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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 11 


Stacie Licon Kristine Scaffidi

Theoretical Framework

Conceptual foundation which provides a
structure for nursing practice.

Foundation Supporting Nursing Practice

By Stacie Licon, MSN, RN, CNS, CPN and
Kristine Scaffidi, BSN, RN, CNOR


Changes in nursing practice are common. Change represents recommendations and standards set by accrediting organizations such as The Joint Commission, and professional associations such as the Association of Perioperative Registered Nurses, American Society of PeriAnesthesia Nurses and American Association of Critical-Care Nurses, to name a few. Practice recommendations and standards set by these organizations are directives supported by authoritative evidence-based research to ensure excellence in practice that promotes positive patient outcomes.

But how do you bridge research into practice? One way is by using the Academic Center for Evidence-based Practice (ACE) Star Model. The ACE Star Model of Knowledge Transformation is dedicated to bridging research into practice with the ultimate goal of improving care, patient outcomes and patient safety.1 The Star Model depicts various forms of knowledge in a relative sequence as research evidence is moved through several cycles, combined with other knowledge and integrated into practice.1 Configured as a simple 5-point star, the model illustrates five major stages of knowledge transformation: 1) knowledge discovery, 2) evidence summary, 3) translation into practice recommendations, 4) integration into practice, and 5) evaluation.1

 

 

Copyright 2004 by K.R.Stevens, ACE Star Model of EBP: Knowledge Transformation

When changing the practice of patient assessments (as with the vital signs policy) from every six hours to every four hours, a model such as the ACE Star Model can be used. Let’s see how the five-step model helped us get to our goal of ensuring better patient outcomes.

Discovery
According to Star Point 1, the first step is “Discovery.” This is a knowledge-generating stage. In this stage, new knowledge is discovered through traditional research methodologies and scientific inquiry.1 In 2009, The Joint Commission identified the need to improve recognition and response to patient deterioration as a National Patient Safety Goal. Through an internal patient safety evaluation at Children’s Hospital Central California in 2010, pediatric acute care cardiopulmonary arrests were identified as the area of most harm for patients. This knowledge-generating stage conducted by the Heads Up Task Force identified through post-code chart reviews that there were an increased number of acute care codes where patient deterioration was not always recognized.

Summary
Star Point 2 in the ACE Star Model involves the evaluation of individual research studies and a synthesis of resultant knowledge into a meaningful statement; this step is the “Summary.”1, 2 Research collected by the Heads Up Task Force identified that there were tools available that could identify children at risk of deterioration 1-24 hours prior to a cardio-pulmonary arrest.3, 4 This tool is known as the Pediatric Early Warning System Score (PEWSS). Utilization of this tool was put into practice following a pilot period in one of the inpatient acute care units, Apollo, at Children’s. 

In December 2010, shortly after full implementation of the PEWSS scoring tool in the acute care areas, the Heads Up Task Force requested that the frequency of assessment and reassessment be evaluated by Practice Council and aligned with the frequency of PEWSS scoring, which was occurring every four hours. Together with the request, the Heads Up Task Force also provided information reflecting assessment frequencies in children’s hospitals across the nation. The majority of assessments occurred every four hours as reported by 11 of the 16 children’s hospitals.

In addition to the research conducted by the Heads Up Task Force, a literature search was completed by the Practice Council Chair to determine the national standard for frequency of routine physical assessments and vital signs. No evidence-based standard was identified due to the variability amongst patients, units and organizations. The literature suggested that standards be established by each facility based on their unique population of patients and should be determined by the clinical nursing “experts” for that facility.5 The other suggested approach was through identification of the community standard of care.

Translation
Star Point 3, otherwise known as “Translation,” is a useful and relevant package of summarized evidence to clinicians and clients in a form that suits the time, cost and care standard.1 Recommendations are generically termed clinical practice guidelines and may be represented or embedded in care standards, clinical pathways, protocols and algorithms.1

Practice Council is responsible for determining the standard of nursing care at Children’s. After several discussions and separate task force meetings based on the recommendation to change the current standard of assessments (with vital signs) from every six hours to every four hours, Practice Council concluded more frequent assessments were necessary due to the increased acuities of patients. In addition, the establishment of every-four-hours assessments was supported by several findings:

  • The majority of children’s hospitals conducted physical assessments every four hours, thus reflecting a community standard of care.
  • The PEWSS score affected assessment frequency. It was identified that a PEWSS score of “4” resulted in the need for assessments every four hours. A large number of patients were identified with this score.
  • Nursing expertise was demonstrated through the collaboration of the Heads Up Task Force, Practice Council and other approving entities within Children’s.

Once the decision was made to change the standard, language was changed in policy PC-4017, Patient Assessment. The policy was changed to not only identify frequency of patient assessment, but also define a comprehensive versus a focused physical assessment.

Integration
The fourth step in the ACE Star Model, called “Integration,” involves changing both individual and organizational practices through formal and informal channels. The Professional Development Council (PDC) is the organizational governing body responsible for staff education. Having received direction from Practice Council, PDC assessed the education required using a scoring tool called COMAS scale. The material is scored on:

  • (C)ontent to be delivered
  • (O)utcome desired
  • (M)ethods of education needed
  • (A)udience to receive the education
  • (S)afety risks involved

The education of changing frequency of vital signs and defining comprehensive versus focused assessment scored a nine out of 10 making it maximal complexity.

Education that has been found to be of maximal complexity can be accomplished utilizing several methods of education to address all types of adult learners. In this instance, information was incorporated into the mandatory Advanced Clinical Systems (ACS) education for licensed and unlicensed staff. During class, staff had several opportunities to demonstrate knowledge, understanding and documentation through scenario-based computerized charting. Resource binders were provided for staff to help with definitions as well as unit superuser support. Multiple education delivery methods helped successfully transition staff to incorporate new practice into daily routines.

Evaluation
Evaluation, the fifth Star Point, is the final stage in knowledge transformation. In evidence-based practice (EBP), a broad array of endpoints and outcomes are evaluated. These include evaluation of the impact of EBP on patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic analysis, and health status impact. In relation to the PEWSS scoring tool and with the increased frequencies in assessments and reassessments, recognized trends in patient care include decreased cardiopulmonary arrests in the acute care units at Children’s, which directly affect decreased mortality. Increased days between cardio-pulmonary arrests have also been evaluated.

As new knowledge is transformed through the five stages, the final outcome is evidence-based quality improvement of healthcare. As long as nurses continue the quest for new knowledge, innovation and excellence, change can be expected. Having a model to use that helps turn research into practice is essential in providing our patients the best possible care. 

References 

1 Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation.  Retrieved from http://www.acestar.uthscsa.edu/acestar-model.asp

2 Bonis, S., Taft, L., & Wendler, M. (2007). Strategies to promote success on the NCLEX-RN: An evidence-based approach using the ACE star model of knowledge transformation.

3 Duncan, H., Hutchison, J., & Parshuram, C. (2006).  The pediatric early warning system score:  A severity of illness score to predict urgent medical need in hospitalized children.  Journal of Critical Care, 21, 271-279.

4 Tume, L. (2007). The deterioration of children in ward areas in a specialist children’s hospital.  Nursing in Critical Care, 12(1), 12-19.

5 Schulman, C. S., & Staul, L. (2010). Standards for frequency of measurement and documentation of vital signs and physical assessment.  Critical Care Nurse, 30(3), 74-76.

 

In This Issue

Professional Practice

Professional Values

Theoretical Framework

Professional Practice

Governance

Collaborative Relationships

Care Delivery

Outcomes

Research / Evidence-Based Practice

Professional Development

Reward and Recognition

Communications

Operations