Evidence

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Through your reading of Chapter 19 and the recorded lecture, you have learned about using evidence to influence organizations and policy. Script then record an elevator speech to either a Chief Nursing Officer or policy maker based on pressure ulcers/injuries evidence from the clinical practice guideline, Dr. Brindle’s lecture and High Tide Health data.

Chapter 19

Using Evidence to Influence
Health and Organizational

Policy

Chapter 19

Using Evidence to Influence
Health and Organizational

Policy

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Defining “Policy”

“Policy” is used to describe both the entity and the
process.

As an entity—policy is a tangible result (a law or
municipal code) or other governmental process that
includes:

• Judicial decrees

• Position statements

• Resolutions

• Budget priorities

Other kinds of broad “health policies” are:

• Published by nongovernmental organizations

• These have impact on health policy

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Defining “Policy”—(cont.)

As a process—it’s the series of actions and activities
taken to bring a problem to the attention of government
actors who work to address the problem.

When policy refers to “health policy,” these actions
are often thought of as those targeting improvements for
the health of populations.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Challenges Unique to the Relationship
Between Evidence and Health Policy

Policy making is:

• Nonlinear

• Influenced by social and political factors such as:

– Partisanship

– Diverse stakeholder values

– Public opinion

– Media coverage

– Timing of congressional and legislative cycles

– Budget restraints

– Strategy and skill of players

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Using Evidence: Clinical Practice vs. Policy

In clinical practice:

• Cultures and organizational structures more apt to
press for practice based on evidence

In political environments:

• Pressing for policy based on evidence can have less
favorable outcomes.

• Terminology in policy is “evidence-informed” policy
rather than “evidence-based” policy.

• Goal: use evidence to inform, influence, or mediate
dialogue between policy makers and stakeholders.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Question

Which of the following statements is false?

A. “Evidence-based” policy is the current term for using
evidence to inform health policy.

B. “Policy” refers to both an entity and a process.

C. “Health policy” refers to both laws that impact
population health and healthcare organization policy.

D. Nuances in clinical practice are different from nuances in
the health policy world, making strategies to use
evidence to drive policy different.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Answer

A. “Evidence-based” policy is the current term for using
evidence to inform health policy.

Rationale: “Evidence-informed” policy is the current term
for using evidence to inform health policy. “Policy” refers to
both an entity and a process. “Health policy” refers to both
laws that impact population health and healthcare
organization policy. Nuances in clinical practice are different
from nuances in the health policy world, making strategies
to use evidence to drive policy different.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Evidence-Informed Health Policy
Model (EIHP)

• Policy makers are more likely to respond positively to
evidence when it is presented in a way that is:

– Compelling

– Understandable

– Conveyed in the context of citizen/constituent
needs

The Evidence-informed Health Policy Model is adapted
from the Melnyk & Fineout-Overholt Seven Steps of
EBP.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Comparison of EBP and Evidence-Informed
health Policy Components

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Preparing Evidence for Dissemination to
Policy Makers

Multiple opportunities exist to disseminate evidence in
Evidence-Informed Health Policy (EIHP):

• During Step 4 (when best evidence is integrated with
issue expertise and stakeholder values and ethics).

– Most likely to happen in “behind-the-scenes”
negotiations/planning or task force meetings
with bill sponsors or regulatory staff

• During Step 6: Policy change is framed for
appropriate dissemination to affected parties.

• During Step 7: Effectiveness of policy change is
evaluated and findings disseminated.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Preparing Evidence for Dissemination to
Policy Makers—(cont.)

Multiple methods used to disseminate (or communicate)
evidence to policy makers.

Informal methods include:

1. “Elevator speech”

2. Policy brief—typically consists of bulleted talking points

• Both are brief

• Used as one-way communication method

Formal method includes:

3. Providing testimony during a hearing

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Dos and Don’ts of Using Evidence
During Testimony

DO:

• Analyze the policy-maker “audience” (lawmakers or
regulators?)

• Know committee membership (chair, minority leader,
etc.)

• Address how the body of evidence is relevant

• Use examples from your own clinical expertise to bridge
the evidence-to-practice reality

• Respond professionally to questions

• Include a reference page as an appendix to your
testimony with URL links

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Dos and Don’ts of Using Evidence
During Testimony—(cont.)

DON’T:

• Use medical jargon or research terms

• Cite individual research studies—focus on the relevant
BODY of evidence

• Get to the point

• Become defensive or emotional during testimony
delivery or questioning

• Express evidence in a way that could be misinterpreted
as a “turf battle”

• Respond to a question you don’t know the answer to
with a simple “I don’t know.” Instead, say “That’s a
great question. I will be happy to find out and get back
to you.”

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Question

Which of the following is appropriate behavior when
testifying on a policy issue?

A. If you don’t know the answer to a question, simply state,
“I don’t know.”

B. Use examples from your own clinical expertise to bridge
the evidence-to-practice reality.

C. Be very detailed in your description of the body of
evidence.

D. Cite individual research studies.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Answer

B. Use examples from your own clinical expertise to bridge
the evidence-to-practice reality.

Rationale: Using examples from your own clinical expertise
to bridge the evidence-to-practice reality, making the issue
more “real.” Don’t

• State “I don’t know” If you don’t know the answer to a
question.

• Give a lot of detail in your description of the body of
evidence; get to the point.

• Cite individual research studies. Instead, discuss the
BODY of evidence.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Using Evidence to Influence Organizational
Policy

EBP should be the foundation for all organizational policy

The EBP competencies:

• Help organizations establish expectations for
clinicians

• Develop mechanisms to build EBP knowledge and
skill

• Measure achievement of each competency

• Hold clinicians accountable to this professional
expectation

EBP is an effective strategy to contribute to improved
care through utilization of best evidence to drive
organizational policy decisions.

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Successful Policy Committee Structures
and Processes

• Committee infrastructure: charter, checklists, and
membership

– Put structures in place to:

• Identify purpose and processes

• Assure representation of all departments who
will be impacted by the policies

• Policy committee leadership

– Need visible, tangible committee leadership

– Responsibilities include

• Engagement of committee members

• Promoting and sustaining an effective EBP
culture

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Competency assessment for policy committees

• EBP competencies set expectation for committee
member expertise.

• Engage EBP experts from within and outside the
organization to provide needed EBP education.

Operationalizing a collaborative interprofessional policy
committee

• Creating an interprofessional collaborative provides a
platform to foster interprofessional collaboration and
engagement.

Successful Policy Committee Structures
and Processes—(cont.)

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Challenges and Change Management

Time: Anticipate need to review policies every 3 years

• Anticipate time needed to engage in EBP to support
sound policy creation/review

– Time to search databases

– Time to appraise and synthesize literature

Committee member variation in skill and confidence

• Engage EBP experts to provide needed education.

• Engage EBP mentors to provide support/guidance.

Changes in committee membership

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Question

Which of the following is NOT a consideration when
applying EBP to organizational policy?

A. The EBP expertise of policy committee members

B. The time needed to manage utilization of EBP to guide
organizational policy review

C. Appointing a strong lead for the policy review
committee; preferably a physician

D. Utilizing EBP experts and mentors to provide needed
education

Copyright © 2019 Wolters Kluwer • All Rights Reserved

Answer

C. Appointing a strong lead for the policy review
committee; preferably a physician

Rationale: Appointing a strong lead for the policy review
committee, preferably a physician, is not a consideration.
Any leader who is able to navigate the challenges of
leading an interprofessional committee is appropriate.
Other considerations to keep in mind when utilizing EBP to
organizational policy include assessing the EBP expertise of
committee membership, planning for the time needed to
manage utilization of EBP to guide organizational policy
review, and utilizing EBP experts and mentors to provide
needed education to committee members.

  • Slide 1
  • Defining “Policy”
  • Defining “Policy”—(cont.)
  • Slide 4
  • Using Evidence: Clinical Practice vs. Policy
  • Question
  • Answer
  • Evidence-Informed Health Policy Model (EIHP)
  • Slide 9
  • Preparing Evidence for Dissemination to Policy Makers
  • Preparing Evidence for Dissemination to Policy Makers—(cont.)
  • Dos and Don’ts of Using Evidence During Testimony
  • Dos and Don’ts of Using Evidence During Testimony—(cont.)
  • Question
  • Answer
  • Using Evidence to Influence Organizational Policy
  • Successful Policy Committee Structures and Processes
  • Slide 18
  • Challenges and Change Management
  • Question
  • Answer

IN TR ODUCTION

MEET TH E PATIEN TS

VISIT TH E UN ITS

High Tide Health System Medical Center

Magnet Journey

Case Studies

Emergency Department

Orthopedic Unit

Operating Room

Surgical Trauma ICU

High Tide Health System Pressure Ulcer Case

Neuroscience Unit

Summary

High Tide Health System Medical Center

The HTHS Medical Center, a 400-bed inpatient facility with a Level 2 trauma center

designation, is part of the High Tide Health System.  It opened in 1974 as a result of a

partnership between Oceanfront Hospital and High Tide University.  It is located in an urban

setting with a largely indigent population.  

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High Tide Health System Medical Center

 Visit the HTHS website to learn more about the Health System and Medical Center.

Website password:  ceomast

C O NT I NU E

High Tide has not previously been a Magnet designated facility, but the organization is

optimistic that its outstanding nursing engagement and positive patient outcomes will help

them achieve this recognition.  

Pressure Injury Prevalence

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Magnet Journey

The hospital environment is especially energized

at this time, as team members on the recently

implemented Magnet Team are hard at work on

their Magnet document that will be ready for

submission in the upcoming quarter.  

One requirement to become a Magnet designated facility is to report a pressure injury

prevalence rate quarterly.  Fortunately, High Tide is currently performing a quarterly

prevalence study.  The quarterly prevalence rate falls below the national benchmark of 2.5%,

but the organization has been unable to consistently meet the internal stretch target of 1.5%. 

Often times there is a signi�cant rise in prevalence in between quarters for an unknown

reason.  

Members of High Tide Medical Center’s Magnet Team review wound care data

The stretch target of 1.5% was proposed by the Wound Care Team in 2017 as a measurable

and attainable goal for hospital acquired pressure injury (HAPI) prevalence when the

organization was tasked with reducing hospital acquired pressure injuries by its hospital

board.  The stretch target was selected by analyzing and comparing High Tide’s performance

against other academic medical centers.  The organization has been given one year to make a

positive and consistent change.

Assessment and Education

Currently, the Wound Care Team at High Tide assesses patients with pressure injuries and

makes recommendations for care.  They provide prevention education for newly hired nurses.

 They also collect data for the quarterly pressure injury prevalence study.  This is a time

consuming task for the small Wound Care Team of 5 Wound and Ostomy certi�ed nurses.

 The team has often considered utilizing the knowledge and skills of bedside nursing sta� to

help collect this data.  Additionally, the team has exploring strategies to change the culture

from treatment to prevention.  It is to the bene�t of the patients and the organization to be

proactive rather than reactive.

Magnet Document Contribution

The Wound Care Team has contributed to the Magnet document with its work in wound and

ostomy care.  At a recent team meeting, a Wound Care Team member acknowledged that a

great deal of work for the Magnet document was created in collaboration with varying levels

of leadership and bedside sta�.  The Wound Care Team consulted with the Magnet team to

discuss how leadership support can be obtained and how the framework utilized for the

Magnet document can be used to successfully implement a comprehensive pressure injury

prevention program. The framework includes the following domains: 

Transformational Leadership

Structural Empowerment

Exemplary Professional Practice

New Knowledge, Innovation, and Improvement

It was also discussed at the team meeting that the culture among bedside sta� can often

re�ect skepticism of new processes. While bedside sta� at High Tide is highly engaged, they

often feel overwhelmed with growing expectations from the organization. Many team

members in the environment are aware that hospitals do not receive reimbursement for the

care of hospital acquired pressure injuries, but not all realize this is about more than money

or “checking a box” to meet a standard.  Instead, it is about taking excellent care of the

patients. As a result, the Wound Care Team posed the following question:

It appears that most of the hospital acquired pressure

injuries occur in the ICU and a large portion of these

injuries are caused by medical devices.   This is useful

information when planning pressure injury prevention

education.

Scene 1 Slide 1

How can we convince team members that
this is not just about money or numbers,
rather, it’s about providing the best
possible care and preventing harm
among our patients? 

Scene 1 Slide 2

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The Wound Care Team has previously met with leaders on the inpatient units to identify

barriers to prevention and to communicate the goal of decreasing the hospital acquired

pressure injuries, but the team is at times met with resistance.  Recent feedback has included

as shown below: 

“The organization is already doing what can be done to decrease pressure

injuries.”

– Valerie Sowards

“Units are already tasked with so many other key initiatives”

– Danny Coyle

“We do not have the sta� or the resources to achieve the goal of 1.5% HAPI

prevalence.”

– Kelly Herrmann

The Wound Care Team recognizes that additional resources are needed for sta�ng,

education, and implementation of best practice guidelines in order for the comprehensive

program to be successful.  

C O NT I NU E

In order to identify opportunities for improvement and determine root cause analysis, the

Wound Care Team pulled the list of patients who sustained a hospital acquired pressure injury

in July 2019.  This month was selected as this was the highest HAPI prevalence month in

2019.  Of the 17 patients with hospital acquired pressure injuries, 5 were selected for review.

 Additionally, two cases in which the patient was hospitalized for >100 days but sustained no

pressure injuries were also selected for review.  This could provide the team with information

as to what processes were in place to promote positive outcomes.

View the 7 cases below:

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Case Studies

Case Study 1 –

UNIT:  MEDICAL RESPIRATORY ICU

51 YO Caucasian male, 86.4 kg, with Hx of: Dysphagia, Malnutrition, MRSA, COPD, DM,
Aortoiliac disease, HTN, ESRD

Pt in ICU for 115 days. NO evidence of pressure injury throughout stay.

What went well? 

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings were utilized

Pt’s family educated appropriately and engaged in patient’s care

Case Study 2 –

UNIT:  NEUROSCIENCE

81 YO African American male, 112.2 kg, with Hx of: HTN, HLD, DM, CHF, CAD, CVA
In ICU for 185 days, no evidence of a pressure injury throughout stay.

What went well?

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings utilized

Family not present, but verbalized concern about patient’s skin on multiple occasions via
telephone conference. This created a stressful environment for the bedside sta�, but it
required them to be diligent with turning/repositioning and thorough skin assessment.

Case Study 3 –

UNIT ASSOCIATION: SURGICAL TRAUMA ICU

32 YO Caucasian male, 207 kg, with Hx of: HTN, Malnutrition, Obesity, Mental Illness,
Multisystem organ failure, sepsis, use of vasopressors to maintain blood pressure. 

Pt hospitalized for signi�cant injuries s/p MVC. Pt was incontinent of stool and had Foley
catheter in place. Pt on bedrest.

Pt sustained Stage 4 pressure injury to sacrum, unstageable pressure injury to occiput (due to
C-Collar), and unstageable pressure injury to anterior neck (due to trach plate).

When providing an explanation for the cause of the injury, nurses on the Surgical Trauma ICU
noted that the Bariatric patient that was di�cult to turn and o�oad appropriately. The C-
Collar utilized was the incorrect size for this patient. The trach plate was sutured tightly in
place for 17 days and was not properly o�oaded.

Case Study 4 –

UNIT ASSOCIATION: EMERGENCY DEPARTMENT

62 YO African American female, 219 kg, with Hx of: HTN, DM, Obesity, Asthma, COPD,
Tobacco use

Pt arrived to ED c/o dyspnea and fever. Pt in ED for 21 hours awaiting room for admission. Pt
laid on hospital stretcher for 21 hours prior to being transferred to hospital bed in room. While
in the ED, the pt had requested that the head of the bed be elevated to at least 60 degrees due
to SOB. Pt reports sleeping on multiple pillows at home to assist with her breathing. Pt had
multiple episodes of urine incontinence while in the ED. Sta� in the ED were not always
available to clean the patient’s skin after each episode of incontinence, so the patient’s skin and
sheets were frequently soiled with urine for long periods of time. Pt found to have signi�cant
pressure injuries to her sacrum and bilateral ischium 3 days into admission.

Case Study 5 –

UNIT ASSOCIATION: ORTHOPEDICS 

72 YO Caucasian male, 76 kg, with Hx of: Asthma, CAD, DVT, HTN, Osteoarthritis

Pt underwent L hip replacement due to osteoarthritis. Pt’s mobility limited during admission.
Per physician order: Weight bearing 25% LLE. ROM: Flexion and extension only. Dilaudid for
pain. Pt had requested Dilaudid frequently for pain. This contributed to his lethargy and his
failure to reposition self in bed.

Review of the documentation revealed that the pt’s left heel was placed in a heel protector
boot. The RLE was not elevated and the right heel was not �oated. As a result, the patient
developed a deep tissue injury to the right heel.  Upon questioning of the nurses, they stated
they believed the patient was repositioning himself since he was mobile prior to surgery.

Case Study 6 –

UNIT ASSOCIATION: OPERATING ROOM

18 YO African American male, 63 kg, with Hx of: metastatic sarcoma, anxiety.

Pt underwent abdominal surgery and was in OR for 22 hours. Pt was placed on a gel overlay
during surgery. Pt had a gel donut pillow placed under head during surgery. OR nurse charted
post-operative skin assessment consistent with pre-operative skin assessment. Pt not turned in
PACU due to signi�cant abdominal pain. Pt was transferred back to ICU 3 hours after
completion of surgery. Three days after surgery, pt found to have circular deep tissue injury to
his occiput and a deep tissue injury to his right heel.

Case Study 7 –

UNIT ASSOCIATION: NEUROSCIENCE

28 YO Hispanic male, 71 kg, with no prior Hx. Pt admitted with to ICU with TBI and
multiple fractures after motorcycle collision with car at high speed.

Pt in ICU for 64 days. No pressure injuries noted during ICU stay. Pt admitted to Neuroscience
unit on day 65. As a result of his initial injuries, pt was left with right sided hemiplegia. On day
72 of admission, pt was transferred to the recliner with maximum assistance and was left to sit
for 8 hours. On day 75 of admission, nurses charted deep tissue injuries to coccyx and bilateral
ischium.

C O NT I NU E

Entrance to High Tide Medical Center’s Emergency Department

Unit Description
3 Sections: 

Red:  Trauma

Yellow:  Observation/Awaiting Admission

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Emergency Department

Green:  Fast Track

Culture
Moderate nursing turnover with recent changes in leadership

– Majorie Hansen, RN, AGACNP-BC 

– Barry Moore, PA-C 

“Our patients aren’t here long enough to get pressure injuries.”

“We don’t have time to think about pressure injury prevention. We

are saving lives down here in this high stress environment.”

High Tide Medical Center’s Therapy Room

Unit Description
24 beds

Culture
Moderate nursing turnover 

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Orthopedic Unit

– Brandy Walters, RN 

“Our patients are often in signi�cant pain and are di�cult to

turn/o�oad due to recent surgeries and orthopedic devices.

Sometimes our patients get pressure injuries under their orthopedics

devices, but there is nothing we can do about that. Also, there are a

lot of activity restrictions, so that presents a challenge in pressure

injury prevention.”

High Tide Medical Center’s OR

Unit Description
32 OR Rooms

Scheduled surgeries performed 7 days per week. Multiple surgical specialties present.

Culture

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Operating Room

Minimal nursing turnover

– Yi Chien, MD 

“We don’t have a pressure injury problem here. Most of the time the

post-operative patient’s skin looks like it did when they arrived to

the OR.”

High Tide Medical Center’s Surgical Trauma ICU

Unit Description
22 ICU beds, 4 step down beds

Scheduled surgeries performed 7 days per week. Multiple surgical specialties present.

Culture

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Surgical Trauma ICU

High nursing turnover

– Sheryl Benfer, RN 

“Our patients are critically ill and have a lot of medical devices to

contend with. It is understood that they will get pressure injuries

frequently. At least we are keeping them alive.”

High Tide Medical Center’s Neuroscience Unit

Unit Description
24 beds

Culture
Moderate nursing turnover

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Neuroscience Unit

“Our patients are usually total care. We take TBI patients, SCI

C O NT I NU E

– Carolyn Ruben, RN-ACACNP-BC 

patients, and CVA patients. It’s very challenging to prevent pressure

injuries in these patients because they are di�cult to turn and keep

o�oaded.”

Based on what you have learned about High Tide Hospital, how would you work with the

Wound Care Team to develop and implement a comprehensive pressure injury prevention

program?  What are key elements across all units that need to be considered for an

organizational plan to reach a goal?

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Summary

You have completed this case.

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