Evidence-Based Practice in Nursing: Barriers and Solutions

Introduction to Evidence-Based Practice in 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 significant, as the aim is to provide the best possible care to clients. Excellence in health care service is only possible, however, 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 growing not only in quality but also in abundance.

According to Hockenberry, Wilson, and Barrera (2006), EBP has been implemented successfully in many institutions, despite criticism from those who dismiss it as a passing trend. However, the authors also note that, despite its many advantages, certain elements must be in place to ensure its success. Time, energy, and financial resources need to be allocated toward implementation. In addition, access to information must be readily available, and an administrative process of implementation must be established. To ensure the smooth functioning of this process, leadership should be both unified and focused on EBP. In short, the process must be incorporated into everyday practice. To accomplish this, the authors suggest that EBP should be part of the institutional vision and mission, and that leadership must 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, Drury conducted a study to determine the reasons for this phenomenon and to identify strategies that could be implemented to remedy the problem.

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

One major problem is the struggle that nurses experience in their efforts to implement evidence-based practice. A further significant factor is that many nurses lack the knowledge and skills to successfully translate research findings into practical care.

Specifically, Melnyk notes that this lack of knowledge manifests itself in several ways: insufficient knowledge of strategies to implement EBP; misperceptions or negative attitudes toward research; limited skill in research appraisal and critical evaluation of evidence; demanding workloads and schedules; lack of administrative support or other organizational constraints; expectations from patients and their family members; and the vast, growing volume of information already available through numerous sources, including the Internet, books, and journals.

Many authors address the barriers to evidence-based practice in nursing and how to remedy them. These authors generally agree that both leadership and organizational practice must be focused on implementing EBP in health care institutions. It is only through effective leadership that adequate incentives can be provided and negative attitudes addressed. Furthermore, such incentives and practices will ultimately benefit patients and improve the overall quality of health care.

Barriers to the Implementation of Evidence-Based Nursing Practice

According to Udod and Care (2006), barriers to evidence-based nursing practice can be divided into three main levels: the individual, organizational, and environmental. All three categories are influenced by leadership and by the degree to which those in leadership positions are committed to implementing evidence-based practice.

One problem regarding leadership, according to Udod and Care, is that leaders themselves often have a stronger understanding of theory than of practice when it comes to the competencies required for effective leadership. This fosters an attitude that applying knowledge directly to practice is not a high priority. A further problem is an individual barrier related to managing nursing care.

The authors note that some nurse managers lack the competence to truly lead nurses toward excellence in evidence-based practice. Many of these managers not only lack advanced academic skills and the ability to inspire such skills in others, but also fail to apply such skills themselves. This deficiency in leadership is frequently identified as a contributing factor to the ongoing research-practice gap among nurses.

Another basic problem within leadership, according to Udod and Care (2006), is the attitude toward nursing as a profession and its use of theory and practice. Many nursing managers continue to view the profession as primarily practical rather than cognitive, and therefore regard additional research and its implementation into practice as unnecessary.

A further individual factor relates to nurses themselves. Poor management is not the only reason nurses fail to implement research into their practice; work-related factors also play a role. Many nurses are so overwhelmed by their daily duties that few have the time or energy to engage with research, even when they recognize that doing so would improve their practice. This situation is not necessarily a manifestation of poor management alone, but also reflects the inherent demands and rigors of the nursing profession.

According to Udod and Care (2006), organizational barriers to implementing evidence-based practice include difficulty accessing evidence, resource constraints, lack of funding for skills development, and insufficient management priority for EBP. Many of these factors overlap and also influence the individual barriers discussed above. Resource constraints, for example, result in nurses being overworked, leaving them with little time, energy, or inclination to advance their EBP implementation. Furthermore, resource constraints also limit what management can achieve, since effective management cannot be sustained without appropriate resources.

Environmental barriers may include influences from the broader sector, such as government policy, which places constraints on both nursing and management practice. Another factor can arise from cultures of rapid change, when management attempts to shift attitudes toward evidence-based practice without adequately implementing new procedures or ensuring that all employees understand the new expectations. Nurses may find themselves overwhelmed by a climate of change that leaves them struggling with both workload pressures and unfamiliar expectations for which they have not been coached or prepared.

According to Drury (1998), research itself can present a barrier to implementing evidence-based practice. Her investigation identified five research-related barriers. The lack of time experienced by health care professionals has already been noted. Because of both time pressure and the sheer volume of available research, practitioners also tend to read far less than they should about best practices. There is additionally a tendency to separate research from practice, treating the theoretical and the practical as having no common ground. In this regard, nursing is frequently viewed as a purely practical profession, while those who conduct research are seen as removed from the practice setting rather than as an essential part of it. There is also a tendency to dismiss research as unimportant, or to regard it as relevant only to undergraduate nursing programs. These attitudes all undermine the potential benefits of evidence-based practice.

The lack of appreciation for research is a matter of great concern for Drury, who argues that nursing research reports are vital for ensuring that hospital practice remains optimal and current. The problem of applying research to practice remains one of the most significant challenges in the health care profession.

A further barrier is the general lack of attention to research not only in professional nursing practice, but also in nurse training. There is no consistent emphasis on teaching nurses to conduct effective research, to evaluate the validity of sources, or to apply research findings to their clinical practice. The role of research in nursing education therefore deserves considerably more attention than it has historically received.

Many of these limitations are confirmed by later authors, including Hockenberry, Wilson, and Barrera (2006), who also cite time constraints, limited access to literature, and nurses' lack of confidence in their own research abilities as significant barriers.

Another important factor concerns how nurses personally regard their capacity to conduct high-quality research. While much has been written about external factors — such as management shortcomings and workload demands — it is equally important to consider internal factors such as self-confidence. Hockenberry, Wilson, and Barrera (2006) note that nurses may feel considerably intimidated by the demands of EBP, and that their limited knowledge of the research process serves as a barrier to its effective implementation.

Furthermore, the authors raise the issue of power within the workplace, noting that nurses may feel disempowered within their environment even when they believe they are capable of meeting the requirements of EBP. This links the research barrier back to the leadership issue. Nurses also frequently experience a lack of autonomy, authority, and adequate resources to provide excellent patient care. The authors suggest, however, that successfully overcoming the barriers to effective EBP could lead to increased job satisfaction for nurses. In this way, improved nursing practice will reinforce job satisfaction and have a cumulatively positive effect on the nursing profession as a whole.

Conclusion

In conclusion, the best approach to implementing evidence-based practice in the nursing profession involves following a number of logical steps. The first is to identify the nature of the challenges involved. In general, these challenges revolve around the dual pressures of workload and research volume. They can be effectively addressed through the formation of research teams, which pool the expertise of multiple individuals rather than placing the burden of both patient care and theoretical research on any single person.

The issue of evidence-based practice is clearly a pressing one in contemporary nursing. It is widely recognized that EBP should be implemented to optimize patient care. However, it must also be recognized that the needs of nursing practitioners and their leaders must be taken into account. Fulfilled and confident nursing and research practitioners are far better positioned to provide high-quality services than those who feel insecure, victimized, or threatened by change. Leadership must therefore be the starting point for implementing the kind of meaningful change that ultimately leads to better hospital practice and health care outcomes. In this way, the satisfaction of both clients and those who serve them will be recognized and sustained.

Drury, P. (1998). Barriers to evidence-based nursing care: Listen to the clinicians! Retrieved from

Hockenberry, M., Wilson, D., & Barrera, P. (2006, October). Implementing evidence-based nursing practice in a paediatric hospital. Medscape Today. Retrieved from http://www.medscape.com/viewarticle/543728

Malloch, K., & Porter-O'Grady, T. (2009). Introduction to evidence-based practice in nursing and health care. Jones & Bartlett Publishers.

Melnyk, B. M. (2002, March–April). Strategies for overcoming barriers in implementing evidence-based practice. Paediatric Nursing. Retrieved from FindArticles.com.

Udod, S. A., & Care, W. D. (2006, October). Setting the climate for evidence-based nursing practice: What is the leader's role? In the Know, Issue 1. Retrieved from http://www.chsrf.ca/research_themes/pdf/pages_from_in_the_know_nursing_issue_1_eng.pdf