CHALLENGES OF EVIDENCE BASED PRACTICE IN NURSING

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1 CHALLENGES OF EVIDENCE BASED PRACTICE IN NURSING Visanth.V.S, Msc Nursing,Mphil nursing(2nd year)aiims,patna ABSTRACT EVIDENCE-BASED PRACTICE (EBP) is a problem-solving approach to clinical care that incorporates the conscientious use of current best evidence from well-designed studies, a clinician s expertise, and patient values and preferences.there are various challenges in implementation of EBP in nursing which include Lack Of knowledge, Barriers that impede advancing in health setting,negative attitude in students,problems in accessing research evidence and dissemination of evidence. Keywords;EBP,challenges INTRODUCTION During the 1980s, the term evidence-based medicine emerged to describe the approach that used scientific evidence to determine the best practice. Later, the term shifted to become evidence-based practice as clinicians other than physicians recognized the importance of scientific evidence in clinical decision-making. Nurses ask numerous questions when looking to integrate evidence-based practice into their clinical environment: What exactly is EBP? Is EBP the same as nursing research? What is the difference between EBP and quality improvement? Is EBP relevant to nursing practice? Major professional and health care organizations as well as federal agencies and policy-making bodies are emphasizing the importance of evidence-based practice (EBP).Using this problem solving approach to clinical care that incorporates the conscientious use of current best evidence from well designed studies, a clinician s expertise, and patient values and preferences, nurses and other health care providers can provide care that goes beyond the status quo. Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. 274

Fig 1:Applying EBP EVIDENCE-BASED PRACTICE (EBP) is a problem-solving approach to clinical care that incorporates the conscientious use of current best evidence from well-designed studies, a

2 Fig 1:Applying EBP EVIDENCE-BASED PRACTICE (EBP) is a problem-solving approach to clinical care that incorporates the conscientious use of current best evidence from well-designed studies, a clinician s expertise, and patient values and preferences. EBP is provided within a context of caring, it leads to the best clinical decision making as well as outcomes for patients and their families. The translation of research into clinical practice is the primary goal of scientific health professions (Ottenbacher, Barris, & Van Deusen, 1986) and is the ideal behind evidence-based practice. Evidence-based practice is an ethical, conscientious, discriminative process of applying the best research-based evidence to decisions regarding client care. The nursing literature has reported the positive effects of evidence-based practice for clients and employees for more than a decade. Heater, Becker, and Olson (1988) conducted a meta-analysis of 84 randomized controlled studies and concluded that research-based nursing interventions yielded gains in behavioral, psychological, and physiological client outcomes compared with standard nursing care. TitchenandBinnie (1993) noted that nurses who accessed research experienced greater motivation and interest in their work as well as a sense of ownership of their profession. This finding, however, may not generalize to other nurses or health professionals because only nurses working on a single hospital ward were studied. low research utilization has been an issue within the nursing profession. fig 2: Evidence Hierarchy 275

3 IMPORTANCE OF EVIDENCE BASED PRACTICE Over the past decade, nurses have been part of a movement that reflects perhaps more change than any two decades combined. The recommendation that nurses lead interprofessional teams in improving delivery systems and care brings to the fore the necessity for new competencies, beyond evidence-based practice, that are requisite as nurses transform healthcare. Directions in nursing education in the 1960s established nursing as an applied science. This was the entry of our profession into the age of knowledge. Only in the mid-1990s did it become clear that producing new knowledge was not enough. To affect better patient outcomes, new knowledge must be transformed into clinically useful forms, effectively implemented across the entire care team within a systems context, and measured in terms of meaningful impact on performance and health outcomes. The recently-articulated vision for the future of nursing in the Future of Nursing report (IOM, 2011a) focuses on the convergence of knowledge, quality, and new functions in nursing. The recommendation that nurses lead interprofessional teams in improving delivery systems and care brings to the fore the necessity for new competencies, beyond evidence-based practice (EBP), that are requisite as nurses transform healthcare. These competencies focus on utilizing knowledge in clinical decision making and producing research evidence on interventions that promote uptake and use by individual providers and groups of providers. Evidence-based practice helps nurses provide high-quality patient care based on research and knowledge rather than because this is the way we have always done it, or based on traditions, myths, hunches, advice of colleagues, or outdated textbooks. Why is EBP important to nursing practice? It results in better patient outcomes It contributes to the science of nursing It keeps practice current and relevant It increases confidence in decision-making Policies and procedures are current and include the latest research, thus supporting JCAHO-readiness. Integration of EBP into nursing practice is essential for high-quality patient care and achievement of ANCC Magnet Recognition Program (MRP) designation Often, nurses feel that they are using evidence to guide practice, but their sources of evidence are not research-based. In a study conducted by Thompson, et al., (2003), nurses reported that the most helpful knowledge source was experience or advice from colleagues or patients. Of concern were reports that up-to-date electronic resources that included evidence-based materials were not useful to nurses in clinical practice. This barrier contributes to significant gaps in clinicians applying research findings to practice and dissemination of innovations. The failure to use evidence results in care that is of lower quality, less effective, and more expensive (Berwick, 2003). Leaders in the field have defined EBP as Integration of best research evidence with clinical expertise and patient values (Sackett et al, 2000, p. ii). Therefore, EBP unifies research evidence with clinical expertise and encourages individualization of care through inclusion of patient preferences. While this early definition of EBP has been paraphrased and sometimes distorted, the original version remains most useful and is easily applied in nursing, successfully aligning nursing with the broader field of EBP. CHALLENGES OF EVIDENCE BASED PRACTICE IN NURSING (1) Lack Of knowledge (2)Barriers that impede advancing in health setting (1) misperceptions about EBP (e.g., it is too time-consuming); (2) negative attitudes toward research; (3) lack of administrative support; (4) insufficient number of EBP mentors and champions in health care systems; (5) inadequate knowledge, beliefs, and skills by advanced practice and staff nurses; (6) continuing education conferences that are didactic only in nature; 276

4 (3) Negative Attitude Inculcated in Students (4)Problems in implementing evidence based medicine and possible solutions Problem The size and complexity of the research Difficulties in developing evidence based clinical policy Poor access to best evidence and guidelines Organisational barriers Ineffectual continuing education programmes Low patient adherence to treatments Nurses often report the following: Lack of value for research in practice Difficulty in changing practice Lack of administrative support Lack of knowledgeable mentors Insufficient time to conduct research Lack of education about the research process Lack of awareness about research or evidence-based practice Research reports/articles not readily available Difficulty accessing research reports and articles No time on the job to read research Complexity of research reports Lack of knowledge about EBP and critique of articles Feeling overwhelmed by the process Solution Use services that abstract and synthesise information Produce guidelines for how to develop evidence based clinical guidelines Use information systems that integrate evidence and guidelines with patient care Develop facilities and incentives to encourage effective care and better disease management systems Improve effectiveness of educational and quality improvement programmes for practitioners Develop more effective strategies to encourage patients to follow healthcare advice (5)Problems In Accessing Research Evidence (6)Barriers To Dissemination Of Research 277

5 Impact on Nursing Practice In this wide-ranging effort, another significant player was added the policymaker. For EBP to be successfully adopted and sustained, nurses and other healthcare professionals recognized that it must be adopted by individual care providers, microsystem and system leaders, as well as policy makers. Federal, state, local, and other regulatory and recognition actions are necessary for EBP adoption. For example, through the Magnet Recognition Program the profession of nursing has been a leader in catalyzing adoption of EBP and using it as a marker of excellence. A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice. In spite of many significant advances, nurses still have more to do to achieve EBP across the board. A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). One example of implementation of EBP points to the challenges of change. The evidence-based program, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) (AHRQ, 2008) carries with it proven effectiveness of reducing patient safety issues and the program is available with highly-developed training and learning materials. Yet, because of the change necessary to fully implement and sustain the program across the system supported by organizational culture, a sophisticated implementation plan is required before the evidence-based intervention is adopted across an institution. While agency policy may be set, implementation and sustainment of TeamSTEPPS remain challenging Impact on Nursing Models and Frameworks Early in the EBP movement, nurse scientists developed models to organize our thinking about EBP. A number of EBP models were developed by nurses to understand various aspects of EBP. Forty-seven prominent EBP models can be identified in the literature. These frameworks guide the design and implementation of approaches intended to strengthen evidence-based decision making. Forty-seven prominent EBP models can be identified in the literature. Once analyzed, these models can be grouped into three thematic areas: (1) EBP, Research Utilization, and Knowledge Transformation Processes; (2) Strategic/ Organizational Change Theory to Promote Uptake and Adoption of New Knowledge; and (3) Knowledge Exchange and Synthesis for Application and Inquiry (Mitchell, Fisher, Hastings, Silverman, &Wallen, 2010). Listed among models in Category 1 is the ACE Star Model of Knowledge Transformation (Stevens, 2004); this model is the exemplar for the present discussion of the impact of EBP on nursing models and frameworks. The ACE Star Model of Knowledge Transformation highlights barriers encountered when moving evidence into practice and designates solutions grounded in EBP. The model explains how various stages of knowledge transformation reduce the volume of scientific literature and provide forms of knowledge that can be directly incorporated in care and decision making. The ACE Star Model emphasizes crucial steps to convert one form of knowledge to the next and incorporate best research evidence with clinical expertise and patient preferences thereby achieving EBP. RECENT STUDIES RELEVANT TO CHALLENGES OF EBP Sandra E. Zwolsman Nynke van Dijk in her article Barriers to the use of evidence-based medicine: knowledge and skills, attitude, and external factors depicts about the fact that that all specialized people,everv physicians find it difficult to impement EBP into practice. However, the transfer of evidence into practice is not optimal and barriers limiting the use of EBM are met by both trainees and their clinical trainers. In order to optimize the transfer of evidence into patient care through installing EBM education in practice current barriers need to be tackled. The aim of the study was to identify barriers that general practice trainees experience while doing EBP practicing. First year GP trainees were the subjects. Training take place in first and third year and in second year they were given training in various area. The questionnaire was simultaneously administered under examination conditions to all trainees at each institute.all barriers identified by a systematic review of barriers faced by the trainees when applying EBM were formulated as statements with alternately positive or negative phrasing to avoid a response set phenomenon. The questionnaire consisted of 19 statements concerning EBM. Answers were given on a 5-point Likert scale. The three single barriers that were experienced most by GP trainees were all time related: When busy, searching for evidence is not a priority to me, The time I have per patient is insufficient to also search for answers to my questions and During consultations, I have insufficient time to work according to EBM. An article on the topic Barriers to research utilization and research use among registered nurses working in the care of older people: Does the BARRIERS Scale discriminate between research users and non-research users on perceptions of barriers was discussed by Anne-Marie Boström and Kerstin Nilsson Kajermo.This was a cross sectional study with nurses caring for elderly. BARRIERS scale and the Research Utilization Questionnaire were used. The scale is composed of 29 items. The respondents were asked to rate to which extent they perceived each item as a barrier to the use of research findings. Descriptive analyses were used to present frequencies and distributions of reported barriers. To describe the RNs perceptions of barriers, the 4-point scale was used by merging the respondents who answered the two response alternatives 3 and 4 into one category representing respondents who reported 278

6 the item as a barrier to research utilization. The barriers mainly concerned the characteristics of the organization and the presentation and accessibility of research findings. The RNs also reported the lack of knowledgeable colleagues as a major barrier. To enhance research use in the care of older people, strategies should focus on organizational issues, including supportive leadership by the unit managers and collaboration between colleagues, staff, and physicians. In the journal issues in Mental Health Nursing, Abdulkarim Subhi Alzayyat discussed about the issues in evidence based utilization in mental health nursing. The reviewed literature revealed that these barriers can be classified into four major categories: the nature of the evidence, contribution of the PMHN researchers to EBP, personal characteristics of psychiatric nurses, and organizational factors. Increasing The Number of PMHN Researchers, Computer Training For Psychiatric Nurses, Integrating EBP Principles into Nursing Curricula, Choosing Suitable Journals For Publication, Conducting Clinical Research Projects and Developing Journal Clubs were some of the stratergies which he suggested to overcome the barriers. PMHN personnel have to further expand and evaluate their models of practice, perform research projects that adhere to the rules of EBP, and can validate the efficacy and effectiveness of their interventions, disseminate the outcomes of their research projects to the target audience properly, familiarize themselves with research appraisal skills, teach nursing students based on EBP principles instead of the traditional ways of nursing research, abandon the hierarchy approach of evidence, and be true patient advocates by integrating EBP in their daily performance. CONCLUSION The impact of evidence-based practice (EBP) has echoed across nursing practice, education, and science. The call for evidence-based quality improvement and healthcare transformation underscores the need for redesigning care that is effective, safe, and efficient. In line with multiple direction-setting recommendations from national experts, nurses have responded to launch initiatives that maximize the valuable contributions that nurses have made, can make, and will make, to fully deliver on the promise of EBP. Such initiatives include practice adoption; education and curricular realignment; model and theory development; scientific engagement in the new fields of research; and development of a national research network to study improvement 1. REFERENCE 2. Alzayyat, A. S. (2014). Barriers to Evidence-Based Practice Utilizationin Psychiatric/Mental Health Nursing. Issues in Mental Health Nursing,, Anne-Marie Boström, K. N. (2008). Barriers to research utilization and research use among registeredworking in the care of older people: Does the BARRIERSScale discriminate between research users and non-research users. BioMed Central, Brian Haynes, A. H. (n.d.). Barriers and bridges to evidence based clinical practice. Getting research findings into practice. 5. Dan Bilsker, E. G. (2004). Teaching Evidence-Based Practice:Overcoming Barriers. Brief Treatment and Crisis Intervention. 6. Dijk, S. E. (2013). Barriers to the use of evidence-based medicineknowledge and skills, attitude, and external factors. Perspect Med Educ, ELLEN FINEOUT-OVERHOLT, B. M. (2005: ). Transforming Health Care from the Inside Out:Advancing Evidence-Based Practice in the. Journal of Professional Nursing, Leilani Tacia, K. B. (2015). Identifying barriers to evidence-based practice adoption -a focus group study. Clinical Nursing Studies, R, B. (2008). Bariers to accessing evidence based information. Art and Science, Suzanne C. Beyea,,. M. (2006 ). A GUIDE TO SUCCESSFUL IMPLEMENTATION Evidence-Based Practice in Nursing. HCPro, Inc., Wallis, L. (2012). Barriers to Implementing Evidence-Based Practice Remain High for U.S. Nurses. AJN, American Journal of Nursing:,

New Evidence-Based Practice Competencies for Practicing Nurses and Advanced Practice Nurses: From Development to Real World Implementation

New Evidence-Based Practice Competencies for Practicing Nurses and Advanced Practice Nurses: From Development to Real World Implementation The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based