Implementing evidence-based practice in long-term care

Author(s): Jill Brennan-Cook, DNP, RN-BC, CNE

Education, training, and collaboration are keys to success.

Takeaways:

  • RN leaders can facilitate education initiatives and geriatric training for long-term care (LTC) staff.
  • RN leaders can initiate evidence-based practice processes and lead staff in measuring outcomes.
  • RN leaders can collaborate with LTC staff by valuing their input for quality improvement projects.
  • RN leaders can support and recognize the entire team by advocating best practices.

Long-term care (LTC) facilities are faced with many care hurdles, including a growing geriatric population, complexities associated with chronic conditions, and an insufficient workforce. Evidence-based practices (EBPs) facilitated by nurses can bridge the gap between current and best practices and help LTC facilities overcome these hurdles.

EBP involves problem-solving that merges nurses’ clinical expertise with evidence derived from systematic research to improve patient care (in conjunction with patients’ values and preferences) and outcomes. Implementing EBP can be a challenge for any healthcare system because of limited resources, time, and knowledge. However, LTC facility challenges are unique and require innovative strategies to overcome them.

Challenges to EBP implementation

Challenges to EBP implementation in LTC facilities include resident and workforce characteristics, lack of geriatric training and EBP education, and staff turnover.

LTC resident and workforce characteristics

Older adults residing in LTC facilities are likely to have multiple chronic conditions, such as dementia, physical disabilities, and decreased functional status. These needs significantly increase the burden on staff to provide quality care and assist with activities of daily living. (See Who are LTC residents?)

According to the Centers for Disease Control and Prevention, LTC facilities have fewer trained personnel than other healthcare agencies, and unlicensed staff provide most of the direct care. In 2016, 971,100 full-time equivalent staff worked in 15,600 U.S. LTC facilities. Of these workers, more than 60% were unlicensed personnel (certified nurse aides/assistants, medication technicians, and other aides) and 22.3% were licensed practical nurses (LPNs). The small percentage of RNs who work in LTCs (about 12% of the staff in most LTC facilities) primarily provide indirect care, such as staff supervision and care coordination; certified nursing assistants (CNAs) provide most of the direct care. This workforce pattern poses a challenge to implementing evidence-based care because although LPN and CNA training may include basics of elder care, these healthcare workers receive insufficient EBP training.

Lack of geriatric training and EBP education

Caring for older adults requires geriatric training and knowledge of the intricacies of age-related changes, as well as how those changes affect chronic conditions, medication metabolism, and functional status. Despite this need, many RNs, CNAs, LPNs, and other healthcare providers don’t have specific geriatric training and are inadequately prepared to care for LTC residents. In addition, LPN programs are 1 year and CNA programs are completed within 12 weeks (about 75 hours of didactic education and 16 hours of clinical training), leaving no time for EBP education. This limited preparation is insufficient for delivering safe evidence-based care for medically complex older adults.

Staff turnover

Turnover rates in LTC facilities are high and have been attributed to low wages, inadequate staffing, and poor relationships with supervisors. Limited staffing further compromises quality care for a fragile dependent population, adversely affecting resident outcomes. Research by Trinkoff and colleagues directly links high CNA turnover to increases in pressure injuries, pain, and urinary tract infections; high RN turnover doubles pressure injury rates. Turnover ultimately results in fewer caregivers taking on more responsibilities, leading to poor care quality in some settings.

Strategies for implementing EBP

Overcoming challenges to implementing EBP in LTC facilities requires making a commitment to staff training, getting staff buy-in, addressing high turnover rates, enlisting advance practice registered nurses (APRNs), and collaborating with other LTC facilities and academic institutions.

Make a commitment to geriatric and EBP training

Staff development sessions for CNAs positively impact resident outcomes, especially for pain, falls with injury, weight loss, use of psychoactive medications, and depressive symptoms. Staff education facilitated by nurse leaders should include both informal and formal learning opportunities tailored to meet individual facilities’ needs. Nurses can begin by encouraging staff (as well as families and residents) to visit hign.org/consultgeri/elearning a clinical nursing website established and maintained by the Hartford Institute for Geriatric Nursing. All content (including podcasts, geriatric protocols, evidence-based assessment instruments, and continuing education opportunities) on the site can be accessed for free.

Short educational programs for staff can be offered each month to address topics such as mealtime difficulties, fluid overload, frailty, or sleep problems. Varying learning styles can be supported by providing access to audio, visual, and printed material. A selected monthly topic can be discussed at staff meetings, at team huddles, or in lunch-and-learn sessions. Nurse leaders also can ask family members if they have topics they’d like to review and discuss with staff. Quality improvement (QI) projects are another way to integrate EBP. (See Combining QI and EBP.)

Get staff buy-in

Successfully integrating EBP requires staff buy-in. Allowing staff to contribute to change at every opportunity empowers them to identify problems, share ideas for practice change initiatives, and improve their clinical practices. When nurse leaders introduce EBP, they must acknowledge and value input from direct care staff who spend the most time with residents and are most likely to recognize new concerns—such as skin changes, weight loss, cognitive changes, or deficits—and can identify opportunities for an EBP project.

Nurse leaders also can involve QI champions who help evaluate intervention effectiveness and provide direction to improve outcomes. QI champions assist in the EBP process, integrating research evidence with clinical expertise and resident input. They facilitate EBP implementation on their units, lead QI teams, encourage staff in QI initiatives, and advocate for practice change. Designating CNAs or LPNs as QI champions validates their importance and demonstrates the belief that they can help improve care quality and resident outcomes. Partnering staff who have QI experience with new hires creates an opportunity for sharing and mentoring. Forming EBP teams, led by a QI champion, can inspire staff to make practice changes and influence EBP adoption. (See Valuing the team.)

Address high turnover and job dissatisfaction

Reducing turnover rates ensures care continuity, ultimately improving resident outcomes, and may improve EBP success. CNA satisfaction is tied to a number of factors including adequate staffing, residents’ overall satisfaction, and management. Nurse leaders can help ensure adequate staffing levels by remaining supportive of CNA staff, demonstrating empathy, and modeling collegial and respectful relationships. CNAs who believe that supervisors are their advocates are more likely to remain in their jobs. Supportive leaders who empower CNAs, giving them greater autonomy in decision-making, will enhance job satisfaction and lower turnover rates.

Enlist APRNs

APRNs employed in LTC facilities can enhance EBP implementation by providing clinical expertise, helping the LTC team reflect on clinical issues, and encouraging clear communication between residents, families, and the LTC team when developing and implementing care plans and practice changes. They also can serve as mentors and leaders, conduct education and training activities, and participate in QI projects. According to Rantz and colleagues, APRNs working in LTC facilities improve care quality, decrease hospital admissions and readmissions, improve health outcomes, and decrease spending.

Partner with other LTC facilities and academic institutions

LTC facility leaders should consider collaborating with other LTC facilities to share best practices, education initiatives, clinical concerns, QI projects, clinical guidelines, and the latest evidence-based clinical recommendations to encourage EBP uptake and sustainability. Learning about successful QI projects and EBP initiatives can help staff reflect on their current practices and consider trying what has worked for others.

Some LTC facilities can collaborate and draw support from academic institutions. Collaborating with faculty on research initiatives might expose LTC staff to research and encourage doctor of nursing practice students interested in LTC to initiate QI projects. Academic partnerships can foster access to the EBP process and guide staff in interpreting the literature and applying standardized guidelines.

Initiate, support, and reward

Healthcare systems benefit when they deliver evidence-based care that improves residents’ health outcomes. Implementing EBP into LTC can be challenging, but it’s possible when leaders initiate, support, and reward positive practice changes that lead to improved resident outcomes.

Jill Brennan-Cook is an assistant clinical professor of nursing at Duke University School of Nursing in Durham, North Carolina.

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