Evidence-Based Practice and Applied Nursing

Evidence-Based Practice and Applied Nursing

Health care is a vitally important component in every area and stage of life from infancy, through adulthood, to old age. From the practitioner's point-of-view, this is even more important, as the aim is to provide the best possible health care to clients. The excellence of such service is however only possible by putting into practice the most recent research. One of the most important concepts in nursing today is therefore evidence-based practice (EBP).

Evidence-based practice in nursing means that nurses use the most recent research and apply it to their daily patient care. Such information is increasingly available, with Internet resources increasing not only in quality, but also in abundance.

According to Hockenberry, Wilson & Barrera (2006), EBP has been implemented successfully in many institutions, despite those who criticize it as a fad. However, the authors also note that, despite its many advantages, certain elements need to be in place to ensure its success. Time, energy and financial resources will for example need to be allocated towards implementation. In addition, access to information must be readily available, and an administrative process of implementation needs to be in place. To ensure the smooth functioning of this process, leadership should be both unified and targeted towards EBP. In short, the process, as intended, must be incorporated in everyday practice. In order to accomplish this, the authors suggest that the EBP process should also be part of the institutional vision and mission. In order to accomplish this, it is important for leadership to be directly involved in evidence-based nursing practice.

Unfortunately, leadership, research, and other institutional and individual elements more often than not create barriers to the effective implementation of evidence-based practice. According to Drury (1998), the common gap between research and practice in health care has been termed the research-practice gap. With this in mind, the author conducted a study in order to determine the reasons for this phenomenon, and secondly, what strategies could be implemented in order to remedy the problem.

In a later writing, Melnyk (2002) also acknowledged that the research-gap problem was still very much in evidence in nursing practice. Melnyk indicates that this is not caused by a lack of evidence relating to the effective use of evidence-based practice in the profession. Instead, additional factors play a significant role as barriers to the implementation of EBP in nursing.

On major problem is the struggle that nurses experience in their effort to implement evidence-based practice. A further significant factor is the fact that many nurses lack the knowledge and skills to successfully implement learning from research into practical care.

Specifically, Melnyk notes that this lack of knowledge manifests itself into several problems: the lack of knowledge in terms of strategies to implement evidence-based practice; misperceptions or negative attitudes; lack of skill in terms of research and evidence appraisal; demanding workloads and schedules; lack of administrative support or other organizational constraints; expectations from patients and their family members; and the vast, growing amount of information that is already available via numerous sources, including the Internet, books, journals and the like.

Many authors address the barriers to evidence-based practice in nursing, and how to remedy these. These authors appear to agree that both leadership and organizational practice need to be focused towards implementing EBP in health care institutions. Indeed, it is only by means of effective leadership that adequate incentives can be provided, and negative attitudes be remedied. Furthermore, these incentives and practices will translate themselves to patients themselves and improve the overall practice of health care.

II.BARRIERS to the IMPLEMENTATION of EVIDENCE-BASED NURSING PRACTICE

According to Udod & Care (2006), barriers to evidence-based nursing practice can be divided into three main levels, or categories. These include the individual, organizational, and environmental levels. These categories are all influenced by leadership, and the concern of those in leadership positions with effectively implementing evidence-based practice.

One problem regarding leadership, according to the authors, is the fact that leaders themselves often have a better understanding of theory rather than practice when it comes to understanding the competencies required to implement good leadership practice. Hence, an attitude also exists that in fact implementing knowledge directly into practice is not a very high priority. A further problem relating to managing nursing care is an individual barrier.

The authors note for example that some nurse managers lack the competence to truly lead nurses towards excellence in evidence-based practice. Indeed, many of these managers not only lack advanced academic skills and hence the ability to inspire this in others, but also to use such skills themselves. Indeed, the authors note that this lack of leadership skill is often to blame for the still-existing research-practice gap among nurses.

Another basic problem within leadership, according to Udod & Care (2006), is the attitude towards nursing as a profession and its use of theory and practice. The authors for example note that many nursing managers still view the profession as practical rather than cognitive. Hence, such managers view extra research and its implementation into practice as unnecessary.

A further individual factor relates to nurses themselves. It is not only poor management that fails to provide nurses with the skills they need to implement research into their practice, but also work-related factors. Many nurses are for example so overwhelmed by their work duties that few have the time or energy to conduct further research, even if this means that their practice and profession would improve. This is not necessarily only a manifestation of poor management, but also simply resulting from the nature of the profession and its rigors.

According to Udod & Care (2006), organizational barriers to implementing evidence-based practice effectively include difficulty to access evidence, resource constraints, lack of funding for skills development, and a lack of management priority for evidence-based practice. Many of these factors overlap and also influence the individual factors that relate to nursing and its management. Resource constraints for example result in nurses being overworked and thus not having the time, energy, or inclination to further their implementation of EBP. Furthermore, resource constraints also place constraints upon management, which cannot be optimized without the appropriate resources.

Environmental barriers could include influences from the wider sector, such as governmental policy, which places constraints upon both nursing and management practice. Another factor could result from the culture of change, when management attempts to force a change of attitude towards evidence-based practice without the appropriate attention to implementing new practices or ensuring that all employees are aware of the new expectations. Nurses could find themselves overwhelmed by a culture of change that appears to leave them behind to cope with both workload problems and a new set of expectations that they are not skilled or coached to meet.

According to Drury (1998), research itself could present a barrier to implementing evidence-based practice. The author's investigation revealed five barriers that relate to research. The lack of time that health care professionals experience has already been mentioned. Because of both this time constraint and the overwhelming amount of research available, health care practitioners also tend to read far less than they should regarding best practices in health care. Furthermore, there is a tendency to separate research from practice, where the theoretical and the practical do not appear to have any common ground. In this regard, it has been mentioned that many view nursing as a practical profession, whereas those who do conduct research are seen as removed from the practical setting, rather than as an essential part of it. Furthermore, there is also a tendency to disregard research as unimportant at most, and as belonging to undergraduate nursing programs. These attitudes all undermine the potential benefits of evidence-based practice.

The lack of understanding relating to the importance of research is a matter of great concern for Drury. Indeed, the author states that nursing research reports are vital in order to ensure that hospital practice remains optimal and up-to-date. At the time of writing, and even today, the problem of applying research to practice remains one of the most significant challenges of the health care profession.

A further barrier regarding research is the basic lack of concern with research not only during professional nursing practice, but also in training nurses. There is no specific concern with training nurses to conduct effective research, to analyze the validity of resources, or to implement such findings to their nursing practice. The place of research in nursing education should therefore enjoy considerably more attention than it has to date.

Many of these limits remain substantiated by authors of much later works, including Hockenberry, Wilson & Barrera (2006). These authors also mention the factors of time, limited access to literature, and a basic lack of confidence in nurses to be able to conduct adequate research.

Another important factor relates to nurses themselves, and how they personally regard their ability to conduct adequate and high-quality research. Much as been written about external factors influencing nurses and their ability to research. Factors already mentioned include management problems and workload constraints. It is however also important to consider the importance of internal individual factors such as the self-confidence levels of nurses. According to Hockenberry, Wilson and Barrera (2006), for example, note that nurses could feel considerably intimidated by the demands of EBP in nursing practice. Their limited knowledge of the research process thus serves as a barrier to its effective implementation.

Furthermore, the authors also raise the management problem, with nurses feeling a lack of power within their environment even if they do believe that they are able to handle the requirements of effective evidence-based practice. This brings the issue of research back to the leadership issue. In addition, nurses often experience a lack of autonomy, authority, and a basic lack of adequate resources to offer excellent patient care. The authors however suggest that overcoming the barriers to effective EBP could lead to increased job satisfaction for nurses.

In this way, improved nursing practice will complement satisfaction from the work and will have a cumulatively positive effect upon the nursing profession as a whole. Many authors make suggestions on overcoming the barriers to evidence-based practice.

III. OVERCOMING BARRIERS to EBP

According to Drury and several other authors, leadership has manifested itself as one of the primary problems creating barriers to the effective implementation of EBP. It therefore makes good sense to make nursing leadership the target as an instrument of overcoming such barriers. According to Drury, a good leader should master three basic skills, all of which relate to change: the leader should initiate change, promote the acceptance of change, and ensure a safe environment for other initiaters of change.

One of the elements that make nurses reluctant to implement evidence-based practice in their nursing is the fact that they experience a basic uncertainty about how to accomplish this. Attempting to force them to do so makes matters worse. Nurses who are treated like this feel not only victimized, but also intimidated. A good leader should avoid this at all costs.

Udod & Care (2006) provide some practical examples about how such leadership can be accomplished. The most important factor is that leaders must promote the cause of evidence-based practice by themselves believing in and championing it. On an individual level, for example, leaders can demonstrate commitment to EBP by role modeling it. In other words, leaders must themselves become instruments of evidence-based practice to show nurses on a very practical level how beneficial it is for practice.

Once nurses become more confident and show a tendency towards acceptance of the new mode of practice, the next step for leaders would be to create a network of opportunities for nurses themselves to practice EBP. This can be done in a variety of ways, where each individual nurse is provided with an information outlet for research, such as a computer, the findings of which she will then later share in a collaborative environment. Collaboration is an important concept. While no profession can be said to ever occur in isolation, nursing is particularly a manifestation of collaborative practice. In this way, EBP becomes not only a more effective way of serving patients, but also of supporting other nursing staff.

This is also important in terms of time constraints. Nurses can take turns to do research and share this with others, along with suggestions on how to implement theory practically. This will both diversify and lighten the workload, decrease unhealthy stress for nurses, and also provide a basis for greater job satisfaction.

Most importantly, Udod & Care (2006) also note that leaders are to provide psycho-social support to nurses who are in the learning process when implementing the new mode of nursing, where research, evidence, and practice converge.

Being at the heart of the barrier matter, research is another important element that should enjoy focus when implementing evidence-based practice. Drury (1998) suggests that research teams should be developed within the nursing profession, which will further the solution to several of the problems mentioned above. In addition to considerably lightening the collective workload, as mentioned above, such research teams should be composed in a very specific way in order to ensure the greatest effect rather than acting as only a further barrier to effective evidence-based research.

The composition of research teams should be such that its leaders are those who are educated in the art of carrying out and evaluating research. These group leaders can then act as coaches to the rest of the group, who can then "graduate" to become future researchers and teachers. Furthermore, group members should also comprise those registered nurses who work directly with patient care and leaders. Such teams can then collectively act to bring the strength of each individual group member to a team that is ultimately able to implement evidence-based practice in a much more effective way than individuals can.

Such research teams, according to Drury's findings, can then also demonstrate the importance and usefulness of research to those who are not aware of this, they can continue to develop the research prowess of graduate nurses, encourage critical thinking, share research, promote research acceptance, and initiate change while developing researchers.

Research teams then have the potential to implement the necessary elements of evidence-based practice to the hospital setting in a very practical way without significantly adding to the workload of any individual nurse or leader. Indeed, teams can provide the solutions to most of the individual, organizational and environmental barriers to EBP mentioned above.