Providing direct care nurses research and evidence-based practice information: an essential component of nursing leadership

staffileno b.a. & carlson e. (2010) Journal of Nursing Management  18, 84–89
Providing direct care nurses research and evidence-based practice information: an essential component of nursing leadership
Aims  This commentary describes the reasons, strategies and benefits of providing direct care nurses with research and evidence-based practice (EBP) education.
Background  A component of nursing leadership is to provide nurses opportunities for professional growth and development, yet this can be challenging during a time when resources are constrained and need to be used wisely.
Evaluation  Our research and EBP education programmes have been evaluated qualitatively, as well as by the number of research/EBP projects implemented.
Key issues  Providing direct care nurses with support and additional education empowers them to seek, critically appraise and integrate research findings into their daily patient care.
Conclusions  Direct care nurses, who participated in our programme, demonstrated a strong desire to learn about research and EBP so they could practice using evidence-based care with confidence, thus transitioning from a 'tradition-based' care approach to an evidence-based way of providing care as the standard for nursing practice.
Implications for Nursing Management  Providing a dedicated time for additional education sends a clear message that research and EBP are important elements embedded in patient care. The organisation, then, is seen as an environment that emphasizes the value of research and EBP at the unit and organisational level.     

Factors influencing the development of evidence-based practice: a research tool

AIM: The paper reports a study to develop and test a tool for assessing a range of factors influencing the development of evidence-based practice among clinical nurses. BACKGROUND: Achieving evidence-based practice is a goal in nursing frequently cited by the profession and in government health policy directives. Assessing factors influencing the achievement of this goal, however, is complex. Consideration needs to be given to a range of factors, including different types of evidence used to inform practice, barriers to achieving evidence-based practice, and the skills required by nurses to implement evidence-based care. METHODS: Measurement scales currently available to investigate the use of evidence in nursing practice focus on nurses' sources of knowledge and on barriers to the use of research evidence. A new, wider ranging Developing Evidence-Based Practice questionnaire was developed and tested for its measurement properties in two studies. In study 1, a sample of 598 nurses working at two hospitals in one strategic health authority in northern England was surveyed. In study 2, a slightly expanded version of the questionnaire was employed in a survey of 689 community nurses in 12 primary care organizations in two strategic health authorities, one in northern England and the other in southern England. FINDINGS: The measurement characteristics of the new questionnaire were shown to be acceptable. Ten significant, and readily interpretable, factors were seen to underlie nurses' relation to evidence-based practice. CONCLUSION: Strategies to promote evidence-based practice need to take account of the differing needs of nurses and focus on a range of sources of evidence. The Developing Evidence-Based Practice questionnaire can assist in assessing the specific 'evidencing' tendencies of any given group of nurses.     

Development of an evidence-based practice questionnaire for nurses

AIM: The aim of this paper is to report the development and validation of a self-report measure of knowledge, practice and attitudes towards evidence-based practice (EBP). BACKGROUND: Evidence-based practice has become increasingly important in health care since the mid-1990s as it provides a framework for clinical problem-solving. However, to date no means exist to quantify the extent to which barriers, such as lack of time in the working day, lack of appropriate skills and negative attitudes, may prevent greater uptake of EBP. METHODS: Questionnaire development was based on established psychometric methods. Principal component factor analysis was used to uncover the underlying dimensions of the scale. Internal consistency of the scale was assessed by Cronbach's alpha. Finally, construct validity was assessed via convergent and discriminant validity. RESULTS: The final questionnaire comprised three distinct scales (EBP, attitudes towards EBP and knowledge of EBP), which had robust validity and internal reliability. CONCLUSION: This tool can be used to measure the implementation of EBP.     

Tensions and contradictions in nurses' perspectives of evidence-based practice

Aim  To explore nurses' understanding and interpretation of evidence-based practice (EBP).
Background  EBP has been welcomed into the nursing lexicon without a critical examination of its interpretation by practitioners. The literature suggests that there is a great deal of confusion and contradiction over the meaning and application of EBP. Although work has been conducted on how EBP might be implemented, the general issue of how nurses understand and use EBP is largely unexplored. This paper seeks to examine in depth the understandings of EBP, to enable managers, educationalists and policy makers to implement it more effectively.
Methods  All registered nurses, midwives and health visitors in one UK National Health Service (NHS) Trust were asked to complete a questionnaire in October 2006.
Results  Despite a disappointing response rate (8.9%, 218/2438), the survey revealed interesting tensions and contradictions in nurses' understanding of EBP. National and local guidelines, practitioners' own experience and patients' preferences were the main influences on nurses' practice. Published research had relatively little impact, particularly among nurses graded E, F and G and those who had not attended a study day on EBP.
Conclusions  The hierarchies of evidence propounded in local and national guidelines are not adopted by practising nurses, who use other sources of evidence, such as reflection on their own experiences, when making clinical decisions. However, subsuming published evidence to clinical judgement does not contradict the original tenets of EBP.
Implications for Nursing Management  Unless it is incorporated into national or local guidelines, research has relatively little impact on practice. To develop nursing practice and nursing knowledge, nurse leaders need to foster the synthesis of experiential knowledge and published research, in accordance with the founding principles of the EBP movement.     

我国临床护理人员循证护理实践研究进展

探讨了循证护理实践的概况及相关概念,从我国临床护理人员的角度剖析循证护理实践的必要性及意义,阐述了循证护理实践程序及注意事项,并分析了当前临床护理人员循证护理实践中存在问题的原因,提出了加强我国循证护理实践的对策。     

Promoting evidence-based practice: an organizational approach

AIM: To examine factors influencing the achievement of evidence-based practice. BACKGROUND: This paper reports on the approach taken by a large teaching hospital in England to promote evidence-based practice. A summary of initiatives spanning a 5 year period is presented in order to set the scene for a recent survey of nurses to review progress made. Consideration is given to how the findings from the survey have been used to inform policy and practice. METHODS: A survey by self-completed questionnaire was undertaken with a sample of clinical nurses (n = 330). The questionnaire examined the extent to which nurses utilised different sources of knowledge to inform their practice; perceived barriers to accessing evidence-based information and effecting change in practice; and a self-assessment of core skills necessary to underpin evidence-based practice. FINDINGS: Nurses relied most heavily on experiential knowledge gained through their interactions with nursing colleagues, medical staff and patients to inform their practice. Organisational information in the form of policies and audit reports was drawn upon more frequently than research reports. Lack of time, resources and perceived authority to change practice influenced the extent to which nurses utilised formal sources of evidence. Whereas nurses were relatively well skilled at accessing and reviewing research evidence, they were less confident about their ability to change practice. CONCLUSION: Health care organisations need to consider multiple strategies to facilitate and promote evidence-based practice. Managerial support, facilitation, and a culture that is receptive to change are essential.     

Creating room for evidence-based practice: Leader behavior in hospital wards

The integration (routinizing and sustaining) of evidence-based practice (EBP) into hospital management is a key element for improving patient safety and ensuring better patient outcomes. Hospital managers and clinical leaders play crucial roles in this integration. Interactions between leaders and integration context influence the improvement's quality, but leader-based actions that are effective for improving nursing practice remain unclear. The relationship between leaders could also either hinder or enable this implementation process. The aim of this study was to generate a theory about patterns of leader behavior that leaders are engaged in when attempting to integrate EBP in a clinical setting. We used a classic grounded theory methodology to generate a substantive EBP theory. In this study, through participant observation, we observed 63 nurses (15 specialist, 39 registered, and 9 assistant nurses). From these, five ward leaders (two head nurses, one assistant head nurse, and two teaching nurses) participated in individual interviews, and 18 clinical nurses participated in four focus groups. “Creating room for EBP” emerged as a theory for explaining the way in which the leaders attempted to resolve their main concern: How to achieve EBP treatment and care with tight resources and without overextending the nurses. Creating room for EBP encompasses a process of interactions, including positioning for, executing, and interpreting responses to EBP.     

Sustainability in changing clinical practice promotes evidence-based nursing care

AIM: To examine the relationship between sustained work with quality improvement (QI) and factors related to research utilization in a group of nurses. DESIGN: The study was designed as a comparative survey that included 220 nurses from various health care organizations in Sweden. These nurses had participated in uniformly designed 4-day basic training courses to manage a method for QI. METHODS: A validated questionnaire covering different aspects of research utilization was employed. The response rate was 70% (154 of 220). Nurses in managerial positions at the departmental level were excluded. Therefore, the final sample consisted of 119 respondents. Four years after the training courses, 39% were still involved in audit-related activities, while 61% reported that they had discontinued the QI work (missing = 1). RESULTS: Most nurses (80-90%) had a positive attitude to research. Those who had continued the QI work over a 4-year period reported more activity in searching research literature compared with those who had discontinued the QI work (P = 0.005). The QI-sustainable nurses also reported more frequent participation in research-related activities, particularly in implementing specific research findings in practice (P = 0.001). Some contextual differences were reported: the QI-sustainable nurses were more likely to obtain support from their chief executive (P = 0.001), consultation from a skilled researcher (P = 0.005) and statistical support (P = 0.001). Within the broader health care organization, the existence of a research committee and a research and development strategy, as well as access to research assistant staff, had a tendency to be more common for nurses who had continued the QI work. CONCLUSION: Sustainability in QI work was significantly related to supportive leadership, facilitative human resources, increased activity in seeking new research and enhanced implementation of research findings in clinical practice. It appears that these factors constitute a necessary prerequisite for professional development and the establishment of evidence-based practice.     

Nursing students can help support evidence-based practice on clinical nursing units

AIMS: A research study was designed to explore whether research utilization projects underwent by student nurses could have an impact on nursing practice on clinical nursing units. BACKGROUND: The use of evidence-based practice is becoming essential for nursing managers and nursing staff, but there are many barriers to implementing research findings in practice. Student nurses can be used to assist when staff nurses do not have time during the work day. METHODS: Baccalaureate nursing students completed a research utilization project during their final comprehensive clinical experience. Telephonic interviews were conducted with the students' preceptors 5 months after the students' clinical experience, to obtain their perceptions of the impact of the student project on the nurses' knowledge and practice. RESULTS: The staff nurse preceptors reported the projects were well received with the primary impact of the projects being to educate the nursing staff and patients and thus improve the level of nursing practice on the clinical units. CONCLUSIONS: Student research utilization projects are one way to save time for staff nurses and increase their awareness of current research findings.     

Barriers to evidence-based practice in primary care nursing--why viewing decision-making as context is helpful

AIM: This paper reports a study examining the barriers associated with research knowledge transfer amongst primary care nurses in the context of clinical decision-making. BACKGROUND: The research literature on barriers to nurses' use of research knowledge is characterized by studies that rely primarily on self-report data, making them prone to reporting biases. Studies of the barriers to evidence-based practice often fail to examine information use and behaviour in the context of clinical decision-making. METHODS: A multi-site, mixed method, case study was carried out in 2001. Data were collected in three primary care organizations by means of interviews with 82 primary care nurses, 270 hours of non-participant observation and 122 Q-sorts. Nurses were selected using a published theoretical sampling frame. Between-methods triangulation was employed and data analysed according to the principles of constant comparison. Multiple linear regression was used to explore relationships between a number of independent demographic variables (such as length of clinical experience) and the dependent variable of nurses' perspectives on the barriers to their use of research knowledge. RESULTS: Three perspectives on barriers to research information use emerged: the need to bridge the skills and knowledge gap for successful knowledge transfer; information formats need to maximize limited opportunities for consumption; and limited access in the context of limited time for decision-making and information consumption. Demographic variables largely failed to predict allegiance to any of the perspectives identified. CONCLUSIONS: Researchers should consider using decision-making as a contextual backdrop for exploring information use and behaviour, avoid relying solely on self-reported behaviour as data, and use a variety of research methods to provide a richer picture of information-related behaviour. Practice developers need to recognize that understanding the decisions to which research knowledge is to be applied should be a characteristic of any strategy to increase research uptake by nurses.     

Improving the implementation of evidence-based practice: a knowledge management perspective

Experience of knowledge management initiatives in non-health care organizations can offer useful insights, and strategies, to implement evidence-based practice in health care. Knowledge management offers a structured process for the generation, storage, distribution and application of knowledge in organizations. This includes both tacit knowledge (personal experience) and explicit knowledge (evidence). Communities of practice are a key component of knowledge management and have been recognized to be essential for the implementation of change in organizations. It is within communities of practice that tacit knowledge is actively integrated with explicit knowledge. Organizational factors that limit the development of knowledge management, including communities of practice, in non-health care organizations need to be overcome if the potential is to be achieved within health care.     

Implementing and sustaining evidence-based clinical practice in Australia: the Evidence Based Clinical Practice Research Initiative

Evidence-based medicine is a process by which clinicians translate clinical information needs into answerable questions, track down answers to those needs as efficiently and effectively as possible using the best evidence available, apply the information to patients and evaluate their performance. Implementing evidence-based medicine is fragmented and variable. The National Health and Medical Research Council of Australia has implemented a research program to determine successful strategies for implementation and sustaining of evidence-based clinical practice. In addition this research program will help to answer whether evidence-based practice improves patient outcomes. This paper describes this program and other strategies that improve the application of evidence-based practice in clinical settings.     

An evaluation of a local clinical supervision scheme for practice nurses

This paper presents the findings of an evaluation of a local clinical supervision scheme for practice nurses in Leicestershire, UK. A baseline and a follow-up postal questionnaire were sent to all practice nurses (including supervisors) and general practice senior partners to find out how far the objectives of the local scheme had been met during the first year of implementation. Two focus groups gathered qualitative data about the process of implementation. Twelve months after implementation 12% of practice nurses and over two thirds of GPs reported that they were unaware of the scheme. Forty-three percent of practice nurses did not know who their local supervisor was; most reported that they would like to have known. Eighteen percent of practice nurses reported uptake of supervision through the local scheme. The benefits of involvement were professional development tailored to individual learning needs and regular opportunities to share work-related problems with peers; about a third reported benefits for the practice as well. The existing availability of peer support and time needed to undertake clinical supervision were common reasons given for non-involvement in the scheme. Misconceptions about the purpose of clinical supervision presented further obstacles. At follow-up over half of the practice nurses remained undecided about their future involvement in the scheme. If the benefits associated with clinical supervision are to be realized, the obstacles that currrently hinder practice nurses' involvement need addressing.     

Pressure ulcers: implementation of evidence-based nursing practice

AIMS: A 2-year project was carried out to evaluate the use of multi-component, computer-assisted strategies for implementing clinical practice guidelines. This paper describes the implementation of the project and lessons learned. The evaluation and outcomes of implementing clinical practice guidelines to prevent and treat pressure ulcers will be reported in a separate paper. BACKGROUND: The prevalence and incidence rates of pressure ulcers, coupled with the cost of treatment, constitute a substantial burden for our health care system. It is estimated that treating a pressure ulcer can increase nursing time up to 50%, and that treatment costs per ulcer can range from US$10,000 to $86,000, with median costs of $27,000. Although evidence-based guidelines for prevention and optimum treatment of pressure ulcers have been developed, there is little empirical evidence about the effectiveness of implementation strategies. METHOD: The study was conducted across the continuum of care (primary, secondary and tertiary) in a Canadian urban Health Region involving seven health care organizations (acute, home and extended care). Trained surveyors (Registered Nurses) determined the prevalence and incidence of pressure ulcers among patients in these organizations. The use of a computerized decision-support system assisted staff to select optimal, evidence-based care strategies, record information and analyse individual and aggregate data. RESULTS: Evaluation indicated an increase in knowledge relating to pressure ulcer prevention, treatment strategies, resources required, and the role of the interdisciplinary team. Lack of visible senior nurse leadership; time required to acquire computer skills and to implement new guidelines; and difficulties with the computer system were identified as barriers. CONCLUSIONS: There is a need for a comprehensive, supported and sustained approach to implementation of evidence-based practice for pressure ulcer prevention and treatment, greater understanding of organization-specific barriers, and mechanisms for addressing the barriers.     

Promoting evidence-based practice: the roles and activities of professional nurses' associations

AIM: This paper reports a study exploring the role perceptions and current activities in evidence-based practice promotion of professional nurses' associations in the Netherlands. Background: The promotion of evidence-based practice contributes to professional standards in nursing and good quality care for patients. As professional nurses' associations can be key players in this process, the nature of their roles and current activities deserves to be explored. METHODS: Roles and activities were explored for 43 professional nurses' associations (83% of all national associations). Data were collected using interviews with the associations' board members. Findings from the interviews were validated with those from an analysis of the associations' policy reports and other publications in the previous 2 years. RESULTS: Board members primarily thought that they had roles in the selection and distribution of evidence. The roles of participant (n = 13) and performer (n = 13) in selecting evidence, and those of facilitator (n = 12), initiator (n = 15) and performer (n = 41) in the distribution of evidence were often addressed. A few respondents reflected on roles in generating evidence and implementing evidence-based practice in patient care. A majority of the associations was contemplating activities in the promotion of evidence-based practice. Specific activities for each of six relevant aspects in the promotion of evidence-based practice were found in fewer than five associations. CONCLUSION: Professional nurses' association roles in the promotion of evidence-based practice need to be viewed in relation to the tasks to be accomplished, especially those of selecting and distributing evidence. Although many organizations expressed motivation, professional nurses' associations have a long way to go in the promotion of evidence-based practice among their members.