Training days
Solid clinical decision-making is basis for population health management
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By Maureen Altieri, MS, RN, NEA-BC; Ann C Eckardt Erlanger, PsyD; and Patricia Eckardt, PhD, RN
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EDITOR'S NOTE: Maureen Altieri, MS, RN, NEA-BC, is director of professional practice at Good Samaritan Hospital Medical Center, West Islip, N.Y.; Ann C. Eckardt Erlanger, PsyD, is a research scientist at Good Samaritan Hospital Medical Center, West Islip, N.Y.; and Patricia Eckardt, PhD, RN, is associate professor, Molloy College, Rockville Centre, N.Y.
Population health management is the focus of much of today’s conversations surrounding healthcare delivery systems. The topic is prompting discussions on three elements — expanding and using large-scale patient clinical data sets to drive clinical decision-making, having a primary-care led clinical workforce, and engaging communities and patients to manage their own health.
At the heart of each of these key elements of managing our patient populations remains one constant: the nursing workforce. Nurses ultimately will decide the success of this approach to caring for our patient and community populations, since the delivery of this care is primarily led by nurses or through teams led by nurses. Nurses know patients have individual needs and differences and that their individuality guides care — known as patient-centered care. Nurses also understand the need for research-driven, evidence-based approaches to direct their practice — known as team science. To provide a team science approach to the delivery of patient-centered care, it’s crucial that nurses are educated in leading and directing our patient and community populations with the best evidence available to them. Academic nursing programs and patient care delivery systems have built education around research and EBP and the use of clinical care pathways developed from the best evidence. As a research team at Good Samaritan Hospital Medical Center in West Islip, N.Y., we set out to teach nurses at the facility how to conduct, assess and implement research at the point of care to be successful in managing population health.
Our team’s goals were to evaluate our existing organizational structure for research and EBP activities and our ability to grow; design an educational program about research and EBP, based on our assessment; mentor staff through EBP and research projects as we built a research program within our organization; reevaluate the program’s success; and make modifications based on our results.
We found that when investigating and developing an infrastructure for a particular health delivery system, the research base must be critically evaluated for the following elements:
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It’s crucial that nurses are educated in leading and directing our patient and community populations with the best evidence available to them.
Provide the tools
We felt the strong foundational planning provided a road map to success, and we were right. In addition to educating our nurse workforce and nursing assistants in the process of conducting research, we were successful in disseminating research findings via publications, posters and podium presentations.

Over the past five years, we have had presentations at international, national and local conferences by nurses, interprofessional teams and nursing assistants. We have applied for about 10 grants with our teams of frontline nurses, nursing assistants and allied health staff and have completed 15 research and 35 EBP projects.
As we continue with this journey, we need to have an impact on the realm of policy, as policy is a large factor in the decisions regarding managing population health and the provision of nursing care to our communities.

A strong foundation in research and appraising and applying research findings will provide our bedside leaders and staff with the expertise needed to participate in policy making and change. After all, policy should also be based on research evidence.
The rubber meets the road
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Do the homework
To begin building a research and EBP program, we conducted a systematic review of the literature. Many organizational resources, as well as journal articles and other articles, discuss building a successful program of research within an organization. The Agency for Healthcare Research and Quality, for instance, provided us with an overview for research-building capacity that included the importance of a multidisciplinary team science approach. The National Institutes of Health’s calls for proposals for bench-to-bedside research projects offered incentives and guidance. The American Nurses Credentialing Center featured stories of how other hospitals built their research programs while on the Magnet journey that we used as case demonstrations. We did a complete and systematic search of fugitive (papers published in conference proceedings and journals that are not peer reviewed) and peer-reviewed literature, both within and outside of nursing, and spoke with experts on building a research infrastructure to get a sense of what our program needed to succeed. We included peer-reviewed journal articles, which increased our review’s validity by providing formally vetted evidence. Including the fugitive literature in our review and discussions with experts increased the validity of our literature search.
Blueprints for success
After collating the literature into a table of evidence and then evaluating the unique needs of our own organization, we developed an executive statement and a two-year timeline for the research and EBP infrastructure-building program. The program included educating all of the nurses, as well as interested nursing assistants, on conducting research and implementing EBP. In our plan, we also included non-nursing scientists, clinical experts and teams who also would champion the team science approach to managing population health. In addition, our plan operationally defined our initiatives and the outcomes we hoped to achieve. Our goal was to keep the plan measurable to increase the rigor of the program and to allow us to respond to the outcomes observed in real-time. For example, if we observed a drop in completion of educational workshops during a particular month we conducted an analysis to identify and respond to special causes, such as bad weather, or normal variation (not a significant drop) in workshop attendance.
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Executive-level support
Any research education or clinical initiative requires resources from leadership, including time for staff to train and execute research projects and leadership influence on key stakeholders regarding the initiative. As our program progressed we kept nursing leadership informed of our plan and milestones.
For example, the quarterly training goals for the number of nurses and the number of completed research and EBP projects were reported each quarter. During this collaboration, we remained sensitive to needed changes or adjustments, and adjusted the plan, as needed. For example, in response to the increasing evidence on collaboration across institutions, research and EBP meetings now include teleconferencing and videoconferencing, which is available to all committee members and includes expert members who may be off-site.
Boots on the ground
The groundwork for the educational plan was based on assessing what our frontline nurses and providers already knew about research and EBP and then giving them the nursing and allied health provider research and EBP material they needed to increase their knowledge, actively participate in research studies and apply their findings to practice. Since adult learning is grounded in a social cognitive constructivist theoretical framework and is used by nurses when educating patients, communities and others, the curriculum was developed using this framework. This approach requires interactive assessments both initially and throughout the program. To assess individual learners’ needs accurately, we knew we needed to gain their trust, so we provided the educational curricula in several formats, for example, bedside-situated learning and classroom style, online and face-to-face, individual and group learning. Workshops were offered on every shift and day of the week, and varied from one-on-one meetings to larger workshops of 30 nurses. Pre- and post-testing measured knowledge deficits, while topic discussions, as well as guidance on application to daily practice augmented the participants’ knowledge and ability. We approached our colleagues as the peer experts they were. We brought research and educational expertise, and they brought the clinical and care delivery expertise. Our educational curriculum was based on the entry-level professional nurses’ research educational requirements from the AACN undergraduate essentials document, and then we tailored the education to individual and cohort needs. As planned, the foundational educational program took two years to complete. We conducted situated learning whenever an opportunity arose during meetings, rounds or hallway conversations, and some of our best research and EBP outcomes arose where there was resistance to use best practice models by frontline workers, who then changed their practices after they reviewed the literature.
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Methodology — Projects conducted away from the bedside in well-controlled, unrealistic settings typically have results that do not easily apply back to the bedside.
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Timing — Research that occurred three years ago but was recently published may not be timely.
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Fit — Findings that apply to one population may not fit another population.
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Uniqueness of the population — Individuals in populations may vary in their responses to EBP interventions.
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