Building and Sustaining an Evidence-Based Practice Clinical Environment


Identify an evidence based practice model and change theory that has been defined in Chapters 13 and 14 of the textbook (Melnyk and Fineout-Overholt, 2015). Describe in detail how you would utilize the practice model and change theory to implement an evidence-based practice change in your clinical practice environment, related to your research topic.

Please submit a PowerPoint presentation of at least 8 slides of content (not counting the title slide and reference slide). You should have at least three scholarly sources in the presentation.

Melnyk, B. M. & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: a guide to best practice (3rd ed.) Philadelphia, PA: Wolters Kluwer Health. ISBN: 978-1-4511-9094-6

Building the Infrastructure to Teach Evidence-Based Practice in Academic Settings
Teaching EBP cannot occur without human, fi scal, and technological resources. Securing these resources prior to initiating a teaching program will help it succeed. Human resources can include EBP champions, mentors, and evidence-based librarians; knowledge of EBP; and time to accomplish the goal. Fiscal resources include committed funds for ongoing development of the teaching program, to educator the educators, and for purchasing the best technology available for enhancing the program and easing the workload of faculty. Technological resources are vast and always changing. Considering how to best use them to enhance EBP is an imperative.
Human Resources
Multilevel support for an EBP teaching program is imperative. Administrators, educators, librarians, and students are key stakeholders in this initiative. Administrators, for the purposes of this chapter, are defi ned as anyone who provides fi scal and managerial support to an EBP program (e.g., university presidents, academic deans, residency directors, department chairs, chief fi nancial offi cers, chief executive offi cers). Administrators must include designated fi scal resources for EBP in their strategic plans and prospective budgets (e.g., for ongoing education, technology, evidence databases, librarian involvement, and recognition of experts’ time in training and compensation). A proposal outlining the EBP teaching program and its potential benefi ts and costs will assist in obtaining support from administration.
Availability of Medical Librarians An invaluable resource to assure you have on the EBP teaching team is a medical/health science librarian who is knowledgeable about EBP. It is imperative that these librarians be involved in the plan to initiate EBP. They can provide perspective and expertise in searching databases, as well as facilitate aspects of information literacy needed by students and faculty who strive to successfully teach and learn about EBP. Early involvement of the librarian in preparing an EBP teaching program is crucial. It is an evidence-based medical/health sciences librarian’s job to be profi cient in knowing where to get information. Librarians’ knowledge of databases, informatics resources, and information retrieval is integral to successful EBP teaching programs. Librarians can assist educators in developing database and Internet searching skills as a means of fi nding relevant evidence to answer clinical questions. In addition, librarians can set up direct search mechanisms in which the faculty or students pose their PICOT question electronically, and the librarian scours the databases for the answer and sends the citations and abstracts for the body of evidence to the inquirer. This approach to evidence retrieval can save enormous amounts of time and use some of the many talents of medical/health sciences librarians well.
Champions As educators support teaching EBP, they must ensure that they are knowledgeable and skilled in EBP and able to meaningfully articulate the concepts to the students. A preliminary investment is required so that educators who are teaching EBP have the expertise required for meaningful and successful delivery and role modeling of EBP concepts. For example, assigning faculty to teach a fundamental critical appraisal methods course when their primary focus is generating evidence and they are novices at using evidence in practice is likely to be frustrating to the faculty member and students. Helping the faculty to become more profi cient in understanding the EBP paradigm and how it blends with their research paradigm can facilitate their transition from frustration to champion of EBP. Educators need to be familiar with the concepts of EBP to be able to assist learners in determining whether observed practice is built on solid evidence or solely on tradition. Educators role modeling EBP concepts (e.g., addressing a student question at the time it is asked with a search of the literature and a discussion of fi ndings and outcomes) can assist learners to integrate EBP concepts into their own practice paradigms. Additional champions required for successful communication of EBP concepts are the learners themselves. There are always different levels of learners. Those who quickly absorb the concepts of EBP can become champions who assist other learners in integrating EBP principles into their practices. Integration of EBP concepts into one’s practice is essential for learners to both see and do. Without learner champions, educating other learners will be less successful. Often in venues such as journal clubs, the learners are the ones who create an environment that encourages the less-than-enthusiastic learner to join in the process. The idea that learning EBP can be analogous to making a quilt may help learners to see the EBP process as wholly integrated. Educators, clinical preceptors, and other learners using EBP concepts are the “patches” in the quilt. When learners see EBP concepts integrated by these patches, the process takes on perspective and purpose, much as patches put together make a pattern that can be seen only in the completed quilt.
Mentors The fi nal champion for successfully teaching EBP is the EBP mentor, sometimes called a coach, information broker, or confi dant (Melnyk, 2007). This individual’s job is to provide one-on-one mentoring of educators, providing them with on-site assistance in problem solving about a how to teach EBP. Mentoring has been a long-standing tradition in academia; however, these efforts must be focused, purposeful, and supported by administration for them to be successful (Peck, Lester, Hinshaw, et al., 2009). Faculty who believe in EBP and desire to teach students to be evidence-based clinicians may fi nd that competing priorities within an academic environment must be overcome in order for them to provide the amount of guidance they would like to their fellow educators. An EBP mentor’s primary focus in the academic setting is on improving the student and faculty’s understanding and integration of EBP in practice and educational paradigms. This is often accomplished through providing the right information at the right time that can assist the student to provide the best possible care to the patient and the faculty to provide the best evidence-based education to the student. These mentorships need to be formal, paid positions with time dedicated for teaching EBP. Chapter 15 has more on the concept of mentoring in EBP.
Technical Resources
Technical resources are an imperative for educators as they develop curricula using multiple instructional technologies to provide varied learning opportunities for students to improve their information literacy skills to effectively and effi ciently access resources to answer their clinical questions (Pravikoff, Pierce, & Tanner, 2005; Schutt & Hightower, 2009). According to the AACN, technology affords an increased collaboration among faculties in teaching, practice, and research. In addition, technology in education may enhance the professional ability to educate clinicians for practice, prepare future healthcare educators, and advance professional science (AACN, 2002). Information technology (IT) provides students and faculty access to evidence-based resources that are necessary for learning about evidenced-based care (Technology Informatics Guiding Education Reform [TIGER], 2007). Through IT support students can collect practicebased evidence (e.g., quality improvement data), combined with external evidence (i.e., research) and apply this evidence-based knowledge at the bedside in their clinical practicums (TIGER, 2007). There is a call for an infusion of innovation, which includes technology, to reform nursing curricula that will prepare healthcare providers of the future (National League of Nursing [NLN], 2003). All educational programs for all levels of healthcare providers should design evidence-base curricula that are fl exible, responsive to students’ needs, collaborative, and technology savvy (NLN). The Summit on Health Professions Education (Greiner & Knebel, 2003) identifi ed the use of informatics as one of the core competencies for the 21st century health education. Through the use of informatics, medical errors can be avoided as students learn in a safe environment from experiences enhanced by technology, thereby, making mistakes without the harm to the patient (IOM, 1999; IOM 2001). In the IOM report, Educating Health Professionals to Use Informatics (2002), informatics is described as an enabler that may enhance patient-centered care and safety, making possible EBP, continuous improvement in quality of care, and support for interdisciplinary teams. When teaching organizations assume a leadership role in enhancing learning with technology, clinical organizations also benefi t (IOM, 2001). As technology in healthcare is increasing exponentially, educators need to integrate the use of technology into the curriculum. Students are using technologies in their everyday lives but can revert backward when in the educational milieu. There are many instructional technologies that are available to educators, including (a) simulation technology; (b) mobile devices; (c) Internet-accessed social networking sites, such as Facebook, Twitter, and Second Life; (d) course management systems, such as Blackboard™ and WebCT®, that provide distance learning through web-enhanced and online courses; (e) audio and video conferencing through Internet-based programs such as WebEx, Adobe® Acrobat® Connect™ Pro, and Skype™; and (f) clinical decision support systems (CDSSs), such as Cerner and PowerChart®. Given that most of these technologies are used in students’ daily lives and/or the clinical environment, integrating technology in healthcare education is essential to prepare the student to enter such an environment and thrive. Students need to know how to use technology to access EBP resources and communicate them to others to facilitate EBP. Simulation, mobile devices, electronic health records (EHRs), and the Internet to access social networking sites via the World Wide Web are expected to be the most used and important technologies in healthcare and healthcare education. These products have the potential of enabling students to access data and information for point-of-care decision making and support healthcare practitioners with work fl ow, continuing education, collaboration, and access to EBP resources. Currently, innovative technology, such as these, is being applied to enhance patient care delivery and provider productivity (Healthcare Information and Management Systems Society, 2002).
Simulation The use of simulation technology allows healthcare educators to prepare students for the current clinical and community environments. The use of the most advanced simulator technology provides the educator with the ability to provide simulation education to challenge and test students’ clinical and decision-making skills during realistic evidence-based patient care scenarios. These simulations are designed to replicate a real-life clinical situation for students so that they can experience, among other things, the integration of internal and external evidence while making decisions using the EBP paradigm. This technology affords students the opportunities to problem solve, use critical thinking skills, and perform to the best of their ability potentially without intimidation and fear. Simulation also promotes participative learning in which students apply their knowledge and recognize the impact of a disease/disorder on a patient, family, or community situation. Simulation is enhancing student learning and is not intended to take the place of clinical sites or clinical experiences. It allows for practice of EBP knowledge and skills within a supportive and safe environment, thus allowing learners to focus on problem solving rather than on attaining a single perfect answer. In a landmark article, Morton (1997) describes how students also can receive immediate feedback from faculty, which reinforces the learning. Advantages to providing simulation experiences include the ability to control the extraneous stimuli, keep the student directly engaged in activity, have the learner focused on instruction, and provide an opportunity to experience a specifi c area or event that might not occur in a clinical setting and learn to integrate the EBP process into one’s clinical practice (Morgan, 2006; Morton, 1997; Rauen, 2004). Simulation allows for learners’ and educators’ time to be used effi ciently and offers faculty an opportunity to simulate learning opportunities that might be diffi cult to fi nd. In addition, learners have performed better in simulated experiences, with an increased ratio of students to faculty. Hallikainen et al. (2009) found in a randomized trial that students using simulation were 25% better in their performance of tasks than students taught traditionally. In addition, the ratio of students to faculty in the simulated group was six to one, compared to one to one in an intense clinical setting due to the extremely high risks involved. During simulation, actions can be paused for refl ection and correction. Mistakes are not only permitted, but expected as learning opportunities; multiple problems can be cleverly introduced, and, if scenarios are videotaped, replay can allow for refl ection and further learning. In this way, technology prevents patient safety from being threatened. It is important that access to IT during a simulation experience mimics what students will experience in their clinical practicums, including access to EBP resources. Creating simulation scenarios that are evidence based addresses the cognitive, affective, and psychomotor domains of learning to bridge theory and practice (Morgan, 2006; Morton, 1997; Spunt, Foster, & Adams, 2004). The evidence-based approach allows faculty to develop creative and innovative ways to teach and prepare clinicians for the demands of the workplace (Jeffries, 2005; Spunt et al., 2004). Focus on the cognitive learning domain (knowledge, comprehension, application, analysis, and synthesis) allows faculty to develop lessons that enhance learners’ ability to gain knowledge and apply principles of physiology, pathophysiology, pharmacology, assessment, and management while integrating evidence from practice and research into their decision making (Morton, 1997; Starkweather & Kardong-Edgren, 2008).

Lessons developed using the affective domain of learning provide an opportunity for students to learn about attitudes and behaviors that are desirable, consistent, and appropriate for the professional clinician role (Kitson-Reynolds, 2009; Morton, 1997). Students learn options and formulate guidelines for expected professional behavior by choosing from alternatives: caring, empathy, sensitivity, integrity, cooperation, independence, and compassion. Students also learn how to interact with colleagues and learn to function as team players. Creative lessons that focus on the psychomotor learning domain involve scenarios that allow for hands-on skill building, such as performing clinical skills, tasks, and procedures. The focus of including all domains in simulated learning is to allow students to become comfortable with the clinical environment, technology, and processes so that evidence-based care of the patient becomes the focus rather than these environmental aspects (Morton; Skiba, Connors, & Jeffries, 2008). Faculty teaching at all levels of the curriculum can incorporate simulation. Faculty can plan lessons and develop creative evidence-based case scenarios for students as well as integrate simulation technology into faculty development workshops. Such continuing education can encourage faculty to integrate simulation technology into the teaching and learning process, which will enhance the nursing curriculum (Skiba et al., 2008). Several schools have led the way in integrating simulation technology into their curriculum (see Table 13.1).
Mobile Devices The use of handheld devices is being introduced with increasing frequency in many healthcare and education settings. A mobile device, such as a smart phone, BlackBerry, iPhone, and iPod touch, is characterized by its handheld size, mobility, ability to communicate with other units, and use of applications. A mobile device is a useful tool that allows one to use it as a date book, to-do list, address book, memo pad, calculator, and Internet access, and it has the ability to download health/medical software programs that can be accessed in the classroom and at the point of care. The use of mobile devices in nursing education supports educators in the preparation of nursing students for current and future work environments. Mobile technology tests students’ clinical and decision-making skills in clinical, laboratory, and classroom settings. Challenges to the use of mobile device technology include cost, faculty acceptance and education, and identifi cation of user-friendly hardware and software (Bauldoff, Kirkpatrick, Sheets, et al., 2008; Huffstutler, Wyatt, & Wright, 2002). Technology that is accessible and usable for both faculty and students allows for the reinforcement of core knowledge for practice, strengthening of professional confi dence, and access to the most up-to-date information in EBP resources (Bauldoff et al.; Kuiper, 2008; White, Allen, Goodwin, et al., 2005). Students are able to retrieve and receive information at the point of care in real time, which allows the student to have instant information when administering medications, completing a care plan,
Arizona State University College of Nursing & Health Innovation Learning Resource Educational Simulation Program
Duke University Human Simulation and Patient Safety Center
University of Texas Arlington School of Nursing, Smart Hospital™ & Health System
University of Maryland Clinical Simulation Laboratories index.htm
table 13.1 abilities of students, and provides the IT infrastructure for EBP (Connors, Warren, & McNamara, 2003; Connors, Weaver, Warren, et al., 2002). Such a system allows students to access reference databases, search the Internet, and document assessments and care plans, and it teaches students necessary skills needed to be competent in the highly technical IT healthcare environment of today and tomorrow (Connors et al., 2002). Developing academic-business partnerships with clinical information system companies, such as the Cerner Corporation, provides faculty the opportunity to incorporate IT into the curriculum; develop evidence-based scenarios; demonstrate through simulated experiences how to document care; access resources; impact cost and quality of care; and promote the EBP process, dissemination and evaluation of knowledge, and research (Connors et al., 2003).
World Wide Web The newer version of the World Wide Web provides an environment that promotes collaboration, functionality, and the ability to interact socially (Kardong-Edgren, Oermann, Ha, et al., 2009; Weberg, in press). Utilizing web-based tools, such as Wikis, blogs, podcasts, social networking sites (e.g., Facebook, Twitter, Ning), and video conferencing (e.g., Skype, Adobe® Acrobat® Connect™ Pro, WebEx, and Wimba), offers an opportunity for educators to develop interactive and creative ways to provide lessons, construct assignments, and encourage critical thinking and decision making along with a satisfactory learning experience (Murray, Belgrave, & Robinson, 2006; Skiba et al., 2008). Faculty have an immense opportunity, challenge, and responsibility to use web tools, defi nitions, and web resources (see Table 13.3) to teach students about healthcare so as to “reduce health care errors and improve care quality, access and cost effectiveness” ( Fetter, 2009, p. 78).
Web Tool Defi nition Resource Web Link
Wiki Internet based pages where groups can edit the work in real time. htm
Blog Places where you can write things that are of interest to you and get feedback from others.
Podcast A video or audio recording that can be retrieved from the Internet that you can watch or listen to.
Video conferencing
Streams audio and visual in real time, bringing people in different sites together for a meeting. products/acrobatconnectpro/
Social networking sites
Online community on the Internet where people join and communicate and share similar interests and connect by sharing pictures, stories, and experiences.
Second life A virtual world where users create an avatar (online person) and interact with others in a virtual world created by those in it.
Second Life, Twitter, and Facebook Schools of nursing are reaching out and connecting with students through various social networking sites. Duke University School of Nursing has developed a virtual world in Second Life where students can access lectures and discussions in virtual classrooms (http://nursing. = 90). Educators need to incorporate technology courses into the curriculum and empower the future healthcare professionals with knowledge and confi dence to use technology. The numbers of schools, journals, businesses, educational institutions, and hospitals are growing everyday. It is estimated that approximately 100 hospitals have some kind of Twitter account, and some 82 hospitals have a Facebook page (Snow, 2009). Social networking sites, such as Facebook, Ning, and Twitter, along with the virtual world of Second Life, allow educators to create innovative teaching and learning and promote various ways to communicate. Educators can use these methods to communicate lessons and assignments, conduct virtual offi ce hours, promote discussions, generate new ideas, link to resources, and provide up-to-date real-time information to students (Weberg, in press). Implementing a curriculum that integrates EBP through incorporating technology provides faculty creative avenues for innovation and offers multiple opportunities to increase students’ information literacy skills (Schutt, & Hightower, 2009). Educational agencies that develop collaborative learning communities with active use of technology to move toward knowledge development, dissemination, and implementation of EBPs are on the cutting edge (TIGER, 2009). In addition, technologies need to be people centered, affordable, useable, universal, useful, and standards-based (TIGER). Healthcare educators have the opportunity to be creatively innovative as they integrate EBP and technology into curricula to give students the ability to practice in real-world settings through simulation, document care, and access to EBP resources. With technology changing the landscape of education, there is concern over copyright and ensuring protection of intellectual property. For the purposes of this chapter, the United States copyright law indicates that a work may be used for the purpose of critique, scholarship, and for teaching, among other uses, and these purposes may be considered fair use (U.S. Copyright Law, section #107; see The Teach Act (Copyright Clearance Center, 2002) addresses use of materials online.
Additional copyright information can be found at Information about the Teach Act, including a checklist for use, can be found in the Teach Act Toolkit at
One way of dealing with the copyright issue, which can sometimes be diffi cult and time consuming, is to use only links to full-text study reports as teaching tools. This places the responsibility on learners to obtain information straight from the source. The disadvantage to this practice is that there are many good teaching tools that are not full text. Despite the challenges that come with electronic information, resources such as the Internet, electronic journals, and other computer databases are essential to a successful EBP teaching program.
Characteristics of Evidence-Based Practice Teachers and Learners
Commitment to excellent patient care is central to becoming an evidence-based practitioner and the most important attribute of the learner. Practitioners who continually strive for excellence will want to understand their patients’ problems thoroughly and apply the current best evidence