Implementing an evidence-based practice (EBP) change with healthcare professionals in a medical setting can be daunting, but implementing it in a practice where some staff members are not medical clinicians presents unique challenges. This article discusses an EBP change for the treatment of acne in adult women by nonmedical clinicians in a medical spa setting.

Background

In this medical spa, patients are seen by members of various disciplines who have differing clinical expertise. Most acne patients are women between the ages of 20 and 60, and they are treated by one or more of the following: a plastic surgeon, a nurse practitioner specializing in aesthetics, a medical assistant, and several estheticians and skin care consultants. The medical assistant, estheticians and skin care consultants are referred to here as "clinicians."

The clinicians exhibited significant disagreement about best practices and the appropriate regimen for patients with acne. As a result, treatment was inconsistent and was often based on each clinician's particular knowledge of acne treatments (usually for adolescents) combined with his or her experience. These treatments were often suboptimal because they did not use the most appropriate scientific methods available. In addition, the treatments selected were often inappropriate for the severity of the patient's acne. For example, clinicians often recommended expensive light-based treatments as a first-line therapy, with no analysis of scientific studies and without using scientifically based guidelines to determine first-line treatment options. Patients expressed frustration and dissatisfaction with treatment outcomes.

The Goal

The goals of this practice change were to improve the selection of appropriate evidence-based treatment based on acne severity, to produce consistent recommendations by all staff members, to increase the number of satisfied patients, and to increase the number of patients who receive appropriate follow-up. The overriding question we grappled with was, "How do you implement an evidence-based practice among staff members who are not medical clinicians?"

Barriers to successful implementation of EBP interventions are often related to the intervention process itself. A critical but often underused step is a planning phase. Organized team processes, documented plans for intervention, and ongoing evaluation are essential. One of the most important components in facilitating interventions is the development of educational materials that include "how to" guides providing direction on how to anticipate and address barriers.¹i>

Several concepts must be considered when implementing clinical interventions for a change in practice. The following five basic steps should be followed:²

1. Clearly define the purposes or goals of the intervention.

2. Identify the scientific and conceptual framework of the intervention.

3. Develop a detailed step-by-step written protocol for the intervention.

4. Train the clinicians to consistently deliver the intervention and to carefully follow the protocol.

5. Monitor the consistency of intervention delivery over time.

Step 1 requires identification of the specific health problem, the target population and the expected positive outcome. Step 2 requires a thorough literature review to assist in developing an understanding of the conceptual and theoretical issues related to the problem and target population.

In Step 3, a step-by-step protocol should be written. Each step should be justified based on the conceptual framework of the intervention. The protocol must be compatible with the setting. Policies, procedures, provider roles and available resources should also be considered. The intervention must be realistic based on the capabilities, limitations, resources and needs of the population. The duration and frequency of treatment should also be included in the protocol.

Step 4 underscores the need for consistent delivery. This can be achieved by appropriately training the clinicians who will provide the intervention. Step 5 requires monitoring of the consistency of delivery over time.²

Readiness for Change

Organizational assessment and identification of barriers are critical to determining an organization's readiness for change. Staff members may be skeptical or have misperceptions about EBP, which can affect the success of the project.³Allowing free expression about the planned change, without negative recourse, can help.

Individual personality styles must be considered when any type of change is implemented.³Each person responds in his or her own ways, and knowledge of how to elicit cooperative behavior from each will make implementing a new practice much easier. Time spent observing and listening to team members is time well spent.

A written plan should identify goals, and goals should be set high enough to allow growth in each person, but not so high as to be unachievable and frustrating to the staff.³The timeline and steps for change constitute the written plan for accomplishing the described vision. Communicating a clear vision and defining each person's role in the practice change are essential for success.

Involving team members promotes buy-in and commitment to the project. This involvement can be accomplished by soliciting input and feedback and by asking for volunteers for various aspects of the practice change. People who contribute in this manner then have a vested interest in ensuring the success of the project, because it becomes their project as well.

For any practice change, gaining the support of the administration is paramount. Administrative support in the form of removing roadblocks and providing manpower hours, office supplies and support material for institutional review board (IRB) approval will add to the success of the project. Explain to the administration that the use of EBP will provide improved outcomes and increased patient satisfaction, which translate into happy customers. Happy customers improve the bottom line, and this is a concept easily understood by any administration.

Framework for Practice Change

To guide the EBP change project to address acne in women, we used the Iowa Model of Evidence-Based Practice to Improve Quality Care.³This model was developed to guide changes in an organization and was the most applicable to our practice setting (see figure). ³ he starting point for a practice change usually is an identified problem. Inconsistent, nonevidence-based treatment of the adult woman with acne was our problem-focused trigger. This problem became a priority because consistent application of treatment for this condition was mandated by the organization's medical director, who also wanted it backed up by written protocols with policies and procedures.

Implementing Change

Following the algorithm of the Iowa model, we formed a team consisting of skin care consultants, medical estheticians, the facility manager and the nurse practitioner (the author). The mandate by the medical director led to a literature review for evidence that might answer the question, "What is the most appropriate treatment for acne in the adult woman?"

I presented the literature review and evaluation of evidence to the team at a monthly meeting. The team determined that there was sufficient evidence to be applied to the treatment of adult women with acne. The team determined that I should move forward with the project and present monthly progress reports. Outcomes to be achieved were consistent evidence-based treatment, improvement of acne and improvement in patient satisfaction.

I prepared a project narrative describing the steps involved in implementation and tools to measure project outcomes and submitted these to the team. We secured IRB approval after obtaining a letter of support from the facility manager.

The proposed EBP change included the development of evidence-based treatment protocol algorithms specific to adult women with acne. These algorithms were based on severity and used treatments identified in evidence-based guidelines and recommendations for the treatment of acne.^4-7?We drafted algorithms and submitted them to the team for feedback. The algorithms were also posted in the staff break room for those not involved in the project to review and provide feedback.

I developed patient educational components and staff training materials, and I sought feedback from the team for the patient education components. I also developed "how to" guides about anticipating and addressing barriers to practice change. The team wrote a step-by-step protocol for interventions that included policies and procedures and roles of clinicians. These were accepted by consensus.

The role of the clinicians in this project, which was agreed on and used in training staff, was defined as follows: The clinician plays an important role in the treatment of acne. It is important that clinicians follow the protocol that has been established, so that all patients are treated in a consistent manner. The clinician may be the difference in whether or not the patient is successful with her acne treatment. Time spent educating the patient about the lengthy nature of acne treatment is of utmost importance. Support and education of the patient are essential components of the acne treatment protocol.

The five basic steps for designing and implementing practice changes involving clinical interventions served as a guide for development of the interventions.² raining in the use and implementation of the finalized protocol algorithms occurred at a special training session prior to initiation of the project. Step-by-step protocols for interventions, policies, procedures and staff roles were presented during the training session and at a facility-wide meeting.

he algorithms were designed to be easy to use, because various disciplines with varied clinical experience background and education would follow them. By following the Acne Management Algorithm, each clinician has the ability to choose the appropriate treatment regimen once the severity of acne has been determined and the corresponding algorithm has been identified.^4-7The clinician chooses the appropriate dosage and frequency of the medication indicated on the algorithm by consulting an associated list, with decisions based on personal preferences of the clinician or patient, and with insurance coverage taken into consideration.

Outcomes Measurement

The clinicians who used the algorithms and protocols expressed satisfaction during the implementation phase of the project. This project seems to have accomplished what it was intended to do. Treatment recommendations were made based on the most appropriate scientific evidence, and they were made in a consistent manner; this was noted during chart audits and direct observations.

Moreover, acne in adult women improved. This was documented by baseline assessment at the initial visit in comparison with assessment at the project's conclusion. We used the Investigator's Global Assessment Scale and an objective severity measurement to make this evaluation.⁸

Patients also seemed to be satisfied with their improvement and treatment. This evidence was obtained using a qualitative measurement that was established as a baseline score at the initial visit and compared with scores at the conclusion of the project.

Barriers and Challenges

The most significant challenge was educating nonmedical clinicians about EBP. Clinicians required education about the strength of evidence presented and how evidence should be evaluated. A priority was educating the clinicians that claims made by manufacturers and their sales reps should not be taken at face value, and that the studies these reps presented required evaluation for scientific strength.

This education was accomplished by presenting several studies, including randomized controlled trials, with wide variances in scientific strength. Each of these studies was analyzed individually and compared with the others. I explained the significance of the analysis and presented the comparison in table format.

Project planning with clinician involvement and input began 6 months prior to the implementation of the algorithm. Planning with clinician participation seemed to minimize barriers and resistance to implementation of the practice change. Written protocols and algorithms provided guidance for implementing the interventions. These, along with the "how to" guides, were helpful in dealing with adversity.

Setbacks and Adversity

Setbacks and adversity were addressed as they arose; no one particular approach is effective for every situation.⁹Patience and flexibility were the keys to surviving these challenges. We leaned on opinion leaders who were respected in the organization to serve as role models and to advance the implementation phase.

Their positive support of the project was sought because their influence was necessary to help diminish any problems.

Direct observation of protocol implementation and concurrent chart audits were conducted. Feedback was provided in a timely manner to ensure consistent delivery of interventions and to provide quick alleviation of any problems. The primary adversity encountered during this project was the small number of patients during the months the project was implemented, which happened to coincide with summer vacations.

Putting It Into Practice

The use of evidence-based studies by nonmedical clinicians is possible with guidance and direction. The use of EBP can be successfully implemented across multiple disciplines with appropriate planning and significant effort. Solicitation of staff input in each phase increase the likelihood of successful implementation.

With organized team processes, documented plans for intervention and ongoing evaluation, evidence-based practice intervention should be sustainable. Nonmedical clinicians can learn that not all studies are scientifically strong. They can learn to carefully consider study details to determine scientific validity. And they can follow and use evidence-based treatment protocols.

By using the Iowa model, implementation went smoothly. The most important outcome was that patients reaped the benefits of successful implementation of this evidence-based practice change.

Cindy Cobb is a women's health nurse practitioner who is the owner of Allure Enhancement Center in Lafayette, La. The content of this article reflects work she did when employed at a different medical spa. Cobb recently earned a doctoral degree in nursing practice. She has specialized in aesthetics for 7 years and has been involved in the evolution of certification options for nurses who practice in this specialty. Cobb is a new member of the ADVANCE for Nurse Practitioners editorial advisory board.

References

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4. Lauharanta J, et al. Finnish Medical Society Guidelines for Acne. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=11030&nbr=005809&string=a. Accessed Oct. 13, 2009.

5. Neely C, et al. Acne management. Institutes for Clinical Systems Improvement Health Care Guidelines. Available at: http://www.icsi.org/acne/acne_management_3.html. Accessed Oct. 13, 2009.

6. Strauss J, et al. Guidelines of care for acne vulgaris management. J Am Acad of Derm. 2007;56(4):651-663.

7. Wirth F. Approach to acne vulgaris. Available with subscription at: http://www.uptodate.com. Accessed Oct. 13, 2009.

8. Tan J. Current measures for the evaluation of acne severity. Expert Rev Dermatol. 2008;3(5):593-603.

9. National Institute for Health & Clinical Excellence. How to Change Practice: Understand, Identify, and Overcome Barriers to Change. London, England: NICE; 2007.