence; clinical documentation forms said to be E-B | |
• Dozens related to EBP project activity and related dissemination efforts, internal and external: | • List of nursing research activity, including students and outside researchers; a PP hospital-based multidisciplinary project; a few single page PI outline for a improvement activities | |
- Proposals for the human subjects committee decision | ||
- PowerPoint (PP) presentations on EBP process and projects | ||
- EBP-related project reports, program evaluations, and an EBP newsletter | ||
- Publications, including multi-disciplinary ones; and evidence of co-operative networking | ||
SURVEY* FOR STAFF NURSES ON THREE EMBEDDED UNITS, with a focus on their unit or self | Respondents = 39 | Respondents = 21 |
Response rate = 34% | Response rate = 20% | |
SURVEY* FOR ALL IDENTIFIED MEMBERS OF THE LEADERSHIP TEAM, with a focus on the department | Respondents = 104 | Respondents = 65 |
Response rate = 56% | Response rate = 50% |
Overview of each case
'Role model' case
'Beginner' case
A general cross-comparison between cases
COMPARISON: | OVERALL@
| LEADERS ONLY | ||||
---|---|---|---|---|---|---|
I
NSTRUMENT
|
Role Model
Site
|
Beginner
Site
|
Role Model
Site
|
Beginner
Site
| ||
MLQ: Multifactor Leadership Questionnaire [39], Transformational Leadership Subscales&:0 to 4 scale | ▪ Ideal attributes* | 3.41 | 3.16 | ▪ Ideal attributes* | 3.53 | 3.24 |
▪ Ideal behavior* | 3.26 | 3.04 | ▪ Ideal behavior | 3.38 | 3.19 | |
▪ Inspirational motivation** | 3.49 | 3.24 | ▪ Inspirational motivation* | 3.58 | 3.34 | |
▪ Intellectual stimulation** | 3.05 | 2.71 | ▪ Intellectual stimulation** | 3.08 | 2.75 | |
▪ Individual consideration* | 2.88 | 2.59 | ▪ Individual consideration | 2.89 | 2.62 | |
NWI PES: Practice Environment Scale of the Nursing Work Index [40]: 1 to 4 scale | Overall score*** | 3.20 | 2.85 | Overall score*** | 3.23 | 2.89 |
OLS: Organizational Learning Survey [38]: 1 to 7 scale | Overall score** | 4.73 | 4.38 | Overall score* | 4.86 | 4.60 |
RU: RESEARCH UTILIZATION[41]: 1 to 7 scale | Overall score | 3.69 | 3.58 | Overall score | 3.74 | 3.55 |
Key contrasting themes
Key people leading change
A culture supportive of EBP
Coherence of policy
ROLE MODEL SITE | BEGINNER SITE |
---|---|
▪ Building EBP capacity (e.g., extensive orientation/education/skill development; EBP model review; active journal clubs; multiple research/EBP experts and mentors) | ▪ Building mostly research capacity (e.g., some orientation/education; some journal clubs; a research expert) |
▪ Providing enablers of EBP activity (e.g., internet resources; project funding; EBP-related councils) | ▪ Providing enablers of activity (e.g., internet resources; research funding; a research champion) |
▪ Creating special EBP-related roles and functions, including for staff nurses (e.g., facilitator/champions and data/outcome specialists) | ▪ APN role created to enhance EBP/research**; a central 'EBP' role focusing on Magnet overall |
▪ Creating broad-based EBP-related incentives and expectations (e.g., career ladders; clear performance expectations for roles and within governance structures) | ▪ Creating incentives (e.g., career ladder and Magnet status) |
▪ Integrating EBP into practice processes (e.g., policy/procedures and documentation). | ▪ Integrating EBP into practice processes (e.g., policy/procedures and documentation) |
**NOTE: QI department has special roles that work collaboratively with nursing, particularly around performance indicators and hospital-wide initiatives; some expertise in EBP. |
Non-receptivity
Environmental pressure
Other themes
Discussion
Leadership
Culture
Inter-related elements
Limitations
Summary
-
Organizations that achieve a highly receptive context for EBP, as described by Pettigrew et al., are more likely to exhibit a higher level of EBP institutionalization.
-
Organizations with elements of receptivity (as described by Pettigrew et al.) and that monitor and act on elements of non-receptivity are more likely to exhibit a higher level of EBP institutionalization.
-
Efforts to transform an organization for institutionalizing EBP requires the proactive, meaningful engagement of formal and informal leaders at all levels of the organization, including staff nurses.
-
A greater number of positive two-way inter-connections between key people leading change and other key contextual elements in the Pettigrew framework will enhance an organization's potential for institutionalization.
-
An organization with a majority of BSN staff nurses and competent, EBP-oriented nurse/ward managers will exhibit greater integration of EBP in routine practice.
-
Executive leaders who have the ability to proactively influence an organization's culture to support EBP and can buffer the related strategic vision from periodic pressures are more likely to institutionalize EBP over time.
-
Inconsistent operationalization of EBP-related infrastructures (coherence in the Pettigrew framework) by formal leaders will negatively impact an organization's ability to institutionalize EBP.
-
Organizations that develop a strategic plan to institutionalize EBP using Pettigrew's key contextual elements as a foundation for professional practice are more likely to have a higher level of EBP activity within three to five years.
Appendix 1. Refined study definitions
-
Context/organizational context:
-
◦ Overall: The healthcare environment in which practice takes place; characterized by organizational culture, leadership, basic organizational components, and type of clinical setting.
-
◦ Pettigrew/Whipp: an essential dimension or the WHY/motivation behind strategic change to EBP and related enablers/barriers.
-
-
Content: One of Pettigrew/Whipp's essential dimensions, in this case the WHAT of strategic change; i.e., the organizational elements or processes in the system changed to enhance or support the use of evidence.
-
Evidence-based practice (EBP): Practice derived from the best available evidence to achieve positive outcomes; this practice may range on a continuum from implementing a discrete practice (e.g., consistently using an evidence-based scale to assess the situation and implementing research-based interventions) to consistent ways or patterns of decision-making and practice (e.g., consistently seeking the best evidence in all decision-making to achieve positive outcomes).
-
Evidence: Knowledge derived from a variety of sources that has been subject to testing and has been found to be credible. This includes:
-
◦ Research,
-
◦ Patient experiences and preferences, and
-
◦ Practical knowledge and local data (e.g., audit, quality assessments, planning and project data)
-
-
Infrastructure: Organizational structures, systems, roles, processes, relations, alignments, and capabilities.
-
Institutionalization: Integration of EBP into the routine fabric of the organization [50]; also known as institutionalization.
-
Levels within the institution/institution levels: Individual, group/team, organization, larger external system. In this study, these levels refer to individual clinicians and leaders; EBP-related project teams or committees; clinical units; clusters of units within a service; department of nursing; hospital; and external healthcare-related environment.
-
Magnet status: The Magnet Recognition Program for Excellence in Nursing Services®, provided by the American Nurses Credentialing Center (ANCC), recognizes outstanding healthcare facilities and systems that demonstrate excellence in patient care and work environments that attract and retain nurses, primarily in the US. Facilities are evaluated on their excellence in nursing leadership, shared governance, staff decision-making, the generation of new knowledge through nursing research, and the use of best evidence to support nursing practices and improve patient outcomes http://www.nursecredentialing.org/Magnet.aspx. Magnet has 14 forces; i.e., quality of nursing leadership, organizational structure, management style, personnel policies and programs, professional models of care, quality of care, quality improvement, consultation and resources, autonomy, community and the healthcare organization, nurses as teachers, image of nursing, interdisciplinary relationships, professional development. Expectations for the use of evidence are threaded (integrated) throughout the forces.
-
Non-receptive context for change: 'A configuration of features which may be associated with blocks on change' [34].
-
Norm or routine per EBP: Integrated into the everyday work of the clinical setting, in the policies, in the practices, in documentation, in the infrastructure, etc.
-
Nurse manager: The leader on a particular patient care unit/ward. Such a role has direct responsibility and accountability for one to two clinical units or wards in terms of budget, hiring, firing, evaluation, quality, and daily operations.
-
Process: One of Pettigrew/Whipp's essential dimensions [30], in this case the HOW of strategic change; i.e., the methods, strategies, or implementation interventions used to try to enable the use of evidence.
-
Receptive context for change: 'A combination of factors from both the inner and outer context that together determine an organization's ability to respond effectively and purposively to change [2].
-
Strategic: Refers to planned, organizational approaches to change and its deliberate management.
-
Sustainability: Changes (practice and outcomes) based on evidence that continue over time as related to specific projects.