Evidence-Based Practice in Nursing: Policy Analysis

Introduction and Problem Identification

Despite many efforts to promote evidence-based practice (EBP), many patients are not receiving appropriate care. Evidence-based practice implies that decisions about treatment options will depend largely on evidence of their clinical effectiveness. The major purpose of EBP is the elimination of expensive, ineffective, or dangerous medical decision-making. However, developing and using this evidence is not always straightforward. Making use of evidence in clinical practice is a major challenge for nurses, who face numerous gaps and barriers to EBP. The major barriers include a lack of time, poor access to literature, and a lack of ability to judge the quality of research.

The goal of policy implementation is to facilitate EBP in ways that ensure patients receive the most cost-effective and efficacious care. To support this goal, the following objectives were formulated: to determine the level of nurses' understanding of EBP and provide necessary education; to identify barriers and ways to integrate EBP effectively into clinical practice; to establish evidence-based guidelines and make them accessible; and to implement strategies to enhance the utilization of and adherence to evidence-based practice.

Many patients today are not seeing the quality of care that they actually need, despite the fact that evidence-based practice has been evolving (Claxton et al., 2005). Patients are too often receiving inconsistent, wasteful, and even harmful interventions (Helfand, 2005). There has been an increasing emphasis on the outcomes of patient care, shifting the focus from tradition- and opinion-driven decisions toward practices guided by evidence (Helfand, 2005). Problems that remain unresolved include the gap between evidence and practice, unnecessary variations in practice, and the rising cost of healthcare (Claxton et al., 2005). Evidence-based practice attempts to eliminate wasteful and harmful practices by improving standards of care, which could also help provide more cost-effective healthcare for many patients (Claxton et al., 2005).

The establishment of EBP is not an easy process. Nurses are confronted every day with challenges in providing both safe and effective care. According to Haines et al. (2004), barriers may exist in the healthcare system such as a lack of financial resources, a lack of access to care, poor practice organization, failure of curricula to reflect research evidence, inappropriate continuing education, and patient demand for care that is not effective in the long run.

Barriers to the proper use of research in nursing practice exist at both the institutional and individual levels. The lack of time is generally seen as the most significant barrier (Claxton et al., 2005). Very few nurses today have either the skills or the time to search for relevant evidence and appraise it properly (Claxton et al., 2005). Quite often, nurses rely mostly on experiential knowledge gained through interactions with colleagues, medical staff, and patients (Pravikoff et al., 2005). Unfortunately, they receive little to no education or training in information retrieval, do not often understand or value research, and are therefore generally unprepared for a practice built on evidence rather than experimentation and common knowledge that may be seriously out of date (Helfand, 2005).

Some of the problems nurses face in this area can be attributed to rapid and significant technological change (Garber, 2005). However, some must also be attributed to nursing education programs and their failure to prepare students at all levels of practice, so that future nurses could understand the importance of maintaining a practice based on something more than tradition, experience, and intuition (Garber, 2005).

Context of the Issue

Evidence-based practice is crucial for care directed toward the improvement of patient outcomes (Helfand, 2005). This kind of practice provides the basis for reducing inappropriate variability in practice patterns and increasing patient compliance. Measurements of patient outcomes in organizations using EBP can help further validate the importance of this practice and help close the gap between practice and research (Helfand, 2005). It is likely that EBP will become much more common as the cost of healthcare increases. The contribution that nurses make in advanced practice roles — such as clinical nurse specialists and nurse consultants — can greatly assist the EBP process (Helfand, 2005). These specialists and consultants can act as a valuable resource for collecting evidence-based information and for supporting an environment more receptive to change (Helfand, 2005).

Evidence-based practice has been strongly driven by a need to deal with scientific information overload, by the need for cost control, and by a stronger public demand for higher quality of care (Eddy, 2005). The EBP movement has also been driven by both public and government pressure for greater accountability from healthcare providers, amid concern that patients are not receiving the highest quality of care while the cost of healthcare continues to rise rapidly (Eddy, 2005). More and more people are without health insurance and cannot afford routine care, deferring visits until something serious goes wrong. Policymakers use scientific evidence to make healthcare policies better for the public, and insurers use scientific evidence to control costs by reimbursing for treatments that are more cost-effective (Eddy, 2005). Patients use the same kinds of scientific evidence to make better and more informed decisions about their health conditions and available treatments. Information about the effectiveness of different interventions can provide a strong foundation for rational decisions about care within the limited resources many people have today (Eddy, 2005).

The inappropriate variability seen in practice patterns is a very costly problem within the healthcare system in the United States (Eddy, 2005). Health services are required by law to justify all of their expenditures, and therefore a detailed examination of the costs associated with any treatment will become an increasingly common practice. The pressure of controlling costs is one of the many reasons behind EBP (Eddy, 2005). EBP identifies the treatments that have been shown to be the most clinically effective and identifies those that have not shown promise in terms of cost-effectiveness, so that these particular treatments can be improved in the future where possible (Gerrish & Clayton, 2004). Cost is a serious issue that can no longer be ignored within the healthcare setting. However, how this can be balanced with local and individual choices and values is not always clear. Nonetheless, awareness of such issues is necessary for nurses, in order to help them facilitate more informed patient choices within the confines of a finite healthcare budget (Gerrish & Clayton, 2004).

Evidence-based practice is also often used to help define the appropriateness of care given if a case ends up in court due to alleged negligence (Gerrish & Clayton, 2004). A lack of comprehensive education and knowledge in EBP could lead nurses to make errors that negatively affect patient care and increase the chances of litigation. This issue also has the potential to undermine support for evidence-based practice among many healthcare providers (Gerrish & Clayton, 2004).

Evidence-based practice is not restricted to the individual patient context, but extends to all areas of healthcare systems and healthcare policy-making. It is therefore seen not only as an important means of improving the quality of medical care, but also as an instrument for controlling costs (Gerrish & Clayton, 2004). In view of the scarcity of healthcare resources, decisions on the allocation of care will need to be made more explicitly, transparently, and accountably (Gerrish & Clayton, 2004). Evidence-based practice combines improving the quality of clinical care with controlling costs through the use of the best available evidence. Changing medical practice so that it is better for patients and more cost-effective for everyone requires the development of political, legal, and medical institutions that can properly oversee medical care (Gerrish & Clayton, 2004). Promoting medical practices based on evidence will therefore necessitate more political engagement, not less, and this is necessary to ensure that patients are properly cared for (Gerrish & Clayton, 2004).

There are three important elements of ethics that also apply to EBP. The first is veracity — the ability of nurses to comprehensively explain to their patients the EBP diagnostic and treatment modalities (Holmes-Rovner & Rovner, 2000). The second is autonomy — the ability of nurses to use EBP to the best of their ability in order to ensure that patient care benefits from it (Holmes-Rovner & Rovner, 2000). The third is the utilitarian perspective — the best way to comprehensively educate the largest number of nurses so that they therapeutically implement EBP properly, thereby affecting the greatest number of patients (Holmes-Rovner & Rovner, 2000).

Issue Statement and Stakeholders

For the purposes of this discussion, the main question is: What are the most effective ways to implement evidence-based practice in order to provide appropriate and quality care to patients?

There are many different stakeholders involved with this type of issue. The stakeholders of EBP can include healthcare organizations (both public and for-profit), insurers (both tax-based and for-profit), health professions, the research community (both funding agencies and researchers), regulators, the legal system, and consumers (both health plan purchasers and the general public) (Holmes-Rovner & Rovner, 2000). Multiple stakeholders therefore shape evidence-based decision-making in many ways (Fox, 2005).

Policy-makers play a very important role in influencing whether — and to what degree — research findings affect health services. Research findings are actually used to help justify some decisions that have already been made (Fox, 2005). Clinicians use the resulting guidelines to take better care of their patients. Both insurers and administrators use these guidelines to set policies on quality of care and reimbursement. Lawyers can also use these guidelines in malpractice litigation, arguing that physicians who have not followed the guidelines without good rationale may be negligent (Fox, 2005). Key stakeholders in the delivery and payment of care also include employers, consumers, plan providers, and regulators (Fox, 2005). These individuals need a full and complete understanding of EBP, its appropriate application, and the ways it can be optimally integrated into patient care.