Beyond Nurse Residency
The Iowa Online Nurse Residency Program brings you the Beyond Nurse Residency Podcast. This interview series provides valuable resources for nurse leaders and educators interested in learning about onboarding, orientation, transition to practice, and ongoing role development of nurses. It is intended for all healthcare professionals supporting various aspects of nursing professional development. Each episode features an expert guest, providing listeners with valuable insights and guidance on relevant topics related to the professional role development of registered nurses.
If you're looking for more information about our program offerings, be sure to check out our website. Additionally, if you're interested in being a guest on the Beyond Nurse Residency Podcast, we invite you to fill out our guest request form. We're always excited to feature new perspectives and insights on the show!
Beyond Nurse Residency
Evidence-Based Practice
In this episode, host Nicole Weathers is joined by Dr. Kirsten Hanrahan and Dr. Laura Cullen from University of Iowa Health Care to explore how evidence-based practice (EBP) can empower new graduate nurses rather than intimidate them. Together, they unpack the Iowa Model, clarify the differences between EBP, quality improvement, research, and innovation, and share practical strategies for supporting new nurses through their professional experience projects. Whether you're a nurse leader or a recent grad, this episode offers valuable insights to make EBP approachable and impactful.
GUESTS:
Kirsten Hanrahan, DNP, ARNP, CPNP-PC, FAAN
Director, Nursing Research & Evidence-Based Practice
University of Iowa Health Care
Evidence-Based Practice Resources | University of Iowa Health Care
Kirsten Hanrahan, DNP, ARNP, CPNP-PC, FAAN, is the Director of Nursing Research and Evidence-Based Practice for the University of Iowa Health Care. Dr. Hanrahan is well-versed in EBP, clinical research, and innovation. She has numerous publications, national and international presentations, and has been named one of Iowa’s 100 Great Nurses, a 2019 Fellow of the American Academy of Nursing, and a 2020-2021 Mayday Pain & Society Fellow.
Laura Cullen, DNP, RN, FAAN
EBP Scientist
University of Iowa Health Care
Laura Cullen, DNP, RN, FAAN, leads Evidence-Based Practice at University of Iowa Health Care. Laura is internationally recognized for her expertise in EBP and implementation. Among her many accomplishments, she is most proud of the many clinicians she has mentored and of staying application-oriented. Laura’s work has led to innovation in practice, improved patient safety, reduced nosocomial events, improved patient, family, and staff satisfaction, reduced hospital LOS and costs, and transformed many organizations’ EBP infrastructure. She has over 100 publications and presents nationally and internationally. Laura has a regular EBP column in the Journal of PeriAnesthesia Nursing, is on the editorial board of the American Journal of Nursing, and has been on the grant review panel for the DAISY Foundation. She has received multiple awards, and her work has supported numerous awards for the nursing department.
Articles or Publications: Cullen, L., Hanrahan, K., Edmonds, S., Reisinger, H., Wagner, M. (2022). Iowa Implementation for Sustainability Framework. Implementation Science,17:1. https://doi.org/10.1186/s13012-021-01157-5
Supporting nurses is our priority. Visit https://nursing.uiowa.edu/ionrp to explore our resources for new graduate nurses and beyond.
00:00:02 Nicole Weathers
You're listening to the Beyond Nurse Residency Podcast, an educational series where we interview experts on all topics related to the transition of new graduate nurses into practice and beyond. I'm your host, Nicole Weathers, director of the Iowa Online Nurse Residency program. Thanks for joining us. Let's jump in.
00:00:27 Nicole Weathers
When our new graduates discover, they'll be completing what we call a professional experience. But what many of you might call a residency project as part of this program, I often see them grimace and look like they maybe want to run in the other direction. For many, the idea of using research to inform our practice. And being a part of making this type of improvement brings back stressful memories of nursing school.
00:00:53 Nicole Weathers
But it really doesn't have to be that way. Incorporating evidence-based processes and procedures into our nursing practice is a fundamental responsibility of every registered nurse. It's not just an extra step or being asked to take, but it's an integral part of what we do and who we are in this episode, we're going to take a deep dive into the world of. Evidence-based practice and nursing. We're going to talk about what it is and how it's maybe evolved over the.
00:01:20 Nicole Weathers
Years. We're going to talk about the Iowa model as a framework for evidence-based practice, and we're going to discuss the differences between some of the change methodologies that are out there, including quality improvement, evidence-based practice research, and even innovation, and how to choose the right approach for your project.
00:01:41 Nicole Weathers
I know supporting new graduate nurses in these residency projects or professional experiences can be really challenging, especially when it comes to providing that right level of support without taking.
00:01:54 Nicole Weathers
Over. So we're going to ask our experts on the call today to share strategies and tips to effectively guide new graduates in this process, along with so much more. My goal for this episode is for our listeners to walk away with practical tips and strategies to support evidence-based practice in their organization.
00:02:15 Nicole Weathers
Especially when it comes to their new graduate nurses. So I have with me today two very special guests, Dr. Kirsten Hanrahan.
00:02:22 Nicole Weathers
And Dr. Laura Cullen from University of Iowa Health Care. So why don't we start off by having both of you give our listeners a little bit of an introduction and background to who you are. So, Kirsten, why don't we start with you?
00:02:36 Kirsten Hanrahan
Yeah. Great. Thank you so much for inviting us to do this. So I'm Kirsten Hanrahan, and I am the director for nursing research and evidence-based practice at University of Iowa Health Care. I have spent most of my nearly 40 year career here at University of Iowa Health Care in a variety of different roles.
00:02:57 Kirsten Hanrahan
So in the last eight years have been in this director role and really have had great opportunity to work with this team.
00:03:08 Nicole Weathers
All right. And Laura, how about you?
00:03:10 Laura Cullen
I'm Laura Cullen, EBP scientist in the Department of Nursing in the Office of Nursing Research and EBP and I have been at Iowa for quite a while as well. It's really quite a unique culture and climate for nursing, and I love that I have worked elsewhere. But have been here for a long time with leading evidence-based practice.
00:03:34 Laura Cullen
I really love this because I get to work with the best of the best and get to help nurses, help patients and really cross patient needs from the tiniest babies to the most elderly and love the variety that nurses bring forward opportunities for us to make improve.
00:03:59 Laura Cullen
So it's just a privilege to get to do the work and really thrilled to get to talk with you today.
00:04:05 Nicole Weathers
Excellent. And I think I guess, I've never really thought about the fact that in roles like the two of yours, you really do get to cross all patient populations and work with all different kinds of nurses. And I think that's just a really special like you said opportunity and helping bedside clinicians really improve.
00:04:24 Nicole Weathers
To care for our patients, it's just, it's gotta be a really rewarding thing that you get to do every day. So so glad for, for you guys to be here. And so in this episode, we're talking all about evidence-based practice in nursing, specifically when it comes to nurse residency programs and supporting.
00:04:45 Nicole Weathers
New graduates and other clinicians in these.
00:04:48 Nicole Weathers
Part so I thought, who better to have on the podcast to talk about this than the two of you? Because this is literally what you guys live and breathe every day. And I think Iowa has some really, really cutting-edge things happening in this area. So I think to kick things off, it would be important for our listeners to make sure we're sort of.
00:05:09 Nicole Weathers
All on the same page about where we're coming from when we talk about evidence-based practice. So maybe you could start by giving us kind of a brief overview of what evidence-based practice is and how it sort of has evolved over the years.
00:05:24 Laura Cullen
Yeah, that's a great question and a good start.
00:05:26 Laura Cullen
Point. There are a variety of definitions of evidence-based practice, and they all basically have 3 components to it that were developed by Sackett decades ago, and those 3 components are combining the best evidence patients, preferences and values, along with clinical expertise to create recommendations for practice.
00:05:47 Laura Cullen
We use the Sigma nursing definition for evidence-based practice in our organization. That definition is that evidence-based practice is the process of shared decision.
00:05:59 Laura Cullen
Making between practitioners, patients and others significant to them based on research evidence the patients experiences and preferences, clinical expertise or know how and other available robust sources of information. So we use research certainly, but we also have to sometimes be creative in using other kinds of evidence.
00:06:21 Laura Cullen
When we're trying to actually find the answer to the clinical questions that nurses bring forward, and they're really fascinating, it's also been really interesting to see how this field has developed over decades.
00:06:35 Laura Cullen
Needs and Kirsten and I have had the opportunity to see the evolution over the last few decades, but evidence-based practice has been in the works for actually quite a bit longer and I think of the early work starting in the work of Florence Nightingale giving getting her credit for.
00:06:55 Laura Cullen
Initiating this data-driven approach to designing, what practice should look like?
00:07:01 Laura Cullen
That work led in the mid 1900s to a number of disciplines doing work in silos, and I think the siloed work is partly the way we share information within a discipline and siloed across disciplines, so.
00:07:21 Laura Cullen
The work in the middle of the last century was led by psychology, sociology, education and nursing and epidemiology. Got into it really much more heavily in the early 70s.
00:07:36 Laura Cullen
But it has evolved and nursing used to call this research utilization, but realized that it's more than just using research and practice and the term of evidence-based practice really helped reflect those kind of additional elements that you have to think about other than just best evidence.
00:07:58 Laura Cullen
So bringing those together has been helpful. And then the science has evolved in the mid to late 90s. What became known as implementation Science developed and we're bringing this science in to cross and connect the silos.
00:08:17 Laura Cullen
So that we aren't as isolated, but in doing so, everybody's bringing their own language to the table. And so we still, as a young science, are trying to figure out what the language will be, what it's going to look like but.
00:08:33 Laura Cullen
Continue to really support those three elements being brought in, where nurses have expertise and experience with individual patients. That's relevant throughout the process and important to consider.
00:08:47 Nicole Weathers
So I just want to take a minute and just kind of reiterate a couple of the things that you said in this, just because I think it it is really important to emphasize this for our listeners, because I think a lot of times when people think about evidence-based practice, we think of the research right. We think of maybe what was it traditionally that research utilization.
00:09:08 Nicole Weathers
And the fact that, you know, shared this definition and reminded us that it we do want to take into consideration, you know, patient preferences, clinician expertise and other areas of of evidence and not only what the research says. And I think maybe as we get into this conversation a little bit and we talk about some of the other topics that.
00:09:29 Nicole Weathers
We have outlined for today, we'll begin to see kind of the importance of you know, when there isn't research available then what do we do to really meet the needs of our patients. And I think the other, the other thing that I guess I hadn't maybe given a ton of thought about is just kind of how this has evolved since the Florence Nightingale era.
00:09:51 Nicole Weathers
So this year, actually, I don't know if you guys know this 205th birthday of Florence Nightingale. And so we talked a little bit about this out of on a previous podcast and we were talking about how her legacy still impacts nurses today. And I think this is another great example of what this looks like. So her.
00:10:12 Nicole Weathers
Desire for this data-driven care.
00:10:14 Nicole Weathers
There all those years ago, is is really what maybe our modern day evidence-based practices is really being based on. I just love that you gave that history and we are all sort of at the same starting point for what it is that we actually mean when we do talk about evidence-based practice.
00:10:32 Laura Cullen
What you're making me realize that.
00:10:34 Laura Cullen
We don't talk a lot about is incorporating the perspective of what we call an implementation science, the local context.
00:10:42 Laura Cullen
So those nurses on the ground at the frontline understand their setting, understand their team, understand the patients that they care for. And that's part of that clinical expertise that they bring to the table when we're designing practice changes that are evidence-based, we need to make it fit.
00:11:02 Laura Cullen
And feasible in that local setting, so that clinical expertise that nurses have because we're here 24/7 365 is critical to bring to the table.
00:11:14 Laura Cullen
So I appreciate your identifying that.
00:11:17 Nicole Weathers
Yeah. And I mean, I think now that you're even saying this, it has me thinking a little bit more about our residency program and the fact that there's a lot of evidence out there that says nurse residency programs are very effective in retention of new graduate nurses. But how that that program is applied in all the unique settings for new graduate nurses exists. Is going to look very different, right? And what works for a large urban hospital like University of Iowa Healthcare might not be what works for a small rural critical access.
00:11:48 Nicole Weathers
Hospital, you know, in the in the middle of Northwest Iowa. So I I really like that emphasis on local context and the fact that the, the nurses or the nursing professional development practitioners working in those specific areas are going to have a little bit of say I guess.
00:12:09 Nicole Weathers
In what might be best in this given situation?
00:12:13 Nicole Weathers
So I attend quite a few conferences and it never fails. That at least one person will walk up to me and say they use my model for evidence-based practice. And at first I was a bit confused like I was like, well, what do you mean? I don't have a model, but then I realized they were talking about the Iowa model of evidence-based practice. So maybe you could share a little bit about the Iowa model.
00:12:33 Nicole Weathers
What makes it so unique and how maybe it's influenced how Iowa and the Iowa model has influenced EBP on a larger?
00:12:42 Nicole Weathers
Scale.
00:12:43 Laura Cullen
The Iowa model was one of the early models to support evidence-based practice and is based on Roger's diffusion of innovation theory. So we have that unique grounding in theory that has helped and actually has been persistent. There continues to be support for the work of Rogers and that diffusion of innovation theory. So having that grounding has been really helpful and the Iowa model then used that that theory to help design the steps in the evidence-based practice process and those steps we see across the Iowa model, that what we find actually as the science.
00:13:25 Laura Cullen
Has continued to evolve and one of the things that I'm completely fascinated about is that the science on sustainability that comes from implementation research actually supports all the steps in the Iowa model.
00:13:41 Laura Cullen
So it continues to be grounded in the science and it continues to be supported by the science, which is really helpful. What's changed is the way that we develop tools behind every step. So in order to make the steps in the Iowa.
00:14:02 Laura Cullen
Model actionable. We have tools for every step and what we include and how we've designed those tools have evolved because the science has evolved. So we keep making the model actionable.
00:14:18 Laura Cullen
The model itself was most recently updated in 2015, so we've looked at that periodically, but then how we use the steps in the model, we keep tweaking as the science advances so that we can make it increasingly actionable, increasingly feasible, and build momentum for adoption and sustainability, because those are our key outcomes from the Iowa model.
00:14:43 Laura Cullen
We're fortunate that the Iowa model has been around for so long and is most used among Magnet organizations, but it's also been picked up and requested in 74 countries around the globe and requested about 15,000 times and cited over 1800 times.
00:15:03 Laura Cullen
Even with translation, so it is widely used and it's when nurses compare the models. The thing that I keep hearing from.
00:15:14 Laura Cullen
From our frontline nurses is that it makes sense. I can see how I can work one step to the other. There's enough information there so that I can see that I'm going to progress steadily, but then the feedback loops also reflect the fact that the process is messy.
00:15:34 Laura Cullen
And how we're going to start initially might lead us to question other things or cause us to do what we call midstream corrections so that we have feedback loops in the model and don't assume that our steps are linear because they're not.
00:15:50 Nicole Weathers
OK, so I think it's really interesting that you bring up all of the tools that are available through the Iowa model. So definitely looking at the Iowa model, it does walk nurses through the process step by step. But I think one of the other really key things and maybe why it has been so widely adopted by so many people across the globe is the fact that it does have these complementary tools that users can use as they are going through the process and are these some of the things when you talk about some of the updates and things that have been done to the model or is this really where you see a lot of the the new things coming in is in these actual tools?
00:16:34 Laura Cullen
Most of the updates are in the tools. The most recent update to the model itself was focused largely on the bottom half, and that's because that's where the science had developed.
00:16:47 Laura Cullen
Where we were learning details about how to design practice changes, how to promote implementation, how to get to sustainability.
00:16:56 Laura Cullen
The evidence for that had changed considerably since the most recent version, and so those updates were intended to really beef up those sections to try to provide a little bit more guidance. We know in general that evidence-based practices provided about 60% of the time and about 30% of Healthcare is waste and about 10% may be ineffective. So we still have opportunity to improve care and to improve use of evidence-based practice.
00:17:34 Laura Cullen
But getting to the point where we can design it for fit and feasibility so that it is adopted and then sustain continues to be an opportunity for us and nurse residents are in a nice position because they've got some protected focused mentoring and work time. So they're able to also bring a really fresh lens.
00:17:58 Laura Cullen
I find it's important when you're new to a clinical area, the questions that you ask are kind of like ohh wow didn't think about it that way. When I've been in that clinical area for a while, so their perspective can be really valuable and I would never want to lose the questions that they bring because of that.
00:18:17 Nicole Weathers
And I love that you point that out, because we do hear from new grads a lot of times it's like I'm new. What? What possible value can I add to a practice change? Or nobody's gonna wanna listen to me because I am new. So I we do really try to emphasize though the fact that they do have this very unique lens and it's it's one of those things where they're questioning it because they it's not the way it's always been done for them because they're new, right?
00:18:48 Nicole Weathers
So, that sort of sacred cow. This is the way we've always done it. This is why we continue to do it this way. Just maybe doesn't exist so much for them. And so that's one piece I really appreciate about bringing new graduates and introducing to them to this type of work is because they they have no sacred cows to kind of hold on to any as they go through the process.
00:19:13 Laura Cullen
And when we can embrace that fresh perspective and the questions that that brings, that creates a climate for us that can be really empowering.
00:19:24 Nicole Weathers
And I think when you have that opportunity to do that as a new graduate, it's easy to continue to want to engage in that kind of work. You know, I think historically like for me, for instance, residency wasn't a thing that was available and I didn't really even get introduced or the opportunity to engage in any of this until I was probably, you know.
00:19:46 Nicole Weathers
Four or five years into my career as a nurse and then at that point it, it almost had.
00:19:52 Nicole Weathers
Would almost gave me the mentality of like Oh well, this is just an extra thing. Whereas when we introduce it to new graduates, it's just a part of their role from the very beginning. And so you don't have that, like, ohh. Now you're asking me to do one more thing sort of mentality.
00:20:10 Kirsten Hanrahan
Yeah, I love that Nicole because it really is the and the residency programs are building that climate and culture, you know, across all of these settings to say, yeah, it's good to question practice. It's good to bring your perspective. It's good to ask those questions because that's what advances us.
00:20:32 Nicole Weathers
It's good to ask why, even if it might, uh, you know, annoy some of your more experienced coworkers if you ask why too much. But it's a good thing to ask why and to really understand why we do things the way we do it. And is there evidence to say that this is the best way? And so I think, like I said, and instilling that into new grads from day one is going to help us down the road.
00:20:56 Nicole Weathers
So when I first started in this role, I was even myself pretty new to evidence-based practice, especially when it came to supporting other people to work in this area. So we had new graduate nurses who were choosing between doing a quality improvement project or an evidence-based practice project. Some even sort of attempted to kind of go down the research route, but fast forward 10 years and now we're considering even
00:21:27 Nicole Weathers
Innovation as another possible route for engaging new graduates in a change process. So with all of these different sort of change methodologies, I think it can get a bit confusing because we have new grads say well like is this quality or is this evidence-based practice or or like I said they are.
00:21:47 Nicole Weathers
They are trying to do their own sort of little mini research projects, so maybe you could talk a little bit about these different approaches where they intersect, how one can decide which route to take. What does that look like?
00:22:00 Kirsten Hanrahan
Yeah, absolutely. There certainly is some confusion out there and Laura's already alluded to, you know, just even confusion in the language and such. But I don't think it the process itself needs to be confusing. It is great for us to have lots of different methods for problem solving. And I think we can all agree on that.
00:22:21 Kirsten Hanrahan
All of these are valuable, but in the right context. So foremost in considering what this is, research evidence-based practice, quality improvement or innovation. Now I think it's thinking about what is the project in.
00:22:36 Kirsten Hanrahan
Hint and there are four questions that really will help us to get to the intent.
00:22:43 Kirsten Hanrahan
The first is with regards to the project scope and what are the boundaries of the project.
00:22:49 Kirsten Hanrahan
The second is what is the projects purpose?
00:22:53 Kirsten Hanrahan
3rd is what evidence is available to guide us?
00:22:57 Kirsten Hanrahan
And then lastly, who is most likely to benefit from this practice change? So when we think about this, then the intent of research is really about creating new knowledge that can be generalized.
00:23:10 Kirsten Hanrahan
And the benefit really then informs the scientific community. So if I think about a research process, it really fits with new clinicians. So we look more for new graduates to have their intent aligned more with local improvement, which is for patients and clinicians and the organization.
00:23:31 Kirsten Hanrahan
That's EBP and Qi, and if the evidence is well known and the process, workflow or experience needs improvement, we think about quality improvement. But if you need to search for the evidence to guide the practice change, then think about evidence-based practice. And mind you that the evidence doesn't need to be perfect.
00:23:52 Kirsten Hanrahan
That really is, but it needs to be at least sufficient to guide that practice change.
00:23:57 Nicole Weathers
And I think that's a question not to interrupt here here, but that's a question we get a lot from new grads is like, how do I know?
00:24:04 Nicole Weathers
If the evidence is sufficient.
00:24:06 Kirsten Hanrahan
Yeah. Well, I think that that's a great question and you know to me, for a new grad, you don't know the evidence. And so that kind of points me in the direction of evidence-based practice and understanding that evidence 1st and then using what you've got to guide practice because you need to make practice decisions today.
00:24:28 Kirsten Hanrahan
Based on your patients needs based on their preferences and what we already know from the evidence. So even for something that for a more experienced nurse might be a quality improvement project because they know the evidence for a new graduate and new clinician, it might be worth going through an evidence-based practice process so that you have that understanding and that foundation.
00:24:51 Nicole Weathers
So, and I'm going to go take you on a tangent here really quick because another question we get is, so how many? How many research articles do I need? And you know within the last five years and and some of those sort of constraints that they come out of nursing school sometimes thinking that there's like this magic number. So maybe you can talk a little bit about that.
00:25:19 Kirsten Hanrahan
Yeah, and absolutely the definitive answer is it depends. You know it depends on the strength of that evidence, the direction of that evidence, the risks that are involved, the benefits that our patients are seeing. And so it's really weighing a variety of different methods so that we can understand all of these components of it. And you know do away with the that five year rule because there's a lot of really important
00:25:50 Kirsten Hanrahan
Research and discovery that happened a while ago. I mean, just the things we've been talking today, of Florence Nightingale, back to some of the early definitions of evidence-based practice. There are certainly landmark cases and landmark research that we don't want to miss out on.
00:26:09 Laura Cullen
Can I just speak to the five year limit?
00:26:12 Laura Cullen
We actually are beginning to write a column addressing this, and I think the five year limit has potential benefit when you're in doing a coursework for academia, but setting a five year limit is an example of where there's actually added risk to the clinical setting is an arbitrary limit. It doesn't reflect the fact that our science is so long standing.
00:26:42 Laura Cullen
It doesn't reflect that many of the clinical issues we have today are long standing. It doesn't reflect that there will be gaps in research windows that if you limit arbitrarily, you could miss some key research that would be informative.
00:27:03 Laura Cullen
The other thing that it creates problems for is also thinking about the type of evidence. So there's times that case studies can be critically important in helping you design and practice change, and there are reports of case studies from research that were missed and contributed to significant and bad outcomes.
00:27:27 Laura Cullen
So, understanding that evidence in a more complete way is much more important than thinking about setting arbitrary limits for the type of literature you want to look at, or the number of years you want to look at, or even the patient populations that you want to be looking at research related to.
00:27:46 Laura Cullen
So it's one of my kind of bees in my bonnet, which is why I just wanted to take that tangent just a little bit in thinking about the evidence more broadly.
00:27:55 Nicole Weathers
And I mean I think as a as a student now because I am currently a student as we're recording this podcast and I do I see where it is helpful on the student side just to like you said, give a little bit of parameters to help a student.
00:28:12 Nicole Weathers
Not go too far down the rabbit hole and I think I'm thinking of my DNP project specifically, which was about, you know, nurses going back to school and continuing their education in some contexts. And I guess I would love your feedback on this. Some of the things that are happening societally, politically.
00:28:32 Nicole Weathers
Like the current five year sort of window is going to, there's going to be some impact that is happening within that current five year window that might help be a little more helpful for us as we're looking at a project and that.
00:28:46 Nicole Weathers
Area because there are some factors that might influence that decision to go back to school, like the economy and things like that. So for me, for this project, I did choose to sort of limit that window a little bit just because I thought that was maybe what was going to be most helpful versus back in the 70s.
00:29:07 Nicole Weathers
Right when people were deciding to go back to school, it was a very different climate at that point.
00:29:11 Kirsten Hanrahan
Yeah, I do think too. Sometimes they think about technology and how it has changed. So we did evidence-based practice project related to central lines and that was one that we thought well the technology for central lines has changed so much. Does it help us to go that far back into the literature.
00:29:31 Kirsten Hanrahan
And so we were looking at the more current stuff, but we also wanted to go back enough to understand what changes came about and why they came about and that also then helped to inform the the project. So even though you may set some limits.
00:29:47 Kirsten Hanrahan
Because of the specific nature of the project, I think it's important to also think about, well, what from a historical perspective, and historical evidence may be important to informing this so that we're not making the same mistakes over again.
00:30:03 Nicole Weathers
And that's a really good point, right? We don't want history to repeat itself and like we're continuing to, like you said, make this the same mistake. So I really appreciate that.
00:30:11 Laura Cullen
Yeah.
00:30:13 Kirsten Hanrahan
Nicole, can I round back because I want to bring us back to innovation because you also mentioned innovation and I love innovation, but I think you know the focus on innovation is really for problems that we don't have a solution for or that the current solution is failing.
00:30:33 Kirsten Hanrahan
And before we can get to new solutions, we have to understand the current practice and the what, what's not working, what's feasible, what's core to an intervention.
00:30:45 Kirsten Hanrahan
That gets you to the desired outcome, and so I really recommend still starting with evidence-based practice, that certainly that will you'll need some creativity and even some innovation in designing that evidence-based change and implementation plan. But for most new graduates.
00:31:07 Kirsten Hanrahan
I really recommend that EBP is the best process for learning what's new in the evidence, and then also how to apply it and get to improving outcomes.
00:31:19 Nicole Weathers
So what I hear you saying is sort of it always starts with a look at the literature. What has known about this problem? And then based on what is known or setting what the, the purpose, the goals are that sort of help dictates if we would need to generate new knowledge.
00:31:39 Nicole Weathers
Right. If we need to just fine tune a process within our organization based on what evidence is available or if we need to bring innovation into the picture.
00:31:51 Kirsten Hanrahan
Yeah, I think that's right.
00:31:52 Laura Cullen
You've got it. The other thing I think is helpful is if, when what I've seen is when nurses learn the EBP process, that will help them troubleshoot with every other process, they're going to use.
00:32:05 Nicole Weathers
Because I think it keeps taking them back to what do we know? What does the research tell us and using that as a guide?
00:32:11 Nicole Weathers
So in our program, we ask residents, of course, to complete what we've called this professional experience. They can choose to do a change project, which is usually quality improvement or evidence-based in nature. They can identify, sort of a case study that they this is usually a patient that they've cared for in the.
00:32:30 Nicole Weathers
Test and then they go to the research to see what does the research say about this. You know situation a lot of times, maybe the patient had some sort of adverse event and so they're looking for what could we do differently at our organization to keep this from happening again and they would take this proposal, if you will, to a unit-based Council or something similar.
00:32:51 Nicole Weathers
To decide if this is something that the facility you know wants to tackle or they can get involved in some existing committee work. But regardless of which route they choose. They need to identify some sort of metric or measurement indicating that there is a need for change and they need to take a look at the evidence that is available to guide their project. But one of the biggest challenges we sometimes face and what I think our listeners can really relate to is how do I facilitate and support this process.
00:33:23 Nicole Weathers
Yes, because not all leaders of course, feel comfortable supporting new nurses through this process. So if they aren't comfortable, it's easy to let the new grad sort of figure it out on their own. And then there's floundering and kind of not knowing which way to go if they are comfortable. The other thing that we see is that they.
00:33:42 Nicole Weathers
Kind of take over the process.
00:33:44 Nicole Weathers
Right. And they don't let them do much of it on their own. And then additionally, we've got, you know, nursing professional development practitioners that are and and nurse leaders that are incredibly busy and supporting these projects can be pretty time consuming, so.
00:34:02 Nicole Weathers
I would be curious if you guys have any strategies or tips that you could share so that our listeners can more effectively support new grads in these efforts.
00:34:16 Kirsten Hanrahan
Yeah. Well, first of all, this is just such an excellent question because the as we know the role of the leader and the EBP facilitator is, you know, just can't be overstated both in terms of project success and mentoring. So I you know, I in thinking about this, I think the first thing to think about is clear goals for the project lead for the manager and for the facilitator. So when we think about new grads, we they really need to develop that subject matter expertise and lead the project managers don't need to be EBP process experts if they bring that that's great, but really they.
00:35:01 Kirsten Hanrahan
Their role is empowering those new grads and providing them with the resources that they need, like time supplies, access to people, connecting them within the organization, and then the NPD's are likely to be the person to the EBP process and help that new grad and keep them on track using the process and then other things that I think of. In addition to that in terms of tips are just to keep the language clean and the process clean. So not dipping a little bit into EBP and a little into quality improvement.
00:35:38 Kirsten Hanrahan
And mixing your methods and that. But for these first projects, keep it clean. It's a straightforward EBP process and follow that process to the end.
00:35:48 Kirsten Hanrahan
And stay true to the intent and that method that you're using. Another tip would be to stick to 1 model and you know I think in school you're learning a lot about different models and that kind of thing. But if we're all within our organization using one model that helps us to communicate.
00:36:08 Kirsten Hanrahan
And understand the next step in the process and where we're going with this. So sticking to that one model, I also think keeping it simple.
00:36:20 Kirsten Hanrahan
Learning the process and getting the win and so you know a lot of times we want to swallow the ocean or eat the elephant, but we need to reel that back a little bit and come up with that small, definitive process. Very well defined process that we know we can get that win with.
00:36:40 Kirsten Hanrahan
And then we can keep adding on and doing iteration and such to get to something more advanced. And then the last tip that I would say is to look at these resources and tools that are available to make the process easier.
00:36:55 Kirsten Hanrahan
There are many online resources that are excellent and no cost. Don't waste time reinventing. Instead, take the tools that are out there and adapt them to meet your needs and don't honestly, I'm just going to say don't waste your money on expensive tools. They're not really any better than some of the stuff that is out there and complimentary.
00:37:17 Nicole Weathers
I'm going to go back to one thing you said about picking a simple, definitive focus for the project because I think that is one of the things our new grads can struggle with the most. Is that idea of well, first, it's like, oh, do I really have to do this? And then when they wrap their brain around? Yep.
00:37:38 Nicole Weathers
They're going to do it. It's like they want to solve World Peace. And so one of the roles I think that we have leading the nurse residency program, the leaders, the NPD's and the organization have is to help them scale it back sometimes and how.
00:37:54 Nicole Weathers
How do we bring it back to a small but simple thing? Because we want them to be successful. I mean, that's the goal here, right? That they learn the process.
00:38:06 Nicole Weathers
And they're successful so that they want to continue to engage in this kind of work into the future. I think sometimes when they do try to take on this big project, then we know change is a challenge. Getting everybody on board is a challenge. When we run into too many roadblocks and get too frustrated, it's like I this this just isn't for me. I don't want to do this.
00:38:28 Nicole Weathers
I don't want to. You know, I don't want to finish this and I don't want to ever do this again. So I think really, especially for these these first time new grads in this process, that probably statement can't be overemphasized enough because I think in order to keep them engaged and keep them wanting to do this work, they've got to have some of those small successes in the beginning.
00:38:51 Kirsten Hanrahan
Yeah. And really that comes back to one of the early steps and I will model and as Laura said, these are foundational, you know, state the question or the purpose and that really provides some guardrails around the scope of the project and helps clinicians to focus in what we see a lot of times.
00:39:11 Kirsten Hanrahan
With student projects or early residency projects is they want to jump right to the intervention instead of getting into the evidence and seeing what really is the the right intervention for the problem that you're facing.
00:39:26 Kirsten Hanrahan
So first of all.
00:39:28 Kirsten Hanrahan
You know, really going back and making sure you have a clean purpose statement and then you know that may evolve as you get into the evidence. But to kind of create those boundaries around the scope of your project.
00:39:43 Nicole Weathers
Well, and I think another early question in the Iowa model is, is this an important project for the organization or I don't know what it actually is, but it's something along those lines and that is another one that we sort of continue to emphasize for our new grads is
00:40:03 Nicole Weathers
do something that matters to the organization, because that's where the buy in and and the support are going to come from, and nobody wants to. I mean, we don't want them doing a project just for the sake of checking the box and saying they did it right. We want this to have some meaningful impact at the end of the day and I think
00:40:24 Nicole Weathers
that is such a simple question, yet I think one that we often forget to ask.
00:40:32 Nicole Weathers
Because we've maybe identified in our own mind that this is something that's important, but if it's not a priority for the organization, I think we really need to reconsider the project.
00:40:44 Kirsten Hanrahan
Yeah, it is an important question. Is the topic the priority it? But it's also important in terms of later thinking about how you're going to evaluate the project.
00:40:57 Kirsten Hanrahan
Because you want to be able to demonstrate back then what made it a priority for the organization, the impact of your project. So it's important to upfront early to be considering that, but it it also downstream has implications.
00:41:14 Nicole Weathers
Well, I think when we're talking about, you know, measurements to really show, did this change this intervention? Did it make a difference if we don't have anything indicating that maybe it is a priority for the organization, that's really going to be hard to show.
00:41:30 Nicole Weathers
So as we look forward to the future.
00:41:33 Nicole Weathers
How do you envision the evolution of evidence-based practice? Do you see any sort of emerging trends, challenges and how can we maybe begin to prepare to address those?
00:41:45 Kirsten Hanrahan
Well, I think as we look to the future, we have to first of all acknowledge our limited resources and primarily in terms of.
00:41:54 Kirsten Hanrahan
For course challenges we can't keep doing things the same old way and expecting better outcomes. And so instead we have to really seize this as an opportunity for evidence-based practice. So things I think about in terms of what we need to do are first of all considering.
00:42:10 Kirsten Hanrahan
And continuing to optimize the EBP process with methods and tools that make it easier. Want to think about how we can leverage technology with caution and with clinical judgment. I think using the implementation science to leverage our change, not just the spaghetti on the wall, but really what is it that impacts change is important.
00:42:33 Kirsten Hanrahan
And then considering those patient values and partnering with them in codesign, as Laura said, this is the, you know, basic definition of evidence-based practice. And then I always think too about the de-implementation and undoing the things that just don't work and instead of keep piling it on the work for our clinicians.
00:42:54 Kirsten Hanrahan
I think it's important to remain practical and feasible in our real world settings and that's why the impact of evidence-based practice is more palpable than in the research world, because it's real.
00:43:08 Kirsten Hanrahan
And then lastly, just to continue to develop EBP skills for the next generation of nurses.
00:43:15 Nicole Weathers
This whole idea of de-implementation I think is really something that we as a profession need to highly consider, because I I think we're all. I mean, it doesn't matter what facet of nursing that you work in. It's so easy to keep adding and adding and adding and everything is so important. And we never take away.
00:43:35 Nicole Weathers
Right. We never think what isn't really adding value. What really isn't making a difference.
00:43:41 Nicole Weathers
At some point, we've got to begin thinking about that, because when we're looking at things like some of the issues in our workforce, some of the issues around burnout, things like that, I think de-implementation has a really important role in helping us fix some of that.
00:43:59 Kirsten Hanrahan
Yeah, I agree. At the very least, we need to be considering what is effort neutral change. We can't just keep adding on and so thinking of de-implementation early in our implementation processes, so that and then that makes decision making easier too, quite honestly, and makes it easier to do the right thing.
00:44:22 Nicole Weathers
And I love this idea of co-creating with the patient because I think it's easy for us to think, you know, this is what is best for the patient or the patients that we care for. However, I think that patient perspective is so important to consider as well.
00:44:38 Kirsten Hanrahan
Yeah. And, you know, as nurses, we think we know what our patients want, but the evidence would show quite differently. And so we really do need to ask them and engage with them and not in a tokenistic way, but in the ways that really matter that they can help to really Co create Co design the care that they want to receive.
00:44:59 Nicole Weathers
So I'm curious, what would that look like? So if I was an organization who wanted to engage patients in this process, what are some examples of how that might look?
00:45:10 Kirsten Hanrahan
Laura, I'm gonna throw that to you because I love how you talk about your vision for the future of nursing. That is patient driven.
00:45:19 Laura Cullen
Yes, thanks. I I do my vision is in fact that healthcare would be patient driven instead of clinician driven and we've got a long ways to get there. So there are things that we can do in our individual interactions with patients, but also as organizational systems certainly shared decision making with patients.
00:45:40 Laura Cullen
So that when they're choosing the interventions that they want to use to help promote their health, that is one area we need to do that. One example for inpatient care is the engagement for patients for fall prevention and trying to shift from doing 2 and doing 4.
00:46:01 Laura Cullen
But having the patient involved, so we're doing with the patient for fall prevention.
00:46:08 Laura Cullen
And so whether we're doing it in an ambulatory setting where they're picking the health promotion activity that they want to try to adopt and whatever, that would be the priority given their current health status, then coaching and guiding them along the way to adopt that health behavior or when we're inpatients
00:46:29 Laura Cullen
We can really address what are their needs, setting goals that are patient driven instead of clinician driven can really change the way we communicate with patients.
00:46:40 Laura Cullen
And from an organizational system perspective, it's building patients into our governance structures so that they're members of committees and can represent the patient perspective in our conversations, in our setting priorities, in our planning for processes in the way we design our educational materials for instance.
00:47:02 Laura Cullen
So that we're including them all along the way, that's one of the things we've added to the Iowa model and our book most recently is tips for patient involvement every step along the way with the Iowa model because we want to move this direction where patients can become drivers at a minimum, we're engaging them. So it's shared decision making but getting to where they can lead us to where they want to be.
00:47:29 Nicole Weathers
I love that and I love the fact that you provide tips in your new book that help organizations figure out maybe how what that looks like. So you also mentioned the idea of leveraging technology, so maybe you could talk a little bit about that.
00:47:43 Kirsten Hanrahan
Yeah, but there is certainly a lot going out on out there in terms of technology advancements and that's all great and could provide some solutions to some of our workforce issues.
00:47:56 Kirsten Hanrahan
But we also have to be very careful about that and not remove that important critical nursing judgment. And even when it comes to evaluating those technologies and making sure that, you know, we're keeping human touch involved, that it's nursing judgment, that is even informing those technologies.
00:48:17 Kirsten Hanrahan
And so thinking about how, when and where we use them will be important.
00:48:23 Kirsten Hanrahan
And you know, and not to just assume that products that are out there have been vetted with nurses, have been vetted with patients. But to really take a critical look at them. And so I think we have a responsibility to our patients to do that as.
00:48:39 Laura Cullen
Well, I like that Kirsten brought that up and would also just add that in other industries, when we bring in new technology, it usually reduces the workload of the worker. But in healthcare, there's evidence that it typically increases the workload of the worker. And one example that comes to mind is the smart pump.
00:49:01 Laura Cullen
I remember going around to patient rooms and counting drips and trying to make sure that the IV rate stayed on track and you know the smart pump is designed to help us with errors. But in that push to get it out and used and then revenue generating from the vendors, it came out really before it was designed for enough safety mechanisms and early evaluation of smart pumps found over 150 points at which error could be generated because of the smart pump, so we have to be really careful with technology that we're using it in a way that is helpful and that it does in fact have the evaluation that Kirsten talked about and we get that input cycled into it in order to make sure that it's usable for the end user, the clinician.
00:49:55 Laura Cullen
And the other thing that technology makes me think about is the focus now on AI and there's certainly opportunity with AI. But we're in a very messy phase right now and we're going to have to be really careful until we can get this perfected for instance.
00:50:18 Laura Cullen
And we're using data from our own electronic records and language learning and big data.
00:50:25 Laura Cullen
What we know is that the information in our electronic records is actually biased.
00:50:31 Laura Cullen
We don't document the same way for all of our patients and so we're using biased data to help direct care. So that's important to think about. I think there's going to be opportunity when we're looking about at synthesizing evidence and using AI to help us synthesize evidence. But there's a lot of detail in evidence reports that are critical to know so that we can plan to avoid intentionally, or at least measure unintended consequences when we're doing practice changes and we're likely to lose that if we do generative AI to help us synthesize evidence.
00:51:12 Laura Cullen
So until we get through this window where we're missing bias and missing the description of the how that comes from reading research to help us avoid those unintended consequences, our use of AI is going to actually potentially create some additional or new errors that we're going to have to watch for.
00:51:33 Laura Cullen
So lots of opportunity here, but there's always a learning curve.
00:51:38 Nicole Weathers
And I think that's a really great point because I think we always think of technology and AI as improving safety, saving clinicians time all of the all of the sort of things. I think technology can help with and AI can help with. But like you said more.
00:51:56 Nicole Weathers
We need to pay attention to some of these other factors and not be too quick to just think technology is going to fix the issues.
00:52:04 Kirsten Hanrahan
Yeah, it makes me think of the cognitive burden as well. You know, sometimes we get so caught up in the technology and the pumps and the all, all of this, we forget to look at the patient.
00:52:16 Kirsten Hanrahan
And and you know really, to peel that back and keep that focus.
00:52:21 Nicole Weathers
Well, I think that brings us back to our discussion on Florence Nightingale and going back to the basics, right, paying attention to the patient themselves and all the important things that she taught us so many years ago.
00:52:36 Nicole Weathers
All right. Well, we have talked about so many great things today. You know, we've talked about evidence-based practice, the Iowa model, the difference between quality improvement, evidence-based practice research and really where innovation begins to fit in the mix as well. And then we've talked about some tips and strategies for supporting new graduates as they learn and engage in these processes for the first time.
00:53:03 Nicole Weathers
So I want to thank you guys both for spending time with us today and sharing all of your valuable expertise that you you bring to the table. But before we go, I have one last quick question and this is something that I ask of all of the guests that come on the podcast. But when it comes to supporting nurses in evidence-based practice. What's one thing that you see organizations doing that makes a significant difference that you wish more organizations would do?
00:53:36 Kirsten Hanrahan
Thanks, Nicole. I'm going to try and get the quick answer to that in response. I you know really I think it's about investing in infrastructure for evidence-based practice. And So what does that look like? You know really it's about building evidence-based practice into the work that we do every day.
00:53:56 Kirsten Hanrahan
And that is seen through things like policies and professional governance standards, strategic plans, those kinds of things. I think it's also important that we're hiring the right people, that we're hiring nurse scientists and EBP facilitators to mentor these projects and people who have that expertise and can pass it to the next generation. We also think about having programs to build EBP skills and we, in our area we talk about it across the career continuum and meeting people where they're at because it's very different if you're a new grad and are getting some evidence-based practice in your academic content versus if you're a career nurse and you've got all kinds of clinical knowledge.
00:54:40 Kirsten Hanrahan
They didn't teach that back when and so having programs that can support nurses from that beginning all the way up to advanced skills, and then last but certainly not least, the biggest barrier is always time. And so thinking about having paid time away from direct care responsibilities.
00:55:02 Kirsten Hanrahan
Or nurses in various roles to lead and engage in evidence-based practice.
00:55:08 Nicole Weathers
Laura, how about you? Anything that you would like to add as far as what you see organizations doing that really is making a difference?
00:55:17 Laura Cullen
I completely agree and think Kirsten did a really nice summary of what organizations really need to provide to support our nursing practice to be able to be evidence-based and make the impact that nurses want to make. I think there's always the opportunity to lead. Every nurse has the opportunity to lead and be a leader.
00:55:38 Laura Cullen
And questioning practice and providing positive influence and setting the bar for what we do high is something we want to do across our career continuum.
00:55:49 Laura Cullen
And as nurse graduates, I would just really encourage them to ask questions, ask questions, ask questions, because this really helpful to whether you've been in the organizational while or whether you're new to really start peeling back the layers of what is it we're doing? Why are we doing it? And is it really the best way we can do things?
00:56:12 Nicole Weathers
And one last question, because you did allude to this as far as you know, programs to build the skills in our nurses. So I know for a lot of the listeners of this episode, of course we begin to introduce this in our nurse residency program. But as we said, a lot of our our coordinators that we work with, a lot of our nurse leaders.
00:56:34 Nicole Weathers
If they're in a hospital where they don't have a Kirsten or a Laura, somebody who's an expert in this work, where would you suggest they could maybe go to learn a little bit more? What sort of resources are out there? I would say specific to the Iowa model given the popularity and how usable this this model really is.
00:56:55 Kirsten Hanrahan
Yeah, great. Well, you know, certainly the World Wide Web has just a, you know, a ton of resources and such out there and we can connect listeners to our website that has a whole list of complementary resources, which includes the Iowa model, our implementation framework.
00:57:15 Kirsten Hanrahan
These tools for every step of the process and through a simple request process they can get those for free. In addition, you know we have programs, there's we have an annual Evidence-Based Practice conference. We're in our 32nd year. It is a national conference and usually in the spring. You know that is a great way to kind of get some exposure to evidence-based practice and then bring that back to your organization. In addition, we do provide consultation and external programming for organizations that may not have that kind of internal support, we are very close to being ready to post some kind of foundational modules for learning evidence-based practice.
00:58:01 Kirsten Hanrahan
And you know, we're just one of a number of sources that do that kind of thing. I would think the things that set us apart are ongoing success in this, that our tools are for the most part all free and they're proven. They're proven by the use by our clinicians.
00:58:21 Kirsten Hanrahan
By that worldwide reach that Laura described and so proven to be very effective.
00:58:28 Nicole Weathers
Excellent. Well, Laura, Kirsten, thank you again so much for being here with us today. I think evidence-based practice is such an important topic, whether we're talking about new grads or not. And you guys have so much expertise and we're so thankful that you were here to share that with us today.
00:58:46 Kirsten Hanrahan
Thank you, Nicole. Thank you for all that you're doing for your residents. So we are going to need them in the future. And so I really appreciate this opportunity to share our perspectives on evidence-based practice.
00:58:59 Laura Cullen
Agreed. Thank you so much.
00:59:08 Nicole Weathers
Wait before you go, I want to make sure you know all about our suite of resources you can use to support your new graduate nurses. This includes our Academy, a coaching program design for organizations as they prepare for the implementation.
00:59:23 Nicole Weathers
And ongoing sustainability of a nurse residency program work one-on-one, with residency program experts to make sure your organization is residency.
00:59:32 Nicole Weathers
Ready our clinician well-being course is an asynchronous online course that aims to enhance the well-being and resiliency of healthcare professionals, equipping them with the necessary psychological capital to navigate challenges inside and outside of work. Supporting nurses is another asynchronous online course for preceptors mentors and coaches.
00:59:53 Nicole Weathers
To learn the skills they need to support any new hire.
00:59:57 Nicole Weathers
Both of these offerings can be used as a stand alone professional development opportunity or to augment any nurse residency program. And we can't forget about the program that started it all. The online Nurse residency program. This includes A comprehensive curriculum designed to support new graduate nurses, applying all the knowledge they learned in school.
01:00:17 Nicole Weathers
To their practice, we focus on professional skills, personal well-being competencies, and new graduate nurses even get the opportunity to create real change in their own organization.
01:00:29 Nicole Weathers
Offered completely online and in a blended format, this program is highly adaptable to all clinical practice settings. You can learn more about all of these programs and more of what we offer using the links in the show notes below.