Evidence-Based Practice: Implementing Trauma-Informed Care of Children and Adolescents in the Inpatient Psychiatric Setting

Background: At our inpatient psychiatric hospital, which cares for children and adolescents, internal data of use of seclusions and holds as crisis interventions for immediate behavioral health issues demonstrated that we were using these too often. Aims: Benchmarking indicated that we were at the 75% in use of these measures, and it became an organizational goal to reduce the use of these strategies in order to reduce the risk of retraumatization to an already traumatized child. Methods: We used the Iowa Model for Evidence Based Practice–Revised to initiate an evidence-based practice project introducing and hardwiring Trauma Informed Care to the staff and institution. This involved implementing six core strategies specifically designed to reduce the use of crisis interventions. Results: Data obtained at 6 months revealed a 40% reduction in the use of holds and seclusions, and at 12 months, this change was sustained and even improved, reducing the use of these approaches by another 9%. Furthermore, the culture in the institution was changed, and Trauma Informed Care became the norm. Conclusions: Evidence-based practice is a viable approach to change the culture and improve patient outcomes in inpatient psychiatric care of children and adolescents. Further investigation is warranted to determine the specific patient and staff experiences of being cared for, and caring within, the context of trauma-informed care.

Determinants of an evidence-based practice environment: an interpretive description

Background Despite the available research to inform nursing practice, many patients still fail to receive evidence-based care. Several evidence-based practice (EBP) models have been developed to guide nurses through the steps in the process, yet these models have not been uniformly adopted or consistently used. The original purpose of this research was to gather perspectives and experiences of nurses using the Iowa Model of EBP to help inform its introduction into other practice settings. As a more in-depth understanding was gained, the emphasis of the study shifted towards understanding the determinants of the EBP environment. Method The study was conducted in an 800-bed comprehensive academic medical centre in the USA with a 25-year history of using the Iowa Model of EBP. Semi-structured in-depth interviews were conducted with twelve nurses from various roles to ascertain their perspectives and experiences using the model. The interview transcripts were reviewed alongside relevant published literature and internal documents in a process of synthesising, theorising, and conceptualising. Data were collected during the first half of 2019. Results Four determinants of the local EBP environment were identified from the perspectives and experiences of participants: (1) the importance of a shared model to guide staff through the EBP process; (2) support for EBP in the form of education, hands-on training, and knowledge infrastructure; (3) active team facilitation by direct care nurses, nurse managers, nurse specialists, and nurse scientists; and (4) a culture and leadership that encourages EBP. Conclusion Introducing an EBP model is an essential first step for an organisation to improve consistent and reliable evidence-based care; to be most effective, this should be done in conjunction with efforts to optimise the EBP environment.

The Use of Tailored Interventions to Prevent Falls: A Quality Improvement Project in the Telemetry Unit

Background: Every year in the United States, hundreds of thousands of patients fall in hospitals with 30 to 50 percent resulting in injury. In Texas, the fall rate in adult patients is 33.9 percent, and in one teaching hospital in South Texas, patient fall rates have been above the national benchmark for two years (2017-2019), despite increased use of sitters for patient safety and multiple fall prevention strategies. The annual direct care cost of all fall events in the United States for individuals more than 65 years old is about $34 billion. Practice problem: The objectives of the fall initiative program were increasing adherence to documentation of data from the Morse Fall Assessment and tailored interventions in the electronic health record. The goal of the project was to promote patient safety by decreasing the fall rate per 1000 patient days to below the national benchmark of 3.44/1000 patient days. Intervention: The project was piloted in two telemetry units over 12 weeks using the Iowa Model of Evidence-based Practice. Telemetry staff received one-on-one education from the educator in the unit using a tailored intervention poster. The Nurse Champion observed 58 rooms and conducted chart documentation to ensure universal fall precautions were carried out during every shift. Incidence of falls was tracked daily, and post fall huddles were conducted after any incidents. Outcome: The average monthly fall rate after implementation was 2.47/1000 patient days, which was below the national benchmark. Conclusion: The fall assessment documentation in two telemetry units at DHR Health can be adapted or implemented hospital-wide. The results showed a statistically significant correlation between the Morse fall score assessment on EHR and monthly fall events (p=0. 0078). Champions were able to identify interventions and areas that needed to be improved such as education, patient engagement and stakeholder buy-in.

Determinants of an Evidence-Based Practice Environment: An Interpretive Description

Background Despite the available research to inform nursing practice many patients still fail to receive care that is evidence-based. A number of evidence-based practice (EBP) models have been developed to guide nurses through the steps in the process, yet these models have not been uniformly adopted or consistently used. The original purpose of this research was to gather perspectives and experiences of nurses using the Iowa Model of EBP to help inform its introduction into other practice settings. As a deeper understanding was gained the emphasis of the study shifted towards understanding the determinants of the EBP environment.Method The study was conducted in a 800 bed comprehensive academic medical centre with a 25 year history of using the Iowa Model of EBP. Semi-structured in-depth interviews were conducted with twelve nurses from various roles to ascertain their perspectives and experiences of using the model. The interview transcripts were reviewed alongside relevant published literature and internal documents in a process of synthesising, theorising, and conceptualising. Data were collected during the first four months of 2019.Results The determinants of the local EBP environment were clustered into four themes: 1) The importance of a shared model to guide staff through the EBP process; 2) Support for EBP in the form of education, hands-on training, and knowledge infrastructure; 3) Active team facilitation by direct care nurses, nurse managers, nurses specialists, and nurse scientists; and 4) A culture and leadership that encourages EBP.Conclusion Introducing an EBP model is an important first step for an organisation to improve consistent and reliable evidence-based care; to be most effective, this should be done in conjunction with efforts to optimise the EBP environment.