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Nurses struggle to implement evidence-based practice

Monday September 3, 2012
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A new national survey of more than 1,000 RNs suggests that resistance from nursing leaders and other barriers prevent nurses from implementing evidence-based practices that improve patient outcomes.

When survey respondents ranked these barriers, the most frequently mentioned also included politics and organizational cultures that avoid change.

When asked what would help them implement evidence-based practice, respondents reported education, access to information and organizational support among their top needs.

Evidence-based practice refers to making decisions about patient care that are based on the best evidence produced by well-designed clinical research. Numerous studies have suggested evidence-based care of patients can reduce patient complications and decrease healthcare costs by as much as 30%.

Overall, a little more than half of respondents reported that evidence-based practice was consistently used in their organization, but only about a third said their colleagues consistently used these practices.

The respondents with more education tended to have more confidence in implementing evidence-based practice. However, the longer nurses had been working in healthcare, the less interested they were in learning more about evidence-based practice.

“This was a distressing finding,” Bernadette Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FANN, the study’s lead author and dean of the College of Nursing and chief wellness officer at Ohio State University, said in a news release. “And it’s a huge problem. The average age of nurses is 47, and they were educated at a time when evidence-based practice was not well integrated into educational programs.

“As a result, many nurses are practicing the way they were taught or steeped in tradition of the healthcare system in which they work. When new graduates who have learned to take an evidence-based approach to care are meeting these nurses in real-world settings, they encounter this prevalence of a ‘this is the way we do it here’ culture.”

Change needed

Melnyk said the findings indicate the need for widespread cultural change in healthcare settings and a new direction in nursing education, where many current faculty tend to emphasize teaching rigorous research methods and critique of existing research rather than how to put research findings to use in clinical practice settings. She also said consumers should feel empowered to ask whether they are receiving evidence-based care.

Examples of care that is not based on evidence are relatively easy to find, noted Melnyk, a longtime consultant with health systems on implementation of evidence-based practice and a former member of the U.S. Preventive Services Task Force.

Many children suffering asthma attacks receive a drug to open their airways with a nebulizer in an ED, for example, when research has shown that using a metered-dose inhaler with a spacer leads to fewer side effects, less time in the ED and lower likelihood of hospitalization. Patients with depression typically receive an antidepressant prescription and nothing else despite research-based evidence that cognitive behavior therapy is more effective than medicine for mild to moderate depression.

The Institute of Medicine issued a report in 2003 calling for health professional education programs to include evidence-based care among five core competencies. As a goal, the IOM has said 90% of all patient-care decisions should be based on evidence by 2020.

A survey of nurses in 2005 conducted by a different research group suggested the profession wasn’t ready then to adopt evidence-based care, said Melnyk, who also is vice president for health promotion at Ohio State. “Now, in 2012, they believe in it and they’re ready for it. But there are so many barriers that continue to exist in our healthcare system and our educational system.

“Another disconcerting finding in our survey was that a substantive number of nurses said their leader or manager is resistant to evidence-based practice,” Melnyk added. “What I’ve seen as a consultant is a lot of leaders and managers will say they want their clinicians to deliver evidence-based care, but they don’t walk the talk. If leaders do not role model evidence-based decision-making and they are not providing tools, education and resources for their clinicians to get the knowledge and skills they need to consistently implement this, it’s probably not going to happen nor will it be sustained.”

Study methodology

Melnyk and colleagues solicited potential participants via emails sent to 20,000 randomly selected members of the American Nurses Association. Of those, 1,015 members completed the survey.

The survey contained questions about the state of evidence-based practice from each respondent’s perspective as well as two open-ended questions: what one thing prevents respondents from implementing evidence-based practice in daily clinical care, and what one thing would help them the most to implement this care.

Respondent ages ranged from 21 to 79, and 93% were female. Nearly 56% held master’s degrees or higher, while 44% had earned a bachelor’s degree, associate degree or diploma. The average number of years in nursing practice was 24, representing a range of zero to 52 years. Almost 47% worked in community hospitals, and 23% practiced in academic medical centers. A quarter of respondents described themselves as nurse educators.

Although 46.4% of respondents agreed that findings from research studies are routinely implemented to improve patient outcomes at their institution, 76.2%, indicated it was important for them to receive more education and skills building in evidence-based practice. Fewer than a third of respondents reported that mentors were available in their healthcare settings to help them learn more about how to adopt these practices.

Nurses working in hospitals with Magnet designation, awarded by the American Nurses Credentialing Center for excellence in nursing, were more likely to report the adoption of evidence-based care at their institutions, plenty of educational opportunities to gain skills in this care and organizational cultures that supported the use of evidence in delivering care.

The study appears in the September issue of the Journal of Nursing Administration. The study abstract is available at http://journals.lww.com/jonajournal/Abstract/2012/09000/The_State_of_Evidence_Based_Practice_in_US_Nurses_.6.aspx.


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