Promoting evidence-based practice: an organizational approach

Transcription

1 Journal of Nursing Management, 2004, 12, Promoting evidence-based practice: an organizational approach KATE GERRISH BNurs, MSc, PhD, RGN, RM, DN Cert 1 and JANE CLAYTON BA(Hons), MSc, PhD, RGN 2 1 Professor, Nursing Practice Development, School of Nursing and Midwifery, The University of Sheffield, Sheffield and 2 Formerly Research Fellow in Nursing, Sheffield Hallam University, Sheffield, UK Correspondence Kate Gerrish School of Nursing and Midwifery University of Sheffield Samuel Fox House Northern General Hospital Herries Road Sheffield S5 7AU UK k.a.gerrish@sheffield.ac.uk GERRISH K. & CLAYTON J. (2004) Journal of Nursing Management 12, Promoting evidence-based practice: an organizational approach Aim To examine factors influencing the achivement of evidence-based practice. Background This paper reports on the approach taken by a large teaching hospital in England to promote evidence-based practice. A summary of initiatives spanning a 5 year period is presented in order to set the scene for a recent survey of nurses to review progress made. Consideration is given to how the findings from the survey have been used to inform policy and practice. Methods A survey by self-completed questionaire was undertaken with a sample of clinical nurses (n ¼ 330). The questionnaire examined the extent to which nurses utilised different sources of knowledge to inform their practice; perceived barriers to accessing evidence-based information and effecting change in practice; and a selfassessment of core skills necessary to underpin evidence-based practice. Findings Nurses relied most heavily on experiential knowledge gained through their interactions with nursing colleagues, medical staff and patients to inform their practice. Organisational information in the form of policies and audit reports was drawn upon more frequently than research reports. Lack of time, resources and perceived authority to change practice influenced the extent to which nurses utilised formal sources of evidence. Whereas nurses were relatively well skilled at accessing and reviewing research evidence, they were less confident about their ability to change practice. Conclusion Health care organisations need to consider multiple strategies to facilitate and promote evidence-based practice. Managerial support, facilitation, and a culture that is receptive to change are essential. Keywords: barriers to research utilisation, evidence-based practice, professional knowledge, survey Accepted for publication: 4 December 2003 Introduction In recent years evidence-based practice has emerged as one of the major policy themes in the modernization of the British National Health Service (NHS) as a whole and of nursing in particular (Department of Health 1998, 1999, 2000). Whereas the evidence-based practice movement has been criticized because of its perceived emphasis on randomized controlled trials as the most robust source of evidence, to the neglect of other research approaches (Newman et al. 1998), increasing recognition is now being given to different sources of evidence (Kitson 2002, Gerrish 2003). To this end, evidence-based practice is purported to require the synthesis of evidence drawn from research, clinical expertise and patient preference to inform clinical 114 ª 2004 Blackwell Publishing Ltd

2 Promoting evidence-based practice decision-making (Sackett et al. 2000). However, there has been little attempt within the literature to explain how these different world views might be integrated. Although Gerrish (2003) draws upon the work of Liaschenko and Fisher (1999) in suggesting that in addition to scientific knowledge derived from research, nurses use knowledge about how patients interact with health care services as well as knowledge about the personal biography of individual patients, there is a need for more research which examines the relationship between the utilization of different forms of knowledge and evidence-based practice. There is a growing body of research literature that focuses on the implementation of evidence-based practice. The diverse outcomes from such studies identify that implementing evidence-based practice in health care organizations is a complex undertaking (Royle & Blythe 1998). Consideration needs to be given not only to the nature of the evidence, but also to the methods of facilitation and the context in which the evidence is to be implemented (Kitson et al. 1998). An examination of the place of facilitation has drawn attention to the part played by external and internal change agents who actively support the process of change and emphasizes the importance of the personal characteristics of the facilitator, the style of facilitation and the role of the facilitator in terms of authority (Harvey et al. 2002). Consideration of the context has highlighted the importance of the ward/team culture in terms of patient centeredness; valuing team members and promoting a learning environment; leadership styles; and audit and review procedures (McCormack et al. 2002). However, little attention has been placed on the wider organizational, managerial and political influences working upon the situation (Kitson et al. 1998). Much of the research to date, which has examined the implementation of evidence-based practice, has focused on the implementation of research findings relating to a particular clinical intervention in a defined setting, for example, a ward or primary care team and often employs the skills of an external facilitator. Whereas such studies have provided a knowledge base to inform an understanding of the complexity of implementing evidence-based practice and identified strategies that appear to work effectively at a local level it is not always easy to transfer such models to the wider complex health care organization. For example, the financial implications of introducing an external facilitator, as change agent in a ward setting may be feasible in a funded research project or as an organizational pilot but the cost of introducing such a scheme across a large organization may well be financially prohibitive. This is not to say that such a model is inappropriate but rather than it does not necessarily have general applicability in contemporary health care settings where financial and human resources are limited. There have been a number of research studies which have examined barriers to research utilization among nurses (Dunn et al. 1998, Parahoo 2000, Bryar et al. 2003). These studies have highlighted that the greatest difficulties that nurses encounter in implementing research findings relate to insufficient time to access and review research reports together with lack of authority and support to implement findings. Whereas there is a general agreement about what the barriers are, researchers have not by and large followed through their work to look at how health care organizations may overcome these barriers. Evidence-based practice requires complex actions on the part of organizations to facilitate its implementation including high level management commitment and putting in place systems for managing information and innovation and for individual skills development (Newman et al. 1998). Although there is a need to develop more knowledge about the organizational processes which can facilitate evidence-based practice researching this area is far from easy. Health care organizations are dynamic and in a constant state of flux as they respond and adapt to changes in health policy. Whereas it may be relatively easy to design a time-limited research study examining, for example, the introduction of evidence-based guidelines on cardiac rehabilitation in a medical ward (and indeed to secure funding for such a study), it is far more difficult to develop a robust design, which looks at the implementation of evidence-based practice across an organization. Such studies will be highly complex and messy; they will need to adapt as the organization under study changes, they are likely to take some considerable time to complete and securing funding will most probably be difficult. Nevertheless such studies are essential to developing an understanding of organizational approaches to promoting evidence-based practice. It is, with this in mind that this paper reports on the approach adopted by a large acute hospital in England in seeking to promote evidence-based practice over a 5 year period. The lead author has had an on-going involvement in this work, initially working closely with the organization while holding an academic post in a local university and for the past 3 years occupying a joint academic research post between a different university and the hospital. The principles of action research have been drawn upon in that the researcher has worked with nurse managers and with clinical nurses in facilitating research and evaluation studies, ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

3 K. Gerrish andj. Clayton which have then been fed back into the organization to inform the process of change. Several of these studies have been published and are referenced in the paper. A major focus of this paper is on a recent survey of ward-based nurses designed to review the progress that had been made in promoting evidence-based practice and to inform the future direction of the organization. However, an overview of the initiative as a whole is presented in order to provide the context for the more recent work. Initial development work The work commenced in 1997 when the Executive Director of Nursing in post at the time sought assistance from nurse academics in local universities to promote evidence-based practice within the hospital. A decision was made to focus initially on implementing evidencebased practice in respect of risk assessment of pressure damage as this was an area of concern across all nursing specialties in the hospital. A survey of nursesõ knowledge of risk assessment of pressure damage and an audit of their record keeping was undertaken in order to assess the extent to which practice was based on the best available evidence. The findings from the survey identified a shortfall in nursesõ knowledge and in their record keeping. The clinical nurse specialist with the help of the researchers then built upon these findings in assisting practitioners and managers to take ownership of the need to base practice on appropriate evidence. Various initiatives were established including, for example, an evidence-based practice group in the operating theatres department comprising clinical nurses supported by the nurse manager who sought to review local practice in relation to risk assessment of pressure damage and successfully worked with the multidisciplinary team to change practice. A more detailed account of this work is provided by Gerrish et al. (1999). At the same time a diagnostic hospital-wide census of ward-based nurses was undertaken in order to identify their perceived barriers to research utilization. The questionnaire, based on the North American ÔBarriers QuestionnaireÕ (Funk et al. 1991a,b), asked nurses to rate the extent to which each of the 29-items were perceived to be a barrier to research utilization. The items considered four dimensions; these being barriers to do with: the organization; the way research is communicated; the quality of the research; the nurse. The top 10 barriers identified by the nurses are shown in Table 1. Significant barriers to research utilization were identified with organizational barriers associated with time, resources and authority featuring most prominently (Nolan et al. 1998). The findings from this survey then acted as a catalyst to develop a number of initiatives to support the development of evidence-based practice across the organization (Gerrish & Clayton 1998, Gerrish 2003). The approach adopted was deliberately multifaceted in response to the needs of very different clinical areas and included both hospital-wide initiatives and small-scale projects focused on particular wards/departments. An important precursor of these activities was to incorporate a commitment to promoting evidencebased practice within the hospital s Nursing Strategy, thereby confirming organizational support for the work. Part of this organizational support has included the creation of two joint university/nhs appointments at professorial and research fellow level to support nursing research and development within the hospital. The survey findings endorsed the need to develop further nursesõ knowledge and skills in research appreciation and utilization. This was supported by a range Ranking Barrier Reporting moderate or great barrier (%) 1 There is insufficient time at work to implement new ideas 84 2 Resources are inadequate for implementation 81 3 The nurse does not feel that s/he has enough authority to 74 change patient care procedures 4 The statistics are difficult to understand 73 5 The research is not easy to understand 72 6 Doctors will not cooperate with implementation 70 7 The nurse does not have time to read research 69 8 Other staff are not supportive of implementation 67 9 The nurse does not know what research is available The relevant research literature is not available in one place 62 Table 1 Top 10 barriers to research utilization ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

4 Promoting evidence-based practice of educational programmes offered by the hospital s Education and Training Department. In addition, a Practice Development Support Team, comprising nurses with expertise in facilitating evidence-based practice was created to facilitate ward-based staff who wanted to take forward evidence-based initiatives, such as the development of evidence-based clinical guidelines and care pathways. A practitioner-led Evidence-Based Council was established with the specific aim to create an integrated approach to evidence-based practice across the hospital (Palfreyman et al. 2003a). With membership drawn from different professional groups and each clinical directorate, the Council meets monthly in order to: facilitate the dissemination of evidence-based practice; coordinate a hospital-wide network of evidencebased practice groups at ward/department level; generate research questions from practice. Evidence of local relevance was also generated. In addition to the organizational surveys referred to above, there have been other research studies involving nurses within the hospital, which have informed the development of evidence-based practice. For example, a project examining the use of an Internet by ward-based nurses was undertaken and subsequently used to inform IT skills training (Harrison et al. 2000). Furthermore, practitioners have been involved in undertaking research projects, where appropriate with the support of more experienced researchers in the university. These studies are driven by questions arising from practice and include, for example, the effectiveness of nurse practitioners in accident and emergency care and determining outcome measures for the nursing management of venous leg ulcers. Approval to undertake the research studies has been sought from the Local Research Ethics Committee. An important part of the action research approach has been to feed evaluative data back into the cycle of change. This has been at two levels. Individual initiatives have been evaluated and information used to further develop the particular initiative. For example, the Practice Development Support Team incorporated piloting and evaluation into the development of all clinical pathways. In order to gain a broader perspective on the impact of organizational developments a second survey of ward-based nurses has recently been completed. Whereas the original survey examined barriers to research utilization, the follow-up questionnaire has looked in more detail at the sources of knowledge nurses use to inform their practice, the barriers they encounter in respect of evidence-based practice and the skills they possess. This change in focus reflects the way in which thinking around evidence-based practice has evolved in recent years from a focus on the linear process of research utilization to a much broader consideration of the issues (Kitson 2002). The remainder of the paper presents the findings from this survey and considers how they are being used to inform the future direction that the hospital takes. Reviewing progress: a follow-up survey The aim of the survey was to identify a range of factors which influenced evidence-based practice within the hospital with a particular focus on identifying: the sources of knowledge that nurses use to inform their practice; perceived barriers to finding and reviewing research and organizational information; perceived barriers to changing practice based on the basis of ÔbestÕ evidence; a self-assessment of nursesõ skills in relation to finding, reviewing and utilizing different sources of evidence. Methods The survey comprised a self-completed questionnaire. The questionnaire included a number of questions that sought to identify the extent to which nurses drew upon various sources of knowledge to inform their practice. These were adapted (with the author s permission) from a Canadian instrument (Estabrooks 1998) that had been developed to examine research utilization. North American terms such as ÔphysiciansÕ were changed to ÔdoctorsÕ and a further item relating to the use of the Internet was added. Additional items were adapted from the Barriers questionnaire in order to consider individual and organizational factors influencing evidence-based practice. In taking a broader definition of evidence-based practice, questions were included relating to research evidence and other sources of evidence which were termed organizational evidence, for example, policies, protocols, audit reports. Whereas the earlier Barriers questionnaire had asked nurses respond to general statements relating barriers to research utilization, feedback from respondents had identified that nurses experienced difficulty when completing the questionnaire in deciding whether the items related to their perceptions of the perceived barriers that nurses ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

5 K. Gerrish andj. Clayton within the organization generally encounter or to the barriers that they may individually encounter. As the objective of the survey was to ascertain the nursesõ personal experience the questions were modified accordingly (e.g. the wording of items was changed from Ôthe nurse does not have the authority to change practiceõ to ÔI do not have the authority to change practiceõ). Finally, nurses were asked to self-rate their knowledge and skills in implementing evidence-based practice. The questionnaire also sought some biographical details from respondents. The questionnaire was piloted with 15 nurses and minor modifications made to the wording of a couple of items to improve clarity. The sample comprised qualified nurses working in all of the clinical directorates with the exception of three areas. These units were omitted because they were participating in a national project, which was utilizing the Barriers questionnaire as part of the data collection, and it was thought inappropriate to make additional requests to these nurses to complete a similar questionnaire. A total of 728 questionnaires were distributed of which 330 were returned. The response rate of 45% is comparable with those obtained in similar surveys reported in the literature (Bryar et al. 2003). The questionnaires were coded and analysed using Statistical Package for the Social Sciences (SPSS). Findings from the survey The findings arising from different sections of the questionnaire are presented separately. Sources of knowledge Nurses were asked to identify the extent to which they utilized 18 different sources of knowledge to inform their practice by rating them on a 5-point scale ranging from never (score 1) to always (score 5). The frequency with which nurses used various sources of knowledge is reflected in the mean scores for each item. These scores ordered from most to least frequent are shown in Table 2. The findings indicate that nurses tended to draw upon experiential knowledge acquired through their interactions with patients and colleagues to a much greater extent than formal knowledge gained from textbooks and journals. Workplace sources of knowledge in the form of information gained from doctors (ranked fourth and seventh) and in-service training and policy and procedure manuals (ranked fifth and sixth) also featured prominently. However, although nurses did not rely very heavily on formal knowledge gained from the literature, the findings suggest that knowledge acquisition does not stagnate in that routinized, traditional practices were ranked fifteenth and sixteenth. Information obtained from the Internet was the least used source of knowledge to inform practice. This may well be because some nurses did not have ready access to IT facilities in the clinical setting. However, in looking to the future, knowledge management through the IT interface will become increasingly important with both the hospital s intranet and the World Wide Web providing valuable sources of evidence-based information. Rank order Source of knowledge Mean score (SD) 1 Information that I learn about each patient as an individual 4.37 (0.678) 2 My personal experience of caring for patients over time 4.08 (0.675) 3 Information my fellow practitioners share 3.85 (0.607) 4 What doctors discuss with me 3.63 (0.745) 5 Information I get from attending in-service training/conferences 3.58 (0.776) 6 Information I get from policy andprocedure manuals 3.57 (0.831) 7 New treatments andmedications that I learn about when 3.55 (0.705) doctors prescribe them for patients 8 My intuitions about what seems to be right for the patient 3.36 (0.719) 9 Information I learnedin my training 3.30 (0.825) 10 Articles publishedin professional journals 3.12 (0.754) 11 Information in textbooks 3.05 (0.732) Information I get from audit reports 3.05 (0.884) 13 Articles publishedin research journals 2.92 (0.828) 14 Articles publishedin medical journals 2.91 (0.841) 15 What has workedfor me for years 2.89 (0.741) 16 The ways that I have always done it 2.58 (0.808) 17 Information I get from the media 2.08 (798) 18 Information I get from the internet 2.05 (0.908) Table 2 Sources of knowledge used to inform practice 118 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

6 Promoting evidence-based practice Table 3 Barriers to finding and reviewing information Rank order Barrier Mean score (SD) 1 I do not have sufficient time to find and review research reports 2.29 (0.889) 2 I do not have sufficient time to find and review organizational information 2.67 (0.914) 3 Research reports are not readily available 2.75 (0.912) 4 I do not feel confident in judging the quality of research reports 3.01 (1.045) 5 Organizational information is not readily available 3.10 (0.925) 6 I find it difficult to understand research reports 3.12 (0.993) 7 I find it difficult to identify the implications of research findings for my own 3.27 (0.923) practice 8 I do not know how to find organizational information 3.72 (0.869) 9 I do not know how to find appropriate research reports 3.78 (0.890) Barriers to finding and reviewing research reports and organizational information This section of the questionnaire asked nurses to rate the extent to which 9-items concerning the finding and review of research and organizational information were perceived to be barriers to achieving evidence-based practice. Each item was scored on a 5-point scale ranging from strongly agree (score 1) to strongly disagree (score 5) with the statement. The extent to which nurses perceived different items to be a barrier is reflected in the mean (average) scores. These scores, ordered from the greatest to the least barrier, are shown in Table 3. The findings indicate that the greatest barriers to nurses accessing and reviewing evidence-based information related to time and the availability of information. Skill in judging the quality of information and identifying the implications for practice were also of concern. However, nurses were generally more confident about where to locate information on evidencebased practice. These observations highlight the need for strategies that ensure that evidence-based information is readily available to nurses in a form in which they can easily understand the implications for their practice. basis of best evidence. Items were again scored on a scale of 1 5 depending on the extent to which the nurse agreed with the statement. The mean scores, ordered from the greatest to the least barrier, are shown in Table 4. The findings again highlight how time was seen to be a major constraint in achieving evidence-based practice. Insufficient resources were also problematic. Although nurses appeared more confident about their ability to begin to effect change, lack of authority and a ward culture that was not receptive to change were seen to militate against changing practice. The second part of this section of the questionnaire was concerned with the extent to which nurses perceived other staff with whom they worked to be supportive of changing practice. A different 5-point scale was used to judge the degree of support ranging from always supportive (score 1) through to never supportive (score 5). The mean scores, ordered from the greatest to the least lack of support, are shown in Table 5. The findings indicate that nurses perceive their various colleagues not to be particularly supportive of changing practice with managers being seen as the least supportive. Barriers to changing practice This section of the questionnaire was divided into two parts. The first asked nurses to rate the extent to which they encountered barriers to changing practice on the Skills in finding, reviewing and using different sources of evidence to change practice Nurses were asked to rate how experienced they were in finding, reviewing and using different sources of Table 4 Barriers to changing practice Rank order Barrier Mean score (SD) 1 There is insufficient time at work to implement changes in practice 2.78 (0.995) 2 There are insufficient resources to change practice 2.98 (0.914) 3 I think that it wouldbe difficult to overcome these barriers 3.17 (0.927) 4 I lack the authority in the work place to change practice 3.45 (10.137) 5 The culture of my ward/department is not receptive to changing practice 3.57 (0.985) 6 I do not feel confident about beginning to change my practice 3.72 (0.870) ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

7 K. Gerrish andj. Clayton Rank order Barrier Mean score (SD) Table 5 Support for changing practice 1 My managers are not supportive of changes in practice 3.09 (0.973) 2 My nursing colleagues are not supportive of changing practice 3.18 (0.810) 3 Medical staff with whom I work are not supportive of changing practice 3.30 (0.861) Table 6 Skills appraisal: rank order of area of greatest skill Rank order Skill Mean (SD) 1 Finding organizational information 2.86 (0.909) 2 Reviewing organizational information 2.73 (0.933) 3 Finding research evidence 2.72 (0.915) 4 Reviewing research evidence 2.67 (0.918) 5 Using organizational information 2.55 (0.912) to change practice 6 Using research evidence to change practice 2.50 (0.880) evidence to change practice using a 5-point scale ranging from complete beginner to expert. Each item was scored ranging from complete beginner (score 1) to expert (score 5). The mean scores ranked according to the area of greatest skill are shown in Table 6. The findings indicate that nurses appear more confident in finding and reviewing organizational information in contrast to research evidence. However, in terms of skills to support evidence-based practice the area of least skill relates to changing practice. Figure 1 presents the data according to each of the five categories and indicates that approximately 20% of the nursesõ surveyed regard themselves as competent or expert in the skills needed to support evidence-based practice. Whereas comparatively few nurses consider themselves to be complete beginners, a substantial proportion judge themselves to be novices. Moving forward: implications for practice The findings from the survey were reinforced by the evaluation of other evidence-based initiatives within the hospital. An evaluation of the Evidence-Based Council highlighted the difficulties practising nurses experience in terms of time, resources and skills in taking forward evidence-based initiatives in the work place (Palfreyman et al. 2003b). The findings from the project referred to earlier examining nursesõ use of the Internet identified that lack of time and resources together with skills deficits were major barriers to accessing evidence-based information via the Internet (Tod et al. 2003). In reflecting upon the findings of the survey and discussing the implications with the hospital s senior nurse managers, a number of issues were identified. Much of the literature on promoting evidence-based practice stresses the importance of developing in nurses the skills to review research findings in order to then implement relevant findings in practice. To do this well requires both skill and time on the part of the nurse. It is widely recognized that nurses do not read journals regularly (Thompson et al. 2001a) so it is hardly surprising that nurses in this survey tended not to rely on published literature as a major source of knowledge to inform their practice. Bearing in mind that nurses identified time as a major barrier to accessing and reviewing evidence-based information, it will not be easy to persuade nurses to read research journals more regularly. Strategies to promote evidence-based practice Finding research evidence Complete beginner Novice Quite skilled Competent Expert Finding organizational information Reviewing research information Reviewing organizational information Using research evidence to change practice Using organizational information to change practice Percentages Figure 1 Skills appraisal. 120 ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

8 Promoting evidence-based practice therefore need to take an account of the current constraints that practitioners are working under and ensure that evidence-based information is readily available to nurses in a form in which they can easily understand the implications for their practice. The survey has also shown that nurses are more likely to draw their knowledge from policy and procedure manuals than from research literature. This highlights the importance of ensuring that protocols and care pathways are evidence-based, relevant to local contexts and readily accessible to practitioners. Work is progressing within the hospital to make evidence-based protocols more readily available via the hospital Intranet. In addition, a web-based interactive database of practice development, research and audit projects undertaken within the organization has been developed. Accessible from ward-based computers, nurses are able to search the database to locate information of interest (Gerrish et al. 2004). This initiative is now being evaluated in order to access its impact on promoting evidence-based practice. However, it is recognized that nurses need to have ready access to computer terminals and receive training in how to use IT to support evidence-based practice (Estabrooks et al. 2003, Webster et al. 2003). A range of initiatives are now being introduced throughout the hospital to develop IT skills. The importance of establishing a culture that is responsive to change is essential in taking forward the evidence-based practice agenda. The survey identified that over half of the nurses considered themselves novices in terms of the skills they require to use evidence to change practice. Moreover, they perceived that the culture of their work environment was not necessarily receptive to changing practice. If progress is to be made with evidence-based practice it is important that the organizational culture shifts further to become more welcoming of change and that more nurses develop skills to become effective change agents. The observation that nurses draw most frequently upon experiential knowledge and work-based information to inform their practice is reinforced by Thompson et al.õs (2001a) recent study of accessibility of research-based knowledge for nurses. It is important, therefore, to consider how evidence-based practice can be facilitated through these channels. Although not explored explicitly in the survey, subsequent discussion of the findings amongst nurse managers and a review of recent research (Thompson et al. 2001b) has suggested that clinical nurse specialists can be instrumental in disseminating evidence-based information at ward level. However, some clinical nurse specialists who completed the questionnaire reported skills deficits in relation to evidence-based practice. Work is now being undertaken to identify the developmental needs of these nurses in promoting evidence-based practice. It is also recognized that continuing professional development programmes need to provide opportunities for developing skills in initiating and managing change. Leadership development needs to ensure that managers at ward level and above develop skills to become effective change agents and create an environment in which change is welcomed. The hospital has been able to capitalize on national clinical leadership programmes supported by the Department of Health (1999). In addition, a specific development programme, based on action learning sets, has been established for senior clinical nurses (F grade) with the intention of further developing the skills of these nurses in promoting evidence-based care. Finally, it is recognized that the organization in which the work has taken place is evolving. Completion of the survey coincided with the merger of the hospital with another large acute hospital in the same city. Whereas this has presented new challenges in terms of the different approaches to promoting evidence-based practice in the two organizations, the merger also created new opportunities for reviewing the organizational support structures to facilitate evidence-based practice. A new Centre for Professional and Practice Development brought together continuing professional education and practice development to provide a more integrated approach to supporting evidence-based practice. This department has taken a lead on a number of evidencebased practice initiatives including Essence of Care clinical benchmarking programme (Department of Health 2001), supporting the Evidenced-based Council, providing workshops and work-based learning programmes to develop skills and establishing a forum for disseminating innovative work undertaken within the organization. Conclusion In reporting on the progress made to promote evidence-based practice undertaken in one hospital this paper has identified some of the complexity and messiness associated with taking forward this objective. A multifaceted approach has been adopted in which research, development and evaluation have been used as a cyclical process to inform change. Whereas it has not been possible to demonstrate the impact of various initiatives in terms of measurable patient, staff or organizational outcomes, small-scale evaluations alongside organizational surveys have ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 12,

9 K. Gerrish andj. Clayton been used to develop an evidence base to inform decision-making. External scrutiny of the organization through an assessment by the Commission for Health Improvement (CHI) has confirmed that evidencebased initiatives are judged to be a considerable strength. Additionally, presentations at local, national and international conferences together with publications in academic and professional journals have resulted from a number of initiatives (some of which are cited in this paper) and bear witness to wider recognition of the value of such developments. In reflecting on the progress that has been made since work first begun in 1997 it has become clear that the organization has come to recognize the need to balance vision in terms of what is desirable with pragmatism in terms of what is achievable. Insufficient time has been identified consistently as a major obstacle to evidencebased practice and bearing in mind the high dependency of many patients and rapid patient turnover, the situation is unlikely to change in the foreseeable future. The challenge is to develop creative strategies whereby nurses can be better enabled to provide evidence-based care as part of their everyday practice. Acknowledgement that nurses rely most heavily on knowledge gained experientially in the clinical setting should guide the development of more work-based approaches to learning and to making information readily available in the clinical setting in a format that can be easily understood and the implications for practice made clear. The growth in national evidence-based guidelines means that nurses need the skills to access and review such guidance and adapt it for application to the local context. The contribution that nurses in advanced clinical roles, such as clinical nurse specialists and nurse consultants, can make to assist in this process needs to be maximized. They can act as a valuable resource for evidence-based information and assist in supporting an environment, which is receptive to change. Whereas nurses in this hospital and more widely do not currently make great use of IT in the workplace, it represents an important vehicle to support evidence-based practice. It should be recognized that none of these strategies in isolation provide a panacea for promoting evidencebased practice, however, if employed collectively and with the full support of senior managers, progress will continue to be made. References Bryar R., Closs S., Baum G. et al. (2003) The Yorkshire BAR- RIERS project: diagnostic analysis of barriers to research utilisation. International Journal of Nursing Studies 40, Department of Health (1998) A First Class Service: Quality in the New NHS. 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