Implementation of evidence‐based nursing practice for diabetic patients: An Iranian experience

Evidence‐based nursing is recognized as an indicator of quality in nursing practice, a basis for accountability and the gold standard of professional nursing care. The aim of this study was to explore nurses’ experiences and perceptions about evidence‐based nursing practice in giving care to patients with diabetic foot ulcers. A qualitative research design was adopted, and content analysis was used to analyse data. Semistructured interviews were held with 19 bachelor‐degree nurses working in a teaching hospital in an urban area of Iran. During data analysis, two main themes developed: ‘structural backgrounds of the organization’ and ‘empowerment’. Accordingly, it was concluded that successful implementation of evidence‐based nursing requires the reconfiguration of the administrative structure in the hospital. In addition, it requires the support of nurse leaders to facilitate the implementation of evidence‐based nursing in the practice.     

Using theory and evidence to drive measurement of patient,nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization‐wide implementation of two nursing‐centric best‐practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence‐informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.     

Evidence‐based nursing: clarifying the concepts for nurses in practice

Aim. To provide a critical analysis of key concepts associated with evidence‐based nursing (EBN) to substantiate an operational definition for nurses to use in practice. Background. Despite the plethora of literature surrounding what evidence‐based nursing is and is not and how it differs from its cousins, evidence‐based medicine and evidence‐based practice, nurses still struggle to get evidence into practice. Several reasons for this have been reported, for example, a lack of understanding about what evidence‐based nursing means or time to engage with and apply the evidence into practice. Design. An in‐depth critical review and synthesis of literature was undertaken. Method. Using the key words; evidence‐based nursing, evidence‐based medicine and evidence‐based practice 496 articles were yielded. These articles were limited to 83. Using Burns and Grove’s (2001) phased approach to reviewing the literature the articles were critically reviewed and categorised into key concepts and themes. Results. The in‐depth critical review and synthesis of the literature demonstrated that evidence‐based nursing could be defined as a distinct concept. The review clearly shows that for evidence‐based nursing to occur, nurses need to be aware of what evidence‐based nursing means, what constitutes evidence, how evidence‐based nursing differs from evidence‐based medicine and evidence‐based practice and what the process is to engage with and apply the evidence. Conclusion. The in‐depth critical review and synthesis of the evidence‐based nursing literature reinforces the need to consolidate a position for nursing in the evidence‐based field. The review confirms that evidence‐based nursing can be defined and conceptualised; however, for nurses to engage and apply with the evidence‐based processes they need to be informed of what these are and how to engage with them in practice. Relevance to clinical practice. This paper examines the concept of evidence‐based nursing and its application to clinical practice.     

Achieving evidence-based nursing practice: impact of the Caledonian Development Model

Aim To determine the impact of the Caledonian Development Model, designed to promote evidence‐based practice. Background The model features practice‐development activities, benchmarking, knowledge pooling and translation through membership of a community of practice and a virtual college. Methods Twenty‐four nurses, from 18 practice sites formed three communities of practice, each selecting evidence‐based guidance to implement. A modified group supervision framework empowered nurses to champion local implementation. Outcomes were determined at 6 months. Results Eighty per cent of the patient‐related criteria and 35% of the facilities criteria were achieved. The Revised Nursing Work Index indicated these nurses experienced greater autonomy (P = 0.019) and increased organizational support (P = 0.037). Focus groups revealed a deepening organizational support for the initiative over time, illuminated work‐based learning challenges and overall enthusiasm for the approach. Conclusion Implementation of the model effectively promoted evidence‐based practice, most notably at the level of the individual patient. Implications for nursing management Time and budgetary constraints necessitate smart, value for money approaches to developing evidence‐based practice and improved care standards. This work demonstrates an effective model that strikes a balance between individual and group learning, virtual and real‐time activities, coupled with resource pooling across organizations and sectors.     

A philosophical analysis of evidence‐based practice in mental health nursing

Mental health nurses need to be aware that their knowledge base does not exist in isolation from other cultural practices. They/I/we must become more willing to engage in theoretical problem solving that directly affects clinical practice issues such as the introduction of evidence‐based practice. Critical discussion of evidence‐based practice should be informed by the complex issues that permeate all our socio‐cultural and linguistic practices. This paper examines some of the major philosophical problems in the debate over the use of evidence‐based practice in mental health nursing using both Foucault’s formulation of discourse analysis and Derrida’s construal of deconstruction. The conclusion reached is that postmodern philosophy offers a way to rid nursing of incessant naiive attacks on either quantitative or qualitative research methods which underpin the debate over evidence‐based practice in mental health nursing.     

Nurses’ experiences of guideline implementation: a focus group study

Aims. The aim of the study was to address the following questions: What kind of experiences do primary care nurses have of guideline implementation? What do nurses think are the most important factors affecting the adoption of guidelines? Background. The implementation of clinical guidelines seems to be dependent on multiple context‐specific factors. This study sets out to explore the experiences of primary care nurses concerning guideline implementation. Design. Qualitative interview. Methods. Data were generated by four focus group interviews involving nurses working in out‐patient services in primary health centres in Finland. Purposive sampling was used to select health centres. Inductive content analysis was used to identify themes emerging from the data. Results. Four main groups of factors were identified from the analysis of data: (i) factors related to the organisation, (ii) factors related to nurses, (iii) factors related to the anticipated consequences and (iv) factors related to the patient group. Nurses’ awareness and acceptance of guidelines and the anticipated positive consequences facilitate the implementation of guidelines. Organisational support, especially the adapting of guidelines to local circumstances, seems to be crucial for successful implementation. Conclusions. Clinical guidelines can be promising tools in enhancing evidence‐based nursing practice, as nurses see them as practical work tools in patient care and so are willing to adopt them. However, support from management and physicians is needed to ensure the successful implementation of guidelines into nursing practices. Relevance to clinical practice. Based on the findings of this study and previous knowledge of guideline implementation some practical recommendations are suggested. Select the most relevant guidelines to clinical practice, organise the adaptation of guidelines to local circumstances, inform all practitioners involved in treatment and give clear instructions for the adoption of the guidelines.     

Organizational support in the recruitment and transition of overseas‐qualified nurses: Lessons learnt from a study tour

The migration of nurses has been a global phenomenon, and the integration of overseas‐qualified nurses within host countries has led to debate worldwide. Evidence suggests that support provided by organizations can vary and that there is minimal information on the nature and extent of organizational support required to enhance a smooth transition of overseas‐qualified nurses into nursing practice. This explorative study tour examined the organizational support provided to enhance overseas‐qualified nurses' transition into the nursing workforce in two countries. The various support mechanisms provided to overseas‐qualified nurses in different organizations include transition, acculturation, mentoring programs, and initial settlement assistance. The successful transition of overseas‐qualified nurses into a host country is a complex issue. A robust support system for these nurses should be based on ethical considerations and a team approach that is linked to strong leadership. In addition, education and support for existing staff is essential for a successful transition of overseas‐qualified nurses into practice. Lessons learnt from this study tour might also be relevant to the transition of other overseas‐qualified health professionals, such as doctors and allied health professionals, in host countries.     

Conceptions of evidence, evidence-based medicine, evidence-based practice and their use in nursing: independent nurse prescribers' views

Aim. The purpose of this study was to explore nurses’ conceptions of evidence and evidence‐based practice, whether there are differences between evidence‐based practice and evidence‐based medicine and to identify the uptake of research evidence in the workplace. Background. The use and comprehension of the term ‘evidence‐based practice’ in relation to nursing shows remarkable variation. Numerous definitions are provided, some tend to be closely related to the concept ‘evidence‐based medicine’. Independent nurse prescribers need to be able to understand the concept of evidence‐based practice to utilize and apply this concept in order to provide adequate medication management of their patients. Method. Data were generated by focus group interview and open question questionnaire and analysed by analytical abstraction. Results. Nurses offered a variety of views on the use and uptake of evidence in the workplace. Some nurses acknowledged that they did not read research papers but were aware that they used a lot of evidence in their practice. Nurses had difficulty differentiating evidence‐based practice from evidence‐based medicine. Conclusions. Nurses were familiar with the research process but not the canons of evidenced‐based practice. The data generated indicate different levels of evidence are used by nurses. This may be a reflection of the level of intrigue of the nurses involved. Relevance to clinical practice. The education and training of independent nurse prescribers should include the exploration of evidence from randomized controlled trials and from naturalistic studies and their contribution to evidenced‐based practice and evidence‐based medicine. Both concepts need to be explored in relation to the medication management of patients.     

Factors influencing evidence‐based nursing utilization intention in Korean practice nurses

The purpose of this study was to describe Korean nurses' perceptions, attitudes and utilization intention for evidence‐based nursing (EBN), and to explore what factors influence utilization intention. We conducted a cross‐sectional survey in 2012. Registered nurses directly involved in clinical practice were recruited at a medical centre in Korea. A total of 420 nurses completed a self‐report questionnaire. Results showed that participants reported moderate scores regarding their perceptions and attitudes towards EBN, and rated themselves as higher than the median for utilization intention. Furthermore, this study revealed that perceptions of and attitudes towards EBN, occupational view and previous EBN education were significant factors affecting utilization intention. Nurse educators and managers should encourage nurses to have better attitudes towards EBN, help them be more satisfied with their work and provide them with appropriate education for EBN to establish evidence‐based practice as a part of daily nursing care.     

A review of evidence-based practice, nursing research and reflection: levelling the hierarchy

Aim. This paper examines the evidence‐based practice movement, the hierarchy of evidence and the relationship between evidence‐based practice and reflective practice. Background. Evidence‐based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice. Method. A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence‐based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence‐based practice, reflection and research. Only material written in English was included. Findings. The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence‐based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence‐based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence. Conclusion. Evidence‐based practice is necessary for nursing, but its’ effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence‐based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence‐based practice movement. Relevance to clinical practice. Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.     

How can we maximize nursing students’ learning about research evidence and utilization in undergraduate,preregistration programmes? A discussion paper

Aim. This article presents a discussion on how to maximize nursing students’ learning about research for evidence‐based practice in undergraduate, preregistration programmes. Background. Evidence‐based practice may use information from many sources, including research. Research utilization concerns the translation of research findings into practice. Thus, while evidence‐base practice may not be solely research‐based and hence more than research utilization, research remains an important ingredient in ensuring quality and cost‐effective care and an academic requirement for nursing students undertaking a science degree‐level qualification. Nevertheless, how educators can best support research‐related learning and application remains uncertain and requires discussion. Data sources. MEDLINE, CINAHL, Social Science Citation Index, British Nursing Index, and Intute were searched for papers published 1980–2011 using the following search terms: research, research utilization, evidence‐based practice, learning, teaching, education, training, nursing, health, and social care. Discussion. Nursing students need to be able to value the relevance, authority, and utility of nursing research for patient care through embedding research learning in both academic and practice‐based settings. Students can be supported in learning how to access, understand, and appraise the authority of research through weaving these skills into enquiry‐based learning. Furthermore, encouraging students to undertake research‐based practice change projects can support research utilization and development skills. Conclusion. Research should be fully embedded throughout nursing curricula beyond the confines of ‘research classes’, integrating learning in academic and practice‐based settings. Although this requires synergistic and integrated support of student learning by nurse educators, managers, clinical practitioners, researchers and policymakers; nurse educators have a pivotal role.     

Exploring the contribution of the Clinical Librarian to facilitating evidence-based nursing

Aim. To examine the potential role of the Clinical Librarian in facilitating evidence‐based practice of nurses in acute hospital settings and develop a model for the role. Background. There is a growing policy and professional expectation that nurses will seek out and apply evidence in their clinical practice. Studies have demonstrated that nurses experience barriers in working with an evidence‐based approach. The role of Clinical Librarian has been used in other countries and within medicine to overcome some of the barriers to evidence‐based practice. There are limitations in the previous work in terms of rigour of evaluation, scope of the Clinical Librarian role and application to nursing in a UK setting. Design. A qualitative consultation of 72 nurses in acute care settings. Methods. Six consultation group interviews of between 4–19 participants. Written records were recorded by the scribe. Content analysis was undertaken to identify the range and frequency of comments. Results. Clinical questions currently go unanswered because of barriers of time, skills deficits and access to resources. Literature searching, skills training and evidence dissemination were the main areas of work the staff requested that a Clinical Librarian should undertake. It was anticipated that the Clinical Librarian could interact and work productively with nursing staff with a limited but regular presence on the ward. Interim communication could be via e‐mail, phone and written suggestions and requests for work. It was seen to be vital that the Clinical Librarian worked in partnership with staff to build evidence‐based practice capacity and ensure clinical relevance of the work. Conclusions. This study has generated the first model for the Clinical Librarian role with an emphasis on nursing. It is derived from the views of clinical nurses. Recommendations are made for the implementation and evaluation of such a role. Relevance to clinical practice. The Clinical Librarian could be an invaluable support to promoting evidence‐based nursing.     

Adaptation of a Best Practice Guideline to Strengthen Client‐Centered Care in Public Health

Best practice guidelines (BPGs) were developed by the Registered Nurses Association of Ontario (RNAO) to support evidence‐based nursing practice. One Ontario public health unit chose to implement the BPG on client‐centered care (CCC). A critical review of this BPG revealed issues that would hinder successful implementation within a public health setting. These included a focus on the client as an individual, the predominance of acute care exemplars and training resources that were not representative of public health nursing practice, and the need to reconcile the enforcement roles of public health with the BPG principles. The purpose of this article is to describe the process of adapting the CCC BPG to more accurately reflect the broad scope of public health nursing practice. A model for CCC in public health nursing context is presented and processes for implementing, evaluating, and sustaining CCC are described.     

A survey of Hong Kong nurses' perceptions of barriers to and facilitators of research utilization

A survey of 1,487 nurses was conducted to examine barriers to and facilitators of research utilization. Characteristics of the organization were the greatest barriers to research utilization; the highest ranked of these were inadequate facilities, lack of authority to change practice, lack of time, and lack of cooperation from physicians. The three highest ranked organizational facilitators were managerial support, colleague support, and education to increase nursing knowledge. Age and years of working experience were not significantly correlated with any of the subscales. To integrate the use of research evidence into the culture of various clinical settings, and with the aim of extending evidence-based practice into the private and primary health care sectors in Hong Kong, local organizational barriers and facilitators need to be addressed.     

Using action research to construct national evidence-based nursing care guidance for gerontological nursing

Aim. This paper explores the development of a low‐cost, involving methodology for constructing nursing‐focused evidence‐based national care guidance, known as Best Practice Statements, the intended users of which are gerontological nurses practising throughout Scotland. Design. The Best Practice Statement construction methodology forms one cycle in a five‐year longitudinal action research study that aims to achieve evidence‐based nursing, facilitate professional networking to support practice development and promote the principles and practice of gerontological nursing. Achieving these aims involved designing a virtual Practice Development College. Methods. A Community of Practice comprising practising gerontological nurses, expert advisors, academic teaching and research nurses collaborated in face‐to‐face meetings and in the virtual Practice Development College to delineate and refine the procedural model for Best Practice Statement construction. Focus groups, telephone interviews, analysis of on‐line archives and documentary outputs formed the analytic dataset. Results. Qualitative analysis indicated that, from the perspective of the community of practice, the emerging methodology facilitated the melding of knowledge sources reflecting the dominant evidence hierarchy with other forms of evidence valued by gerontological nurses, in the Best Practice Statement. Relevance to clinical practice. Current methods of care guidance construction rarely address the concerns of nurses and the evidence from which guidelines are developed is narrowly defined with regard to inclusion and acceptability. In contrast this model focuses on nursing issues, embraces a wider definition of evidence and ensures that the published Best Practice Statements are credible and achievable in gerontological practice, where they are tested and refined as an inherent aspect of the development process.