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.     

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.     

The Australian experience of nurses' preparedness for evidence-based practice

Aim  This study aimed to determine current knowledge and attitudes towards evidence-based practice (EBP) among pre- and post-registration nurses in New South Wales (NSW), Australia.
Background  Educational and clinical strategies for EBP in nursing assume a readiness to interpret and integrate evidence into clinical care despite continued reports of low levels of understanding and skill in this area.
Method  Perceptions of EBP were examined through a self-complete, anonymous postal survey distributed to 677 (post-registration) clinical nurses and to 1134 final year (pre-registration) nursing students during 2002 and 2003.
Results  A completed survey was returned by 126 post-registration and 257 final year nursing students (combined 21% response rate). Both pre- and post-registration nurses had a welcoming attitude towards EBP. Pre-registration nurses expressed more confidence in their EBP skills but self-rated knowledge and skill were low to moderate in both groups.
Conclusion  Nurses in Australia are clearly supportive of EBP but it is incorrect to assume that even recent graduates have a level of knowledge and skill that is sufficient to permit direct engagement in evidence implementation.
Implications for nursing management  Among a range of clinical supports, nurse managers and leaders can contribute to evidence-based health care by understanding the EBP knowledge and skills of their workforce and demanding a more practical approach in nursing education towards evidence-based guidelines and summaries appropriate to the clinical context.     

Evidence-based practice: the importance of education and leadership

johansson b., fogelberg-dahm m. & wadensten b . (2010) Journal of Nursing Management 18 , 70–77
Evidence-based practice: the importance of education and leadership
Aim  To describe evidence-based practice among head nurses and to explore whether number of years of duty is associated with such activities. Further to evaluate the effects of education on evidence-based practice and perceived support from immediate superiors.
Background  Registered nurses in Sweden are required by law to perform care based on research findings and best experiences. In order to achieve this, evidence-based practice (EBP) is of key importance.
Method  All 168 head nurses at two hospitals were asked to participate. Ninety-nine (59%) completed the survey. Data were collected using a study-specific web-based questionnaire.
Results  The majority reported a positive attitude towards EBP, but also a lack of time for EBP activities. A greater number of years as a head nurse was positively correlated with research utilization. Education in research methods and perceived support from immediate superiors were statistically and significantly associated with increased EBP activities.
Conclusions  The present study highlights the value of education in research methods and the importance of supportive leadership.
Implications for nursing management  Education is an important factor in the employment of head nurses. We recommend interventions to create increased support for EBP among management, the goal being to deliver high-quality care and increase patient satisfaction.     

Beyond evidence-based nursing: tools for practice

Aim  This commentary shares my views of evidence-based nursing as a framework for practice, pointing out its limitations and identifying a wider base of appraisal tools required for making good clinical decisions.
Background  As the principles of evidence-based nursing take an increasingly greater hold on nursing education, policy and management, it is important to consider the range of other decision-making tools which are subordinated by this approach.
Evaluation  This article summarizes nursing's simultaneous reliance on and critique of evidence-based practice (EBP) in a context of inadequate critical reasoning. It then provides an exemplar of the limitations of evidence-based practice and offers an alternative view of important precepts of decision-making.
Key issue  I identify means by which nurses can develop skills to engage in informed and robust critique of practices and their underpinning rationale.
Conclusion  Nurses need to be able to locate and assess useful and reliable information for decision-making. This skill is based on a range of tools which include, but also go beyond EBP including: information literacy, humanities, social sciences, public health, statistics, marketing, ethics and much more.
Implications for nursing management  This essay prompts nursing managers to reflect upon whether a flurried enthusiasm to adopt EBP neglects other important decision-making skills which provide an even stronger foundation for robust nursing decisions.     

Navigating the evidence-based practice maze

Aim  This article's purpose is to provide nurses with key points to consider in facilitating informed decision making while navigating the evidence-based practice (EBP) maze.
Background  EBP in nursing evolved from the medical model and continues developing within the holistic nursing paradigm. Inconsistent terminology, multiple applications, and lack of a unifying theory create challenges for nurses.
Key issues  Recognition that multiple knowledge sources to support clinical decision making have merit for facilitating 'best' patient outcomes; EBP must be an internalized value of professional nursing.
Conclusions  Multiple ways of knowing, or evidence, for informed clinical decision making must be considered based on situational context. No hierarchy fits all situations. Nurses must provide support and resources to facilitate nurse empowerment; nurses are accountable for using EBP to enhance patient outcomes.
Implications for nursing management  Effective EBP implementation relies on nurses being cognizant of what current nursing EBP trends are based on and where they are going. Nurses have a key role in facilitating consensus regarding evidence to be used in EBP, and ensuring availability of resources for empowering nurses to be accountable for outcome-oriented patient care through utilizing EBP.     

What is the evidence on evidence‐based nursing? An epistemological concern

AIM: This paper adopts an epistemological perspective in order to support the assertion that there is very little evidence to support the existence of evidence-based nursing as a distinct construct or process. RATIONALE: This analysis of concept meaning is based on the theory of symbolic interactionism. By adopting this theory the commonalities and inconsistencies in the use of evidence-based symbolism by nurses and other health care professionals can be used to evaluate the perceived meaning of the term. METHODS: A frequency analysis of relevant key words in one publications data-base demonstrates the increasing use of evidence-based terminology and its euphemistic status visa vi research. An epistemological analysis is conducted on a sample of concept clarification statements taken from the popular literature, defining the nature of 'evidence' and 'evidence-based practice'. FINDINGS: The results of the frequency analysis show that the keywords 'evidence-based medicine' revealed 5612 papers, evidence-based practice (EBP) 432 papers, evidence-based nursing 47 papers, evidence-based health care 60 papers, and evidence-based decision making 43. Almost all of these papers have been published since 1995 and the earliest use of the symbol 'evidence-based' is 1992. There is also an increase in papers adopting 'evidence-based' symbolism along with a commensurate decrease in the use of the term 'research' in the nursing context. CONCLUSION: 'Evidence-based practice' is commonly a euphemism for information management, clinical judgement, professional practice development or managed care. There is insufficient evidence to demonstrate that evidence-based nursing is a single construct or process that can be distinguished from its concomitants. The term adds little more to the existing long standing traditions of quality assurance and research-based practice. Nurses must avoid the inefficiency brought about by the 'intense enthusiasm followed by sad disenchantment' that has been associated with other attempts to introduce innovation in health care delivery (Fienstein & Horowitz 1997).     

临床护士循证实践培训体系的构建

目的 构建科学系统的临床护士循证实践培训体系,为培养循证实践临床护理人才提供依据。方法 以循证实践七步模型为依据,通过文献研究、小组讨论拟定临床护士循证实践培训体系专家咨询问卷,采用德尔菲专家咨询法选取25名专家进行2轮函询。结果 2轮专家咨询问卷有效回收率分别为80%、100%,专家权威系数为0.93。最终形成的临床护士循证实践培训体系包括5项一级指标,23项二级指标和61项三级指标。结论 本研究构建的临床护士循证实践培训体系具有较高的可靠性和科学性,对开展临床护士循证实践培训具有较好的指导作用和参考价值。     

循证护理:理论与实践

长期以来 ,护理实践的特点就是按照工作程序提供护理服务 ,在用科学证据指导临床护理决策和行动方面存在局限性。在讲求证据的年代 ,护士应积极寻求现时的证据来更新知识结构 ,增强解决问题的能力 ,为病人提供高效优质的护理 ,以满足 2 1世纪循证的要求 ,迎接所面临的挑战。循证护理实践就是实现此目标的一个很好的方法。文章从认识循证医学的内涵及以科学证据为基础的实践对临床护理服务影响的角度出发 ,主要讨论证据的质量分级、循证护理实践的主要步骤及其与临床路径的相互关系、我国循证护理实践现状、护理人员实施循证护理面临的挑战。     

Promotion of evidence-based practice by professional nursing associations: literature review

AIM: This paper reports a literature review examining the activities of professional nursing associations in the promotion of evidence-based practice. BACKGROUND: Professional nursing associations can play a role in the implementation and achievement of evidence-based practice as such associations aim to develop and further educate nurses professionally, build professional networks representing the interests of nurses and the nursing profession, influence the government and policymakers, and support and protect the basic values of nurses. The exact role of professional nursing associations in the promotion of evidence-based practice is as yet unclear, along with just how the role of such associations can be expanded and which strategies can be used to promote evidence-based practice among members. METHOD: A literature and Internet search was undertaken using the PUBMED, CINAHL, SCIRUS, INVERT, and the Cochrane databases using the terms evidence-based practice(s)* or EBP*, which were then combined with Nursing Society*, Nursing Organization*, Nursing Organisation*, Nursing Association* or Nursing Council*. Other sources included a Google search of the Internet, and the sites of various members of the International Council of Nurses. Publications in English, French or German from 1993 to 2004 were used, and the Internet search was conducted on 17 July 2003. RESULTS: Sixty nursing associations described the dissemination of evidence-based practice using one or more types of activities (179 activities in total). All of these activities were of a voluntary nature, with a predominant focus (132/179 activities) on intrinsic motivation of nurses. More specifically, most of the activities were aimed at nurses' competences and attitudes in relation to evidence-based practice. CONCLUSION: Professional nurses' associations are active in promoting evidence-based practice among their nurse members, but only those focusing on changing competences and attitude by addressing intrinsic motivation are well used. Other types of activities deserve to be explored, including behaviour-oriented approaches, approaches using structural, social or financial influence measures and perhaps methods based on 'involuntary involvement'.     

Evidence-based practice. Part 1: Origins, definitions, critiques, obstacles, advantages and impact

The increasing popularity of evidence-based practice (EBP) requires that nurses take a stand regarding this type of practice. This positioning rests on knowledge of EBP, however this notion varies by discipline and many definitions exist even within the nursing discipline. An improved understanding of the basic tenets of this type of practice is thus essential. This first, of a series of two articles describes the origin of EBP as well as various definitions, it also presents the major criticisms raised and takes a look at the impact of the increased tendency towards EBP on professional practice.     

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.     

Professional nursing societies and evidence-based practice: strategies to cross the quality chasm

The Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health Care System for the 21st Century nearly 10 years ago. Nursing societies are in a unique position to promote evidence-based practice (EBP). The purpose of this article is to describe EBP strategies that nursing societies can use to improve the quality of health care, thus decreasing the gap between research knowledge and practice. Nursing societies can take the lead in two key EBP activities: (1) development of evidence-based syntheses, systematic reviews, and guidelines for EBP; and (2) development, implementation, and testing strategies for these EBP resources to become available and used in clinical decision-making. The Oncology Nursing Society will be discussed as an exemplar of developing EBP programs and increasing knowledge of EBP and practice change resources for its members. The discussion stresses the importance of nursing society members and leaders in guiding their societies to contribute to the closing of the US health care quality chasm.     

Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review

Solomons N.M. & Spross J.A. (2011) Journal of Nursing Management 19, 109–120
Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review Aims The purpose of the present study is to examine the barriers and facilitators to evidence-based practice (EBP) using Shortell’s framework for continuous quality improvement (CQI). Background EBP is typically undertaken to improve practice. Although there have been many studies focused on the barriers and facilitators to adopting EBP, these have not been tied explicitly to CQI frameworks. Methods CINAHL, Academic Search Premier, Medline, Psych Info, ABI/Inform and LISTA databases were searched using the keywords: nurses, information literacy, access to information, sources of knowledge, decision making, research utilization, information seeking behaviour and nursing practice, evidence-based practice. Shortell’s framework was used to organize the barriers and facilitators. Results Across the articles, the most common barriers were lack of time and lack of autonomy to change practice which falls within the strategic and cultural dimensions in Shortell’s framework. Conclusions Barriers and facilitators to EBP adoption occur at the individual and institutional levels. Solutions to the barriers need to be directed to the dimension where the barrier occurs, while recognizing that multidimensional approaches are essential to the success of overcoming these barriers. Implications for nursing management The findings of the present study can help nurses identify barriers and implement strategies to promote EBP as part of CQI.     

Factors facilitating and inhibiting evidence-based nursing in Iran

AIM: This paper is a presentation of a study to clarify the concept of evidence-based nursing and to explore the factors that influence evidence-based nursing by Iranian nurses. BACKGROUND: Evidence-based practice was introduced as an approach to high-quality care intended to improve results for patients. Several nurse researchers have studied factors affecting implementation of evidence-based nursing in western countries. However, there is little or no research on the perceptions of evidence-based nursing and its barriers in eastern countries, especially Iran. METHODOLOGY: Grounded theory method was used. Interviews with 21 participants and 30 hours of observation were conducted in hospitals in Iran during 2005. Constant comparative analysis was used to analyse the data. FINDINGS: Two main categories, 'the meaning of evidence-based nursing', and 'factors affecting it', emerged from the data. From participants' perspectives, evidence-based nursing was defined as 'caring for patients based on the nurse's professional knowledge in meeting patients' needs'. The second category, factors affecting evidence-based care, had six subcategories: possessing professional knowledge and experience; having time and opportunity; becoming accustomed; self-confidence; the process of nursing education; and the work environment and its expectations. CONCLUSION: Managers and educators need to be committed to the principles of EBP, provide resources and create a supportive environment for its implementation. Individual nurses also have a responsibility to carry out evidence-based nursing, and researchers should work with practitioners to generate high quality evidence to support nursing practice.     

Evidence-based practice guidelines and school nursing.

The use of evidence-based practice (EBP) has become the standard of health care practice. Nurses are expected to use best evidence on a wide range of topics, yet most nurses have limited time, resources, and/or skills to access and evaluate the quality of research and evidence needed to practice evidence-based nursing. EBP guidelines allow nurses and other health care workers to have research information collected, analyzed, and condensed into specific practice recommendations by experts. This article defines EBP guidelines and discusses the process of guideline development, including identification of topics, systematic literature searches, and evaluation and rating of research. Criteria for determining the quality of existing guidelines are reviewed. The steps needed to develop EBP guidelines specifically for school nursing are discussed.     

护理人员循证护理知识、态度、行为、技能调查研究

目的；调查了解护理人员循证护理知识、态度、行为、技能状况，为临床开展护理人员的相关培训和循证护理教育的方向及管理灾践提供理论依据。方法：在参考国内外文献基础上自行设计调查问卷，对广州市5所医院的101名护理人员进行循证护理知识、态度、行为、技能状况调查。结果：63．7％的护理人员熟悉循证护理知识（人群集中在本科学历以上的护理人员），31．5％的护理人员对循证护理知识有一定的了解，只有4.8％的护理人员对循证护理一无所知；97．5％的护理人员对循证护理具有正向态度；护理人员的循证护理技能掌握较好的占18.4％，大部分人（58．3％）对检索知识、在实施循证护理过程与患者的沟通能力掌握较好，但在评价研究质量的优劣、决策能力技能方面能力不自信；20．80％的护理人员具有主动寻找解决问题的行为，而且集中在职称较高的人群；56．1％的护理人员会利用业余时间通过互联网获取需求知识，但有23．1％的护理人员墨守成规。结论：护理人员均对开展循证护理具有支持与正向的态度，但相当一部分护理人员对循证护理知识缺乏。     

Nursing based evidence: moving beyond evidence-based practice in mental health nursing

Various authors suggest mental health nursing is dominated by knowledge borrowed from psychiatry, pharmacology and the behavioural sciences. These disciplines favour knowledge developed using quantitative methodologies so they and evidence-based practice (EBP) and evidence-based nursing (EBN), increasingly called for in mental health nursing, fit seamlessly together. Nevertheless, as these movements dismiss qualitative approaches to knowledge (evidence) development, I argue against the move toward EBP/EBN in mental health nursing. This is because the specialty's primary interests - human experiences of illness/health care and human relationships, often do not lend themselves to being quantitatively researched. Using nursing examples, I demonstrate how qualitative research, wholly unacceptable in relation to EBP/EBN quality of evidence scales, is indispensable to mental health nursing. The need for evidence arising from qualitative research in no way precludes the need for quantitatively derived evidence. Indeed, the specialty's twofold interest - the work of nurses with clients and the explication of phenomena which inform practice, require diverse knowledge and thus, diverse research approaches. This twofold interest defines the area of mental health nursing practice, and knowledge informing it is referred to as nursing based evidence (NBE). Because it values multiple approaches to knowledge development, NBE provides a way to articulate the specialty's distinct contribution to the health care of people experiencing mental illness and advances mental health nursing.     

Nursing leadership and management effects work environments

Aim  The aim of this literature search was to identify recent research related to nursing leadership and management effects on work environment using the 14 forces of magnetism.
Background  This article gives some historical perspective from the original 1983 American Academy of Nursing study through to the 2002 McClure and Hinshaw update to 2009 publications.
Evaluation  Research publications were given a priority for references.
Key issues  The 14 forces of magnetism as identified by Unden and Monarch were: '1. Quality of leadership…, 2. Organizational structure…, 3. Management style…, 4. Personnel policies and programs…, 5. Professional models of care…, 6. Quality of care…, 7 Quality improvement…, 8. Consultation and resources…, 9. Autonomy…, 10. Community and the hospital…, 11. Nurse as teacher…, 12. Image of nursing…, 13. Interdisciplinary relationships… and 14. Professional development….'.
Conclusions  Correlations have been found among positive workplace management initiatives, style of transformational leadership and participative management; patient-to-nurse ratios; education levels of nurses; quality of patient care, patient satisfaction, employee health and well-being programmes; nurse satisfaction and retention of nurses; healthy workplace environments and healthy patients and personnel.
Implications for nursing management  This article identifies some of the research that provides evidence for evidence-based nursing management and leadership practice.