Implementation of Preoperative Education on the ...

Running head: APPROPRIATE OPIOID USE EDUCATION 1

Implementation of Preoperative Education on the Appropriate Use of Opioids

John M. Craker

Gannon University

Author Note

Requirement for: 19SPDNURS804NA: 10SP Scientific Underpinnings APN NA

1. APPROPRIATE OPIOID USE EDUCATION 2

Abstract

The current opioid epidemic has magnified the need for a multipronged approach to decrease

opioid abuse and misuse. Current evidence has revealed a knowledge gap in patient and clinician

education on the appropriate opioid use, storage, disposal, and non-opioid alternatives. Evidence

also supports that a consistently applied opioid education strategy reduced the incidence of

opioid misuse, improved opioid management, decreased opioid prescriptions, and improved

patient satisfaction. A study by Sugai et. al., found that the use of patient education utilizing

discussion and written materials was effective in reducing the use of narcotics after surgery. Of

note, 90% of the patients that received preoperative education declined a prescription for opioids

whereas 100% of the participants that did not receive the training requested a prescription. The

purpose of this project was to implement a patient education program during the preoperative

visit. The program included a face-to-face discussion of the appropriate use of opioids, proper

storage, appropriate disposal, and an overview of non-opioid alternatives for pain management.

The information was provided in the form of an informative handout that also included

additional information about opioid abuse and access to helplines. To provide a consistent

approach the preoperative clinic staff was provided an overview of the program at a pre-

implementation in-service. A structured framework using Nola Pender’s Health Promotion

Model and the IOWA Model was incorporated from implementation to evaluation of the project.

The project was successfully implemented in two rural access hospitals with continued use noted

during the ninety day post implementation evaluation. The results of this project supported

previous evidence based research findings that preoperative education on appropriate opioid use

in combination with an informational pamphlet was effective in reducing the misuse of opioids.

Keywords: patient education, opioid misuse, nursing, preoperative, literacy, guidelines


Chapter One

Introduction

There is overwhelming evidence within the literature and throughout the media that the

opioid crisis has not abated and will likely continue to escalate as a larger aging population seek

surgical interventions that will require effective pain management. Although recent

breakthroughs with non-opioid adjuncts have shown some promise the mainstay for

postoperative pain control continues to be high potency opioids. Current efforts related to

prescription management systems, treatment programs, and increased federal funding have also

had minimal effect on the epidemic.

Multiple studies have also identified that there is a significant gap in the education

patients receive regarding the appropriate use, risks, and alternatives to opioid use. The evidence

within the literature has identified the valuable role that nurses play in the education of their

patients as the primary care provider (Costello & Thompson, 2015). Unfortunately, the evidence

in the literature has also identified a gap in the knowledge base of nurses in regards to the safe

use of opioids. The literature supports that due to limited time, increased patient discharge

instructions, and daily tasks nurses are unable to effectively provide thorough patient education

during discharge. Evidence consistently supports that the majority of patients do not receive the

appropriate education regarding opioids which has contributed to opioid misuse and long-term

use (Costello & Thompson, 2015).

The literature supports that the most effective patient education occurs during the

preoperative period with face-to-face discussion in conjunction with educational materials to

review later for reinforcement of the education (De La Cruz, et. al., 2017). The literature also

supports that the lack of opioid education increases the risk of misuse, readmission, and


decreases patient satisfaction. Government agencies and accrediting bodies have mandated that

appropriate opioid education must be implemented within all healthcare facilities including rural

access hospitals as of January 1st 2019 (Joint Commission, 2018).

The most relevant barriers found in the literature are, lack of focused education, limited

time, inconsistency of materials and nursing knowledge. The literature supports that the

development of clinical and patient education is effective in decreasing opioid misuse, time

constraints can be overcome by implementing a clear but simple educational handout in

conjunction with a face-to-face discussion during the preoperative visit, and that providing

education to the nursing and clinical staff in the preoperative clinic provides the most accessible

individuals to effectively provide consistent patient education.

The clinical finding of opioid use disorder (OUD) can be a result of the misuse of

prescribed opioids. OUD has been identified as a chronic illness with frequent relapses

associated with significant increases in morbidity and mortality. The diagnosis of OUD has

replaced the previous diagnoses of opioid abuse and opioid dependence in the Diagnostic and

Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Strain, 2018). Each day opioid

related overdose claims the lives of 115 people in the United States (CDC, 2017). The misuse of

prescribed and illicit opioids has reached epidemic proportions and is recognized as the most

serious national crisis that significantly impacts public health and the socioeconomic welfare of

communities across the United States.

The Centers for Disease Control (CDC) reported that opioid related costs which include

healthcare, loss of productivity, treatment for addiction, and the criminal justice system represent

an economic burden to the United States in excess of $78.5 billion dollars per year (Florence,

2017). The current opioid epidemic continues to escalate despite increased federal funding for


addiction counseling, mental health counseling, public education, and prescription management

initiatives. Studies have established that a large portion of people using illicit drugs first became

addicted from the use of prescription opioids. Additional data has revealed that people that live in

low socioeconomic areas have a significant increase in the use of prescription and illicit drugs

(CDC). Ohio has been significantly impacted by the opioid epidemic and leads the nation in

opioid related morbidity and mortality. One of the most impacted areas within the state is

Northeast Ohio (Figure 1). This region is served by rural access hospitals and the population has

a high percentage of low income families and higher unemployment rates (The Alliance, 2018).

The CDC also reported that opioid prescriptions in rural areas remain 4% higher than

metropolitan areas.

Current research has identified the need to curb the use of narcotics in acute and chronic

pain management. A 2012 retrospective study of 391,139 patients found that for low-risk

procedures patients prescribed opioids within 7 days of their short-stay surgeries were 44% more

likely to become long-term opioid users at 1-year postoperatively compared to those who were

not given an opioid prescription (Alam et. al., 2012).

Needless to say, an effective strategy to combat the opioid epidemic will require multiple

levels of intervention and the implementation of preventative measures such as patient and

clinician education on the appropriate use of opioids including the risks associated with their use.

To stem the tide of opioid misuse every clinician should investigate how their unit or facility can

incorporate evidence based interventions to decrease potential unwarranted access to opioids or

maximize the use of evidence based alternatives for pain management such as multimodal

therapies.


The purpose of this project was the implementation of an evidence based quality

improvement program to provide patient education on the appropriate use, alternatives, disposal

and storage of opioids. This included a step by step overview as well as a comprehensive

evaluation of the outcomes and potential barriers. The project framework was guided by Nola

Pender’s Health Promotion Model and the implementation process and evaluation was developed

using the IOWA Model which will allow other facilities to duplicate the step by step process

without difficulty.

Problem Statement

Opioid use disorder has reached the level of epidemic status throughout the United States

and is similarly represented in Northeast Ohio. There is widespread evidence that there is a lack

of appropriate patient and clinician education on the proper use, disposal, and alternatives to

opioid use. This lack has also been substantiated in the rural hospitals of Northeast Ohio and was

the focus of this evidence based quality improvement project.

Objectives and Aims

The primary aim and long term goal of this project was to address the current health

disparity of opioid use disorder by implementation of evidence based educational material (See

Appendix) for the preoperative clinical staff to enhance the surgical patient’s knowledge of the

appropriate use of opioids, non-opioid alternatives, opioid storage, and disposal to decrease the

incidence of misuse.

The measureable objectives were as follows; obtain stakeholder approval for the

implementation of an opioid educational program during the preoperative visit, classroom in-

service for the clinical staff, implementation of an educational pamphlet, and the development of

an effective evaluation tool. This educational material will be reviewed with the patient by


preoperative clinical staff and distributed during the preoperative visit by a member of the

clinical staff which includes registered nurses and advanced practice nurses. Prior to

implementation the preoperative clinical staff, comprised of nurses and APNs will participate in

a classroom review of the educational material so open dialogue can occur to enhance provider

knowledge and a consistent approach to the application and discussion of the educational

material. The educational material utilized for this quality improvement initiative was developed

via a joint effort by the Centers of Disease Control and the American Hospitals Association. The

educational pamphlet provides a thorough review of the risk, benefits, alternatives, and

appropriate handling of opioids (Appendix A).

Chapter Two

Search Criteria

The search criteria was developed with emphasis on major concepts of person,

environment, health, and nursing presented within Nola Pender’s Health Promotion Model. A

list of keywords were developed and additional terms were identified from search strategies used

in current literature that were evaluated for content and applicability to the focus of the current

study. MeSH terms were used as well as Booleans to refine the search strategy. Multiple

databases were included in the initial search. PubMed, Cinahl, Embase, Cochrane, Clinical

Trials.gov, Google Scholar, and Medline were queried with the MeSh terms for the health

disparity of opioid abuse, preoperative health education, health literacy, self-efficacy, guidelines,

protocols, and patient/clinician education. Additional articles were evaluated manually by

reviewing the reference lists for high quality studies obtained from the initial search. Additional

reviews were done for specific websites such as SAMSHA and CDC. The titles and abstracts

were reviewed and studies that did not meet the inclusion criteria were excluded from further


evaluation. The initial literature review 768 articles, after all duplicates, and articles that were not

relevant to the focus of the current study were removed a final list of 112 full text articles were

reviewed. These articles were further evaluated as described and 21 articles were included.

Review of the Literature

According to the CDC approximately 51.4 million inpatient surgeries were performed in

the United States in 2010 and approximately 90% of all surgical patients receive opioids for pain

control. In a recent opinion statement Seely and Neufeld (2018) stated that the focus of the

opioid epidemic needs to shift from treatment to prevention. Interventions must be focused on

raising the awareness, promoting self-efficacy, promoting the benefits of change and positively

impacting the health promoting behavior.

A case study by Costello (2015) presents that many patients discharged with opioids

often do not know the appropriate use or management of the medications and that this lack of

knowledge contributes to the misuse of opioids. A potential barrier to a patient’s ability to

actively participate in their health can be related to health literacy. Gaglio, et. al., (2012) define

health literacy as an “individuals capacity to obtain, process, and understand basic health

information”. Patients with inadequate health literacy have poor comprehension of instructions

and tend to ask fewer questions during health related encounters. Bennet, et al., (2009) found that

health information that is not designed for low health literacy can potentially exacerbate health

disparities. A study by Gaglio, et. al., concluded that participants of all health literacy levels

preferred receiving health information face-to-face with a health care provider which could be a

doctor or nurse. The participants also preferred a handout of the information discussed as a

reminder for after the visit.


A systematic review and development of a clinical guideline by Chou, et. al., (2016)

adopted by several national organizations recommends education on opioids for all surgical

patients to reduce the consumption of opioids postoperatively. Face-to-face instruction and

written materials are effective. A random control trial by McCarthy et. al., (2014) evaluated the

use of a dual-modality (written and spoken) literacy appropriate patient education on the safe use

of opioids. The findings recommend that incorporating this approach increases the patient’s

knowledge on appropriate opioid use.

For the surgical patient the most effective time to educate patients is during the

preoperative visit. Information provided prior to the surgical event is not impeded by pain,

anxiety, and distractions inherent to the recovery process (Kruzik, 2009). The clinicians

servicing the preoperative clinic must create an environment that promotes building a trusting

rapport with the patient and family (Tarig et. al., 2016). A narrative review performed by Atreja

et. al., (2005) identified environmental factors that can effectively improve patient adherence to

healthy behavior changes identified by the mnemonic “SIMPLE”. This includes providing

simple regimens, imparting knowledge, modifying patient beliefs, communication, lack of bias,

and evaluation. The environment must also be cognizant of the socioeconomic status, cultural

beliefs, and level of health literacy of the patients being served.

The Joint Commission considers communication and patient education a standard

element of patient centered care and has recently added the expectation that patient care facilities

have established guidelines for educating patients about appropriate opioid use. According to the

most recent release of results from a systematic literature and public field review, the Joint

Commission has also mandated that “effective January 1, 2019 new and revised pain

management standards will be applicable to Joint Commission accredited rural access hospitals,


the enhanced elements of performance will require organizations to do the following; Provide

staff and licensed independent practitioners with educational resources and programs to improve

the safe use of opioid medications based on the identified needs of the patient population,

involve patients in developing the treatment plan, and conduct quality improvement activities to

increase safe opioid prescribing” (The Joint Commission, 2018).

The CDC also has recommended that clinicians should discuss with their patients the

known risks of opioid therapy including the risk of long term use, risk posed to family if opioids

are shared, and the appropriate use of opioids and non-opioid adjuncts (Dowell et. al., 2016). A

qualitative interview study performed by Smith, et. al., (2009) revealed that participants with a

higher education conceive a shared decision making involvement whereas lower educated

participants rely on the clinicians recommendations. Both groups identified that several aspects

of the clinician patient relationship were important for acceptance and adherence to the

information received. These aspects included continuity of information, negotiation, trust, and

interpersonal communication skills. To provide effective patient education the environment must

establish a trusting clinician-patient relationship, opportunity for thorough discussion of the

health education being provided, inclusion of the patient and family in the education process, and

clear written educational materials that can be applied to patients with varying levels of health

literacy. For the purposes of this project the handout (See Appendix) created by the CDC in

conjunction with the American Hospital Association (AHA) will be distributed to the patients

during the preoperative clinic visit after a face-to-face discussion with the nurse, NP, or CRNA.

Effective patient education can impact the use and misuse of opioids. A study by Sugai,

et. al., found that the use of patient education utilizing discussion and written materials was

effective in reducing the use of narcotics after surgery. Of note, 90% of the patients that received


preoperative education declined a prescription for opioids whereas 100% of the participants that

did not receive the training requested a prescription. The study also concluded that the

intervention group reported less pain then the group using the opioids. A literature review by

Scarlett, et. al., (2017) stated that up to 10% of opioid naïve patients remained on opioids one

year later, unused opioids are retained and available for nonmedical purposes, and improper

disposal is a major source of opioids for misuse and abuse.

Chou, et. al., (2016) in their updated guideline emphasized the importance of setting

realistic patient expectations for pain which should be initiated during the preoperative visit and

that patient collaboration, education, and shared decision making results in improved health

outcomes. A recent population representative survey concluded that there was a 60% decrease of

participants saving pills if they had received information regarding the risk of long-term opioid

use disorder (Hero, et. al., 2016). A randomized control trial performed by Syed, et. al., (2018)

confirmed that patients are not routinely informed about the risks of opioid use and that a

preoperative education intervention significantly reduced the use of opioids. Implementing an

education strategy that includes the patient can help alleviate the current opioid epidemic. It was

also noted that the intervention had even greater impact on participants currently using opioids to

stop using them.

A common barrier to appropriate opioid use identified within the literature is a lack of

knowledge concerning the appropriate use of opioids and the inherent risks. This lack of

knowledge is not only prevalent amongst patients but includes clinicians as well. The

implementation of a defined educational intervention on the appropriate use of opioids, risks of

use, and alternatives will facilitate greater understanding and as noted by the evidence presented

a positive impact on reducing opioid misuse. A descriptive study by Costello & Thompson


(2015) confirmed that nurses play a vital role in providing education on the appropriate use of

opioids, however the study also determined that nurses lack sufficient knowledge of opioids to

provide patients with the information for proper use. This study supported previous findings that

there is a nursing knowledge deficit regarding opioids. The study also identified that nurses that

received prior education performed significantly higher supports the premise that implementing a

training program would improve the nurse’s knowledge and more effectively be able to educate

patients on the appropriate use of opioids. The study further identified a barrier which was the

lack of time during the discharge period to properly educate the patient. The recommendation to

overcome the lack of time was to initiate education during the initial patient visit. Costello

(2015) also found that less than one third of 314 nurses knew how to correctly store or dispose of

opioids and that an urgent need for nurse education on these topics is required to provide patients

with accurate information for safe opioid use. The study also emphasized that patient education

on opioid use is essential but effective education can only occur once the nurses have a thorough

understanding.

A prospective study by De La Cruz, et. al., (2017) concluded that providing universally

consistent education that is clear and simple and reinforced throughout the patient experience

reduces unsafe opioid use, storage, and disposal practices. The study also supported previous

studies that found a face-to-face education and a second mode of education such as written

material was superior to a preoperative visit alone. A study by Best, et. Al., (2018) noted that

nurses present patient education based on personal preferences, time limitations, and the

availability of educational materials. The study further concluded that the use of consistent

scripted education and specific written patient education has a positive impact on patient

knowledge and satisfaction.


The initial literature search supported the premise that providing patient centric education

during the preoperative visit can be an effective method to improve the patient’s understanding

of the appropriate use of opioids and the current alternatives that are available. The literature

further identified the need to educate the clinical staff prior to the implementation of the program

and to augment the face to face education with a pamphlet that summarizes the information that

the patient can refer to after the preoperative visit.

Using the systematic search criteria developed for the project a second search was

performed after the conclusion of the implementation and evaluation of the quality improvement

program. The results of the second search returned no studies refuting the results of the initial

literature search. However, four additional studies were obtained that further support the results

of the initial literature search.

In a prospective random control trial Usman et. al., found that a preoperative education

intervention significantly decreased the number of narcotic pills consumed at 3 months after

surgery. Patient education resulted in earlier cessation of opioids and that directed patient

education can help alleviate the current opioid epidemic. The results of a randomized control trial

performed by Farley et. al. (June, 2019), found that patients receiving preoperative education

took opioids for significantly fewer postoperative days (4.5 vs 3.5 days; difference, 1.0 [95% CI,

0.2-1.9] days.

A prospective randomized study to evaluate the premise that preoperative opioid

counseling would decrease the use of opioids postoperatively found that “patients in the group

with counseling reported significantly fewer prescribed opioid pills consumed compared with

patients in the group without counseling, while experiencing no significant difference in pain

level experience. In addition, patients in the group with counseling reported a significantly lower


number of total pain pills consumed over the course of the study than the group without

counseling” (Alter & Ilyas, 2017). Horn et. al., (July, 2019) concluded that providing

preoperative education on the surgical procedure, related postoperative pain, and how the pain

will be managed decreases patients anxiety levels and has resulted in lower use of opioids

postoperatively and decreases the incidence of acute pain resulting in chronic pain and long term

opioid use.

The current opioid epidemic has also resulted in current legislative action, Florida HB

451 was signed into law on June 25th

2019 requiring all healthcare providers to discuss all opioid

alternatives, advantages and disadvantages of non-opioid alternatives, provide educational

pamphlets, and list non-opioid alternatives requested by the patient in their medical record.

Failure to follow these steps can result in disciplinary actions by the state nursing and medical

boards.

Theoretical Model

Theoretical frameworks provide the professional nurse with a guide to develop creative

new ways to address the ever changing environment of healthcare and how that care needs to be

delivered. The evolution of nursing as a distinct discipline with knowledge that is derived from

nursing based research is dependent on the overarching conceptual theories (Fawcett, 2005).

Advanced Practice Nurses must strive to expand the knowledge of nursing by implementing

evidence based practice, interpret research, and appropriately apply the findings to clinical

practice. Conceptual models also provide “structure, process, function, resources, and goals for

nursing as a discipline and a profession. This leads to creative approaches for human care by

defining the person, the environment, and health” (Fawcett, 2005).


The most relevant theory for this capstone project was The Health Promotion Model

(HPM) introduced by Nola J. Pender in 1975. The model is considered a mid-range theory which

makes it directly applicable to clinical practice. (Fawcett, 2005). This is an integrative theory

with a basis in social cognitive theory which guides a nursing perspective of holistic patient care

(Pender, 1996). The patient is considered unique with characteristics that are derived from

personal experiences and behavioral outcomes. The nurse can use this model to introduce

interventions that can alter the behavioral specific variables because they can be changed by

providing information that alters the perceived benefit of actions from prior experiences. Human

behavior and acceptance is also derived from interpersonal and situational influences. Health

promoting behavior can be introduced and accepted by family, peers, and healthcare providers.

These interpersonal influences shape the patients participation and acceptance of health

promoting behaviors.

This capstone project was focused on implementing a preoperative educational

intervention for health care providers and surgical patients to minimize the potential for opioid

misuse as well as non-opioid alternatives for acute pain management. The focus was on the

translation of knowledge to the caregivers directly interfacing with the patient to provide

education, influence, an intervention that promotes the appropriate use of opioids, and

knowledge of the potential risks associated with opioid use. The literature has been summarized

into the four major concepts of the Health Promotion M0del which are person, environment,

health, and nursing.

Person

The Health Promotion Model identified the person as the individual that the model is

focused on. For this project the person referred to surgical patients and their families that


interface with the perioperative clinic and are currently using opioids or will undergo a procedure

that will potentially require the use of opioids postoperatively.

Environment

In the Health Promotion Model the environment relates to the physical, interpersonal or

economic state. The healthcare environment can be an overwhelming experience for the patient

and confounded by varying levels of fear, anxiety and uncertainty. Creating an environment

conducive to learning is vital for effective transfer of information. The literature review

supported that the most effective format for providing opioid education to the surgical patient is

during the preoperative visit. The nurse has the opportunity to address the patients concerns and

provide evidence based information that can influence the patients understanding of the

appropriate use of opioids and the access to non-opioid alternatives. The literature further

supported that this preemptive education has significant positive impacts on the patient’s

expectations and reduces fear and anxiety as well as the use of opioids.

Health

According to the Health Promotion Model, Pender describes health as activities that

support health promoting behavior, this is also a common theme within healthcare facilities to

promote preventative health rather than only focusing on the treatment of existing disease.

Applying this premise to the current opioid epidemic supports the need to implement not only

treatment of those currently suffering from opioid abuse but also the implementation of health

promoting interventions that are focused on educating the patient, family, and community about

the inherent risks related to the misuse of opioids as well as the appropriate use.


Nursing

The role of nursing in the Health Promotion Model is to promote healthy behaviors, self-

efficacy and conveying the benefits of healthy behavior. The opioid epidemic has challenged not

only patients but also nurses. According to the Health Promotion Model the nurse plays a pivotal

role in the patients care by providing evidence based education, assessing the patients concerns

and understanding of the plan of care, offering additional information to support the plan of care,

and developing a relationship that can promote open dialogue and the incorporation of the

patients and families (if desired) healthcare expectations into the plan of care.

To augment the theoretical model the IOWA model was also utilized to develop the

project design, timeline, evaluation of the implementation, and the outcomes including barriers

and facilitators (See Appendix C). The IOWA model was chosen because this project was an

institutional based quality improvement project that required the involvement of multiple

members of the clinical staff, physician leadership, and administrative leadership. A strength of

the IOWA model is the ability to implement institutional change projects.

Project Design

The initial project design was developed after the literature search was concluded and

significant evidence supported that the implementation of a patient focused preoperative opioid

educational program can reduce the amount of opioids used during the perioperative period and

can decrease the potential for inappropriate use after discharge. Evaluation of two rural access

hospitals located in areas of Northeast Ohio with the highest percentages of opioid abuse

revealed that patient focused opioid education during the preoperative visit was lacking. The first

step was to identify an evidence based opioid educational pamphlet for this quality improvement


project. The pamphlet developed by the Centers for Disease Control and the American Hospital

Association (See Appendix A) was selected.

An initial literature search was conducted to determine if supportive evidence based

research was available to support this quality improvement project. The results of the literature

review supported the use of a preoperative opioid educational program. The project was then

submitted to the hospital and university’s institutional review boards for evaluation. Approval

was obtained from both entities and the project was deemed to be a quality improvement project.

Clinical and administrative key stakeholders were identified and an initial meeting was

conducted to discuss the project objectives and the impact to preoperative workflow. The key

stakeholders included the hospital’s chief operating officer, chief medical officer, chief nursing

officer, chief nurse anesthetists, departmental nurse managers, and representatives from the

hospital education and quality departments. The meeting resulted in approval for the

development and implementation of the project at two rural access hospitals.

The implementation process was inclusive of the entire clinical staff in the preoperative

assessment clinics, the preoperative nursing staff, the nurse anesthesia staff, nursing educators

from both facilities, and representatives from the quality department. The entire step by step

process was disseminated to all stakeholders during two classroom training sessions. To maintain

consistency and organization the project implementation, timeline, and evaluation was recorded

using the IOWA Model (Appendix C).

To provide structure and clarity of the goals and steps involved in the implementation and

evaluation process a formal evaluation tool was designed using the IOWA model toolkit.

Permission was requested and granted for the use and modification of the toolkit on May 20th

2019 by the IOWA Model consortium. The tool outlines the implementation steps from inception


of the project to completion and dissemination of findings and included the project timeline

which was shared with the key stakeholders for approval (See Appendix B). The tool provided

the key objectives, specific activities to meet the objectives, who was responsible to complete the

objective, date of completion, and the evaluation of the objectives

Chapter Three

Evaluation of the Effectiveness of Project Implementation

The overarching goal of this project was the implementation of an evidence based patient

focused opioid education protocol that would be administered during the pre-anesthesia visit.

The literature review supported the premise that a face to face conversation in conjunction with

providing a handout that could be referred to after the visit was the most successful method to

provide the patient education. The success or failure of applying evidence based practice

changes is closely linked to the structure of the implementation strategy and the evaluation

process used to monitor the progress, identify barriers, make appropriate changes to overcome

the barriers, engage stakeholders, develop the action plan, and provide continuous evaluation of

the process (Tucker, 2019). Limited use of theoretical models for implementation and evaluation

has made it difficult to define why the implementation ultimately succeeded or failed (Nilsen,

2015).

Although there are multiple models and frameworks available for the implementation and

evaluation of evidence practice change (EBP), the revised IOWA model (see Appendix A) was

selected for this project. The IOWA model is considered a process/action model which provides a

structured process for the translation of evidence based research into practice. “Cited more than

650 times, the IOWA Model is the basis of EBP protocols in many institutions and settings. Its

reputation and reach are demonstrated by the nearly 5,500 recorded requests for the IOWA


Model, which have come from every U.S. state and more than 40 countries. In 2017, the IOWA

Model Revised article had over 3,000 downloads in just six months, making it one of the most

downloaded articles published in Worldviews on Evidence-Based Nursing”(Cullen et. al., 2018).

The steps are clearly defined so an effective action plan for implementation and evaluation can

be produced and used throughout the project. The IOWA model also promotes an organizational

approach requiring collaboration amongst a comprehensive group of stakeholders to provide the

optimal environment for the implementation of EBP and evaluation to determine if patient care

can be improved by adopting the evidence based research findings (Titler, 2006, 2018).

The evaluation process provides important information for the clinicians, organizational

leadership, and the patients. The focus of the evaluation tool is to gain data, feedback, potential

barriers, financial impact, outcomes related to the practice change, and whether the intervention

can be effectively utilized by several clinicians and still obtain the expected outcome. The results

of the evaluation are vital and should be disseminated to the key stakeholders as well as the

clinicians impacted by the evidence based change. Effective evaluations also promote increased

engagement utilizing evidence based practice implementations and assist in the creation of a

culture that relies on evidence based practice to guide changes on how we care for our patients

(Titler, 2018).

For the purpose of this project the evaluation of each key objective as well as any barriers

and how the barrier was addressed were presented. The first four key objectives listed; develop

the EBP project proposal, completion of the literature review, obtain facility and university

institutional review board approval, and the selection and implementation of a theoretical model

were successfully completed in the previous semester and incorporated into chapter two of the

capstone project. Baseline status revealed that neither facility currently offered opioid education


during the pre-operative visit. Both hospitals had similar patient demographics and the

communities served by these facilities struggle with opioid abuse representing the highest

percentage in Northeast Ohio. The evaluation of the implementation began with the engagement

of the key stakeholders.

Key Stakeholders

A fundamental aspect of successful EBP change is gathering a team that has been

assembled in consideration of the chosen topic. The primary stakeholders should include

representation from administration, physician leadership, nurse management, nursing staff,

quality and compliance, and support staff. Managerial involvement is essential so the team is

supported and have the authority to implement the EBP change (Doody & Doody, 2011). “A

crucial factor in delivering high-quality patient care is nursing implementation of evidence-based

practice (EBP); institutional leadership, such as nurse managers (NMs), plays an integral role in

the implementation of EBP on nursing units”(Kueny et. al., 2015).

Key objectives

Conduct stakeholder kickoff meeting, discuss project goals and there alignment with the

hospital mission statement. Obtain consensus and support on the implementation plan

Evaluation

The initial meeting was conducted during week one with the chief operating officer, chief

medical officer, chief nursing officer, chief nurse anesthetists, departmental nurse managers, and

representatives from the hospital education and quality departments. Additional update meetings

were scheduled at the project midpoint and conclusion of the implementation. Overview of the

capstone project, goals, and documents were reviewed and recommendations or concerns were

solicited. A copy of the chapter two paper had also been provided prior to the meeting to allow the


key stakeholders time to evaluate and develop questions and talking points for the meeting. The

project was met with overwhelming acceptance from all of the key stakeholders. There was

discussion related to resources needed for the project and approval was received to perform the

implementation at both facilities.

Barriers and facilitators

For this phase of the project no barriers were presented by the key stakeholders. There was

discussion of how alternative treatments could be used to reduce the use of opioids and it was

suggested by the stakeholders that these alternatives should be considered for implementation. The

group was notified that the current project would present available options and that the patient

could discuss alternatives with their surgeon.

Clinician Education

To successfully implement EBP at a unit level the training should be presented in a

format that includes the direct care providers as well as the nurse managers so the appropriate

level of support for the change is available and communicated (Doody & Doody, 2011). With

consultation from nursing leadership it was decided to incorporate the project education during

the preoperative nurse’s annual proficiency training. This platform provided access to all of the

preoperative nursing staff as well as the nurses that routinely work in the pre-admission testing

clinic. The other advantage was that the operating rooms were closed for the day allowing the

chief nurse anesthetists, nurse managers, and the nurse educators to attend the sessions. The

classroom education was presented at the hospitals during week two and three of the project

implementation. The format was a classroom in-service with the use of a comprehensive power

point presentation followed by a period of open dialogue. To facilitate ongoing communication a


sign in sheet was incorporated and all participants received a copy of the slide deck, a copy of

the educational handout, and a copy of the project design paper.

Key Objectives

Finalize clinician in-service education, disseminate educational materials, provide ample

time for open communication and feedback, obtain consensus on the project timeline and goals

of the project, recruit clinical champions for each facility, create a process for recording

voluntary patient feedback, and locate a color printer at each facility to print off additional

handouts as needed.

Evaluation

Clinician in-services were presented in a formal classroom setting, a comprehensive

power point presentation, educational handout, and materials were provided. A total of 42

clinical nursing staff attended the educational offering which was recorded on sign in sheets. At

the completion of the education all participants were e-mailed the slide deck and handout

materials. Open discussion prompted the creation of an introductory statement to initiate the

communication with the patient. A total of 4 clinical champions were appointed consisting of two

preoperative charge nurses and two nurse anesthetists. A simple data collection form devoid of

any identifiers was created so voluntary patient feedback could be recorded. The nurse in charge

of the pre-admission clinic was provided with the files for the patient handout so additional

copies could be printed when needed. Each location was provided 200 color copies of the

handout which would be an ample supply for the project. There was also consensus amongst the

preoperative nurses not working in the pre-admission clinic that they would want to have the

educational material available for patients that did not have a pre-operative clinic visit. Both

facility nurse educators and representatives from the quality department participated in the


training session and were very supportive of the effort. There was robust discussion after the

presentation and two specific suggestions were offered for consideration. The first was to have

the anesthesia staff provide an in-service for the staff in regards to the current alternatives to

opioids presently available. The second was related to the current hospital mandate based on the

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) that if a pain scale

is used then the clinician must provide narcotics for pain relief even in the event that the

physiologic indicators do not warrant pain medication. The nurse anesthetists provided the

information of the current regional techniques and non-opioid medications available at each

facility. The second issue was brought to the attention of the key stakeholders for further review

during the surgical quality meeting. A follow up meeting with the key stakeholders and the DNP

mentor to go over the results of the in-service training during week three. In collaboration with

the DNP mentor the introductory script was completed and disseminated. Implementation of the

project was scheduled for week four and five.


The initial barrier was directly related to access to all of the providers due to the inability

to pull away from clinical work, alternating shifts, and the inability to pay overtime for the

training. The initial plan to overcome this barrier was to schedule multiple times, Webex

meetings, and one on one sessions. This concern was brought to the attention of the nurse

managers and they coordinated the training to become part of the annual competency in-service

which simply required that the training sessions were moved back one week from the original

date. Another perceived barrier was how the training would be presented to the patient. The staff

requested a formal introductory script to be written. The statement was written and disseminated

to the staff prior to the initiation of the pilot program.


Project Implementation

A core component of successful implementation requires direct interaction with the

clinicians providing the EBP change and the nursing leadership (Doody & Doody, 2011). A

staggered start approach was used so that during the initial kickoff the project director was

available as a resource and to monitor the application of the EBP initiative. The project was

implemented at each hospital in weeks four and five.

Key Objectives

The key objectives for this phase is the implementation of the project, monitoring for

consistency of the project, provide resources as needed, directly engage with the point of care

clinicians, and review and evaluate the feedback as the project progresses.

Evaluation

The process was well received by the staff and patients, the presentation of the handout

and overview took approximately 5 to 10 minutes depending on any patient questions or

comments. During the pilot 75 patients received the presentation, there were no negative

comments received. 31 patients provided additional positive comments and asked questions

relating to the topics covered on the handout. During the project, feedback was obtained from the

nurses in regards to the process and there were no issues related to the educational process in

regards to time limitations, workflow, or level of comfort reviewing the handout. There was a

request to consider a facility specific document on available non-opioid alternatives currently

available. Both locations followed the same implementation process, introductory script, tally

sheet, and the project educational handout. The project continued at each location until the

scheduled conclusion in week 7. At this time the results and provider feedback were collected for


review. The consensus of the participants was to continue the evidence based intervention until

the final determination was received from the key stakeholders.


Due to the comprehensive in-service training and dissemination of the educational

material and evidence based literature supporting the initiative there were no actual barriers

vocalized or witnessed during the implementation phase. The pre-admission personnel were

supportive and engaged in the process. The presentation of the material to the patient would vary

slightly amongst the clinicians but the core material was presented and discussed using the

introductory script and the provided handout. The support of the leadership was evident

throughout the project and I believe this had a significant positive impact on clinician

engagement and participation.

Post Implementation Debriefing and Survey Results

Quality initiatives can often be perceived as additional workload added to an already

busy work schedule (Doody & Doody, 2011). To facilitate the collection of post-implementation

feedback a survey was constructed using Survey Monkey (See Appendix C). The survey was sent

to the staff engaged in the pre-admission clinic. All clinicians were provided email and cellphone

access during the pilot to communicate any issues, suggestions, or additional support needs.

Key Objectives

To receive objective feedback for determination if the evidence based practice change

was effective and considered to have a positive impact on patient care. Evaluation of the nurse’s

perception of the viability of the ongoing use of the evidence based practice change. Direct care

providers evaluation of the program and any additional comments to guide future refinement if

needed.


Evaluation

Week 7: Completed debriefing session with the pre-admission visit staff and

gathered patient feedback. The response to the project was positive, both the nurses and the nurse

anesthetists vocalized that they had become increasingly comfortable initiating the conversation

and addressing the opioid crisis. It was also stated that JCAHO was made aware of this

additional opioid education during their visit. The staff not only vocalized the success of the

project but also engaged in conversation regarding developing opioid sparing protocols for

surgical procedures. The project triggered several of the nursing and anesthesia staff to research

additional opioid sparing initiatives. Patient feedback ranged from no comment to engaged

conversation on the topic and appreciation for the initiative. Data gathering was performed using

a survey that was sent during week 7, nursing leadership was notified and asked to notify the

staff to complete the survey. The survey was open until week 8 to provide sufficient time for the

recipients to respond. An 85% response rate was obtained with 17 of 20 clinicians responding.

The results of the survey (See Appendix D) were very supportive of the initiative with 100%

responding they would be Very Likely of Likely of incorporating the intervention into their

practice. There was also consensus that the intervention was relevant to their clinical practice and

the patient population being served. Consistent with current research findings on the successful

implementation of EBP change, the majority of the staff positively identified that support from

nursing and administrative leadership would be necessary for the successful adoption of the EBP

change.


No barriers were noted in this phase. The collection and display of the survey results

were facilitated by using the Survey Monkey software. The continued involvement of the nurse


managers and their communication with the staff resulted in obtaining a good response to the

survey within the proposed timeframe.

Conclusion

The focus of this capstone project was to implement an opioid educational initiative

which included a face-to-face discussion, educational opioid handout provided to the patients

during the preoperative visit, and clinician education in two rural access hospitals located in

Northeast Ohio with the highest percentage of opioid abuse and misuse. The project objective

was supported by the evidence and determined to be effective in decreasing the potential for

opioid misuse. This initiative also satisfied the requirements of the Joint Commission mandate

for accredited hospitals to provide staff and licensed independent practitioners with educational

resources and programs to improve the safe use of opioid medications based on the identified

needs of the patient population. Because the training material was clear and succinct there was

no additional time or resources required to implement the educational project discussed and

distributed during the preoperative visit. The significant benefits related to this evidence based

project to improve patient and clinician education on appropriate opioid use as well as the

minimal requirements for resources made it relevant and applicable to the rural access healthcare

facilities of Northeast Ohio.

The evaluation process is a fundamental aspect when translating evidence based research

into clinical practice. Utilizing process models or theoretical frameworks for the implementation

and evaluation provides necessary insight as to why the adoption of the EBP change was a

success or a failure. The evaluation also brings structure to the key steps and outlines the

objectives and expected outcomes that support successful implementation. Considering that this


capstone project implementation was developed to meet appropriate opioid education for patients

at two hospitals the decision was made to utilize the IOWA model.

The IOWA model emphasizes an organizational approach to EBP implementation from a

bottom to top approach. Baseline data verified there was not a current pre-operative opioid

education program and both hospitals are located in areas of NE Ohio that has the highest

percentage of opioid abuse and misuse. Both facilities are also rural access hospitals and as of

January 2019 JCAHO mandated that rural access hospitals must have documented opioid

education programs in place. The IOWA model clearly defines that stakeholders must represent

administrative and nursing leadership as well as the direct care clinicians. The implementation

and evaluation tool was created using the IOWA model toolkit with a comprehensive

implementation and evaluation plan. The tool was used throughout the process to guide and

evaluate each step.

The key objectives and expected outcomes were completed within the proposed timeline

with minimal variation. The evidence based practice change was successfully implemented and

supported by all of the key stakeholders. The results of the final project survey also supported the

premise that the evidence based practice change was a needed intervention and would be of

continued use for the care of the patient population accessing the healthcare facilities in rural NE

Ohio. A primary indication of the success of this project was the continued use of the process.

Evaluation of the project at ninety days post implementation concluded that the process had been

continued without alteration and the feedback remained positive.


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Figure 1

0

1

2

3

4

5

6

Category 1 Category 2 Category 3 Category 4

Series 1 Series 2 Series 3


Appendix A


Appendix A Continued


Appendix B


Appendix C


Appendix C Continued








Appendix D

Final Project Survey

INSTRUCTIONS: Considering the pre-operative educational project in conjunction with the educational material

presented please complete the following survey. This information will remain anonymous and will be used to improve patient

and clinician knowledge.

1. To what extent do you agree that this intervention: Strongly

Agree Agree Disagree

Strongly

Disagree

a) Addresses a common or high-priority problem in our

practice 1 2 3 4

b) Would need to be modified to meet the needs of our

practice 1 2 3 4

c) Would be simple to implement in our practice 1 2 3 4

d) Is likely to improve patient knowledge and patient

outcomes related to opioid use in our practice 1 2 3 4

e) Could be pilot tested in our practice prior to fully

implementing 1 2 3 4

f) Is relevant to our patient population (from the patient

or provider perspective) 1 2 3 4

g) Would work for our patient population 1 2 3 4

2. Consider how you would adopt or adapt this intervention in your

practice. What level of resources would you need in the following

areas? Low High

Don’t

Know

a) Extent of training for clinicians 1 2 3 4

b) Changes to workflow, roles, and tasks among team members 1 2 3 4

c) Technical assistance to access educational materials 1 2 3 4

d) New and/or additional financial investment/support 1 2 3 4

e) Support from nurse manager/clinic leadership 1 2 3 4

3. What is the likelihood that you will adopt or adapt this intervention

in your practice at the conclusion of the pilot? 1 2 3 4

4. If you were going to adapt this intervention to your practice, note your ideas about what you would change.

Appendix E



Appendix E Continued

Implementation of Preoperative Education on the ...

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