Evidence-based nursing

Evidence-Based Nursing or EBN is a type of evidence-based healthcare, drawing on some of the traditions of evidence-based medicine. It involves identifying solid research findings and implementing them in nursing practices, in order to increase the quality of patient care. The goal of EBN is to provide the highest quality and most cost-efficient nursing care possible. EBN is a process founded on the collection, interpretation, and integration of valid, important, and applicable research. Some define EBN tightly, considering only the application of the findings of randomized clinical trials, while others also include the use of case reports and expert opinions.[1] In order to practice evidence based nursing, practitioners must understand the concept of research and know how to accurately evaluate this research. These skills are taught in modern nursing education and also as part of professional training.

The 5 steps of EBN

he first step is to select a topic. Ideas come from different sources but are categorized in two areas: Problem-focused triggers and Knowledge focused triggers(see below). When selecting a topic, nurses should formulate questions that are likely to gain support from people within the organization. An interdisciplinary medical team should work together to come up with an agreement about the topic selection. The priority of the topic should be considered as well as the severity of the problem. Nurses should consider whether the topic would apply to many or few clinical areas. Also, the availability of solid evidence should be considered because providing proof of the research will increase staffs' willingness to implement into nursing practice.
[edit] Problem & Knowledge Focused Triggers

Problem focused triggers are identified by health care staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems. Problem focused triggers could be clinical problems, or risk management issues. Knowledge focused triggers are created when health care staff read research, listen to scientific papers at research conferences or encounter EBP guidelines published by federal agencies or organizations. Knowledge based triggers could be new research findings that further enhance nursing, or new practice guidelines. It is important that individuals work closely together to reach the optimum outcome for the chosen topic. Some things that would ensure collaboration are working in groups to review performance improvement data, brainstorming about ideas, and achieving consensus about the final selection.1

[edit] Form a Team

Some might become overwhelmed when they first learn about EBP and apply it for reasons other than improvement of patient care. Forming a team increases the chance of EBP being adopted. A team becomes paramount in implementation, and evaluation of the EBP. It is important to have representatives of the team from authority members of the organization and also grassroot members. It is also important to consider interdiscipline involvement to decrease rejection, and for all to have an understanding of the project. All these individuals have a great impact on the possibility of successful implementation. Other factors to put into consideration include power figures in the organization who may directly or indirectly sabortage the efforts if they are not consulted, and fully included in EBP implementation. The EBP team should have explanations that clearly define the types of patients, setting, outcomes, interventions and exposures. This should be in simplified language that is comprehensible to a lay person. The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitable and their role becomes pivotal. The approach they adopt and their ability to educate the coworkers, answer their questions, and clarify any misconceptions greatly improves the outcomes.
[edit] Evidence Retrieval

One of the most challenging issues in using EBP in the clinical setting is learning how to adequately frame a clinical question so that an appropriate literature review can be performed. When forming a clinical question the following should be included: the disorder or disease of the patient, the intervention or finding being reviewed, possibly a comparison intervention, and the outcome.[2] An acronym used to remember this is called the "PICO" model:
P = Who is the Patient Population? I = What is the potential Intervention or area of Interest? C = Is there a Comparison intervention or Control group? O = What is the desired Outcome?

Once the topic is selected, the research relevant to the topic must be reviewed, in addition to other relevant literature. It is important that clinical studies, systematic reviews, (including metaanalyses, metasyntheses and meta-aggregation) and well-known and reliable existing EBP guidelines are accessed in the literature retrieval process. With the internet at ones fingertips, a plethora of research is just a few clicks away. However, just because you found it in a respectable journal does not signify high quality research. When reviewing any article for evidence retrieval read it very closely. Articles can appear to be precise and factual on the surface but with further and much closer examination, flaws can be found. The article can be loaded with opinionated and/or biased statements that would clearly taint the findings, thus lowering the creditability and quality of the article. Use of rating systems to determine the quality of the research is crucial to the development of EBP. There are several rating systems

available online. The National Guideline Clearinghouse is a database of published EBP guideline abstracts.[3] Time management is crucial to information retrieval. Nurses making their way through the vast amount of research available may find it helpful to read research articles or critical reviews instead of clinical journals. To maintain high standards for EBP implementation, education in research review is necessary to distinguish good research from poorly conducted research. Equally important is that the materials being reviewed, consider if they are current.[
Apply the Evidence

After determining the internal and external validity of the study , a decision is arrived at whether the information gathered does apply to your initial question. Its important to address questions related to diagnosis, therapy, harm, and prognosis. The information gathered should be interpreted according to many criteria and should always be shared with other nurses and/or fellow researchers.[5]

[edit] Qualitative Research Process

One method of research for Evidence based practice in nursing is 'Qualitative Research': "The word implies a entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity." With qualitative research, researchers learn about patient experiences through discussions and interviews. The point of qualitative research is to provide beneficial descriptions that allow insight into patient experiences. "Hierarchies if research evidence traditionally categorize evidence from weakest to strongest, with an emphasis on support for the effectiveness of interventions. That this perspective tends to dominate the evidence-based practice literature makes the merit of qualitative research unclear;" 1 Some people view qualitative research as less beneficial and effective, with its lack of numbers, the fact that it is "feeling-based" research, makes the opponents associate it with bias. Nevertheless, the ability to empathetically understand an individual's experience (whether it be with cancer, pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care workers providing care. For qualitative research to be reliable, the testing must be unbiased. To achieve this, researchers must use random and non-random samples to obtain concise information about the topic being studied. If available, a control group should be in use, if possible with the qualitative studies that are done. Evidence should be gathered from every available subject within the sample to create balance and dissolve any bias. There should also be several researchers doing the interviewing to obtain different perspectives about the subject. Researchers must also obtain negative information as well as the positive information gathered to support the data. This will help to show the researchers were unbiased and were not trying to hide negative results from readers, and actually makes it possible to objectively understand the phenomenon under investigation. The inclusion of this negative information will strengthen the researchers initial study, and may actually work in favor to support the hypothesis. Any data that has been gathered must be appropriately documented. If the data collected was obtained from interviews or observation, it must all be included. Dates, times and gender of the sample may be needed, providing

background on subjects, such as breast cancer in women over thirty-five. Any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy. In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials. Within this context qualitative research findings are considered to have little value and the old debate in nursing has been re-ignited related as to whether qualitative versus quantitative research findings provides the best empirical evidence for nursing practice. In response to this crisis qualitative scholars have been called upon by leaders in the field to clarify for outsiders what qualitative research is and to be more explicit in pointing out the utility of qualitative research findings. In addition, attention to "quality" in qualitative research has been identified as an area worthy of renewed focus. Within this paper two key problems related to addressing these issues are reviewed: disagreement not only among "outsiders" but also some nursing scholars related to the definition of "qualitative research", and a lack of consensus related how to best address "rigor" in this type of inquiry. Based on this review a set of standard requirements for qualitative research published in nursing journals is proposed that reflects a uniform definition of qualitative research and an enlarged yet clearly articulated conceptualization of quality. The approach suggested provides a framework for developing and evaluating qualitative research that would have both defensible scholarly merit and heuristic value. This will help solidify the argument in favor of incorporating qualitative research findings as part of the empirical "evidence" upon which evidence-based nursing is founded.

[edit] How to Critique a Research Article

The critiquing process is the building block and foundation for the multiple steps that are to follow in the successful implementation of EBP. This is so because you must first ensure that the material and research that you are trying to convince others to accept is reliable and accurate. By taking the time to thoroughly critique a study you can point out both the strengths and weaknesses of the findings and weigh them accordingly. Successful completion of this vital step will help "weed out" the material lacking the needed proof of effectiveness, therefore minimizing useless, or even harmful, implementation of new practices in the healthcare field. Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) an article. In analyzing a research report, the reader must evaluate each step of the research process and ask questions about whether each step of the process meets the criteria. Remember when you are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique an article you must have some knowledge on the subject matter. There is no replacement for reading the article many times. The reader must search the article for contradictions, illogical statements, and faulty reasoning. It is important to evaluate every section of the research article. Each section has different criteria to meet, in order to be considered a well-written addition to the article.

[edit] Introduction, Purpose, and Hypothesis

Introductions need to at least include a literature review and a purpose statement, but they may also contain a theoretical framework, a research question, and a hypothesis. The research question presents the idea that is to be examined in the study and is the foundation of the research study. A well-developed research question guides a focused search for scientific evidence about assessing, diagnosing, treating, or assisting patients with understanding of their prognosis related to a specific health problem. The hypothesis attempts to answer the research question. A hypothesis is a declarative statement about the relationship between two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement, implications regarding testability, and consistency with a defined theory base. They can be formed by either a directional or nondirectional method. The literature review needs to explain the reason the study was conducted and why it was important for the study to be conducted now. The theoretical framework and the literature review should also work together. The purpose statement needs to explain what the study wants to accomplish. The purpose, aims, or objectives often provide the most information about the intent of the research question and hypothesis and suggest the level of evidence to be obtained from the findings of the study. The introduction should cover these topics, and should not throw in a lot of excess, useless knowledge. The research question, hypothesis, and the study should all correlate together. You have to be careful when critiquing research articles because sometimes researchers will try to cover up a poor study with lots of information that does not belong. It may look good to the reader at first glance so it is always a good idea to reread the articles a few times to fully understand it and to see if there are any discrepancies.
[edit] Methodology

The methodology section must start off by gathering a sample. There are a few definitions you must understand first. 'Population' is the group that you want you study findings to apply to. A 'sample frame' is the target population, in which the study will affect. There are three different ways to select a population. The researchers can choose who they want in the study, the participants can choose if they want to be in the study, or it can be a random selection in which neither the researcher or the participant chooses. The study must either have external validity or internal validity. If the study has external validity then the study's findings have different settings, procedures, and participants. External validity will also question what types of subjects and conditions in which the same results can be expected to occur. If the study has internal validity then the findings are held true within the sample. The researchers will rule out factors or threats as rival explanations of the relationship between the variables that are present. Be careful with internal validity and external validity because there are a number of threats for both that can affect the outcome of the study. These should be considered by the researchers who are planning the study and by consumers before implementing the results into practice. Phenomenological method In qualitative research phenomenological methods are used to learn and construct the meaning of the human experience through intensive dialogue with persons who are living the experience. The researcher's goal is to explain the meaning of the experience to the participant. This is achieved through a dialogic process, which is more than a simple interview.

[edit] Results and Discussion

The results section puts forth the findings of a study in a clear, logical, and unbiased manner. It presents the findings according to the variables studied without extrapolating beyond what those variables yielded. Qualitative studies do not contain statistical tests. Therefore, the themes, concepts, observational or print data are described in the "Methods" or "Data Collection" subtitles and are reported in the "Results" or "Findings" section. A good results section should also make use of descriptive statistics. Descriptive statistics are used to summarize, reduce, and organize the data and characteristics of the data into an easily understood, manageable format. Finding data's mode, median, and mean are three techniques used to easily recognize central tendency. Techniques such as range and standard deviation are used to measure variability and scatter plots are used to measure correlation. After analyzing the data and finding central tendency, variability, and correlation, this information should be worked into an easily understood format such as a frequency distribution table, chart, or graph. The reader should be able to easily recognize and interpret the data. However, the reader must be on alert to recognize that this may yet be another opportunity for the author of the study to make the results appear more grandiose than they are. Always look at what the actual numbers amount to instead of just looking at how significant the graph or chart makes the data look. In a good results section, the author will not try to make insignificant data look significant, but simply show the results. If the numerical data of a study does not show the same claims that the researcher stated then this is a major flaw in the study and raises significant concerns about the study's validity and reliability; therefore, a nurse and other healthcare providers should not only stay current on new research but should be able to decipher the research in order to determine its true value to the medical practice. The very last section of a research study is known as the discussion section. Here, the researchers draw all the pieces from the study together to present the whole picture. The researchers review the literature and discuss how the results compare and contrast previously completed studies. The researchers often present biased opinions in the discussion section but these should always be supported by the research and not just the interpretation of the researchers. This overview of the study serves to make a comparison with the background literature. The results and discussion sections can sometimes be combined into one by the researcher, but normally, the researcher will report the findings into separate "results" and "discussion" sections. One way is not better than the other when it comes to combining or dividing the findings into sections. Any new or unexpected results are usually described in the discussion section as well.
[edit] Evaluating The Conclusion

A conclusion can be identified as paragraphs that state the main claims that came out of the findings that were read earlier in the article. It should have a summary of the findings (strengths and weaknesses), status of the hypothesis, limitations, and recommendations, implications, or applications. In each section the best and worst needs to brought forth. In a quality conclusion section the author will only state what has been found, or not, without adding anything extra. The hypothesis will be proven true or false and nothing in between. Limitations will be discussed such as the statistical framework or design errors made in the beginning. The researcher should

also present the limitations or weaknesses of the study. This presentation is important because it effect's the studies generalizability. The generalizations or inferences about similar findings in other samples also are presented in light of the findings. Recommendations will be few in quality research. If no loop holes or oversights are made at the beginning then these will not have to be expressed at the end. When all of these come together in a simplified manner then a conclusion can be considered strong. A limitation is an admission of how certain aspects of the study, such as the sampling, were not as unbiased as they should have been. This lets the reader know that improvements can be made from what was accomplished in the article. The last thing the conclusion should do is give the reader a recommendation. This recommendation should be derived from the results gathered earlier in the article. Based on the results, the reader will be able to judge whether the data and hypothesis should be applied to nursing practice.[6]

Barriers to promoting Evidence Based Practice

The use of evidence based practice depends a great deal on the nursing student's proficiency at understanding and critiquing the research articles and the associated literature that will be presented to them in the clinical setting. According to, Blythe Royal, author of Promoting Research Utilization in nursing: The Role of the Individual, Organization, and Environment, a large amount of the preparation requirements of nursing students consists of creating care plans for patients, covering in depth processes of pathophysiology, and retaining the complex information of pharmacology. These are indeed very important for the future of patient care, but their knowledge must consist of more when they begin to practice. Evidence based nursing in an attempt to facilitate the management of the growing literature and technology accessible to healthcare providers that can potentially improve patient care and their outcomes.[7] Nancy Dickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change agents in creating and implementing community and population-focused health systems."[8] There is also a need to overcome the barriers to encourage the use of research by new graduates in an attempt to ensure familiarity with the process. This will help nurses to feel more confident and be more willing to engage in evidence based nursing. A survey that was established by the Honor Society of Nursing and completed by registered nurses proved that 69% have only a low to moderate knowledge of EBP and half of those that responded did not feel sure of the steps in the process. Many responded, "lack of time during their shift is the primary challenge to researching and applying EBP."[9] There is always and will always be a desire to improve the care of our patients. The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of evidence based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of literature not just the basics. There is a definite need for nurses, and all practitioners, to have an open mind when dealing with the modern inventions of the future because these could potentially improve the health of patients. There are many barriers to promoting evidence based practice. The first of which would be the practitioner's ability to critically appraise research. This includes having a considerable amount of research evaluation skills, access to journals, and clinic/hospital support to spend time on

EBN. Time, workload pressures, and competing priorities can impede research and development. The causes of these barriers include nurse's and other professional practitioners lack of knowledge of research methods, lack of support from professional colleagues and organizations, and lack of confidence and authority in the research arena.[10] Another barrier is that the practice environment can be resistant to changing tried and true conventional methods of practice. This can be caused because of reluctance to believe results of research study over safe, traditional practices, cost of adopting new practices, or gaining momentum to rewrite existing protocols. [11] It is important to show nurses who may be resistant to changes in nursing practice the benefits that nurses, their patients, and their institutions can reap from the implementation of evidencebased nursing practice, which is to provide better nursing care.[12] Values, resources and evidence are the three factors that influence decision-making with regard to health care. All registered nurses and health care professionals should be taught to read and critically interpret research and know where to find articles which relate to their field of care. In addition, nurses need to be more aware of how to assess the information and determine its applicability to their practice.[13] Another barrier to implementing EBN into practice is lack of continuing education programs. [14] Practices do not have the means to provide workshops to teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed dismissed. If this occurs, valuable treatments may never be utilized in patient care. Not only will the patients suffer but the staff will not have the opportunity to learn a new skill. Also, the practitioners may not be willing to implement change regardless of the benefits to patient care. Another barrier to introducing newly learned methods for improving treatments or patients' health is the fear of "stepping on one's toes". New nurses might feel it is not their place to suggest or even tell a superior nurse that newer, more efficient methods and/or practices are available. The perceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising. Resistance to change and to authority is part of human nature. When we make decisions based upon good quality information we are inconsistent and biased. Human nature offers many challenges to evidence-based practice. Can we do a better job of promoting evidence-based practice? And even if we find and use the evidence, will we make consistent unbiased decisions? Even if clinicians do act consistently it is possible that their decisions are consistently biased. People put different values on gains and losses. Tversky and Kahneman gave people the two identical problems (with the same probabilities of life and death outcomes - see fig 1) but framed the outcome choices as either lives saved or as deaths.10 Most people wanted to avoid taking risks with gains which could be safeguarded, but would take risks with losses which might be avoided; this is a framing effect. If people are given identical options but different words are used to emphasize a gain rather than a loss, then a different response is given by a large proportion of the population under study. Such a change in response appears to be inconsistent

Implementing Evidence-Based Nursing Practice

A methodology for establishing and supporting evidence-based nursing practice is examined. Description of a clinical and administrative scenario serves as an example of a systematic appraisal of the relevant literature that had implications for clinical practice.
Abstract

Within the nursing profession, it is expected that new information in the form of research findings will be incorporated constantly and knowledgeably into nursing practice. The staff nurse is a critical link in bringing research-based changes into clinical practice. Depending on the environment, a health care organization may or may not have the resources to ensure critical, succinct, reasonable evaluation and application of research findings as they relate to the point-ofcare delivery. Health care organizations are beginning to create mechanisms to facilitate the process of information translation from the literature to practice.
Introduction

The Purpose of this article is to describe a methodology for establishing and supporting evidence-based nursing practice (EBNP). After establishing the background for this project, authors describe a clinical and administrative scenario in which an issue was identified that warranted a systematic appraisal of the relevant literature to inform clinicians. An operational definition for EBNP is presented, and a conceptual framework for translating evidence into practice is outlined. Next, a case study is presented to describe the process of critically appraising the evidence and translating the findings into nursing practice, education, and administration. The clinical and administrative outcomes are highlighted and the roles of EBNP team members explained. The hospital described in this article has 205 licensed beds, 15 operating rooms, and a level II emergency department. Inpatient specialty units include critical and intermediate care as well as several medical/surgical units serving various specialties (orthopedics, neurology and neurosurgery, hematology and oncology, bone marrow transplant, solid organ transplant, cardiology, and cardiac surgery). The environment is technology based, with an electronic medical record for all nursing documentation, telemetry available to each inpatient bed, an epilepsy monitoring unit, electronic supply charging, filmless radiology, wireless phones for each nurse, and a robotic surgical system. The hospital staff members are registered nurses assisted by patient care assistants. Staff participation in nursing committees is encouraged. Support staff include unit-based educators and specialty-based clinical nurse specialists (CNSs). Participation in nursing and other clinical research studies is encouraged. In examining the issue of translating research-based evidence into practice, authors focused on collaboration, service, and integration. Each of these components figures prominently in the work performed at the medical center. The approach selected to use research in practice reflects

the structure and mission of the organization, which is to provide the best care for the patient using the three "shields" of practice, education, and research. The themes of collaboration, service, and integration were used to weave together the expertise of library sciences and nursing services as well as collaboration among the nursing practice subcommittee (NPS), the nursing education subcommittee (NES), and the nursing research subcommittee (NRS). This project is an example of the integration of the work of these three subcommittees that was presented to the nursing staff in an attempt to identify the best possible service for patients.

Nursing Innovations
By David Ollier Weber A number of initiatives founded by nurses have saved countless lives and millions of dollars.

David Ollier Weber

We all know what nurses do. Well, to be sure, some fly in helicopters. Some deliver babies. Some sit at the head of an operating table administering anesthesia. Some oversee the front-line primary care of patients at clinics and neighborhood medical offices. Some teach in colleges and universities. Some serve as senior executives of hospitals and medical enterprises. Mostly, though, we think of nurses as tending the sniffles and skinned knees of schoolchildren, staffing physician practices, bustling among the elderly in nursing homes and solicitously bending over patients in hospital ICUs and medical units. Those really are the settings in which the vast majority of registered nurses work. They pop into rooms to deliver medications, change IVs, re-bandage wounds, check vital signs and, in the process, maybe fluff a pillow, empty a bedpan and murmur an encouraging word. They walk on soft soles. They hunch in the dim light of nursing stations, carefully charting. They speak in low, soothing tones. Nurses are consistently ranked by respondents to the Gallup Poll as the most trusted, most honest and ethical of American workers. Thats no small point of pride to Pat Ford-Roegner, M.S.W., R.N. But as president of the American Academy of Nursing (AAN), she wants the world to know that her profession has more to contribute than stereotypical, susurrous bedside TLC. At a time when the U.S. health care system is displaying all the signs of septic shock inaccessible to many, expensive for most and fragmented for all, the AAN summarizes

Ford-Roegners organization has launched a campaign, Raise the Voice, to bring nursing into deliberations over how to resuscitate the failing patient. Cases in Point In fact, nurses can already point to dozens of remarkably effective initiatives theyve spearheaded to improve the quality and, concomitantly, the scope, equity, efficiency and economy of American health care. Consider these nurse-driven programs and their results: Evercare. Introduced in 1987 by two Minnesota nurse practitioners, Jeannine Bayard and RuthAnn Jacobson, the Evercare model today serves more than 120,000 people in 35 states through Medicaid, Medicare and private-pay health plans. Evercare was designed to overcome the fragmentation of resources that drive up medical costs and contribute to poor outcomes for people with long-term or advanced illnesses, the elderly and those with disabilities. The Evercare model places a nurse practitioner or care manager at the center of an integrated team that includes the enrollees physicians, family members and nursing home staff or representatives from community service agencies. Working with the enrollee and the care team to develop a personalized plan, the nurse practitioner or care manager coordinates multiple services, facilitates communication among the various physicians, institutions, patients and their families, and helps ensure effective integration of treatments. Where Evercare has been adopted, it has reduced hospitalizations for nursing home residents by 45 percent and cut emergency room trips by 50 percent. The state of Texas estimated that it saved some $123 million in Harris County alone between February 2000 and January 2002 by implementing this nurse-inspired innovation. Nurse-Family Partnership. Headquartered in Denver, the Nurse-Family Partnership serves first-time mothers in low-income families in more than 280 counties in 23 states across the nation. Under the program, a registered nurse provides in-home advice and care to primiparous women through frequent visits14 during pregnancy, 28 during infancy and 22 during the toddler stageover a two-and-a-half-year period. The Nurse-Family Partnership has shown dramatic results. Studies indicate pregnancy-induced hypertension among participating women is reduced by 35 percent, preterm deliveries for women who smoke are reduced by 79 percent, child abuse and neglect is reduced by 50 percent, emergency room visits are reduced by 35 percent overall and by 56 percent for accidents and poisoning, and language delays in children at 21 months of age are down 50 percent. Indeed, the Washington State Institute for Public Policy found that the program had the highest return on investment among all home visiting and child welfare programs evaluated, with a net benefit to society of $17,180 (in 2003 dollars) per family served$2.88 saved for every dollar invested. Family Health and Birth Center. Founded by Ruth Watson Lubic, Ed.D., R.N., and housed in a former supermarket in a low-income section of Washington, D.C., this exemplary facility provides modern birthing, comprehensive womens and childrens health care, social support, and early childhood development services in a nurse-driven setting.

Backed by hospital obstetrical and gynecological consultants, nurse midwives at the Family Health and Birth Center delivered 150 babies in 2006, 25 percent at the facility. After less than six years of operation, the program in 2005 recorded a 9 percent preterm birthrate as compared with 14.2 percent for the District of Columbia overall, a low birth weight incidence of 7 percent compared with 14.6 percent, and a Caesarean section rate of 15.3 percent versus 29 percent. Those achievements in a medically underserved community translated to reduced costs for the District of Columbias health care system of at least $1.15 millionmore than the centers total annual operating budget. 11th Street Family Health Services, Drexel University. This nurse-managed center, founded in 1998, brings a full range of primary care, dental, behavioral health, health promotion, and disease prevention services to residents of four public housing developments and their surrounding urban community in Philadelphiawhere 57 percent of patients are covered by the state Medicaid plan and 33 percent are uninsured. No one who shows up at 11th Street is turned away. In 2005-06, more than 19,000 visits were recorded. Not only does the center provide one-stop shopping for health concerns to its largely African-American clients, it boasts a fitness center, a teaching kitchen, and weekly distribution of fresh fruits and vegetables. Almost 8,000 primary care visits took place in 2006, with significant documented benefits to patients. Hemoglobin A1C levels among 11th Streets diabetic patients were reduced by 20 percent; almost 70 percent of hypertensive program clients now have their blood pressure under control (for African-Americans that far exceeds the nationwide 2010 goal of 50 percent, from a 2000 national baseline of 19 percent); immunization rates for adults were increased by 14 percent; and sharp improvements were recorded in the number of low birth-weight babies, depression rates in vulnerable adults with chronic illness and breast cancer screening rates. APN Transitional Care Model. Poor hospital discharge planning and follow-up of elderly patients frequently results in costly and debilitating readmissions that could have been prevented. Aetna and Kaiser Permanente are now testing a model developed at the University of Pennsylvania School of Nursing under which advanced practice nurses (APNs, all of whom have masters degrees) establish a relationship with patients and their families soon after hospital admission; design the discharge plan in collaboration with the patient, the patients physician and family members; and implement the plan in the patients home following discharge, substituting for traditional skilled nursing follow-up. Three clinical trials funded by the National Institute of Nursing Research confirmed that the APN Transitional Care Model improves quality and substantially decreases health care costs. Compared with standard care there are longer intervals before initial rehospitalizations, fewer rehospitalizations overall, shorter hospital stays and greater patient satisfaction. In a four-year trial with a group of elderly patients hospitalized for heart failure, the APN Care Model cut inpatient costs by more than $500,000 compared with a group who received standard carefor average savings of approximately $5,000 per Medicare patient. Edge Runners

Those are just a handful of 35 thoroughly documented innovationsall readily replicable and adaptabledesigned by nurses and outlined on the AAN Web site. Each was formulated by what the organization lauds as edge runnersnurses whose ability to think outside conventional boxes spurred major improvements in local, regional and even national health care delivery. (Each profile also includes the telephone number and e-mail address of a contact person for more information.) Funded by the Robert Wood Johnson Foundation, the Raise the Voice campaign kicked off in November 2006 to highlight nursings leadership in devising practical solutions to health cares systemic problems, declares Ford-Roegner. Donna Shalala, president of the University of Miami and former Secretary of Health & Human Services, chairs its prestigious national advisory board. Health care reform was a major issue in the 2008 presidential election; it will clearly command the attention of legislators, physician organizations, insurers, purchasers, pharmaceutical and medical technology companies, hospital executives, academics, and consumer groups throughout the country in the months ahead. Nurses have ideas and need to be engaged at the highest level of discussion, emphasizes FordRoegner. After all, whether its you whos sick or its your health care system, who are you going to call? You could do worse than to start with the advice of a nurse. David Ollier Weber is principal of The Kila Springs Group in Placerville, Calif. He is also a regular contributor to H&HN Weekly.