Translating nursing knowledge into practice: An uncommon partnership

Addressing complex issues 

As organizations evolve over time, their natural tendency is to become increasingly complex. In acute care settings, no clinical role is more complex or interwoven across the interdisciplinary team than nursing. A collaborative approach to dealing with complex problems of bringing evidence to the point of care for nurses is essential and we are committed to approaching complex nursing workflow issues together rather than independently. The complexity of undertaking this project across organizational boundaries is astounding. The ACW KBNI lessons learned, to date, include the need to: (1) continually clarify communication and language amongst partners; (2) seek the simplest and most elegant solutions despite the complexity of the problems addressed; and (3) undertake operational analyses of the impact of KBNI on clinical practice and operations, while simultaneously establishing research protocols and a data repository that includes standardized nursing data suitable for rigorous longitudinal research and scientific discovery.

Transcending organizational boundaries 

All ACW partners recognize that identifying, evaluating, and synthesizing nursing knowledge to embed it into the workflow of the clinical information system (executable knowledge) requires the expertise of nurse researchers, practitioners, informaticians, and technology experts3, 4 Each of our organizations brings a unique and vital perspective to this collaboration as well as an existing culture related to problem-solving and solutions. ACW KBNI collaborators provide the strengths of the organizations they represent. University of Wisconsin-Milwaukee (UWM) team members identify and monitor the rigor of evidence, synthesize it to actionable recommendations, and take the lead on the research agenda. The nurses at Aurora, who are the consumers of the technology, bring real world perspectives on the complexity of patient quality and safety issues related to clinical practice at the bedside. They incorporate EBNP into professional practice and training materials. The informaticians from Cerner work with the other partners to appropriately code data elements to standard terminology and leverage the technology of the clinical information system to deliver EBNP at the point of care. A joint research team works to validate and extract data for analysis both for operations and outcomes research. Collectively, the partners are leveraging the technology of a clinical information system to fill the gaps between practice and knowledge.

Effective communication is essential to help group members build trust and respect, foster learning, and help to better leverage our knowledge and expertise across teams. Spanning physical boundaries is also important since our organizations are located in different locations/states. Telecommunication tools play an important part in eliminating the boundaries of distance. The Internet is used for web conference meetings to share documents and presentations, allowing everyone to collaborate as if we are in the same room. Teleconferences of the Executive Group and a larger Operations Group are conducted weekly, and frequent emails assure daily one-on-one communications. A secure Internet site facilitates efficient shared access to minutes of meetings, project planning documents, and operational updates.

Promoting a culture of innovation 

Transformational change requires the ability to openly challenge the way organizations do business. We are creating a shared vision of transformational change and a sustainable culture of innovation that consistently challenges accepted practices and asks our team members to work outside their comfort zones. The ACW project intends to transform nursing practice, education, and research in the service of improved patient outcomes by embedding EBNP at the point of care and documenting nursing practice systematically to enable a program of research. Innovations will be measured by our ability to: (1) identify, synthesize, and make actionable nursing evidence defined by nursing phenomena of care; (2) educate staff nurses and managers to enhance the uptake of new workflows; (3) rapidly embed new evidence-based decision support and documentation into the work flow of nurses at the point of care; (4) populate a data repository and analyze data to improve the quality of care and outcomes; (5) conduct research; and (6) disseminate new knowledge.

Recognition of the prevailing culture within each partner/organization has been critical in establishing a culture of innovation and engagement. Measuring the innovation capability before each implementation serves as a baseline to enable monitoring and control. This process highlights areas of strengths and concerns and guides the organizations in planning appropriately for innovations in the future.

Driving innovation also requires more imaginative use of resources, including the skills and abilities of the innovators. Faced with the challenge of growing the teams into a standard development methodology while refining the process, we added a step into the methodology to collect feedback with multiple shareholders acting as reactor panels.

Shared governance 

Many of the changes often seemed disruptive and challenging in the short term. It has been critical to establish a viable structure for shared governance consistent with standards within each of the organizations. This structure consists of:

In summary, our success in transforming healthcare practice and research through this unique tripartite partnership will require that we constantly challenge each other to rethink how new knowledge is generated. The old rules no longer apply and we must be creative in our approaches to knowledge development and capture, as well as the development and testing of HIT solutions in the real world if we are to achieve success. We believe we are on the right track. Nurse satisfaction scores were evaluated pre- and post- KBNI implementation with a 34% improvement in overall nurse satisfaction with the EHR with no change in their perceived time spent in documentation. The ACW partnership has adopted the philosophy of successful NFL coach Tony Dungy who declares in his book, UNcommon, “We are learning how to win another way.”6 With recent focus on the American Recovery and Reinvestment Act of 2009, Academy members will benefit from the knowledge gained from partnerships between healthcare providers, HIT vendors, and academic institutions in planning strategic initiatives to transform practice and cut healthcare costs while improving patient outcomes.