Keywords

community health, community orientation, evidence-based practice

 

Authors

  1. Schutte, Debra L. PhD, RN
  2. Kisting, Mary MS, RN, CCNS, CCRN-K
  3. Warren, Chastity DNP, RN, CCRN-K
  4. Stoneman, Miranda BSN, RNC-OB, C-EFM

Abstract

Abstract: Evidence-based practice (EBP) and innovation are critical to quality and improved outcomes in the acute care setting and are often driven by bedside caregiver and clinical nurse specialist collaboration. Several EBP models and frameworks exist to guide these efforts. Although existing models do not preclude external evidence and community-based stakeholders, they largely do not explicitly connect the hospital-based effort to the community either. In our experience in facilitating EBP projects within an acute care hospital in the upper Midwest, we observed multiple situations in which nurse-led EBP projects intersected with the surrounding community in multiple phases of the project. The purpose of this article is to demonstrate an explicit connection between hospital-placed EBP processes and community/population health. To illustrate this assertion, 3 exemplars of nurse-driven, hospital-placed innovation are presented. Implications for practice and research are discussed.

 

Article Content

Evidence-based practice (EBP) and innovation are critical to quality and improved outcomes in the acute care setting and are driven by acute care nurses and clinical nurse specialists. Several EBP models have been derived and evaluated to guide this process. According to Speroni et al,1 the most commonly used EBP models include the Iowa Model of Evidence-based Practice,2 the Johns Hopkins Evidence-Based Practice Model,3 and the Advancing Research and Clinical practice through Close Collaboration model.4 The Iowa Model and Johns Hopkins models provide a process framework for the conduct of an EBP project, whereas the Advancing Research and Clinical practice through Close Collaboration model provides a system-wide framework for building and sustaining EBP within healthcare systems. All have demonstrated positive impacts on patient and systems-level outcomes.4,5

 

By definition, EBP is designed to impact outcomes at the unit, organization, or system level by integrating evidence into practice in a systematic and sustained manner. Across EBP models, nurses are guided to broadly identify triggers for an EBP change, such as new evidence or trends in unit or hospital quality data. Nurses are also guided to consider stakeholders, or those likely to influence or be influenced by a project, as they plan and implement an EBP practice change. Although the consideration of triggers and stakeholders in these models does not preclude external evidence and community-based stakeholders, they largely do not explicitly connect the hospital-based effort to the community either. In our experience in facilitating EBP projects within an acute care hospital in the upper Midwest, we observed multiple situations in which nurse-led EBP projects intersected with the surrounding community in multiple phases of the project.

 

Certainly, the connection between a hospital and the surrounding community is not a new phenomenon. This connection was coined "community orientation" by Proenca6 and defined as the activities that healthcare organizations must undertake to manage community health, including activities such as long-term planning to improve community health, commitment of resources for community health, conducting community health needs assessments to identify unmet community needs, and use of health status indicators to inform programming and care. Evidence also suggests that the degree to which a hospital is oriented toward or connected to community can generate benefits for the organization in the areas of patient satisfaction and quality of care7 as well as positive outcomes for the community, such as increased provision of health promotion services to a community.8 What is less evident in the literature are examples of community-oriented activities, such as EBP, that are nurse driven and hospital based. The purpose of this article is to demonstrate an explicit connection between hospital-placed EBP processes and community/population health (or community well-being) by providing exemplars of community-oriented care driven by direct care nurses in the acute care setting.

 

ILLUSTRATING HOSPITAL-PLACED EBP WITH A CONNECTION TO THE COMMUNITY

The formal construct of hospital community orientation is commonly described as the organizational-level assessment of population health and aggregate programming. However, in our experience, we observed and assert that community assessment and programming also occurs at a unit level, that is, individual direct care nurses who identify an unmet community health need and use this as a driver of inpatient practice change and/or individual direct care nurses who see the need to extend an inpatient practice change into the community.

 

To illustrate this assertion, 3 exemplars of unit-level EBP with a connection to the community are presented hereinafter. These exemplars occurred or are occurring in the context of a 600+ bed, level 1 trauma hospital that recently achieved second redesignation of Magnet status. These innovations emerged directly from direct care nurses and were supported, at least initially, through an EBP fellowship program with the Department of Nursing, which links together a direct care nurse with a clinical mentor (usually a clinical nurse specialist) and a nurse researcher. All exemplar projects were reviewed by the hospital Nursing Research Council and the hospital institutional review board for either approval or nonresearch determination.

 

Exemplar 1: Standardizing Nasogastric and Orogastric Tube Placement Verification

A direct care nurse in a pediatric subspecialty outpatient clinic observed that (1) the clinic was receiving an increasing number of calls from parents at home about nasogastric (NG) tube care in the children and (2) families were returning to the emergency department after accidental tube removal for tube placement and at-home care instructions. These observations raised questions about the components and delivery of discharge instructions to parents of children going home with NG or orogastric tubes. This nurse received support through an EBP fellowship with the initial goal of standardizing discharge instructions for these parents. However, through an early performance gap assessment across pediatric units, considerable variability in nurse knowledge and practice were identified related to tube placement verification and care in patients within and across pediatric units. As a result, the project expanded to develop and evaluate an NG/orogastric Tube Placement Algorithm across 5 pediatric units.9 After the successful rollout of this protocol, a standardized education plan for children and infants discharged home with feeding tubes was developed for families and incorporated into the electronic medical record for consistent, comprehensive discharge teaching. In addition, the pediatric subspecialty clinic is launching a multidisciplinary coordinated clinic day to meet the needs of families related to feeding assistance. In this exemplar, the observation of an unmet community need by a direct care nurse in the outpatient setting led to an inpatient practice improvement, which circled back to improved discharge care for parents and their children in the community.

 

Exemplar 2: Implementing a Coping Algorithm in Labor and Delivery

A direct care nurse in the labor and delivery unit applied for an EBP fellowship to improve strategies for assessing pain and to assist women in coping with pain throughout the labor experience. This EBP project was triggered by internal indicators, such as the opportunity to improve patient satisfaction with the labor experience, the opportunity to improve performance around Healthy People 2020 national goals to reduce cesarean section rates,10 and the need to align practice with new professional organization recommendations.11 This project led to the development, implementation, and evaluation of a Coping with Pain Algorithm to standardize the assessment of the laboring woman's coping response and the delivery of evidence-based nonpharmacologic interventions to support coping through the labor experience with goals of impacting patient satisfaction, epidural use, and cesarean section rates. A pivotal moment in this project, however, occurred with the bedside nurse's observation that "we really need to back this project up into OB clinics so that moms are consistently coming to us with birthing plans. How could we provide anticipatory guidance to moms about what to expect during their labor experience and what strategies are available to them to cope with labor pain?" This community-oriented insight moved this project from a hospital-centric focus to a community-centric focus in an exciting way. After this observation, regular monthly communication occurs between hospital obstetrics staff (particularly through the clinical nurse specialist) and clinic staff to share information about resources available to laboring moms in the labor and delivery unit.

 

Exemplar 3: Standardizing Oral Care in an Acute Care Hospital

Two direct care nurses on a surgical unit, with the support of an EBP fellowship, successfully implemented the transition to evidence-based oral care products on their surgical unit. Their project was initially triggered by the opportunity to improve postoperative pulmonary outcomes and to improve patient satisfaction with oral care products. After the successful implementation on a single unit, the team and project were extended, under the direction of a clinical nurse specialist, to implement and evaluate the impact of the Oral Care Protocol hospital-wide. The Oral Care Protocol provided a standardized decision tree for the delivery of oral care, the use of oral care kits stratified by risk level, and patient education materials to highlight the patient's own role in oral care and its impact on pulmonary outcomes.12,13 The evaluation of hospital-wide implementation was successful in influencing key patient outcomes12 as well as caregiver knowledge and attitudes.13 The internal, hospital focus of the project continues with identifying and addressing areas requiring protocol and product adjustments to accommodate particular unit types (eg, behavioral health). However, an external, community focus emerged when conversations about the next steps for this project turned to potential community partnerships such as collaborating with long-term care facilities to implement and evaluate standardized oral care, and/or partnering with shelters for persons experiencing homelessness to provide oral care kits and resources. Decisions remain underway in how best to engage with, fund, and implement these next steps. However, these discussions and decisions remain grounded in the observation that these partnerships would not only improve the health of community-dwelling individuals but also potentially improve outcomes in the event future hospitalizations are needed.

 

In each of these examples (see Figure), advances in care were driven by direct care nurse and clinical nurse specialist teams toward the goal of improved patient outcomes. Furthermore, in each of these examples, direct care nurses articulated an awareness of and potential to impact an unmet community need or opportunity to improve community health. These nurses also recognized the need to reach out beyond the hospital boundaries to further improve patient outcomes and the patient experience. With this recognition came the desire to engage with stakeholders outside traditional boundaries, such as with patients, families, primary care providers or specialty clinics, long-term care facilities, community health agencies, and health insurance company foundations toward the goal of health and wellness at the individual and community levels.

  
FIGURE. Summary of l... - Click to enlarge in new windowFIGURE. Summary of linkages between evidence-based practice (EBP) and community need.

DISCUSSION

Although, traditionally, hospital-community connection (ie, community orientation) is described as an organizational-level attribute, these exemplars illustrate that community orientation is occurring at the unit level as well and is driven by direct care nurse and clinical nurse specialist collaboration. The importance of the integration of hospitals into the fabric of a community has become increasingly apparent during the current COVID-19 pandemic where hospitals play critical and direct roles in community well-being by providing antigen and antibody testing, monitoring local positivity rates, preserving the health of their workforce, caring for the sick, and administering vaccines to the community. Even before the COVID-19 pandemic, however, several factors were driving healthcare organizations' engagement in community health. These policy drivers include changes in financial reimbursement, increased scrutiny of not-for-profit status, and a growing emphasis on quality improvement, including the emergence of quality criteria that emphasize customer and supplier collaboration (eg, Baldrige criteria).14

 

In addition to policy, community orientation is also driven by a socio-ecological view of health and health determinants, which posits that health is influenced not only through individual characteristics and behaviors but also through multiple levels of influence, including intrapersonal (individual), interpersonal, institutional, community, and policy spheres.15 Specifically, this framework suggests bidirectional and iterative relationships between the structure and processes within hospitals (institution level), individual health (intrapersonal level), and the structure and processes within a community (community level). The precede-proceed model is another framework that applies an ecological lens to developing and testing health programs, asserting that health is influenced by multiple factors and that influencing health requires participation and collaboration across many sectors.16 Our exemplars provide evidence for the multisector connections proposed by these and other frameworks. Specifically, we observed hospital and community interaction through internally driven EBP initiatives and with consistent collaboration and consultation between direct care nurses and clinical nurse specialists.

 

Our exemplars also illustrate an opportunity to more explicitly connect a hospital-based EBP culture and processes to the community within existing EBP models and frameworks. One example of a framework that does explicitly incorporate a broad contextual frame is the Joanna Briggs Institute Model for Evidence-based Healthcare.17,18 The Joanna Briggs Institute model includes global health as one of the steps involved in achieving evidence-based clinical decision making and as the key end point of all evidence-based healthcare. In their framework, global health is defined as achieving health and health equity for all people worldwide but offers the flexibility to consider local health as global health.18 Similar opportunities exist to expand the conceptualization of other EBP models and frameworks by placing them within a broader community or global context and allowing for the flow of data and innovation between community and healthcare organizations.

 

IMPLICATIONS FOR PRACTICE

These exemplars suggest opportunities for further supporting direct care nurse and clinical nurse specialist teams in the provision of care delivery and innovation within a community frame. First, opportunities exist to formally integrate (or hard wire) the consideration of community context into the development and implementation of EBP changes within the hospital setting. For example, when identifying triggers for an EBP project, nurses can consider the extent to which this project is triggered by an unmet community need. When developing the implementation and evaluation plan for an EBP project, nurses can consider the extent to which there are implications of this practice change beyond the hospital setting. A second critical opportunity is the consideration of how hospitals can support nurses in forging and sustaining these potential community connections. One approach is the identification of a broad range of stakeholders (including community-based stakeholders) during the planning phases of an EBP project. In addition, collaborating early on with a hospital's population health department to leverage their resources for facilitating and sustaining community interactions will also be essential.

 

These exemplars also suggest opportunities at the hospital level to leverage and synergize with nurse-driven EBP activities. For example, are there opportunities to integrate direct care nurses, including clinical nurse specialists, as part of an advisory group into the population health departments within hospitals? Integration of direct care nurse expertise has the potential to expand the context in which community-level needs assessments are implemented and interpreted and to provide additional expertise in the development and evaluation of efforts to meet community needs. Direct care nurse and clinical nurse specialist engagement in population health departments can also serve to alert population health departments about in-house practice innovations that could be extended to help meet community-level needs.

 

IMPLICATIONS FOR RESEARCH

Several hypotheses and subsequent research opportunities are generated through the exploration of these exemplars. To facilitate further research into the connection between hospitals and community health, the inclusion of unit-level indicators of community orientation to the Community Orientation Scale6 would be beneficial to capture a broader range of activities directed toward the community. On a descriptive level, a systematic comprehensive assessment of unit-level community-oriented activities, particularly driven by nursing department innovation, would assist in characterizing the construct by further defining key characteristics and establishing the prevalence of these activities. Next steps could include establishing the relationship between organizational-level and unit-level community-oriented activities and their potential synergistic impact on both hospital (eg, patient satisfaction and/or quality indicators) and community outcomes.

 

CONCLUSION

In our view, these exemplars demonstrate that the connection between a hospital and the surrounding community is as much a direct care nurse attribute as it is an organizational attribute. In our experience, unit-level connection to the community exerts positive outcomes for the benefit of caregivers and their patients both within and outside the hospital walls. Finally, we assert that hospital-based outcomes and community health are, in fact, best served by an integrated approach to community orientation. An integrated approach to community orientation would link the administrative-led, top-down, organizational-level approach with the nurse-led, bedside-up, unit-level approach for maximal impact on patient outcomes and community health in both the short and long term.

 

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