Evidence-Based Practice Model

Evidence-Based Practice Model

Section A: Organizational Culture and Readiness Assessment

The Institute of Medicine (IOM) identifies evidence-based practice (EBP) as a core competency for all healthcare providers and a central part of clinical nursing practice, involving the use of the best evidence available in decision making and problem-solving related to patient care. Implementing EBP is regarded highly because of the higher inspection and tighter rules on patient outcomes. This proposal aims to implement EBP in an organization by evaluating its organizational culture and its willingness to adopt EBP.

EBP plays a crucial role in the organization’s mission and philosophy, although the level to which the organization is implementing the practice is unsatisfactory. Areas for improvement exist since, besides the management’s commitment to the adoption of EBP in planning and support, minimal commitment is evident from nurses and physicians. Possible barriers to implementation include the negative impact of organizational changes, which usually consists of restructuring and service decentralization (Mathieson et al., 2019). The difference absorbs staff energy and time, distracting them from implementing EBP practices. However, the implementation process is facilitated by practical issues like cost-effectiveness, saving clinical time, and ease of use.

Organizational Culture and Readiness for System-Wide Integration of Evidence-Based Practice (OCRSIEP) is an ideal survey tool for corporate culture. The OCRSIEP scale is a 25-item scale measuring the level to which cultural factors affect the system-wide adoption of EBP and the general apparent readiness to incorporate EBP relative to six months earlier (Yoo et al., 2019). From the results of the OCRSIEP assessment, the organization is willing to engage in EBP. Nurses have the dedication to drive EBP while physicians have a passion for encouraging other clinical staff members to implement EBP. Essential factors that influenced the perception of readiness included whether EBP was crucial to the organizational mission and philosophy and practiced in the institution, the commitment of nursing and physician staff to EBP, and practitioners’ use of EBP in the clinical setting. Integrating clinical inquiry into the organization can be achieved by building interdisciplinary links in the clinical setting, creating rapport and credibility, and developing a continuous, reliable system to promote EBP practice.

Section B: Proposal/Problem Statement and Literature Review

There is robust evidence supporting the practice of skin-to-skin contact (SSC), which points to several benefits for both the infant and the mother. A Cochrane Review of 2016 promotes using instant or early SSC to encourage breastfeeding (Cadwell et al., 2018). The review shows that mothers that had SSC were very likely to be breastfeeding for one to four months after birth, showed longer breastfeeding, or breastfed exclusively after hospital discharge until six months after birth. Besides, the babies who received SSC showed increased stability of the cardio-respiratory system and higher blood glucose levels. The research aimed to determine how skin-to-skin contact in newborns, as opposed to no skin-to-skin connection, delivered positive mother-infant health outcomes, as shown by the commencement of breastfeeding within the first hour of life and its sustainment for six months.

The literature review focused on all randomized, controlled experiments where active encouragement of early SSC between mothers and healthy infants was contrasted against regular hospital care. Study subjects included mothers and their healthy full-term or late-preterm newborn babies, meaning those with around 34 to a maximum of 36 completed gestation weeks, with early SSC, meaning under 24 hours after delivery, and control undergoing usual care patterns. The study method involved the search of several databases: Medline, CINAHL, PubMed, ProQuest, and Cochrane Library, using the key phrases, “skin to skin contact,” “maternal-infant contact,” “breastfeeding initiation,” or “maternal newborn contact.”

Evidence from the literature showed that immediate SSC offers early colonization of the infant’s microbiome outside of a mother. The microbial colonization of the newborn starts before birth and persists through the birth canal. Therefore, this explains the reason why newborns should not be washed during this period. Colonization following surgical delivery does not match the vaginal one, and skin-to-skin contact plays an additional significance in these instances. As the first hour progresses, the first taste of colostrum will offer crucial nourishment to the baby’s growing gut microbiota that has been implicated in gene expression (Widstom et al., 2019). Moreover, studies in epigenetics underscore the value of an optimal microbiome promoted by breastfeeding. This has been connected to long-term health, including reduced obesity and metabolic diseases.

The analysis further showed positive infant-maternal health outcomes in SSC, coupled with vaginal deliveries. In one longitudinal survey, researchers found that a mother’s breast temperature rises when the mother and the newborn are in skin-to-skin interaction, leading to an increase in the infant’s foot temperature (Safari et al., 2018). A warmer foot temperature is a sign of the reduced adverse effects of the stress of being born. Mothers who hold their newborns immediately after birth, offering them skin-to-skin contact, show minimal coarseness when latching and motivating them to breastfeed during the fourth day of postpartum. Moreover, skin-to-skin contact was associated with mother-newborn affinity a year later. After birth, skin-to-skin contact positively influenced the babies’ self-regulation, which is part of the self-control concept.

The findings of this literature review should be looked at with a critical eye because of its limitations. Although the report identified several studies, a majority were not designed to evaluate the frequency of SSC and were not founded on national samples. Study generalizability is also restricted by the idea that most researches were based on a small sample and were not descriptive of the broader population. Moreover, minimal study existed on exclusive breastfeeding, and little assessment was done on the breastfeeding period. Other significant limitations could be the absence of a standard definition of skin-to-skin contact and the heterogeneity of research design.

Skin-to-skin contact (SCC) between the mother and the infant right after birth offers several advantages to both the individuals, including better bonding between the mother and newborn, as well as the increase in the breastfeeding duration. Unfortunately, though, the implementation of the SSC practice at birth has not yet been optimized in the organization. There is, however, no doubt that when integrated into the standard infant care, SSC has the potential to improve several primary maternal-newborn healthcare and nursing outcomes (Sanchez-Espino et al., 2019). The objective is thus to implement SSC as a routine evidence-based practice in the labour and delivery unit for healthy infants delivered vaginally.

Section C: Solution Description

SSC is a procedure affecting the child and the mother; therefore, before initiating the SSC procedure, every mother would be given written guidelines on the advantages of SSC to help her understand the importance of the procedure and to seek her consent. With a mother’s approval, the infant will be put on a warm blanket on a mother’s belly and will be allowed to rest until the cord is clamped and cut, after which the blanket will be removed, and the baby placed on the mother’s chest. A cap and a diaper will then be placed over the baby, and both the baby and the mother will be covered with a warm blanket. The early infant assessments, as well as the assigning of Apgar Scores, and putting on the ID bands can be done while the baby undergoes the SSC procedure with the mother (Moore et al., 2016). Throughout this protocol, the nurses will assist the mother on the proper positioning for breastfeeding, although the infant will be allowed to move instinctively towards the breast. In the current labour setting, the implementation of this intervention is viable since the clinical nurses specialize in the labour procedure, and the delivery units are well-equipped to handle the change. That being said, there may still be a need for the early education of all pregnant women experiencing healthy pregnancies, particularly at the start of week 36 of the gestation period.

The implementation of this intervention aligns with the organization’s commitment to applying the evidence-based practice (EBP). Aligning with the organizational culture and readiness assessment, nurses in the organization are keen to make use of EBP. The physicians also understand the importance of EBP and thus seek to inspire other clinical personnel to adopt the practice. Generally, healthcare professionals realize that EBP is core to the mission and philosophy of the organization.

The implementation of EBP in the organizational setting is intended to accomplish several outcomes. For instance, the intervention is expected to improve the rate of breastfeeding initiation in infants by over 75 percent in the first hour of birth. This improved rate also fulfills the recommended Healthy People goal of 2020 (Kremer & Kremer, 2018). Besides, the intervention is intended to achieve the purpose of providing exclusive breastfeeding during the discharge period, which may last up to six months. It may also improve the maternal levels of satisfaction, and help gather significant staff acceptance of SSC in clinical practice.

The intended outcomes can be attained through a systematic procedure entailing several steps that will be followed to facilitate a smooth and successful implementation of SSC.

• Nursing personnel to attend a brainstorming session to identify the strengths, prospects, weaknesses, and threats to the proposed solution
• The feedback is reviewed, as well as the recurrent themes noted
• An implementation task force or project team formed
• The task force is required to create a piloting plan
• This pilot plan is evaluated to decide whether it is ready for the full implementation
• Efforts will be made to adopt unit-wide changes that would promote SSC.

To achieve the above outcomes, some barriers must also be overcome. For instance, creating the task force may cause some scheduling problems during meetings since the team will consist of individuals from across the organization. Moreover, since the intervention is voluntary, only a few pregnant women are expected to participate in the exercise. Besides, it is not guaranteed that all labour and delivery unit nurses, physicians, and other clinical practitioners will wholeheartedly participate in the process; therefore, a motivation strategy needs to be worked on to encourage the full participation of all the professionals.

Analyzing the viability and the overall effectiveness of the intervention, it can be safely stated that evidence-based practice provides nurses with certain incentives to implement practices to boost patient health and experiences. Incorporating SSC in routine infant care can improve maternal-child health outcomes and the quality of maternal care in general. Adopting early SSC can help nurses to assist in the improvement of maternal and newborn health, as well as to attain patient-centred quality care; however, several barriers need to be overcome before the benefits of the exercise can be completely realized.

Section D: Change Model

The decision-making process in health care has changed radically, with nurses expected to make judgments based on the best existing evidence and continuously to review them as novel evidence emerges. Evidence-based practice involves using reliable, explicit, and thoughtful data to make decisions on the care of individual patients. Implementing a skin-to-skin contact (SSC) practice in the health care organization requires the best evidence-based practice model to achieve the intended results. In this EBP proposal, the Iowa Model of evidence-practice will be applied to improve care quality.

The Iowa Model of EBP focuses on the organization and collaboration, integrating the conduct and application of research, accompanied by other forms of evidence. The model was introduced in 1994, and it has found regular mention in numerous nursing periodicals and applications in clinical research programs (Buckwalter et al., 2017). Through the seven steps listed below, the model enables nurses to improve patient outcomes, promote the nursing practice, and examine healthcare costs.

Stages of the Change Model

Step 1: Topic/Trigger

A topic trigger for EBP is selected after several considerations, such as the scale and urgency of the health concern, availability of evidence and data in the identified issue area, staff’s commitment to EBP, and the complex nature of the problem. The topic can also be chosen by its contribution to the improvement of health care and the overall implication to the area of practice. The trigger for the current EBP proposal is improving staff understanding and attitude of care associated with skin-to-skin contact in vaginal deliveries.

Step 2: Forming the Team

The team will be in charge of development, implementation, and assessment. It should represent all interested stakeholders. The team for this change proposal will consist of doctoral nurse research consultants, clinical nurse specialists (CNSs), and staff nurses involved with EBP, who have decided to act as advisors and consultants to the rest of the staff.

Step 3: Retrieving Evidence

During evidence retrieval, the team brainstorms to find the resources and set the terminologies that will guide the evidence search. According to the Iowa Model, health care professionals should discuss research to understand scientific grounds for the proposed change in practice and for novices to learn the critique procedure and apply research results to practice (Buckwalter et al., 2017). In the current change proposal, evidence was retrieved from electronic databases like CINAHL, Medline, and Cochrane, among other sources.

Step 4: Grading Evidence

During evidence categorization, the implementation team focuses on specific areas of quality of research and the strength of the type of data. The research will be grouped based on the type of evidence, as either quantitative or quality study. The stage will involve sharing project reports within and outside the health care organization through publications and presentations, and educating expectant mothers on skin-to-skin contact.

Step 5: Creating an EBP Standard

The implementation team reviews the literature and then works on creating a practice proposal. The nature and strength of evidence applied in practice should be precise and based on the reliability of replicated studies. In this proposal, the team will commit to adopting SSC immediately after the birth of all healthy term babies as an evidence-based approach of the childbirth experience, which should exist to all stable infants and their mothers (Zwedberg et al., 2015). The team can also proceed with piloting early SSC in the labour department and assess whether to make the change practice permanent.

Step 6: Implementing EBP

Based on the Iowa Model, successful implementation requires careful consideration of several factors, including a written procedure, strategies, and policies supporting the evidence. The implementation phase also requires direct interaction of all care providers, the healthcare organization, and the management supportive of the changes (Association for Women’s Health, Obstetric and Neonatal Nurses, 2016). Standard admission for newborns will be changed to incorporate the introduction of SSC for healthy term infants. This is to be sustained for around one hour with the mother’s accord and except for any maternal or newborn problems.

Step 7: Evaluation Process

This stage is meant to assess the significance and contribution of the evidence into clinical practice. The first approach is to examine whether staff was providing SSC by conducting pre-discharge interviews with mothers. The team can also review medical records to establish whether nurses recorded giving families SSC education before birth and if early SSC happened and for how long.

The above steps of the Iowa Model of EBP to implement SSC practice in the organization has enabled the nurses to help the newborn to adjust to life outside of the womb and for the mother and baby to develop a close bond. The model also promotes the nursing practice given to the baby and the mother and complies with Unicef standards.  It also helped to analyze the costs involved in the implementation of the SSC practice.

Implementation Plan for Skin To Skin Contact between Infant and Mother

Skin-to-Skin (SSC) which is the art of placing an infant on the mother’s bare chest within the first one hour of birth, has significant benefits to the mother and the infant as well (Sanchez-Espino et al., 2019). It lowers infant mortality rate, facilitates the infant’s transition to life outside the uterus, enhancing hemodynamic stability and promoting thermoregulation among others (Safari et al., 2018). It also increases the mother’s oxytocin level enhancing milk outflow as well as promoting mother-infant bond. Following these benefits, an intervention plan to promote the SSC for mothers in the region will be developed.

Setting and Access to Potential Subjects

The study will be carried out in a local level-three hospital in TTTTTTT rural community in YYYYYYY in May 2020. The study will use a simple random sampling procedure to identify pregnant women between 34 and 36 weeks gestation without complications. The intervention will focus on steps of early skin to skin contact (SSC), its implication for breastfeeding and the potential benefits it has for the infants since it is one of the most studied phenomena in this regard (Sanchez-Espino et al., 2019). The hospital setup is selected as it will be easy to recruit the mothers easily as they come for the prenatal clinic. The subjects will be trained before they give birth, immediately after and a few weeks later as a follow-up program. The study will include all the mothers who fit the said criteria within the region. The participants will have to sign a consent form for ethical purposes before their inclusion in the study.

The Time Requirement

The intervention will be a two-step educational program targeting the staff members of the hospital in the labour wards, who are the first recipients or handlers of mothers and infants. These will undergo a 40 minutes lecture covering SSC methodology, benefits, and importance of early breastfeeding. The initial recruitment phase for the women will also take 40 minutes for the mothers to be introduced to the study using lecture methods. They will have to ask questions, and upon consent, they will be included in the intervention program. The program will run for five months, two months prenatal and three months postnatal. During every week of the visit, the pregnant mothers will be taken through routine training to ensure that they stick to the instructions. After birth, the intervention will assess how the mothers conduct the SSC for three months. The training session will be different for different categories due to the dynamics of the availability of subjects. Some are available in the mornings, others in the evenings, others at night while some are only available over the weekend. In the end, all teams will reconcile their knowledge on a day that will be mutually acceptable for all to ensure that everyone shares the same records and information.

Resources Needed

There will be two senior pediatrics residents to train staff members. All the nurses who will receive the training will have to be present in person during the session. The senior nurses, under the supervision of the trainers, will then train the mothers at different intervals according to the intervention design. The majority of the lectures will require writing material for the subjects as well as handouts to revise in their free time. DeLozier and Rhodes (2017) assert that there is a need to provide learners with written material for reference after a lecture to enhance retention. The learners rely on these materials as they discuss among themselves after the sessions or as they revise alone later. The sessions will also require a computer installed with PowerPoint® for presentation purposes.

Methods and Instruments

After the training, a structured questionnaire will be used to assess the level of knowledge of pregnant women on the topics studied. Their perception of the SSC will also be investigated to ascertain their willingness to go on with the procedure after they give birth. After birth, nurses will record the time that SSC starts, the duration it takes, and the time when the infant starts breastfeeding in the newborn’s chart. The researcher will collect the data from the nurses and analyze it independently. The study will exclude births through cesarean section, premature births, and newborns with advanced resuscitation requirements.

Delivering the Intervention

After the data analysis, it will be incumbent upon the researcher to provide the results of the study to all stakeholders. The presentation, which will also act as a training session, will be necessary to inform the mothers on the significance of SSC with their newborns going forwards. Specialists will train them on the best time to establish contact with the newborns. The mothers will act as trainers when they get to their respective homes, which will help to disseminate the information to those who were not part of the study.

Data Collection Plan

The researcher will develop the questionnaire with the help of the supervisors for mothers before giving birth. Variables on the perception of the importance of SSC will include the mothers’ thoughts on how it helps her, how it helps the infant, and how it helps the infant attach with other members of the society or family later. After birth, the nurses will record the variables of interest on newborns chart. The Analysis of Variance (ANOVA) will be the primary statistics to use to ascertain if there are statistically significant differences in SSC between the first, second and third months after giving birth.  The study will use ANOVA since it can help to show the significant difference between groups, as Emerson (2017) suggests. It will be useful in showing the variation in breastfeeding tendencies for the mothers from birth onwards for the study period.

Addressing Study Limitation

The language barrier might be inherent in the data collection phase. The medical terminologies may hinder communication between the trainers and the pregnant mothers. However, using illustrations, examples and vivid descriptions, the trainers can overcome the challenge. Also, some study participants may fear that their private data may be exposed to the public. To address this, the researcher will inform the subjects of their rights and the confidentiality with which the information will be treated.

Feasibility of the Implementation Plan

The implementation will occur within the hospital setup. The mothers will appreciate the importance of SSC as they handle their young ones. The major cost implication will occur during training, especially for facilitators. However, these are routine employees who will only require over-time pay for their services. Such services will be determined from their salaries and will be paid as per diem. The hospital has several facilities that will be relevant for the implementation. The boardroom with its accessories will help during the training. The projects will nonetheless have to get pamphlets to provide the clients once the training is done. There will be a need to have training manuals for all participants involved in the study for future reference.

After Implementation

Once the study results are out, it will be prudent to ensure that the training sessions are embedded in the hospital clinic program. The study may come up with a need for radical changes in which the hospital handles the infants. As Amarantou (2018) note, extreme changes in status-quo in the health sector may experience resistance. Thus, it is necessary to have a multi-stakeholder forum to ensure that everyone embraces the new changes that will improve healthcare. On the other hand, if the study will prove that the intervention does not have a significant change in the routine as it is, and then there will be no need for a change. In sum, there will be necessary efforts to maintain the training sessions at regular intervals for mothers on the significance of SSC with their infants. Upon realization of the benefits of the intervention, the results could be extended to other categories of mothers and caregivers. The intervention program may start targeting mothers who give births using other methods like CS or stillbirths. It would be necessary to establish the optimal time for this category of mothers and include it in the training manuals.

The Rationale for Methods Used in Collecting the Outcome Data

The evaluation methods will entail collecting information using a structured questionnaire. The scholar has selected the method due to its cost factor. Questionnaires are easy to administer inexpensive. That is, one does not have to recruit surveyors as it is with the case of face-to-face interviews (Patten, 2016). This approach can help to collect data from a large sample within a short time, especially if the participants are aware of the study. Secondly, questionnaires offer a practical way of getting results since the researcher can target the instruments to the audience and manage the process.

Measuring Outcomes

The outcome measures will evaluate the extent to which the project objectives are achieved by looking at the variables independently. For instance, the study will want to establish the perception of mothers on the importance of SSC, including their thoughts on the help it offers them, the infant, and infant’s attachment to the mother, other family members and the society later in life. That way, the study can realize the extent to which the training program’s objectives have been achieved or not.

Measuring and Evaluating Outcomes Based on Evidence

To ensure that the goals are achieved, the instrument will have to be tested for its validity and reliability.  Reliability is the ability of a study instrument to produce consistent results after repeated trials (Mohajan, 2017). The questionnaire’s reliability will be assessed by carrying out a pre-test using a group of women with similar knowledge and have the same characteristics as the target sample but in another location far from the one where the implementation will take place. A reliability coefficient of ≥ 0.7 will be accepted as a test that the instrument can be used in the evaluation. Validity measures the accuracy of the tool, which is an implication of whether the instrument can measure what it purports to measure. To ascertain the internal, content, and phase validity of the instrument, the scholar will work closely with senior members in the medical field. Also, peers will be asked to give their opinion on certain areas. The applicability of the results will depend on whether the tool has met all the standard criteria set forth by the scholar, including both validity and reliability.

Strategies to take if the Outcomes are Negative

The primary step will be to train the subjects again. Negative outcomes would imply that the subjects did not understand the topic. Thus, there will be a need to intensify the program activities to ensure that the mothers are sensitized on the importance of SSC for attachment. More so, the implementation procedure could use a different approach since it could also mean that the training procedure used was not adequate. For instance, demonstration coupled with real-life experiences from animals could help mothers to understand the importance.

Implications for Practice and Future Research

The concept of SSC is critical to the attachment between infants and mothers from the onset. Infants get to know their mothers closely as mothers develop the bond for their young ones (Hubbard & Gattman, 2017). It also facilitates the time between birth and the first suckling of the infant. In the future, the child also learns how to bond with other members of the family and the larger society easily. The training will inform mothers about the relevance of this important aspect of human beings. Future research will endeavour to establish if there are significant differences in the type of bonding that children from mothers who were trained on the topic of SSC form with others in the society compared to those who did not receive the information. Does the training on SSC affect the mothers and children later in life?

References

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