The rapid noticeable change in healthcare delivery coupled with professional responsibilities of nurses to incorporate research evidence into their decision making underscores the need to understand the factors involved in implementing evidence-based practice. Linking current research findings with patients’ conditions, values, and circumstances is the defining feature of evidence-based practice.
Significant and rational for using evidence in practice in nursing care Evidence-based practice (EBP) is an approach to health care where the best evidence possible is used in health professionals to make clinical decisions for individual. It involves complex and conscientious decision-making based on the available evidence, patient characteristics, situations, and preferences( McKibbon, 1998). Evidence-based practice in nursing is defined as “integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served” (“Sigma Theta Tau International position statement on evidence-based practice February 2007 summary,” 2008).
The gist of evidence based health care is the integration of individual clinical expertise with the best available external clinical evidence and the values and expectations of the patient. There are different recourses of evidence which includes the following: •Research Evidence: which refers to methodologically sound, clinically relevant research about the effectiveness and safety of interventions, the accuracy of assessment measures, the strength of causal relationships and the cost-effectiveness of nursing interventions.
•Patients Experiences and Preferences: identification and consideration of patient’s experiences and preferences are central to evidence-based decision making. Patients may have varying views about their health care options, depending on factors such as their condition personal values and experiences, degree of aversion to risk, resources, availability of information, cultural beliefs, and family influences. • Clinical Expertise.
AS the mixing of these different types of evidence may be influenced by factors in the practice context such as available resources, practice
cultures and norms leadership styles, and data management, we must consider the level of evidence while using the research evidence to take the proper decision, look to appendix A which is represent the level of evidence. (Haynes, Devereaux, & Guyatt, 2002; Sigma Theta Tau International position statement on evidence-based practice February 2007 summary,” 2008).
Evidence-based practice is a prominent issue in international health care which is intended to develop and promote an explicit and rational process for clinical decision making that emphasizing the importance of incorporating the best research findings into clinical care to ensure the best possible treatment and care derived from the best available evidence (E. Fineout-Overholt, Levin, & Melnyk, 2004) Once a new research is completed new evidence comes into play every day, technology advances, and patients present with unique challenges and personal experiences(Krainovich-Miller, Haber, Yost, & Jacobs, 2009).
The nurse who bases practice on what was learned in basic nursing education soon becomes outdated, then becomes dangerous. Patients are not safe if they do not receive care that is based on the best evidence available to assist them at the time their needs arise, so all aspects of nursing, from education to management to direct patient care, should be based on the best evidence available at the time (Reavy & Tavernier, 2008). Through reviewing the literature there is a dramatically changing and advancing in the technology, available body information and quality of care provided, the rapid pace of change in healthcare delivery coupled with professional responsibilities of nurses to incorporate research evidence into their provided care and decision making underscores the need to understand the factors involved in implementing evidence-based practice (Boström, Ehrenberg, Gustavsson, & Wallin, 2009; Ellen Fineout-Overholt, Williamson, Kent, & Hutchinson, 2010; Gerrish, et al., 2011;
Gifford, Davies, Edwards, Griffin, & Lybanon, 2007). Before that nurses must first believe that basing their practice on the best evidence will lead to the highest quality of care and outcomes for patients and their families(Ellen Fineout-Overholt, et al., 2010; Melnyk, et al., 2004). To let change occuring, “there must be a clear vision, written goals, and a well-developed strategic plan, including strategies for overcoming anticipated barriers along the course of the change”(Melnyk, et al., 2004). Emerging evidence indicates that the leadership behaviors’ of nurse managers and administrators play an important role in successfully utlizing research evidence into clinical nursing(Amabile, Schatzel, Moneta, & Kramer, 2004; Antrobus & Kitson, 1999; Gifford, et al., 2007).
There is a consistency between many researches that clamethe importance role of the leadership and leadership factors such as support and commitment of managers on the staff at the implication of EBP(Aitken, et al., 2011; Antrobus & Kitson, 1999; Melnyk, et al., 2004; Winch, Creedy, & Chaboyer, 2002). Nurse managers and administrators are responsible for the professional practice environments where nurses provide care, and are strategically positioned to enable nurses to use research. As being a role model, administrators must be committed to provide the necessary resources such as EBP mentors, computers, and EBP education. Some administrators have tried to encourage a change to EBP by integrating EBP competencies into clinical promotions. However, Miller (2010) argue that this extrinsic motivational strategy is unlikely to be as effective as when people are intrinsically motivated to change. Also there is a claimed that if people are involved in the strategic planning process, they are more likely to change to EBP.
Intervention protocol for promoting nurses compliance to EBP As the Decision making in health care has changed dramatically, with nurses expected to make choices which based on the best available evidence and continually review them as new evidence comes to light (Pearson et al, 2007). Evidence-based practice involves the use of reliable, explicit and judicious evidence to make decisions about the care of individual patients. As an important role in providing safe and high quality care the nurses must take into account the quality of evidence, assessing the degree to which it meets the four principles of feasibility, appropriateness, meaningfulness and (Doody & Doody, 2011; Johnson, Gardner, Kelly, Maas, & McCloskey, 1991).
What nurses need to operate in an evidence-based manner, is to be aware of how to introduce, develop and evaluate evidence-based practice. There more than one model for introducing the EBP in health care one of them that I chose is the Iowa model.
The Iowa model focuses on organization and collaboration incorporating conduct use of research, along with other types of evidence(Doody & Doody, 2011; Johnson, et al., 1991). Since its origin in 1994, it has been continually referenced in nursing journal articles and extensively used in clinical research programmes. This model uses key triggers that can be either problem focused or knowledge focused, leading staff to question current nursing practices and whether care can be improved through the use of current research findings(Bauer, 2010; Doody & Doody, 2011; Johnson, et al., 1991; Titler, et al., 2001). By using Iowa Model; a question is generated either from a problem or as a result of becoming aware of new knowledge. Then a determination is made about the question relevance to organizational priorities.
If the question posed is relevant, then the next step is to determine if there is any evidence to answer the question. Once the evidence has been examined, if there is sufficient evidence, then a pilot of the practice change is performed. If there is insufficient evidence, then the model supports that new evidence should be generated through research (Bauer, 2010). Step one of the Iowa model is to formulate a question. The question if asked in a PICO format is easier to use to search the literature. A PICO format uses the following method to frame the question: Frame question in PICO format • P= Population of interest
• I= Intervention
• C= Comparison of what you will do
• O= Outcome(Hoogendam, de Vries Robbé, & Overbeke, 2012). The final step to the process is to share the outcomes of the practice change with other in the form of an article or poster. In using the Iowa model, there are seven steps to follow in detail as it is outlined in the figure shown in appendix B. Step 1: Selection of a topic
In selecting a topic for evidence-based practice, several factors need to be considered. These include the priority and magnitude of the problem, its application to all areas of practice, its contribution to improving care, the availability of data and evidence in the problem area, the multidisciplinary nature of the problem, and the commitment of staff. Step 2: Forming a team
The team is responsible for development, implementation, and evaluation. The composition of the team should be directed by the chosen topic and include all interested stakeholders. The process of changing a specific area of practice will be assisted by specialist staff team members, who can provide input and support, and discuss the practicality of guideline. A bottom-up approach to implementing evidence-based practice is essential as change is more successful when initiated by frontline practitioners, rather than imposed by management.
Staff support is also important. Without the necessary resources and managerial involvement, the team will not feel they have the authority to change care or the support from their organization to implement the change in practice. To develop evidence-based practice at unit level, the team should draw up written policies, procedures and guidelines that are evidence based. Interaction should take place between the organization’s direct care providers and management such as nurse managers, to support these changes(Antrobus & Kitson, 1999; Cookson, 2005; Doody & Doody, 2011; Hughes, Duke, Bamford, & Moss, 2006). Step 3: Evidence retrieval
Evidence should be retrieved through electronic databases such as Cinahl, Medline, Cochrane and up-to-date web site. Step 4: Grading the evidence
To grade the evidence, the team will address quality areas of the individual research and the strength of the body of evidence overall (see appendix A for level of evidence). Step 5: Developing an Evidence-Based Practice (EBP) standard After a critique of the literature, team members come together to set recommendations for practice. The type and strength of evidence used in practice needs to be and based in the consistency of replicated studies. The design of the studies and recommendations made should be based on identifiable benefits and risks to the patient.
This sets the standard of practice guidelines, assessments, actions, and treatment as required. These will be based on the group decision, considering the relevance for practice, its feasibility, appropriateness, meaningfulness, and effectiveness for practice. To support evidence-based practice, guidelines should be devised for the patient group, health screening issues addressed, and policy and procedural guidelines devised highlighting frequency and areas of screening.
Evidence-based practice is ideally a patient centered approach, which when implemented is highly individualized. Step 6: Implementing EPB
For implementation to occur, aspects such as written policy, procedures and guidelines that are evidence based need to be considered. There needs to be a direct interaction between the direct care providers, the organization, and its leadership roles (e.g. nurse managers) to support these changes. The evidence also needs to be diffused and should focus on its strengths and perceived benefits, including the manner in which it is communicated. This can be achieved through in-service education, audit and feedback provided by team members. Social and organizational factors can affect implementation and there needs to be support and value placed on the integration of evidence into practice and the application of research findings(Aitken, et al., 2011; Doody & Doody, 2011; Gerrish, et al., 2011; Reavy & Tavernier, 2008) Step 7: Evaluation
Evaluation is essential to seeing the value and contribution of the evidence into practice. A baseline of the data before implementation would benefit, as it would show how the evidence has contributed to patient care. Audit and feedback through the process of implementation should be conducted and support from leaders and the organization is needed for success. Evaluation will highlight the programme’s impact. Barriers also need to be identified. Information and skill deficit are common barriers to evidence-based practice.
A lack of knowledge regarding the indications and contraindications, current recommendations, and guidelines or results of research, has the potential to cause nurses to feel they do not have sufficient training, skill or expertise to implement the change. Awareness of evidence must be increased to promote the translation of evidence into practice . A useful method for identifying perceived barriers is the use of a force field analysis conducted by the team leader. Impact evaluation, which relates to the immediate effect of the intervention, should be carried out. However, some benefits may only become apparent after a considerable period of time. This is known as the sleep effect. On the contrary, the back-sliding effect could also occur where the intervention has a more or less immediate effect, which decreases over time.
We must not to evaluate too late, to avoid missing the measures of the immediate impact. Even if we do observe the early effect, we cannot assume it will last. Therefore, evaluation should be carried out at different periods during and following the intervention (Doody & Doody, 2011). Nursing leadership is an essential role for promoting evidence-based practice while the nurse managers and administrators are responsible for the professional practice environments where nurses provide care, are strategically positioned to enable nurses to use research. AS the leadership is essential for creating change for effective patient care the leadership behaviors are critical in successfully influencing the stimulation, acceptance, and utilization of innovations in organizations (Antrobus & Kitson, 1999; Gifford, et al., 2007).
From my perspective I consider that the leaders and managers are the corner stone for utilizing researches and make practices based on evidence. By playing a role model for staff and handling the authority they have a magic force to urges the staff to use evidence based in there practice. Leaders can encourage the staff to use EBP in their practice in several ways such as increase the staff awareness, stimulating the intrinsic motivation of people, implying an effort to increase the will and internal desire to change through support encouragement, education, and appealing to a common purpose, monitoring performance, strengthen the body of knowledge that the staff have by forcing them to attend and participate in conferences, workshops & Journal clups, giving rewards to staff who collaborate in finding, utilizing and applying the EBP and make promotion and appraisal according to adherence to application of EBP.
Implication of EBP
For implementation to occur, aspects such as written policy, procedures and guidelines that are evidence based need to be considered. There needs to be a direct interaction between the direct care providers, the organization, and its leadership roles (e.g. nurse managers) to support these changes. The evidence also needs to be diffused and should focus on its strengths and perceived benefits, including the manner in which it is communicated. This can be achieved through in-service education, audit and feedback provided by team members. Social and organizational factors can affect implementation and there needs to be support and value placed on the integration of
evidence into practice and the application of research findings. There are many ways that can be used to create an environment to implement and sustain an area of EBP such as : -Development of EBP champions;
– Use of EBP mentors;
– Provision of resources such as time and money;
– Creation of a culture and expectation related to EBP;
– Use of practical strategies including EBP workgroups, journal club and nursing rounds (Aitken, et al., 2011). EBP is being used in every aspect of the life, especially in the health care. The most common application of EBP is not only in intervention or treatment plane, but also the EBP process has been applied to making choices about diagnostic tests and protocols to insure thorough and accurate diagnosis, selecting preventive or harm-reduction interventions or programs, determining the etiology of a disorder or illness, determining the course or progression of a disorder or illness, determining the prevalence of symptoms as part of establishing or refining diagnostic criteria, completing economic decision-making about medical and social service programs.
Nursing research proves pivotal to achieving Magnet recognition, yet the term research often evokes an hunch of mystery. Most of the policy, guidelines. And protocols that guide the work in the organization are based on evidance (Weeks & Satusky, 2005). Also, it is also useful to think of EBP as a much larger social movement. Drisko and Grady (2012) argue that at a macro-level, EBP is actively used by policy makers to shape service delivery and funding. EBP is impacting the kinds of interventions that agencies offer, and even shaping how supervision is done. EBP is establishing a hierarchy of research evidence that is privileging experimental research over other ways of knowing.
There are other aspects of EBP beyond the core practice decision-making process that are re-shaping social work practice, social work education, and our clients’ lives. As such, it may be viewed as a public idea or a social movement at a macro level (“Evidence-Based Practice: Why Does It Matter?,” 2012). Cost effectiveness of using EBP in health care Beneficial outcomes of the implementation and use of evidence-based practice by staff nurses include increased ability to offer safe, cost-effective, and patient-specific interventions. Critical thinking skills and leadership abilities can also grow because of the use of evidence based practice; it is a way for staff nurses to become involved in change and regain ownership of their practice (Reavy & Tavernier, 2008). EBP used in clinical practice lead to make improvement in quality of provided care, which lead to improve the patients outcome, patient satisfaction and employee satisfaction.
All these aspect are directly and indirectly lead to increase the cost effectiveness of the organization. When the patient satisfaction increased the patient acceptance to the organization increased, the employee satisfaction also increases and turnover will decrease all these things will increase the financial revenue to the organization. Also when using EBP in health care this will lead to decrease errors, complications and losses (e.g. compliance of evidence based infection control guidelines will lead to decrease incidence of infection, decrease length of stay an d decrease the cost of patient treatment), another example is using EBP to treat diabetic foot will result in decreasing the loses and increases the satisfaction so adherence to EBP will be costly effective when it result in better outcome, quality of care and satisfaction. Sometimes using EBP in certain area is costly; in such cases we must weighing the benefits ( immediately and after considered period of time) and make our decision based on the collected data and information.
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