Relevance of evidence-informed decision-making to nursing practice

Patients depend on nurses to do the best on their behalf. As part of their professional accountability, nurses must continually examine the best way to deliver care.

One of the seven primary values of the CNA code of ethics is being accountable (Canadian Nurses Association, 2008). According to Morin, “the proliferation of information, the focus on outcomes and quality improvement, and societal pressure to receive the best care grounded on reliable current information underpin current efforts in the profession to enhance practice based on evidence” (Morin, 2010, p. 1). A major stimulus to evidence-based practice was the Institute of Medicine’s recommendation to base health-care practices on evidence in an effort to close the health-care quality chasm (Institute of Medicine, 2003).

The positive effects of evidence-based practice (EBP) are numerous and have been described in the literature for years. “When delivered in a context of caring and an organizational culture that promotes best practices, EBP is associated with higher quality care and better patient outcomes than care that is steeped in tradition” (Wallen et al, 2010, p. 2762).

EBP also reduces practice variations, promoting greater consistency of care and contributing greatly to quality and patient safety agendas (Wells, Free & Adam, 2007). EBP leads to improved health care provider satisfaction (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011) including increased nurse autonomy (Novak, Dooley, & Clark, 2008). Work stress is reduced for nurses when evidence-based guidelines are enacted (Van Patter Gale & Schaffer, 2009). At a system level, “nursing and health-care services based on the best currently available evidence have been shown to decrease costs” (Levin et al, 2011, p. 22) and improve cost-effectiveness (Winch, Creedy & Chaboyer, 2002).

Types of evidence

According to the Canadian Nurses Association, a variety of sources are being used by nurses to facilitate their use of evidence. These sources include systematic reviews, research studies and abstraction journals that summarize valid, clinically useful published studies, and clinical practice guidelines. “Guidelines are based on the most rigorous research available, and when research is not available, they are grounded in expert opinion and consensus” (Canadian Nurses Association, 2010, p. 4).

Various systems have been developed to rank evidence. Here are two examples.

The Canadian Institutes for Health Research (2009) created a hierarchy of quantitative evidence:

• systematic reviews of randomized controlled trials;

• randomized controlled trials;

• systematic reviews of nonrandomized or cohort studies;

• cohort studies;

• case control studies;

• case series;

• case report;

• ideas, editorials, opinions;

• animal research; and

• invitro (test tube) research.

Brian Haynes (2007) developed the 5S Pyramid for finding the best evidence with the least amount of time and effort:

• Studies are individual studies related to a particular focused question. There are several searchable databases that would help you find individual studies. The most used in Canada include Medline, PubMed and CINAHL, but there are many other specialized databases.

• Syntheses include systematic reviews of all studies that could be found on a particular focused question. These include The Cochrane Library, Worldviews on Evidence-Based Nursing, the Agency for HealthCare Research and Quality (AHRQ) Evidence-based Practice Centre Reviews. Both groups have similar, rigorous methods for review. Another source for systematic reviews and summaries about interventions related to public health in Canada is the Effective Public Health Practice Project. Further, Health-Evidence.ca rates reviews that are relevant to public health in Canada, summarizes them and provides recommendations for practice and policy that arise from the reviews.

• Synopses are brief reports (1-2 pages) of pre-appraised individual studies or systematic reviews that give key methodological details and results, along with an expert commentary, on issues of applying the results in practice. Examples of synopses are found in 23 evidence-based journals that cover topics such as medicine, nursing, dentistry and health policy (e.g., Evidence-Based Nursing ).

• Summaries are usually text-based and are related to a specific disease or condition (e.g., Clinical Evidence ).

• Systems are electronic systems that can be linked to patient records and prompt practitioners with guidelines for care (e.g., what tests to order, what interventions to provide). For example, for a patient with type 2 diabetes, it would prompt the caregiver that blood work, eye exam, foot exam and diet review need to be done.

Barriers to nursing: Evidence-based practice home/Evidence-informed decision-making

Barriers to evidence-based practice involve individual nurse characteristics, organizational characteristics, the nature of research information and the health-care environment.

Repeatedly, lack of time is identified one of the most crucial barriers to implementing evidence-based practice in the workplace (Bradshaw, 2010). Other documented barriers include:

Nurse characteristics:*

• lack of the knowledge needed to interpret statistical analyses;

• lack of interest;

• lack of confidence in critical appraisal skills;

• lack of knowledge and skills to confidently conduct computer based literature searches and utilize the research process;

• nurses feeling overwhelmed by the volume of evidence (Wells, Free & Adam, 2007);

• nurses’ perceptions that they lack the authority and cooperation to change patient care procedures;

• negative beliefs, attitudes and values; and

• educational preparation.

*Except where otherwise indicated, all items in the above list are from Bradshaw, 2010.

Organizational characteristics:*

• limited or lack of time;

• heavy patient workloads;

• inadequate staffing;

• limited access to resources;

• lack of support from nurse managers;

• different goals for practice between administrators and staff nurses (Van Patter Gale & Schaffer, 2009); and

• lack of evidence-based practice mentors in health-care systems (Bertulis, 2008).

*Except where otherwise indicated, all items in the above list are from Bradshaw, 2010.

Nature of research information:

• “Research is seen as too complicated, too scholarly, excessively statistical, ambiguous, and having limited or no relevance to practice” (Van Patter Gale & Schaffer, 2009, p. 91); and

• “Research reports lack clear practice implications and generalizability” (Wells, Free & Adam, 2007, p. 136).

Health-care environment:

• “Multiple barriers have contributed to the slow uptake of EBP across healthcare systems…traditional approaches to teaching healthcare students the rigorous process of how to do research rather than how to use research to guide best practice” (Wallen et al, 2010, p. 2762).

Strategies to promote evidence-based practice/evidence-informed decision-making by nurses

There are several evidence-based strategies to promote a culture of evidence-based practice or evidence-informed decision-making.

Strategies include, but are not limited to:

• provide nurses with “access to a rich library with nursing and medical journals” (Eizenberg, 2011, p. 33), such as NurseONE;

• provide nurses with “opportunities for working with a computer and for searching the Internet in the workplace” (Eizenberg, 2011, p. 33);

• “system support for searching and reading professional literature” (Eizenberg, 2011, p. 40);

• implementation of a virtual journal club (Lehna, Berger,Truman, Goldman & Topp, 2010);

• “provide nurses with access to evidence-based practice resources via mobile information technologies” (Doran et al, 2010, p. 4);

• implement an EBP mentorship programme with EBP mentors who are “skilled in both EBP and organizational culture and change” (Wallen et al, 2010, p. 2762);

• support nurses to acquire the skills needed to read, evaluate and critically appraise evidence (Eizenberg, 2011);

• establish leadership, a coherent change strategy, and relationships between point of care providers and managers (Baeza, Fitzgerald & McGivern, 2008);

• nurse managers act as role models (Van Patter Gale & Schaffer, 2009, p. 95);

• nurse managers “provide the resources and the support for the work and celebrate success with recognition of unit staff “(Van Patter Gale & Schaffer, 2009, p. 92);

• designate a champion who is “accessible to the nurses, along with other leaders and innovators who can answer questions and reinforce the practice change “(Van Patter Gale & Schaffer, 2009, p. 96); and

• involve the “clinical educator as a part of the support system of the EBP change” (Van Patter Gale & Schaffer, 2009, p. 96).