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Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical practice Hannele Saunders

Aims and objectives. To describe quantitative and qualitative best evidence as sources for practical interventions usable in daily care delivery in order to integrate best evidence into clinical decision-making at local practice settings. To illustrate the development, implementation and evaluation of a pain management nursing care bundle based on a clinical practice guideline via a real-world clinical exemplar. Background. Successful implementation of evidence-based practice requires consistent integration of best evidence into daily clinical decision-making. Best evidence comprises high-quality knowledge summarised in systematic reviews and translated into guidelines. However, consistent integration of guidelines into care delivery remains challenging, partly due to guidelines not being in a usable form for daily practice or relevant for the local context. Design. A position paper with a clinical exemplar of a nurse-led, evidence-based quality improvement project to design, implement and evaluate a pain management care bundle translated from a national nursing guideline. Methods. A pragmatic approach to integrating guidelines into daily practice is presented. Best evidence from a national nursing guideline was translated into a pain management care bundle and integrated into daily practice in 15 medical-surgical (med-surg) units of nine hospitals of a large university hospital system in Finland. Conclusions. Translation of best evidence from guidelines into usable form as care bundles adapted to the local setting may increase implementation and uptake of guidelines and improve quality and consistency of care delivery. Relevance to clinical practice. A pragmatic approach to translating a nursing guideline into a pain management care bundle to incorporate best evidence into daily practice may help achieve more consistent and equitable integration of guidelines into care delivery, and better quality of pain management and patient outcomes. Key words: care bundle, clinical practice guidelines, evidence-based practice, implementation, knowledge translation, pain management, quality improvement

What does this paper contribute to the wider global clinical community?

• The paper presents a pragmatic

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approach to translating best evidence from high-quality CPGs into a more usable form in clinical practice that is feasible to implement in the local setting, to advance integration of EBP into daily care delivery. Care bundles are small sets of evidence-based, nursing-sensitive, core clinical interventions for a defined patient population and care setting that when implemented together at a high adherence, will result in significantly better outcomes than when implemented individually. Implementation and adoption of the Pain Management Nursing (PMN) care bundle may increase the consistency of evidence-based pain management interventions in daily practice, improve the structure and process of pain management care delivery, and result in higher care quality and better pain management outcomes.

Accepted for publication: 14 February 2015

Author: Hannele Saunders, MS, APRN-BC, CNS, Advanced Practice Registered Nurse, Helsinki University Central Hospital System, Helsinki and Early Stage Researcher and PhD Student, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Correspondence: Hannele Saunders, Early Stage Researcher and PhD Student, Department of Nursing Science, University of Eastern Finland,

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051, doi: 10.1111/jocn.12812

PO Box 1627, 70211 Kuopio, Finland. Telephone: +358 50 428 6868. E-mail: [email protected] Sources of support: Fellowship as an Early Stage Researcher for 2014–2016 at University of Eastern Finland, Faculty of Health Sciences, Department of Nursing Science.

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Introduction For over a decade, evidence-based improvement of care quality guided by clinical practice guidelines (CPGs) has been the focus of healthcare organisations worldwide. CPGs, also known as best practice guidelines (BPGs), are intended to offer concise, evidence-based instructions on how to deliver care suitable for clinical practice (Grol & Grimshaw 2003). Currently, a strong movement exists in healthcare organisations internationally to use CPGs to move best evidence into daily practice, increase standardisation of care practices and improve consistency of care delivery among frontline nurses and other clinical practitioners. The underlying assumption for this push is that care delivery based on best evidence occurs with the uptake of CPGs in daily practice (Harrison and Graham (2012). As part of a systematic approach to EBP implementation in clinical practice, the most important benefit of CPGs is their potential to improve care processes, quality of care and clinical outcomes (Grimshaw et al. 2006, Thomas et al. 2009). However, even though healthcare organisations have invested considerable resources into developing, implementing and adopting CPGs in daily care delivery, a chasm between what we know and what we actually do in the care of patients still exists regarding how to systematically move evidence into practice (Institute of Medicine 2001, Wallen et al. 2010, Matthew-Maich et al. 2013, Stevens 2013). Although CPGs represent a significant advance in translating best evidence into the form of practice recommendations to guide clinical decision-making at the point-of-care (Edwards et al. 2005), numerous studies show that there is still a lack of sufficient understanding on how to consistently and efficiently implement CPGs and foster their uptake into practice (Eccles et al. 2005, Grimshaw et al. 2006, Bick & Rycroft-Malone 2010). This is further complicated by the wide variation in the quality of the CPGs, depending on the methods by which the guidelines were developed, as well as the group or body which had developed them (Graham & Harrison 2005). Nevertheless, highquality CPGs from credible bodies such as the Agency for Health Care Research and Quality (AHRQ) and the Royal College of Nursing (RCN), and the development of many EBP models to guide their implementation, have facilitated the organisational push to use CPGs to improve the quality and consistency of care delivery both within and across settings (Harrison & Graham 2012). However, despite a wide recognition that high-quality evidence-based CPGs are excellent summaries and syntheses of best evidence on a clinical topic translated into a recom-

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mendation form, they are not consistently implemented in practice. This is in part because they frequently are not in a usable form for clinical practice, as CPGs often are too long, their language or structure is too complex (Korhonen et al. 2012), and they do not incorporate local evidence to be easily integrated into daily clinical decision-making (Harrison & Graham 2012). Consistent feedback from practising clinical nurses and nurse managers indicated that although most CPGs comprised a comprehensive summary of best evidence in a recommendation form, often at several pages long, they are far too lengthy to be either usable or feasible to be integrated into daily practice. In addition, as CPGs generally have not been adapted to the local practice setting, it is essential to consider how local factors affect their implementation to ensure the success of their integration into daily practice. For the uptake of EBP to take root in clinical practice, the summarised and synthesised best evidence needs to be translated and packaged into a concise and actionable form that has been adapted to the local context and more easily integrated into daily care delivery than most CPGs (Harrison & Graham 2012). This can be accomplished via further translating the CPGs into care bundles and lines of action (LOA), which are practical core interventions grounded in the local circumstances and thus relevant and more readily integrated into the local practice context. The purpose of this position paper was to describe a pragmatic approach for translating a national nursing CPG into a more usable format for clinical decision-making in the local context as a care bundle and successfully integrating it into daily practice. The aim was to use a real-world exemplar to illustrate the knowledge translation process from CPGs to care bundles by explaining how a pain management nursing (PMN) care bundle based on a national nursing CPG on postprocedural pain management of adult surgical patients was integrated into the daily practice of frontline nurses via a nurse-led, collaborative, evidencebased quality improvement project.

Background Many studies have highlighted the long-standing recognition that patients’ postprocedural pain is both prevalent and undertreated (Ger et al. 2004, Horner et al. 2005, Solman et al. 2005). Despite the existence of dedicated acute pain services and advancement of pain management modalities, including a wide range of analgesic medications routinely available in many hospitals, 20–30% of surgical patients continue to experience moderate to severe postprocedural pain (Dolin et al. 2002, MacLellan 2004, McGrath

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

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et al. 2004, Mhuircheartaigh et al. 2009). Inadequate management of postprocedural pain and wide variation in pain management practices have been identified as reasons why unacceptably high levels of postprocedural pain remain (McCaffery et al. 2000, Watt-Watson et al. 2001). High levels of unrelieved postprocedural pain are associated with an increased risk of physiological and psychological complications, such as hypertension, tachycardia, chest infections, pulmonary embolus, deep vein thrombosis, paralytic ileus, and delirium (MacLellan 2004, Steis & Fick 2008, Agency for Healthcare Research and Quality [AHRQ] 2010) as well as anxiety, fear, and unnecessary distress and suffering (MacIntyre & Ready 2002, Carr et al. 2005). Unrelieved postprocedural pain is the most common reason for delayed discharge and unexpected hospital readmissions after ambulatory surgery (McGrath et al. 2004), and is responsible for prolonged recovery and length of stay after inpatient surgery (United States Acute Pain Management Guideline Panel 1992, AHRQ 2010). In addition, high levels of unrelieved postprocedural pain have also been associated with an increased risk for chronic pain (Kehlet et al. 2006). Therefore, sufficient and timely treatment of postprocedural pain may be particularly important in improving patient outcomes, decreasing unplanned hospital readmissions, and reducing the potential for development of chronic pain. Effective treatment of postprocedural pain is often cited as an important indicator of the quality of care (Ferrell 2005, Gunningberg & Idvall 2007). Although postprocedural pain management requires an interdisciplinary team effort, most pain management interventions are implemented by nurses in daily practice. As studies have shown that pain assessment and management of postprocedural patients is suboptimal (Manias et al. 2005, Schoenwald & Clark 2006) and a wide variation in pain management nursing practices exists (Pasero & McCaffery 2011), integration of CPGs into daily nursing practice has been advocated as a solution for improving patients’ pain management outcomes and quality of care. However, as integration of CPGs into daily practice has proved to be a complex and challenging process, more recently, knowledge translation into care bundles has been used in some healthcare organisations to increase standardisation of care practices and improve consistency of care delivery among clinical nurses. This position paper reports on how a PMN care bundle was developed and implemented based on a national nursing CPG on postprocedural pain management of adult surgical patients (Finnish Nursing Research Foundation 2013) in the med-surg units of a large university hospital system in Finland. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

Best practice care bundles

Knowledge translation Knowledge translation (KT) is a process by which best available evidence from high-quality primary studies is transformed into rigorous evidence summaries and CPGs to facilitate integration of EBP into daily practice (Stevens 2004). KT literature seeks to explain the processes involved in CPG adoption, guide their consistent implementation and foster their uptake into clinical practice (Eccles et al. 2005, Grimshaw et al. 2006, Bick & Rycroft-Malone 2010). Common underlining assumptions in the KT process include: 1) healthcare delivery based on best evidence occurs with the translation of high-quality summarised evidence into CPGs and the implementation and adoption of CPGs in practice; and 2) when best evidence is embedded in a CPG, it will be fairly straightforward to move it into practice (Harrison & Graham 2012). In reality, however, translating evidence into clinical practice via the KT process is neither simple nor straightforward, but instead a complex, multifaceted, contextual and challenging process that is often poorly understood (Grimshaw et al. 2004, Rycroft-Malone 2007, Matthew-Maich et al.2013) and overwhelming for both the individual nurses and their healthcare organisations (Harrison & Graham 2012).

ACE Star Model of Knowledge Transformation In the last few years, many EBP models and frameworks have been published in the literature to guide integration of best evidence into clinical practice, some of which have been summarised by Ciliska and colleagues (Mazurek Melnyk & Fineout-Overholt 2010) and by Rycroft-Malone and Bucknell (2010). The ACE Star Model of Knowledge Transformationâ (Stevens 2004) focuses on how the successive steps of knowledge translation reduce the volume of the scientific literature while at the same time increasing the robustness and rigour of the evidence, and providing usable forms of evidence that can readily be integrated into clinical decision-making (Stevens 2013). Rather than requiring frontline nurses to possess the technical expertise needed in critical appraisal of scientific evidence from single primary research studies, the ACE Star model directs their efforts to be focused instead on accessing summarised best evidence that has already been translated into a relevant and usable form, and integrating it into daily clinical decision-making (Stevens 2013). Depicted as a simple five-point star, the ACE Star model illustrates the five sequential stages of knowledge transformation (Discovery, Summary, Translation, Integration and Evaluation), as newly discovered best

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evidence is translated from one form of knowledge to the next and moved into clinical practice (Fig. 1). The ACE Star model thus illustrates the levels of knowledge usability in clinical practice, i.e. evidence from single primary research studies, evidence summaries in the form of systematic reviews and best practice recommendations in CPGs, as the KT process sequentially progresses and best evidence is combined with other knowledge (e.g. a clinician’s expertise and a patient’s preferences and values in the local context), integrated into practice (i.e., practice is changed to reflect best evidence), and evaluated for impact through an evidence-based quality improvement process. In summary, the ACE Star model provides a practical roadmap for systematically implementing and integrating best evidence via KT and EBP processes into clinical practice. For these reasons, the ACE Star model was chosen to guide the translation of the national nursing CPG on postprocedural pain management of adult surgical patients into a PMN care bundle at the med-surg units of a large hospital system in Finland. The goal of knowledge translation is evidence-based quality improvement to raise the consistency and quality of care delivery. The importance of summarising and synthesising evidence into rigorous systematic reviews (Star point 2 of the ACE Star model) lies in linking best evidence and clinical decision-making (IOM 2008a,b). The implementation of EBP is then taken one step further by translating the summarised best evidence into more usable format as CPGs (Star point 3) guide the integration of evidence into practice. The significance of this evidence-based quality improvement process has been emphasised in several Institute of Medicine (IOM) reports and announcements (Institute of Medicine 2001, 2008a,b, 2011a,b,c, 2013). While bibliographic

databases have been available for over six decades for knowledge forms in Star point 1, resources for the evidence forms on Star points 2, 3, 4 and 5 have been developed only in the last few years. First published in a concise table format in an article by Stevens (2013), the forms of knowledge resources have been outlined in Table 1.

Aims The aim of this position paper was to describe quantitative and qualitative best evidence as sources for clinical interventions usable in daily practice and to illustrate the translation process of best evidence into care bundles and LOAs as a potential solution to the common problem of CPGs not being consistently adhered to in care delivery. In addition, the aim was to illustrate the design, implementation and evaluation of a PMN care bundle through a clinical exemplar of an evidence-based quality improvement project, which used the ACE Star Model of Knowledge Transformation (Stevens 2004) to guide the integration of EBP into daily practice. Lastly, the aim of the project was to explain the continuous evaluation process based on a quality measure developed from the PMN care bundle to appraise and monitor the consistency and completeness of the care bundle implementation into daily practice. The main clinical practice questions for the quality improvement project were: 1 What can be done to improve CPG compliance in clinical care delivery? 2 How can the usability in daily practice of the national nursing CPG on nursing care of short-term pain in adult patients after a surgical procedure (Finnish Nursing Research Foundation (HOTUS) 2013) be improved on the med-surg units of a large university hospital system? 3 How can the consistency of the implementation of the postprocedural pain management CPG be evaluated on the med-surg units on an ongoing basis?

Approach

Figure 1 ACE Star Model of Knowledge Transformationâ (Copyright Stevens 2004). Reproduced with explicit permission.

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This position paper describes a systematic approach to using quantitative and qualitative best evidence as sources for clinical interventions usable in daily practice and discusses the levels of knowledge usability in clinical practice. More specifically, this paper describes a pragmatic approach to implementing the EBP and KT processes to translate a national nursing CPG into a more usable format in clinical decision-making in the local practice setting, integrate it as a care bundle into daily practice, and evaluate adherence to it on an ongoing basis. This process is illustrated by a © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

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Best practice care bundles

Table 1 Resources for forms of knowledge in the ACE Star model (Stevens 2013). Reproduced with explicit permission Form of knowledge at star point Star Point 1 – Discovery Research Star Point 2 – Evidence Summary Star Point 3 – Translation into Guidelines Star Point 4 – Practice Integration Star Point 5 – Evaluation of Impact

Description of knowledge resources Bibliographic Databases (e.g. CINAHL) provide single research reports Databases of Systematic Reviews (e.g. Cochrane Collaboration Database of Systematic Reviews) provide reports of rigorous systematic reviews on clinical topics, http://www.cochrane.org/ Databases of Guidelines [e.g. National Guidelines Clearinghouse sponsored by the Agency for Healthcare Research and Quality (AHRQ)] provide online access to evidence-based clinical practice guidelines, http://www.guideline.gov Innovations Exchanges (e.g. Health Care Innovations Exchange sponsored by AHRQ) provide profiles of innovations and tools for improving care processes, http://innovations.ahrq.gov/ Databases of Quality Measures (e.g. National Quality Measures Clearinghouse sponsored by AHRQ) provide detailed information on quality measures and measure sets, http://qualitymeasures.ahrq.gov/

real-world quality improvement project to design, implement, and evaluate a PMN care bundle derived from a national nursing CPG on postprocedural pain management of adult surgical patients (Finnish Nursing Research Foundation (HOTUS) 2013). Thus, the nurse-led, evidence-based quality improvement project operationalises the KT process of quantitative best evidence from CPGs into care bundles, using the PMN care bundle as a clinical exemplar. The PMN care bundle was developed and integrated into the daily practice of clinical nurses working in 15 med-surg units of nine hospitals of a large university hospital system in Finland. A collaborative networking approach for the advancement of nursing practice at the hospital system was used to design and implement the quality improvement project. The development and implementation of the PMN care bundle was approved by the Nursing Leadership Council of the university hospital system, which did not require approval for this quality improvement project to be obtained from the hospital’s research ethics committee, as the project was not a research study but deemed to be quality improvement and evaluation of a nursing practice which did not require data collection from patients.

Levels of knowledge usability in practice The levels of knowledge usability in evidence-based clinical practice refer to the degree to which the best available knowledge is in a form that is usable for frontline nurses to be easily integrated into their daily clinical decision-making with patients (Saunders 2012). Usability refers to relevant, concise and actionable best evidence that has been critically appraised for methodological quality, summarised and synthesised into rigorous systematic reviews, translated into CPGs, and further translated into care bundles and LOAs to be more readily integrated into daily practice.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

Another important aspect of usability is the integration of local knowledge into the best evidence. Local knowledge includes evidence generated through local studies (e.g. local population needs assessments, local prevalence studies of the clinical problem and environmental assessments), internal evidence (e.g. patient assessment, outcomes management and quality improvement data) and information about local circumstances, i.e. the implementation context. Evaluation of the local circumstances (e.g. any local gaps or variations in practice related to the clinical issue of interest and the local care delivery model), and how they affect CPG implementation and adoption is essential, because it is seldom possible to directly adopt a CPG ‘as is’ in practice but instead, tailoring of the CPG to the local circumstances is necessary for effective integration (Harrison & Graham 2012, Singer & Vogus 2013). Systematically translating evidence into a usable form in clinical practice as care bundles and LOAs is illustrated in the levels of knowledge usability in Fig. 2. The key points from the CPGs are further synthesised into care bundles or LOAs, which help answer the clinical question or problem of interest by providing evidence-based core clinical interventions for addressing it. A central idea of interest to clinical practitioners in this position paper is to describe quantitative and qualitative evidence syntheses as sources for pragmatic clinical interventions usable in daily practice, using meta-analysis as an example of a systematic review of quantitative best evidence, and meta-aggregative meta-synthesis as an example of a systematic review of qualitative best evidence. Meta-analyses and meta-syntheses produce synthesised best evidence that complement each other and together, help understand the problem or issue of interest more comprehensively. Meta-analyses help answer the question ‘What works?’, while meta-syntheses help answer the question

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Clinical question or problem, to which an evidence-based answer is sought

Evidence summaries and syntheses: systematic reviews, meta-analyses, meta-syntheses

Best available evidence in recommendation form: evidence-based clinical practice guidelines (CPG, BPG)

Best evidence in more usable form for clinical practice in the local context: evidence-based care bundles and lines of action (LOA)

Integration, uptake & evaluation of evidence-based answer in clinical practice

Figure 2 Levels of knowledge usability in evidence-based clinical practice.

‘How or Why it works?’ When synthesised into a Systematic Mixed Studies Review ([SMSR] Polit & Tatano Beck 2012) which combines the strengths of quantitative and qualitative techniques and studies, they provide frontline nurses and other clinical practitioners the most comprehensive understanding of the clinical problem or issue of interest, answering the question ‘What works under which circumstances?’ (Borglin 2013). Because of the higher level, more comprehensive synthesis of evidence grounded in pragmatism, the SMSRs based on meta-aggregative meta-synthesis and quantitative systematic reviews (e.g. meta-analysis) may provide practical interventions based on best evidence ready to be implemented in clinical practice (Hannes & Lockwood 2011). Of particular interest to frontline nurses and other practitioners engaged in clinical decision-making is that they both produce synthesised statements (i.e. CPGs when based on quantitative best evidence) that directly support clinical practice (Hannes & Lockwood 2011). When the synthesised statements are further translated into concise and actionable form as care bundles and LOAs, they provide clinicians with practical interventions in a most relevant and usable form ready to be integrated into daily practice. The similarities and complementary qualities of these two types of evidence syntheses as sources of best evidence for clinical practice and how practical interventions for addressing the clinical issues of interest are produced through the KT process are illustrated in Fig. 3.

The care bundle approach Care bundles are small sets of evidence-based clinical interventions for a defined patient population and care setting that, when implemented collectively and consistently, will

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result in significantly better outcomes than when implemented individually (Resar et al. 2012, Clarkson 2013). Care bundles are not intended to comprise a comprehensive list of care interventions, but rather, consist of three to five core interventions to be implemented together to all patients. Care bundles were originally developed during quality improvement campaigns in medicine focused on critical care, due to a desire to improve the care and patient safety of the most vulnerable and sickest patients in hospitals through preventing serious adverse clinical outcomes (Institute for Healthcare Improvement (IHI) (2012a, b, c). In addition, care bundles are frequently used to measure CPG compliance with a core set of evidence-based, clinician-accepted interventions for a defined patient population derived from the CPG and adapted to the local care setting. Adherence to care bundles is measured by documentation of compliance with all core interventions of the care bundle, i.e. only when all care bundle interventions have been administered together to a patient, the care bundle is counted as complete. This type of ‘all or none’ measurement of compliance focuses attention to the importance of delivering all core interventions of the care bundle together to every patient of a defined population (unless medically contraindicated), which is the key to effective care quality and performance improvement efforts (Nolan & Berwick 2006). According to Resar et al. (2012), when adherence to the implementation of all core interventions is measured collectively, often inaccurate clinician assumptions about evidence-based care being reliably delivered to the patients are frequently changed. In addition, care bundles increase clinician awareness of the necessity for effective teamwork, communication, and collaboration to achieve high compliance and sustained performance (i.e. reliability and consistency of care delivery) to improve clinical outcomes. However, to significantly affect patient outcomes, it is essential that the compliance rate of the care bundle is targeted at least at 95% for all care bundle interventions (Resar et al. 2012), and to achieve high adherence requires continuous monitoring of compliance rates in bundle implementation, not only instituting care bundle policies (Furuya et al. 2011, Pogorzelska et al. 2011). Three key factors have been noted as crucial in previous studies for successful implementation of care bundles to ensure reliability and consistency of care delivery. First, all clinicians participating in the design, implementation and adaptation of the care bundle to the local setting need to achieve consensus that there is sufficient best evidence supporting each individual core clinical intervention in the care bundle. Second, the list of core interventions included in the care bundle needs to be short, i.e. only core clinical © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

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Best practice care bundles

QUALITATIVE PRIMARY RESEARCH STUDIES

QUANTITATIVE PRIMARY RESEARCH STUDIES

QUALITATIVE AND QUANTITATIVE EVIDENCE SUMMARIES AND SYNTHESES

e.g.,METAAGGREGATIVE METASYNTHESIS

SYNTHESIZED STATEMENTS

LINES OF ACTION

CARE BUNDLES

EVIDENCEBASED CPGS

e.g., METAANALYSIS

INTERVE INTERVENTIONS R NTIONS FOR CLINICAL PRACTICE PRA R CTICE

SUMMARIZED AND SYNTHESIZED EVIDENCE IS IN MOREUSABLE USABLEFORM FORMFOR FORCLINICAL CLINICAL INMORE PRACTICE IN THE LOCAL CONTEXT

‘How/whyititworks?’ works?’

Figure 3 Sources of quantitative and qualitative evidence for synthesis into practical interventions for clinical practice. (Copyright Saunders 2014).jocn

interventions based on rigorous evidence are included in the care bundle (Resar et al. 2012). Third, continuous monitoring of compliance of the care bundle used as a quality measure facilitates consistency and reliability in clinician practice (i.e. attainment of high adherence) and a culture of change necessary for achieving uniformity in the process of care (Nguyen et al. 2007).

The PMN care bundle In early 2012, the nursing leadership at a large Finnish university hospital system consisting of 23 hospitals, approximately 21,500 employees and 3300 hospital beds wanted to focus the nursing quality improvement efforts on the postoperative pain management of surgical patients. To emphasise the importance for improving the quality and consistency of pain management nursing practices and nursing-sensitive outcomes measurement, nursing management of postoperative pain was included as a focal area for practice development in the systemwide nursing implementation strategy. The primary reasons for the selection included (1) concerns about the inconsistency of EBP implementation and uptake at the hospital system, with small pockets of success alternating with large areas of practice where integrating EBP into daily patient care had not yet taken root or was at a very early stage of development; (2) concerns about substantial variations in outcomes and provision of nursing care related to postoperative pain management affecting large segments of patient populations from many clinical specialties, resulting in unequal treatment and care quality for patients; and (3) availability of high-quality national and international CPGs that could be implemented © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

META-AGGREGATIVE METASYNTHESIS AND META-ANALYSIS ARE SYNTHESIZED INTO SYSTEMATIC MIXED STUDIES REVIEW (SMSR) ‘What works under which circumstances?’

‘What works?’

INTERVENTIONS FOR CLINICAL PRACTICE

to improve the consistency and quality of care and clinical outcomes in this specific area of clinical nursing practice. Developing the CPG In early 2013, the Finnish Nursing Research Foundation (HOTUS) published a national nursing CPG on nursing care of short-term pain in adult patients after a surgical procedure, which had been developed as a research-practice-education collaborative effort by a consensus panel of nurses. The CPG was based on 191 primary research studies and systematic reviews on postprocedural pain management, which were appraised for quality of evidence by the panel. The CPG had been designed to follow the phases of the nursing process to increase its relevance and usability in clinical nursing practice, as most of pain management interventions are implemented by nurses in daily practice. With the publication of the nursing CPG, the nursing leadership at the university hospital system wanted to refocus their efforts at improving the quality and consistency of nurses’ postprocedural pain management practices through the implementation and adoption of the CPG in daily care delivery. The aim was to achieve standardised nursing practices for postprocedural pain management and more equal treatment of postprocedural pain for surgical patients. However, despite the best efforts of the nursing leadership, during 2013 it became evident that the integration of the nursing CPG into daily practice had not taken place at the hospital system. Forming the workgroup To develop a new systematic strategy for the implementation and adoption of the national CPG into daily nursing practice, the Clinical Nurse Specialists (CNS) at the Surgery

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Division collaborated to establish a workgroup with the Acute Pain Service (APS) nurses at the hospital system. The workgroup collaborated with the nursing leadership and clinical nurses to devise a specific plan for improving the consistency of implementation and uptake of the CPG. As the structure of the CPG followed the nursing process, it was conducive to integration in clinical practice, which assisted nurses in incorporating it with their clinical decision-making. However, based on the feedback from clinical nurses and nurse managers that at 21 pages long (excluding references), the CPG was far too lengthy to be usable in daily practice at the med-surg units, and also needed to be adapted to the local practice setting prior to implementation, the workgroup deemed it necessary to find a more concise format for the CPG to be integrated into daily practice. Developing the PMN care bundle and audit tool In the spring of 2013, one of the Surgical Division CNSs who had worked at Magnet-designated hospitals in the USA explained about the successful implementation of the care bundles in some Magnet hospitals. The CNS had assessed the quality of the national nursing CPG on postprocedural pain management using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system (Guyatt et al. 2008). Based on the appraisal, the CNS proposed using the care bundle approach to improve the implementation and uptake of the CPG and using the ACE Model of Knowledge Transformation to guide the development and integration of the care bundle into daily nursing practice. In early fall 2013, the workgroup began development of the PMN care bundle by reviewing the nursing CPG and other relevant literature, and sought approval for the practice development plan from the nursing leadership of the hospital system. The aim of the workgroup was to translate the evidence-based recommendations in the nursing CPG into a usable form as a PMN care bundle that was practical, actionable and feasible to implement in daily practice at the med-surg units. The goal was to translate the CPG into five or six evidence-based core nursing interventions on postprocedural pain management that were easily integrated into daily patient care and adapted to the local practice setting. In addition, to facilitate the consistent documentation and evaluation of the implementation of the PMN care bundle, integration into the electronic health record (EHR) of the hospital system as a quality measure was necessary so that it could be used as an electronic audit tool. To accomplish this, the CNS specialising in nursing informatics collaborated with the IT specialists at the health informatics department of the hospital system.

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Pilot testing the PMN care bundle After a draft PMN care bundle based on the CPG had been developed in late 2013, the workgroup sought feedback from frontline and APS nurses, nurse managers and leaders, and APS doctors. While some frontline nurses were at first concerned about the implementation of the care bundle increasing their workload, other nurses noted that the PMN care bundle had the potential of empowering the surgical patients to take more responsibility of their own pain management, promoting their active participation in shared care decisions and collaboration with nurses, and increasing the patients’ satisfaction with their pain management. After incorporating the nurses’ feedback, the care bundle was pretested in the med-surg units of one hospital. Additional revisions were made to the care bundle based on the pretest, after which the care bundle was finalised and piloted in the med-surg units of two hospitals. The nurses who participated in the pilot noted in their feedback that after the initial learning process on the care bundle, using the PMN care bundle actually made pain management interventions more straightforward to implement and faster to document in the EHR. After final feedback on the usability of the PMN care bundle was obtained from clinical nurses and nurse managers, official endorsement for the care bundle was obtained from the Nursing Leadership Council of the hospital system in the early spring of 2014. Education and training Prior to implementation of the PMN care bundle at the med-surg units of the hospital system, the Surgical Division CNSs in the workgroup collaborated with the APS nurses and other CNSs through the CNS network at the hospital system to disseminate the care bundle by holding numerous clinical nursing meetings, in-services and clinical education sessions throughout all the med-surg units. In addition, the APS nurses served as ‘superusers’, i.e. clinical support for the frontline nurses’ implementation and adoption of the care bundle on the med-surg units. Implementation of the PMN care bundle The implementation of the PMN care bundle began on 15 med-surg units in nine hospitals of the hospital system in the late spring of 2014. The med-surg units included patient care units specialising in orthopaedic surgery, trauma surgery, neurosurgery, EENT surgery, ob-gyn surgery, vascular surgery, urologic surgery and emergent surgery patients of different specialties. To date, 516 adult surgical patients have been ‘bundled’, and preliminary results reported by 15 APS nurses indicate that the PMN care bundle may help improve both the structure and process of pain management © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

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care delivery. Anticipated longer term benefits of the care bundle also include improved utilization of existing pain services for the benefit of surgical patients and reduction in delayed discharges from med-surg units due to problems with pain management. Based on the early results, implementation of the PMN care bundle is scheduled to be expanded from the Surgery Division to other areas of patient care in the hospital system in the near future. Ongoing outcomes measurement and evaluation The ongoing monthly evaluations of the consistency of the PMN care bundle implementation and documentation are part of the continuous quality monitoring process, and also aid in adopting and sustaining the practice change in the longer term. The monthly evaluations are carried out by the APS nurses via the electronic clinical audit tool, which was formulated from the care bundle into a quality measure in the EHR. The electronic audit tool consists of the core interventions in the care bundle, to which a simple Yes/No answer is documented by the APS nurse, who evaluates the results of the care bundle based on whether all core interventions were implemented together for the patient being assessed. The workgroup continues to meet regularly to review the monthly clinical audit data, to evaluate adherence to the PMN care bundle, to launch further initiatives related to the implementation of the care bundle as gaps in practice are detected, to revise and update the content of the care bundle as necessary, and to disseminate the monthly care bundle results to the clinical nurses, nurse managers and leaders in the hospital system. To facilitate transparency and benchmarking of the quality improvement efforts and further adoption of the care bundle, the monthly care bundle results from each med-surg unit are also being published in the electronic journal of the hospital system. The PMN

Best practice care bundles

care bundle based on the national nursing CPG on nursing care of short-term pain in adult patients after a surgical procedure is presented in Table 2.

Lines of action As many problems or issues of interest for clinical practice cannot be captured by using quantitative study designs alone, systematic reviews of qualitative evidence are an important source of pragmatic interventions for clinical practice which complement quantitative reviews. Systematic reviews of quantitative evidence (including meta-analyses) provide information on whether an intervention or treatment method is effective, while systematic reviews of qualitative evidence help understand and explain the phenomena of interest more comprehensively (Pearson et al. 2005, Walsh & Downe 2005). This position paper uses meta-aggregation as an example of one approach to conducting systematic reviews of primary studies using qualitative study designs (i.e. meta-syntheses) that synthesise and summarise qualitative best evidence into synthesised statements, which are further translated into LOAs. LOAs are practical interventions derived from synthesised statements and produced as a result of the process of meta-aggregation, which is a method of synthesising qualitative primary study findings into a qualitative evidence summary (Hannes & Lockwood 2011). The LOAs are in effect practical interventions based on best evidence to be implemented in clinical practice, and therefore of interest for clinical nurses and other practitioners. Because LOAs provide practical interventions for clinicians based on best qualitative evidence, they are analogous with care bundles, which also provide practical clinical interventions translated and synthesised from CPGs, which in turn are based on systematic reviews of quantitative primary studies. When conducted on the same clinical

Table 2 Pain management nursing (PMN) care bundle PMN care bundle based on the national nursing clinical practice guideline on nursing care of short-term pain in adult patients after a surgical procedure (Finnish Nursing Research Foundation (HOTUS) 2013) Give patient education on the causes of pain, pain assessment with a pain scale and the possible side-effects of pain Select the pain scale to be used in collaboration with the patient (NRS, VAS or VRS) Ask for patient’s own assessment of pain intensity using the pain scale selected in collaboration with the patient, assessing pain at rest and at movement at least once in eight hours Assess the location, nature and timeliness* of the patient’s pain Treat the patient’s pain, when NRS > 3 (on a scale of 0–10), VAS > 30 (on a scale of 0–100 mm) or VRS > 1 (on a scale of 0–4) Ask for the patient’s own assessment of pain intensity using the pain scale selected in collaboration with the patient after each intervention for pain management NRS, Numeric Rating Scale; VAS, Visual Analogue Scale; VRS, Verbal Rating Scale. *Timeliness refers to the following aspects of pain: Is the pain continuous/discrete, regular/irregular, repetitious (frequency) and when does it usually appear?

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problem or issue of interest for clinicians, the practical core interventions in care bundles and LOAs complement each other and together provide more comprehensive answers and practical actions to address the clinical problem or issue of interest. To illustrate the practical clinical interventions based on qualitative best evidence, the nature of which is analogous to the practical clinical interventions provided by care bundles (which are based on quantitative evidence), an example of the synthesised statements and LOAs based on qualitative primary studies on young people’s experience of chronic illness conducted by Venning et al. (2008) is presented in Table 3. In the example, the LOAs derived from the synthesised statements inform clinicians to consider using in their practice evidence-based, practical interventions related to the promotion of health and prevention of potential mental health issues in the treatment of young people with chronic illnesses.

Discussion Similarly to most of the rigorous research conducted on CPG implementation which have been studies in the field of medicine (Davies et al. 2008, Thompson et al. 2008), the reports published to date on care bundle implementation in clinical practice have predominantly been in the field of medicine. However, many of the recent clinical applications of care bundles to practice have involved nursing-sensitive measures, i.e. measures that are strongly influenced by the care interventions that nurses provide (Montalvo 2007),

such as hospital-acquired pressure ulcer prevention, as well as care for ventilator-associated pneumonia (VAP) and central line-associated bloodstream infections (CLABSI). The Central line (CL) care bundle has been successfully implemented in clinical practice and shown in several large studies to be effective in significantly decreasing the mean CLABSI rates per 1000 catheter-days (Pronovost et al. 2006, Render et al. 2011), although Furuya et al. (2011) found that the CL bundle was associated with decreased CLABSI rates only when compliance is high. Similarly to the results of Furuya et al. (2011), in a large study focusing on the implementation, adoption and effectiveness of the Ventilator bundle on VAP rates, Pogorzelska et al. (2011) found that only when an ICU had a VAP prevention policy, monitored compliance and achieved high compliance, were lower VAP rates achieved. Although some concerns have been expressed in the literature related to the quality of the evidence supporting each individual intervention in the Ventilator bundle and their relative importance, and to the variance between the definitions used for surveillance and clinical diagnosis (Morris et al. 2011, Munroe & Ruggiero 2014), the Ventilator bundle has been widely adopted in many critical care units and has become a central component of ICU patient safety programmes at hospitals and healthcare systems internationally. Until lately, the focus of care bundle design and implementation has thus been on critical care, due to a desire to improve the care and patient safety of the most vulnerable and sickest patients in hospitals. Other recent examples of

Table 3 An example of synthesised statements and lines of action based on a meta-aggregative meta-synthesis (i.e. a synthesis of qualitative best evidence) on young people’s experiences of chronic illness conducted by Venning et al. (2008) Synthesised statements (n = 5) 1. 2. 3. 4. 5.

The experience of chronic illness made a young person feel uncomfortable in their body and world The experience of chronic illness disrupts ‘normal’ life The experience of chronic illness is not all bad Ways of getting through the experience: ‘What others can do’ Ways of getting through the experience: ‘What I can do’

Lines of action (n = 5) 1. Bolster young people’s sense of self to reduce the perceived differences and provide the cognitive strategies needed to move beyond the symptoms and deal with any associated changes 2. Normalise the experiences of chronic illness and provide young people with the cognitive strategies needed to deal with the restrictive, unwanted and uncertain impact that chronic illness has on their life 3. Understand, acknowledge and foster the positive impact that the experience of chronic illness has on young people 4. Provide a young person with information and knowledge about their chronic illness and facilitate the development of supportive relationships 5. Help a young person to come to terms with the situation and promote the development of their positive and future-oriented coping strategies to deal with the experiences

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the emphasis of care bundle development on treating and preventing the most serious clinical outcomes are the Pain, Agitation and Delirium (PAD) care bundle (Barr & Pandharipande 2013), the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ADCDE) care bundle (Balas et al. 2013), and the two severe sepsis care bundles: the Sepsis Resuscitation bundle and the Sepsis Management bundle (Levy et al. 2010). Studies have shown that the completion and correct application of the severe sepsis bundles have significantly decreased in-hospital mortality rates and also reduced patients’ length of stay in the ICU (Nguyen et al. 2007, Zambon et al. 2008). More recently, nursing-sensitive care bundles have also been developed and implemented in other clinical care environments than critical care (e.g. med-surg units), with positive outcomes in daily patient care. Examples of such care bundles include the Pressure Ulcer Prevention care bundle (Baldelli & Paciella 2008), the Patient-Participatory Pressure Ulcer Prevention Care Bundle (Gillespie et al. 2014) and the Chronic Obstructive Pulmonary Disease (COPD) Discharge Care Bundle (Hopkinson et al. 2012). The PMN care bundle was also developed for implementation in the med-surg units of a large hospital system, as med-surg nurses are the group of healthcare professionals who take care of most of the hospitalised surgical patients who require postprocedural pain management interventions for the majority of their hospital stay. The additional benefits of the PMN care bundle included the fact that it was derived from a national nursing CPG which was based on the nursing process to increase its usability and relevance to nursing practice and to facilitate its easy integration into daily care. Another benefit of the care bundle was its further development into an electronic audit tool, which has been used on a monthly basis to monitor nurses’ adherence to the pain management core interventions contained in care bundle, thereby contributing to improving the quality and consistency of pain management care delivery to postprocedural surgical patients. In summary, the benefits of care bundles include their succinct format, i.e. best evidence contained in the CPG synthesised into three to five core interventions and adapted to the local practice environment. The succinct format of care bundles and their adaptation into the local context are regarded as contributing to a more usable and practical form of best evidence by many clinicians and thus facilitate its integration into daily practice. This in turn helps improve adherence to CPGs and thus improve the quality, consistency, efficiency and equality of care delivery which has been demonstrated © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

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in a growing body of literature since the early 2000s. Table 4 provides an overview of recent studies on care bundles supporting this claim, focusing on the improved outcomes.

Conclusion This position paper provided a clinical exemplar of the development, implementation and adoption of a PMN care bundle in daily practice, based on a national nursing CPG on postprocedural pain management of adult surgical patients in the med-surg units of a large university hospital system in Finland. The exemplar described an evidencebased quality improvement project, during which CNSs, APS nurses, nurse leaders and APS physicians collaborated at the point-of-care to develop and integrate the PMN care bundle into daily practice. Early results indicate that the PMN care bundle may improve communication and teamwork between practitioners, increase standardisation of pain management practices in the med-surg units, raise quality of nursing documentation of pain management interventions, improve patient satisfaction with postprocedural pain management, increase adherence to the recommendations of the CPG, advance measurement and monitoring of pain management practices, and improve quality, consistency, and equality of pain management care delivery to patients. These positive results may in turn help with nurses’ acceptance and further adoption of the care bundle in daily practice, and help sustain the practice change in the future. More research into the usability of CPGs in clinical practice is needed, i.e. which form of best evidence would be most relevant, usable and readily integrated into daily care delivery in the local setting. This has been rarely explored in the nursing literature to date. In addition, further investigation is needed to study CPG translation into care bundles in clinical nursing practice, as most of the rigorous research published in the literature to date has been in the field of medicine. More research is thus needed on nurse-driven, patient-participatory care bundles, including critical evaluations of their effectiveness, as nurses not only represent the largest number of clinical professionals, but the nature of their practice also differs from medicine in many major aspects, such as their role, autonomy and emphasis of care interventions (i.e. whole-person v. curative care). Nurses play a central role in daily practice as a patient advocate and an interdisciplinary communication link, coordinating the patient care activities of different specialities and keeping everyone abreast of the advancing clinical goals for the patient. Nurses’ clinical assessments of the patient’s

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Care bundle The Pain, Agitation and Delirium (PAD) care bundle

The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ADCDE) care bundle

The COPD Discharge care bundle

The Pressure Ulcer Prevention (PUP) care bundle The Patient-Participatory Pressure Ulcer Prevention (PUP) care bundle

The Ventilator care bundle

Author

Barr and Pandharipande (2013) USA

Balas et al. (2013) USA

Hopkinson et al. (2012) UK

Baldelli and Paciella (2008) USA

Gillespie et al. (2014) Australia

Pogorzelska et al. (2011) USA

Table 4 Selected care bundle studies from 2008–2013

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All adult inpatients in ICU and med-surg units of one university medical centre in the USA Adult hospitalised patients in two med-surg units of one public regional hospital in Australia

All hospitalised patients with COPD exacerbation in one hospital in the UK

Critical care units in one academic medical centre

Critical care units

Patients/Setting

Decrease VAP rates and increase compliance with Ventilator Bundle

Promote patient participation in pressure ulcer prevention

Decrease pressure ulcer rates below national levels

Improve quality of care and patient experience, minimise risk of rehospitalisation

Identify facilitators and barriers to ABCDE bundle adoption, evaluate effectiveness of bundle implementation

Provide a roadmap for clinicians to manage PAD in ICU patients

Aims

415 ICUs

PU prevalence and incidence in all adult inpatients monthly and annually 58 of 112 patients (51
7%) used the PUP intervention, 11 of 58 (19%) participated in qualitative interview

94 patients in the respiratory unit

ICU team members in five ICUs, one stepdown unit and one special care unit

N/A

Sample

Outcomes on the individual interventions available from several studies, but the impact of implementing all the PAD care bundle interventions together is yet to be measured Implementation would benefit from prospectively addressing elements of intervention, inner and outer setting, individuals involved and process of implementation via intense and sustained education, coordination and collaboration Significant improvements with compliance of four of five care bundle interventions, downward trend in readmissions Med-surg PU prevalence and ICU PU incidence rates decreased below national averages PUP care bundle was wellreceived by participants, but patients’ perceived risk of acquiring a PU and short HLOS contributed to low participation rate Only when an ICU had a VAP prevention policy, monitored compliance, and achieved high compliance, were VAP rates lower

Outcomes

H Saunders

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2035–2051 The Central Line (CL) care bundle The Central Line (CL) care bundle

The severe sepsis care bundles: Sepsis Resuscitation bundle, Sepsis Management bundle

Furuya et al. (2011) USA

Render et al. (2011) USA

Levy et al. (2010) USA ED, critical care and other units in the USA, Europe and South America

Critical care units in 123 Veterans Administration (VA) hospitals

Critical care units in 250 USA hospitals

Patients/Setting

Determine compliance with care bundle targets, association with hospital mortality

Decrease CLABSI rates, increase compliance with the CL care bundle Decrease CLABSI rates

Aims

Care bundle decreased CLABSI rates only when compliance was high CLABSI rates fell significantly (3
8–1
8/ 1000 line days), CL bundle adherence and CLABSI rates showed strong correlation (r = 0
81) Compliance with resuscitation bundle increased from 10
9– 31
3% and with management bundle increased from 18
4– 36
1% in two years, unadjusted hospital mortality decreased from 37–30
8% in two years

250 hospitals (out of 441 eligible, response rate of 57%) 174 ICUs

15,022 subjects at 165 sites

Outcomes

Sample

ICU, Intensive Care Unit, ED, Emergency Department; med-surg, medical-surgical patient care units; HLOS, hospital length of stay; VAP, Ventilator-associated pneumonia; CLABSI, Central line-associated bloodstream infections; CL, Central line; LOS, length of stay.

Care bundle

Author

Table 4 (continued)

Discursive Paper Best practice care bundles

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progress form the basis for decisions to advance patient’s care to subsequent steps of the care bundles, and most of the clinical interventions contained in the care bundles are implemented in practice by nurses. Nurses are also uniquely positioned for leadership roles required for adapting care bundles to the local context, as nurses possess practical knowledge and insights about local care processes, support structures, available resources and training required for care bundle implementation. As many studies have demonstrated that nursing care clearly impacts patient outcomes, aiming to help nurses consistently use clinical interventions based on best practices is essential to advance excellence in nursing care delivery. Further, as achieving high adherence to all clinical interventions contained in care bundles is essential for achieving an impact on patient outcomes, additional research is needed on innovative, effective, nurse-driven strategies for increasing nurses’ compliance on implementing care bundles in daily practice. Finally, it is important to keep in mind that a care bundle itself does not improve reliability of care and clinical outcomes, but rather, improvement is the result of a well-led, coordinated approach to care delivery, including systematic strategies consistently implemented by all clinicians to redesign, adapt and implement care processes in the local setting, communicate better, and collaborate more effectively as a team.

Relevance for clinical practice Several issues were identified in this position paper that are of relevance to frontline nurses and other clinical practitioners. First, the levels of knowledge usability in clinical practice outlined in this article provide a summary of the forms of best evidence related to their usability in clinical practice, which may help further EBP integration efforts into daily care delivery. Second, this article describes quantitative and qualitative best evidence as sources for pragmatic clinical interventions that are usable and actionable in daily practice, which may help utilization of research-based interventions in daily care delivery. Lastly, the real-world clinical exemplar of an evidence-based quality improvement project to illustrate the translation of best evidence from a nursing CPG into a PMN care bundle may advance the development, implementation and evaluation of new, more pragmatic strategies, based on the needs of clinical practitioners and realities of daily care delivery, for successful integration of EBP into daily practice.

Contributions HS was responsible for the study design, data analysis and manuscript preparation of this paper.

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