Adopting Best Nursing Practices

In Houston, Doris Quinn, PhD, MSN, RN, promotes evidence-based practice (EBP) using butcher paper and sticky notes in a rainbow of colors.

Some 1,500 miles northeast of her in Reading, PA, a two-pronged approach has cemented enthusiasm for EBP by encouraging bedside nurses to ask questions and utilizing advanced practice care coordinators who lead by example.

As W. Edwards Deming, the father of quality improvement using statistical evidence wrote: “It is not enough to do your best; you first have to know what to do and then do your best.”1

This is the age of nursing practice utilizing researched methods.

Case in point: the December 2011 Joint Commission annual report highlighted some 400 hospitals using EBP processes with proven positive patient outcomes.2


Magnet Research: Raising the Bar

Almost 30 years of evidence documents the program’s mission.

No one disputes the importance of caring for patients using the best research.

However, the frantic pace of healthcare today, demanding nurses care for more and sicker patients, doesn’t allow time to stop and contemplate what paradigm is best for patients.

That’s where leaders like Quinn, director of process improvement and quality education at The University of Texas MD Anderson Cancer Center, Houston, as well as the shared governance and practice council teams at Reading Hospital and Medical Center, Reading, PA, have created solutions and incentives to get nurses’ attention.

Squares, Triangles

Quinn, who worked with Deming from 1988-93, is passionate about one tool – the flowchart.

“When I die you’re going to see a flowchart on my headstone,” she jokingly said.

For Quinn, flowcharting “quantifies what care is provided, how long it takes, what it costs, and whether patients and staff are satisfied with it.”

The green, teal, pink, orange, yellow, red, tan and white squares and triangles on an MD Anderson flowchart “identify who does what, how long it takes, where there is duplication of work and where steps are wasted,” she said.

Each color represents different professionals involved in a process – pink designates nursing.

Numbers in circles just to the bottom right corner of each square indicate the time spent on a task. A sticky note arranged as a square denotes a process step. One tilted as a triangle means there is a question about this step. Arrows mean a connection to the same page or to another page of the flowchart.

The process begins with a large roll of butcher paper tacked to a wall in a conference room on the unit. All staff on that unit is encouraged to participate and outline their steps to care.

“We ask questions as the person is telling us what they do,” Quinn told ADVANCE. “The flowchart will flag where there is waste, rework and variation.” Quinn calls needless variation the enemy. “We need a consistent procedure based on evidence-based practice.”

Once the many steps in a care process are recorded, the chart is copied using an electronic drawing application, and then sent back to the unit.

“The beauty of this is some may never have seen their process set out this way,” Quinn explained. “After they receive the copy, they will go through it again and tweak it where necessary. Often when looking at it on the flowchart, a staff person will say, ‘oh, I forgot, we also do this step at this time.’ Once it’s all laid out, then we can begin to improve the process using research.”

Applying the Chart

As Quinn said, the final questions then become: “What kind of care will I give? Do I know how to do that? What is the evidence for what I am doing?”

Quinn demonstrated how mapping a process on a flowchart resolved issues with treating psychiatric patients in the emergency department at Vanderbilt University Hospital, where she was a director of improvement education and measurement until 2008.


Click to view larger graphic.


“These patients could be disoriented, combative and might even need police to calm them down,” Quinn explained.

“We asked staff to tell us what happens in detail. It took about 8 months, but every Friday for an hour or so we recorded the process step by step on a flowchart,” she said. “Everyone was involved, moving steps from one area to another to get the process down as accurately as possible.


“As we built it, what was going on became clearer,” she continued. “We learned that if patients were acting up they were put in a room with a cop, which made things worse.

“So once the flowchart was finalized, we examined the steps, streamlined the process and one refinement was to create a safe room, next to where police are housed in the ED.

“The most significant improvement was adding a psychiatric nurse in the ED.”

Encourage Questions

For nurses at the 673-bed Reading Hospital and Medical Center, the steps toward EBP begin with questions posed by nurses.

“The most important aspect to gaining buy-in to a practice change is for nurses to initiate a practice question and ask where does this go and how do we resolve this,” said Vicki Smith, MSN, RN, advanced practice care coordinator (APCC).

“We accomplish this through shared governance and our EBP internship,” added Barb Zuppa, MSN, RN, director for professional practice. “Practice and research council representatives collaboratively explore evidence that addresses clinical questions and improves care. The EBP internship provides nurses with structured time and resources to complete research projects.”

To further promote research, “we establish from day one in our RN orientation that EBP is part of our practice and provide information about resources that are available if they have questions.” Resources can include clinical nurse specialists and the APCC, of which there are several at Reading Hospital.

“We have to lead by example,” said Charlene Haley, MS, MSN, RN, CCRN, an APCC. “We have to be knowledgeable about the best practices out there and we must care for patients using those practices. When questions come up as to why we are doing that, we share that knowledge with staff.”

Barbara Romig, MSN, RN, CPHQ, director of nursing clinical practice and education, said another incentive is financial. “We recognize activities through our clinical ladder, so staff gets points for doing an EBP project. Points are required to challenge to a new level, with an increase in hourly rate for each level achieved.”

Nurses at Reading Hospital have tackled several complicated issues with EBP, among them an alcohol withdrawal assessment scale that provided greater objectivity, and a nurse-directed mobilization protocol.


Evidence-Based Case Management

Nurse case managers shepherd patients safely throughout the care continuum.

“Vicki [Smith] spearheaded that protocol,” Haley explained of the mobilization protocol. “Nurses knew it was good to get patients moving sooner to facilitate oxygenation [and] cardiac health, and prevent pressure ulcers and depression.

“We had seven different mobilization orders and once nurses fulfilled one step of the process they would have to wait for a physician order to implement the next level. And there was some confusion about nursing and physical therapy tasks,” Haley continued.


“In collaboration with intensive care, we brought the team together, researched it and put a new protocol in place that is nurse-driven and moves the patient to the next level as soon as the patient is capable.”

As evidence-based practice becomes the norm at Reading Hospital and Medical Center, nursing administration is learning there is no need to “sell” it. “More and more we hear nurses say ‘where’s the evidence for that,'” Smith said.

“When I was a bedside nurse, it wasn’t important to ask questions,” said Debra Stavarski, MS, RN, director of nursing research. “At Reading it’s encouraged.”

Gail Guterl

is a frequent contributor to ADVANCE.


1. Fischer, J. (2009). Toward evidence-based practice: Variations on a theme. Retrieved Aug. 27, 2012 from the World Wide Web:
2. Joint Commission. (2011). Improving America’s hospitals – The Joint Commission’s annual report on quality and safety. Retrieved Aug. 27, 2012 from the World Wide Web:

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