Evidence-based nursing: how far have we come? What’s next?
- Donna Ciliska, RN, PhD
This text is based on the Joanna Briggs Oration, given at the 2005 Joanna Briggs International Conference, Adelaide, Australia. It is printed here with permission.
This paper provides an opportunity to reflect on evidence-based nursing. Where have we been? How far we have come? What are the current issues, and where are we going in terms of incorporating high quality evidence into clinical, education, management, and policy decisions? Is evidence-based nursing a passing fad, or does it contribute to quality, efficient health care?
WHERE WE HAVE BEEN?
Although the use of evidence is often recommended in relation to healthcare reform, institutional change, healthcare practitioner competence, or healthcare practitioner education, opponents argue that there is no evidence that evidence-based healthcare makes a difference. There are no sensitive system indicators; healthcare costs are highly influenced by the adoption and spread of technology; and mortality and morbidity are also influenced by many factors. Yet, evidence-based health care should have an impact on all 3 of these outcomes.
One of the earliest reviews to assess the effect of research based nursing practice on patient outcomes identified 84 relevant studies and showed “sizeable gains” in patients’ behavioural, knowledge, physiological, and psychosocial outcomes compared with patients who received routine nursing care.1 However, evidence-based nursing is more than research utilisation. It is the incorporation of the best research evidence along with patient preferences, the clinical setting and circumstances, and healthcare resources into decisions about patient care.2 More recently, Thomas et al updated their review of the use of guidelines by healthcare practitioners other than physicians. They identified 18 studies of 467 healthcare providers (participants were nurses in all but 1 study). Although reporting of methods was poor in all included studies, 3 of 5 studies found improvements in at least some processes of care, and 6 of 8 studies found improvements in outcomes of care when care was based on guidelines rather than no guidelines.3
Much research has focused on barriers to evidence-based practice. Dicenso et al collated literature on the topic3 and identified the following barriers: lack of time; lack of access to search engines, databases, and research articles; lack of skills in critical appraisal or understanding of research language; lack of sense of control over practice or confidence to implement change; and difficulty seeing applicability or generalisability of results from different institutions or clinical units. In addition, nurses reported institutional lack of leadership, motivation, vision, strategy, or direction among managers.3 There are probably many other barriers related to the culture of nursing and nursing education that determine the attitude of questioning current clinical practices.
Another body of research concerns changing healthcare practitioner behaviour; that is, what strategies can be used to change practitioner behaviour in light of research evidence? The Cochrane Effective Practice and Organisation of Care Group reviewed 41 systematic reviews and found that most studies of practitioner behaviour change focused on physicians; the most effective strategies involved one-to-one contact, such as academic detailing, audit and feedback, and use of opinion leaders. Less effective strategies were impersonal or passive communications such as written materials, continuing education, workshops, or conferences. A range of interventions have been shown to be effective in changing professional behaviour in specific circumstances. The review of reviews concluded that multifaceted interventions targeting different barriers to change are likely to be more effective than single strategies and that a diagnostic analysis should be done to identify factors likely to influence the proposed change.4 However, there are many unanswered questions about intensity, duration, and combinations of interventions that may impact on behaviour change.
In truth, we have little evidence that evidence-base practice makes a difference, and in most institutions, there is still a considerable gap between research evidence and what happens in practice.
HOW FAR WE HAVE COME?
If healthcare costs and population mortality and morbidity are not sensitive outcomes to assess the effects of evidence-based practice, are there other “macro-indicators” to assess climate change? Are practitioners and policy makers “warming” to evidence-based practice beyond “lip service?” Dedicated publications, centres, and websites may be macro-indicators of climate change. Five English texts about evidence-based nursing or evidence-based practice within nursing have been published recently. Evidence-Based Nursing, an abstract journal, began publishing in 1998. It contains abstracts of high quality articles of relevance to nurses, each accompanied by a commentary about the clinical implications of the results. It now has more than 9000 individual subscribers. The website has over 30 000 unique visitors each month and about 100 000 full article downloads per month. Furthermore, a second dedicated journal, Worldviews on Evidence-Based Nursing, began publishing in 2004. It includes primary studies, reviews, and theoretically based articles on research dissemination and utilisation in clinical, policy, and educational arenas. Sales of these texts and subscriptions to these 2 journals indicate a high level of interest in evidence-based nursing.
Evidence-based nursing centres around the world were highlighted in an editorial in 1999.5 At the time, the Joanna Briggs Institute had 5 collaborating centres. 4 other known centres were located in the UK, Canada, Germany, and the US. Today, the Joanna Briggs Institute has nursing centres in 7 different countries, plus 7 other centres of nursing with midwifery, and other multidisciplinary sites. As a rough indicator, a Google search on center AND evidence AND nursing in November 2005 resulted in 8 710 000 hits. Although this could represent multiple hits from a few centres, many different centres were represented in the first few pages of hits. As well, this search would miss the many centres that have different, but related, titles, such as the Centre for Advancement of Evidence-Based Practice at Arizona State University (http://nursing.asu.edu/caep/), Academic Centre for Evidence-Based Practice (http://www.acestar.uthscsa.edu/About.htm), or the Knowledge Utilization Studies Program at the University of Alberta (http://www.nursing.ualberta.ca/kusp/).
As another macro-indicator, a PubMed search of titles and abstracts using the terms evidence and nursing resulted in 1075 hits for the entire database before 1998 and 2336 hits from 1998 to the present. Although this appears to be a large increase in the past 7 years, a similar search using the terms evidence and medicine yielded 1689 and 5664 hits, respectively—a far greater increase in medicine than in nursing over the same time period. Collectively, these macro-indicators suggest considerable growth in interest in evidence-based nursing.
WHAT ARE THE CURRENT ISSUES?
What are the current issues in research, clinical practice, education, and management/policy development about implementing evidence-based health care? Regarding research, some of our group’s current funded research includes randomised trials to assess the effectiveness of various dissemination strategies and the effectiveness of knowledge brokers as a knowledge translation strategy in public health. It is difficult to directly change patient outcomes, and we may need an intermediate step to assess changes in practice or utilisation of evidence. Although valid and reliable tools are not yet available, Estabrooks and colleagues at the University of Alberta are working to develop such tools. Furthermore, we may not know enough about particular interventions, such as knowledge brokers and how they see their role, how they function, and the barriers and facilitators to this role. We need more descriptive studies of such interventions. Current research is also aimed at understanding the types of decisions that nurses make6 and identifying the information sources that nurses use to make clinical decisions.7 Others are assessing nurses’ understanding of evidence-based practice. Banning found that nurses had difficulty differentiating evidence-based practice from the research process and that evidence-based practice was equated with the research process.8 These areas of research are particularly important as a basis for intervention studies.
In clinical practice, who needs to know about evidence-based practice? Does every nurse in an institution or agency need to knowledgeable about evidence-based practice? Is so, can institutions afford to educate every bedside caregiver in the principles and skills of evidence-based practice? If not, is evidence-based practice to be considered the role of nurse educators? Clinical specialists? Advanced practice nurses? As more undergraduate programmes include evidence-based practice courses, with the expectation that students will be able to function as evidence-based practitioners, a critical mass of nurses will have such a skill set at some time in the future. However, some educational programmes are evidence based, without teaching evidence-based practice. Content taught is based on current, high quality research, but faculty may not teach students how to find, critique, and apply the evidence for themselves; or they have shifted content from research courses to what is called an evidence-based practice course, without fully recognising or understanding the conceptual shift. Furthermore, at the Master’s level, most curricula include research skills, but not the evidence-based practice process. Graduates may know how to design studies, but not necessarily how to critique and use research results.9 Incorporating evidence-based practice content into a curriculum requires continuing education of faculty and overcoming their barriers to teaching the process.
What is needed to practice in an evidence-based way? Many institutions have policies, procedures, best practices, or guidelines that use high quality evidence in their development. If this is true, the staff who follow the guidelines will be practising in an evidence-based way, without knowing the evidence-based practice process. This may be a short term strategy to promote evidence-based practice while staff are being educating in the process and the critical mass is being built. Every nurse should have at least an understanding of the purpose and process of evidence-based practice, be able to ask relevant clinical questions, and know who in their environment can assist them in answering questions. Currently, clinical specialists, clinical educators, or advanced practice nurses appear to be the ones who seek out whatever answers are available. These nurses are at a prime interface of recognising clinical problems, having the time, skills, and resources to access the research literature, critically appraising the relevant literature, and translating the findings in a way that front-line nurses can understand.
In order to ensure use of guidelines in practice, the systematic reviews (on which guidelines are based) must be perceived as being done by “credible” people and accessed by someone in the workplace who can help translate the language of research.10 Furthermore, management teams must be clear about their expectations of nurses once they become familiar with the evidence-based practice process. This may mean declaring expectations of critical appraisal skills and application of high quality research in practice decisions in job postings, job descriptions, and annual performance appraisals.
Does teaching evidence-based practice change anything? Coomarasamy and Kahn did a systematic review of 23 studies, all of which involved postgraduate trainees in medicine.11 Eighteen studies evaluated stand-alone classroom courses, which improved knowledge but not skills, attitudes, or behaviour; 5 studies evaluated clinically integrated teaching, which improved knowledge, skills, attitudes, and behaviour. Although it is not possible to generalise these findings to nurses, particularly undergraduates, this is an important area of research. Currently, many nursing programmes have an isolated evidence-based practice course, with little or no expectation or requirement that the knowledge and skills are to be used in clinical practice or other courses. Ideally, teaching of evidence-based practice should be incorporated into every course—both classroom and clinical. Strauss et al have offered a framework to guide evaluation of teaching of evidence-based medicine.12 It involves an evaluation matrix around learners, interventions, and outcomes. They classify learners as doers (do all steps of the evidence-based practice process), users (ask the clinical questions and go directly to the pre-appraised literature), or replicators (trust and follow recommendations of others considered to be leaders).12 This framework could have considerable relevance for evaluating nursing education.
At the management and policy level, an appreciation of the evidence-based practice process is necessary to support a culture of evidence-based care. Several pilot projects have been done, although the results have yet to be published. For example, in Canada, the Executive Training for Research Application (EXTRA) fellowships are awarded to provide healthcare managers with the skills to better use research and thus increase evidence-based decision making within their healthcare systems. It is supported by a group of national organisations including the Canadian Health Services Research Foundation, Canadian College of Health Service Executives, Canadian Nurses Association, and Canadian Medical Association (http://www.chsrf.ca/extra/index_e.php). The first graduates of the 2 year programme will occur in spring 2006. Each fellow must do a project within their own institution, using evidence and evaluating the policy results and/or dissemination and uptake. This programme involves tremendous commitment from institutional management executive and governing boards of the fellow’s institution.
WHAT ARE PRIORITIES FOR NEXT FEW YEARS?
Now for some crystal ball gazing:
The vision for nursing practice for the year 2010 is that we have successfully bridged the research transfer gap. We have 30 second access to the best information available, including pre-appraised information in easily searched databases. We use research evidence in making decisions related to clinical practice, management, and policy.
What steps must we take to help us reach that vision?
1 We need equitable access to evidence around the world, for the public, practitioners, and policy makers. Far too often, computers are lacking or shared, and not available at times convenient to nursing staff. Although many of us take computers and internet access for granted, many countries have no access or only sporadic access. Increased access to computers would also allow global sharing of expertise rather than commercialisation of evidence-based nursing.
2 We need effective strategies to get evidence into use by practitioners, managers, and policy makers. A high priority is research on practice change in nurses, the variables that affect knowledge translation, and the strategies that can overcome the various barriers to use of evidence in practice.
3 We need effective strategies to teach evidence-based practice at diploma, undergraduate, graduate, and continuing education levels. Educational research on the topic is in its infancy, particularly with respect to nursing education. Many undergraduate and graduate programmes include evidence-based practice courses but have done little or no evaluation of skills and behaviour change. Faculty development is an urgent requirement to ensure that these teachers have the skills to incorporate evidence-based practice concepts in clinical and classroom teaching.
4 We need more economic evaluations, involving long term data collection, to establish the effectiveness of evidence-based practice. This information will provide us with the rationale to support and promote the use of evidence-based nursing.
This list may seem short, but each item is actually a large field of research. Within these practice and research priorities, there is a lifetime of work for each of us!
Don’t be too timid and squeamish about your actions. All life is an experiment. The more experiments you make the better!Ralph