Nursing Leadership

Leadership Perspectives Research: Evidence-based Nursing Practice: How to Get There from Here A ba !i"enso

Abstract
As a nursing student# $ earned to shave patients in preparation for surger%& as a pub ic hea th nurse# $ taught mothers to c ean their infants' umbi ica cords with a coho and showed patients new % diagnosed with diabetes how to wipe the s(in with a coho before in)ecting insu in* +ince then# high-,ua it% research has shown that pre-operative shaving increases rather than decreases post-operative infections -.)onni(sen et a * /00/1# that c eaning umbi ica cords with steri e water shortens the time to cord separation without increasing infections -2edves and 3'4rien 56671 and that insu in can be safe % in)ected through c othing -8 eming et a * 56671* These are on % three of innumerab e e9amp es of how high-,ua it% studies of nursing care can inf uence our practice* And whi e it is heartening to (now that new evidence is constant % emerging to inform our nursing practice# it is disheartening to earn that man% nurses continue to re % on the increasing % dated (now edge the% ac,uired as nursing students -Estabroo(s 566:1* $n this paper# $ wi describe how high-,ua it% evidence fits into c inica decision-ma(ing in nursing practice# and $ wi ca upon (e% professiona groups# such as associations of nursing educators# e9ecutive nurses and nationa nursing organi;ations# to combine forces and create b ue ribbon pane s or tas( forces charged with ma(ing recommendations for changes in nursing education and practice that wi advance us towards fu deve opment as an evidence-based profession*

Evidence and Clinical Decision-making

<4est research evidence< refers to methodo ogica % sound# c inica % re evant research about the effectiveness and safet% of nursing interventions# the accurac% and precision of nursing assessment measures# the power of prognostic indicators# the strength of causa re ationships# the cost-effectiveness of nursing interventions and the meaning of i ness or patient e9periences* Research evidence a one# however# is never sufficient to ma(e a c inica decision* As nurses# we must a wa%s trade the benefits and ris(s# inconvenience and costs associated with a ternative management strategies# and in doing so consider the patient's va ues -!i"enso et a * 566:1* Patient va ues and preferences refer to the under %ing assumptions and be iefs that are invo ved when we# a ong with patients# weigh what the% wi gain - or ose - when we ma(e a management decision* The e9p icit enumeration and ba ancing of benefits and ris(s that are centra to evidence-based

nursing -E4N1 bring into bo d re ief the under %ing va ue )udgments invo ved in ma(ing management decisions* The s(i s necessar% to provide an evidence-based so ution to a c inica di emma inc ude defining the prob em& conducting an efficient search to ocate the best evidence& critica % appraising the evidence& and considering that evidence and its imp ications in the conte9t of patients' circumstances and va ues* Attaining these s(i s re,uires intensive stud% and fre,uent# time-consuming app ication -Gu%att et a * /0001* The ma)orit% of nurses have a positive attitude about evidence-based practice -=pton 56661* However# there are substantia barriers to E4N at both the individua and organi;ationa eve s* At the individua eve # nurses ac( s(i in eva uating the ,ua it% of research -Parahoo /0001# are iso ated from (now edgeab e co eagues with whom to discuss research -Ni sson .a)ermo et a * 566:1 and ac( confidence to imp ement change -Parahoo /0001* 3rgani;ationa characteristics of hea thcare settings are overwhe ming % the most significant barriers to research use among nurses -Parahoo /0001* Nurses spea( about not having enough time to go to the ibrar% to read or to imp ement findings from research -=pton 56661* Re ated to this comp aint is the inade,uac% of ibrar% ho dings in hea thcare institutions# with man% ac(ing nursing research )ourna s -2itche et a * 566>1* Nurses have identified a ac( of organi;ationa support for E4N# noting ac( of interest# ac( of motivation# ac( of eadership and ac( of vision# strateg% and direction among managers -Parahoo /0001* ?et# this organi;ationa support is crucia in situations where nurses do not be ieve the% have the authorit% or autonom% to imp ement change in patient care -Parahoo /0001* 8or e9amp e# a ph%sician ma% read about the effectiveness of a new pain medication and ma% choose to begin prescribing it immediate %& nurses who identif% a new# effective nursing intervention for pain management must often obtain approva from nursing administration before imp ementing it* " inicians and patients recogni;e that whi e not the so e consideration# current# accurate information is a vita component of c inica decision-ma(ing* @ith advances in information techno og% and reporting of research findings in the media# patients# armed with <facts< the% have read on the $nternet or in the newspaper# are beginning to as( their care providers about the app icabi it% of research findings to their particu ar hea th prob em* A vivid e9amp e is the wide % pub ici;ed stud% of the ris(s and benefits of estrogen and progestin in post-menopausa women that was stopped ear % because the investigators found a higher incidence of cardiovascu ar disease and breast cancer in women ta(ing the combined hormones when compared to women ta(ing p acebo -@riting Group for the @omen's Hea th $nitiative $nvestigators /00/1* Ph%sicians and nurse practitioners have been de uged with patient in,uiries about whether the% shou d discontinue their hormone rep acement therap%# re,uiring these c inicians to be sufficient % aware of the stud% methods to )udge the va idit% of the resu ts and their app icabi it% to individua patients*

Grounding nursing practice in evidence# rather than tradition# is necessar% to meet nursing's socia ob igation of accountabi it%# to gain and maintain credibi it% among other hea th discip ines and to bui d a nursing (now edge base that can be used to inf uence po ic% at agenc% and governmenta eve s -Rafae /0001* Governments around the wor d Aare encouraging evidence-based practice* $n "anada# the Nationa Hea th 8orum# a federa % funded group charged with ma(ing hea thcare recommendations# has stated that <a (e% ob)ective for the hea th sector shou d be to move rapid % toward the deve opment of an evidence-based hea th s%stem# in which decisions are made b% hea thcare providers# administrators# po ic%-ma(ers# patients and the pub ic on the bases of appropriate# ba anced and high ,ua it% evidence< -Nationa 8orum on Hea th 56671* $n the =nited .ingdom# the !epartment of Hea th has stipu ated that# to enhance the ,ua it% of patient care# nursing# midwifer% and hea th visiting# practice needs to be evidence based -=. !epartment of Hea th 56661* $n the =nited +tates# the Agenc% for Hea thcare Research and Bua it% -AHRB1# former % the Agenc% for Hea th "are Po ic% and Research -AH"PR1# eads nationa efforts in the use of evidence to guide hea thcare decisions through funding of Evidence-4ased Practice "enters that underta(e s%stematic reviews on se ected c inica topics# sponsoring a Nationa Guide ine " earinghouse of abstracts of evidence-based practice guide ines -www*guide ine*gov1 and funding studies that eva uate strategies for effective % disseminating research findings to practitioners and po ic% ma(ers -Tit er /00/1* $n !ecember /00/# the 4oard of !irectors of the +igma Theta Tau $nternationa Honor +ociet% of Nursing adopted a position statement supporting the deve opment and imp ementation of E4N and committing itse f to wor(ing c ose % with (e% partners to provide nurses with the most current and comprehensive resources to trans ate the best evidence into the best nursing research# education# administration# po ic% and practice -Honor +ociet% of Nursing /00/1*

Towards Full Development as an Evidence-based Pro ession

Carious activities have been initiated to faci itate E4N practice# inc uding the deve opment and offering of undergraduate courses on ocating and critica % appraising research evidence -.essenich et a * 56671# the deve opment of c inica practice guide ines -Grinspun et a * /00/1# the deve opment of E4N committees in c inica settings and research to identif% the most effective strategies for disseminating research findings to nurses* 4ut there is a ong wa% to go* How do we create a cu ture shift that ensures that a nursing student (nows how to search the iterature for high-,ua it% studies as proficient % as she can measure a patient's b ood pressure# and that a staff nurse has access to the best research evidence to incorporate into c inica decision-ma(ingD Let's begin b% considering changes to nursing education programs* A number of ideas come to mind re ated to curricu um deve opment# facu t% deve opment# ibrarian resources and accreditation criteria* Rather than iso ating the teaching of critica appraisa of research in its own undergraduate course# can we re-e9amine our nursing curricu a and

consider how critica appraisa of research can be integrated into each and ever% earning e9perience# whether earning of c inica s(i s such as ta(ing b ood pressure# or in-c ass nursing courses# or c inica e9periences in hea thcare settingsD "an we see a wor d where students in c assrooms or in c inica settings go off to earn about a specific patient or hea th prob em and return with a c ear % stated ,uestion# the search strateg% the% used and the strengths and imitations of the highest-,ua it% stud% the% found on the topicD $f this were the approach to ever% course students too( and ever% c inica e9perience the% had# wou d consideration of best research evidence in their c inica decision-ma(ing become second nature for these future nursesD " ear %# none of this wi happen if nursing facu t% are not comfortab e with critica appraisa s(i s* To be fair# the opportunities to deve op these s(i s have been re ative % scarce* There is much to be done in this area* Carious mode s can be e9p ored for facu t% deve opment& for e9amp e# at 2c2aster =niversit%# an interdiscip inar%# wee(- ong# intense wor(shop on How to Teach Evidence-based " inica Practice is conducted ever% Eune that attracts c inician educators from around the wor d* To ensure that nurse educators of the future are prepared to teach in an E4N curricu um# it is vita % important that the graduate nursing programs inc ude re,uired courses on critica appraisa and app ication of research evidence* Librarians are an indispensab e resource to evidence-based practice* $n a number of undergraduate and graduate nursing courses at 2c2aster =niversit%# a hea th sciences ibrarian has set up course-specific @eb +ites providing read% access to numerous sources of evidence-based materia * As we # she spends a ha f da% with the students in the computer aborator% providing hands-on e9perience in efficient advanced searching strategies to ocate high-,ua it% research evidence and to in( with resources that can automatica % notif% the student when new studies are pub ished in a specific area of interest* +he is a so avai ab e to meet individua % with students* These ideas# whi e promising# cannot be imp emented without the bu%-in and support of the deans and directors of schoo s and facu ties of nursing* These are not resource-free ideas& instead# the% are ideas that i(e % re,uire financia and human resources as we as a supportive environment for change* $ncorporation into the accreditation process of specific ob)ectives and recommendations for transforming nursing education programs into evidence-based education programs are (e% to he ping deans and directors obtain assistance with re,uired resources from the universit% or co ege administration* $n c inica settings# et's consider computer and ibrarian resources# deve opment and introduction of the nurse educatorFpractitionerFresearcher ro e# )ourna c ubs# interdiscip inar% rounds and accreditation* As(ing nurses to practice nursing without the too s to ocate best evidence to inform their c inica decision-ma(ing is comparab e to as(ing them to ta(e a b ood pressure measurement without a stethoscope* 2an% nurses# whi e high % motivated to become evidence-based practitioners# have not had an% opportunit% in their nursing education to earn searching and critica appraisa s(i s* To comp icate matters further# time is more imited than ever*

There e9ist# however# numerous secondar% sources of pre-appraised evidence that provide immediate % app icab e information for decision-ma(ing* Administrators of c inica settings can ma(e a significant contribution to the deve opment of evidencebased practice b% providing access to these resources# a ong with opportunit% for nurses to earn how to trac( down and efficient % use them* +uch resources# which app % a methodo ogica fi ter to origina investigations and therefore ensure a minimum standard of va idit%# inc ude Clinical Evidence, The Cochrane Library, Evidence-Based Nursing -and other discip ine-specific abstraction )ourna s# such as Evidence-Based Mental Health1# high-,ua it% c inica practice guide ines and an increasing number of computeri;ed decision-support s%stems* Read% access to computers in the c inica setting and ibrarians is (e%* At a minimum# ibrarians can teach nurses how to frame an answerab e ,uestion and how to use the secondar% sources of pre-appraised evidence efficient %* The ibrarian becomes# in effect# a (now edge bro(er who is e9pert in sources of high-,ua it% information and in teaching others how to access them efficient %* 8or the most part# nursing educators are not active c inicians# and nurse c inicians are not nursing educators* At Rush =niversit% "o ege of Nursing# the% have deve oped the nurse educatorFpractitionerFresearcher ro e in which facu t% members have an ongoing research invo vement and c inica practice a ongside their responsibi ities as educators# ecturers and advisers -<$nside the Rush 2ode < /00G1* Picture c inica settings in which the nurse educatorFpractitionerFresearcher wor(s c ose % with nursing staff to produce and disseminate new (now edge and# as an advanced practice nurse# mode s and faci itates evidence-based practice* +hou d we consider bringing together# in the c inica setting# the nurse educator# the students and the nurse c inicians in the form of a )ourna c ubD Together# the% can identif% a patient prob em& vo unteers can then offer to search out the best evidence and bring it bac( for presentation and discussion with the group* This might provide a forum for earning from one another whi e at the same time he ping nurses in the c inica setting# who ac( time and critica appraisa s(i s* There is an increasing awareness of the importance of interdiscip inar% earning to faci itate the effective wor(ing of the mu tidiscip inar% hea thcare team in service de iver%* @e are beginning to see how cha enging it is to promote interdiscip inar% service when earning has occurred in unidiscip inar% si os* $s there an opportunit% in the c inica setting to bring together students from programs such as nursing# midwifer%# medicine# occupationa therap% and ph%siotherap% to consider a common patient prob em and to search out and discuss re evant research findingsD 8or e9amp e# at 2c2aster =niversit%# a mu tidiscip inar% team has been awarded funds from the provincia government to deve op mode s for co aborative education and co aborative service de iver% in ong-term care# inc uding fami % medicine residents# nurse practitioner students and pharmac% students* $t is envisioned that both mode s wi inc ude the opportunit% for these interdiscip inar% earners and c inicians to wor( together through patient prob ems# identif%ing and using best evidence in their c inica decision-ma(ing*

Cer% itt e of this is possib e without the support and provision of resources b% the administrators of hea thcare settings* Nurse managers ma% want to consider obb%ing for inc usion of standards re ated to E4N practice in the accreditation mechanisms for their c inica settings* This action wou d appropriate % high ight the importance of evidencebased practice and wou d ensure that essentia resources be a ocated to its deve opment* The ideas offered above are mere % suggestions* The deve opment of an evidence-based profession is an e9treme % important initiative in nursing# one that warrants nationa attention and co aboration* $ encourage (e% nursing groups# inc uding associations of nursing educators# e9ecutive nurses and nationa nursing organi;ations# to combine forces and create b ue ribbon pane s or tas( forces charged with ma(ing recommendations for changes in nursing education and practice that wi move us rapid % towards fu deve opment as an evidence-based profession* Enthusiasm for evidence-based practice is growing in the nursing communit%* @e must now deve op# imp ement and eva uate a p an to ma(e it happen*

About the Author

Alba DiCenso# RN# Ph! Professor# Nursing and " inica Epidemio og% and 4iostatistics !irector# 3ntario Training "entre in Hea th +ervices and Po ic% Research "H+R8F"$HR Nursing "hair in Advanced Practice Nursing 2c2aster =niversit%# Hami ton# 3N Past Lead Editor# Evidence-4ased Nursing Eourna

!e erences
!i"enso# A*# N* "u um and !* "i is(a* 566:* <$mp ementing Evidence-based Nursing: +ome 2isconceptions*< Evidence-Based Nursing 5-/1: G:-H0* Estabroo(s# "*A* 566:* <@i Evidence-based Nursing Practice 2a(e Practice PerfectD< Canadian Journal of Nursing Research G0: 5>-GI* 8 eming# !*R*# +*E* Eacober# 2*A* Candenberg et a * 5667* <The +afet% of $n)ecting $nsu in Through " othing*< iabetes Care /0: /HH-H7* Grinspun# !*# T* Ciraniand and $* 4a)no(* /00/* <Nursing 4est Practice Guide ines* The RNA3 Pro)ect*< Hos!ital "uarterly >: >I-I0* Gu%att# G*H*# 2*3* 2eade# R*J* Eaesch(e# !*E* "oo( and R*4* Ha%nes* /000* <Practitioners of Evidence-based "are*< British Medical Journal G/0: 6>H->>* Honor +ociet% of Nursing# +igma Theta Tau $nternationa # +TT$ 4oard of !irectors* /00/ -!ecember 5/1* #osition $tate%ent* $ndianapo is# $N: Author*

<$nside the Rush 2ode : Leading an 3rgani;ation of Leaders*< /00G* E&cellence in Nursing 'd%inistration H-/1* Retrieved November /># /00G*K http:FFwww*nursingsociet%*orgFpub icationsF EL"ELMNA/M/B*htm N* .essenich# "*R*# G*H* Gu%att and A* !i"enso* 5667* <Teaching Nursing +tudents Evidence-based Nursing*< Nurse Educator //-I1: />-/6* .)onni(sen# $*# 4*2* Andersen# C*G* +ondenaa and L* +egada * /00/* <Preoperative Hair Remova - A +%stematic Literature Review*< '(RN Journal 7>->1: 6/:-G:# 6H0* 2edves# E*2* and 4*A* 3'4rien* 5667* <" eaning +o utions and 4acteria "o oni;ation in Promoting Hea ing and Ear % +eparation of the =mbi ica "ord in Hea th% Newborns*< Canadian Journal of #ublic Health ::-I1: G:0-:/* 2itche # A*# .* Ean;en# E* Pas( and !* +outhwe * 566>* <Assessment of Nursing Research =ti i;ation Needs in 3ntario Hea th Agencies*< Canadian Journal of Nursing 'd%inistration :-51: 77-65* Nationa 8orum on Hea th -"anada1* 5667* Canada Health 'ction) Building on the Legacy* Co * 5* 3ttawa: Author# G-HG* Ni sson .a)ermo# .*# G* Nordstrom# A* .rusebrant and H* 4)orve * 566:* <4arriers to and 8aci itators of Research =ti i;ation# as Perceived b% a Group of Registered Nurses in +weden*< Journal of 'dvanced Nursing /7-H1: 76:-:07* Parahoo# .* /000* <4arriers to# and 8aci itators of# Research =ti i;ation Among Nurses in Northern $re and*< Journal of 'dvanced Nursing G5: :6-6:* Rafae # A*R*8* /000* <Evidence-based Practice: The Good# the 4ad# the =g %# Part 5*< Registered Nurses Journal 5/-H1: >-I# 6* Tit er# 2*G* /00/* <=se of Research in Practice*< $n G* Lo4iondo-@ood and E* Haber# eds*# Nursing Research* ->th ed*1* +t* Louis: 2osb%-?ear 4oo(* =. !epartment of Hea th* 5666* <2a(ing a !ifference: +trengthening the Nursing# 2idwifer% and Hea th Cisiting "ontribution to Hea th and Hea thcare*< Retrieved November 7# /00/* K http:FFwww*doh* gov*u(Fnurstrat*htm N* =pton# !* 5666* <Attitudes Towards# and .now edge of# " inica Effectiveness in Nurses# 2idwives# Practice Nurses and Hea th Cisitors*< Journal of 'dvanced Nursing /6: ::>-6G* @riting Group for the @omen's Hea th $nitiative $nvestigators* /00/* <Ris(s and 4enefits of Estrogen P us Progestin in Hea th% Postmenopausa @omen: Principa Resu ts from the @omen's Hea th $nitiative Randomi;ed "ontro ed Tria *< Journal of the '%erican Medical 'ssociation /::: G/5-GG*