Evidence-Based Practice in Healthcare: An Exploratory Cross-Discipline Comparison of Enhancers and Barriers
For more information on this article, contact Joanna Asadoorian at firstname.lastname@example.org.
Abstract: In order to improve health outcomes, healthcare providers need to base practice on current evidence. The purpose of this qualitative study was to explore and compare the understanding and experiences with evidence-based practice (EBP) in three different disciplines. Researchers conducted individual interviews with psychiatrists, nurses, and dental hygienists. The majority of study participants demonstrated an understanding of EBP and were able to identify enhancers and barriers to implementing EBP. Using a grounded theory approach, several major themes acting as enhancers and barriers to EBP emerged and revealed both differences and similarities within and across the three health disciplines. While saturation was not attempted, this exploratory research is important in contributing to understanding the cultural practice milieu in relation to individual characteristics in implementing evidence into practice with the overall aim of improving healthcare delivery and outcomes.
Implementing current research findings has the potential to improve the provision of healthcare quality and its outcomes by informing clinical practice and necessitating change (Berwick, 1996; Greco & Eisenberg, 1993). However, studies suggest that the lag time between the new research findings and their general application is considerable (Balas & Boren, 2000; Bloom, 2005; Greer, 1988; Jolley, 2002; Kanouse & Jacoby, 1988). Delays in implementing more effective procedures and the discontinuation of ineffective or harmful ones can have serious implications in patient outcomes and treatment costs (Lavigne & Forrest, 2004) and has been the impetus for knowledge translation research, which attempts to address the gap between theory and practice (CIHR, 2008). The evidence-based practice (EBP) movement emerged largely in response to the theory–practice gap in order to minimize variation and improve healthcare quality (Forrest & Miller, 2001, 2004; Melnyk & Fineout-Overholt, 2005). The contemporary understanding of EBP can be defined as “the integration of best research evidence with clinical expertise and patient values” (Forrest & Miller, 2001; Lavigne & Forrest, 2004; Melnyk & Fineout-Overholt, 2005; Sinclair, 2004). While this definition encompasses practitioner expertise and the patient preferences, some have criticized EBP for potentially being used by external groups to limit decision-making autonomy of practitioners (Pepler et al., 2005; Sinclair, 2004).
While many barriers to implementing an EBP approach, and ultimately quality healthcare delivery, have been suggested in the literature, enhancers to implementing research into clinical settings have also been identified (McLaughlin & Kaluzny, 2006; Melnyk & Fineout-Overholt, 2005). This qualitative study explored the integration of EBP by front-line clinicians in three distinct health disciplines.
This qualitative study used a grounded theory approach as described by Patton (2002) and Strauss and Corbin (1998). The constructs, barriers and enhancers to EBP, served as sensitizing concepts for this study providing direction and focus for the analysis (Patton, 2002). Despite entering the research with some preliminary ideas from the literature about the sensitizing concepts, the researchers immersed themselves in the data and inductively allowed meaning to emerge (Patton, 2002). In addition, a grounded theory approach provides the researchers with a systematic way to deal with large amounts of raw data through coding and thematic analysis (Patton, 2002).
Human ethics approval by the Psychology/Sociology Research Ethics Board, University of Manitoba, which operates according to the Tri-Council Policy Statement, was obtained before proceeding with the study in November 2005. Participant confidentiality and anonymity were ensured using appropriate security measures for handling data. Study subjects agreed to participate in audio taped face-to-face interviews supplemented by field notes in a location agreeable to the participants.
The investigators selected colleagues with a variety of practice locales and case mix to obtain a purposeful, convenience sample of 10 healthcare professionals (n=3 dental hygienists, n=4 nurses, n=3 psychiatrists). Because of the exploratory nature of the study, the three co-investigators aimed to interview three to four individuals from their own health profession with no attempt at saturation (Patton, 2002). All participants provided written consent to participate in the study after discussion of the project and its objectives.
A semistructured interview method was used (Patton, 2002) and employed a general interview guide developed by the researchers. The interview guide directed questioning about the participants' general understanding of EBP and, in order to generate rich discussion about implementing EBP, a discipline-specific practice scenario was presented (see Box 1) based on a currently contentious practice issue where considerable variation in care may exist.
Table Box 1.. Discipline Specific Scenarios for Interviewing
|Dental hygiene||• Evidence-based practice regarding selection of clients and tooth surfaces requiring mechanical polishing|
|Nursing||• Evidence-based practice related to the assessment and selection of best route of analgesia administration for end-of-life pain control|
|Psychiatry||•Evidence-based practice regarding treatment of depression in children and adolescents|
A systematic, three-staged analysis was used for the study. Subsequent to individually conducting and transcribing interviews, each investigator independently organized data into substantive codes, which fell into the predetermined sensitizing concepts of enhancers and barriers to EBP (Ayres, Kavanaugh, & Knafl, 2003; Maxwell, 2005; Patton, 2002).
Together the investigators identified emergent themes from the coded data (Ayres et al., 2003; Patton, 2002). Finally, a comparison of the experiences with EBP across the three professions was conducted using Ayres and colleagues' comparative approach as a model (see Table 1 for a description), which depicted themes occurring at several levels of analysis (Ayres et al., 2003). Throughout the analysis, coding, emerging clusters, and themes were compared and discussed to reach consensus among the researchers. Because of the exploratory nature of the study and lack of saturation of data, the findings are considered to be preliminary.
Table 1. Organizational Categories of Themes Analysis
|Within cases||Reported by an individual participant||One dental hygienist|
|Across cases||Reported among more than one individual participant within the same discipline||Two of three dental hygienists|
|Across disciplines||Reported among participants in more than one discipline||One dental hygienist and one nurse|
|Across cases—across disciplines||Reported among more than one participant and more than one discipline||Two dental hygienists, three nurses, and two psychiatrists|
Interviews ranged from 30 to 75 minutes in length generating over 100 pages of transcribed data. Participants were predominantly female (n=7) and ranged in age from the mid-20s to mid-50s. The participants had a minimum of four years of university education, with the exception of one dental hygiene graduate who had 3 years. Length of practice ranged from 1 to 29 years with the majority demonstrating a wide range of practice experience. The understanding of the concept of EBP had little variation across cases and disciplines. All but one participant had some understanding of the concept. Of the participants familiar with the term EBP, all identified the element of research evidence in their understanding. However, only one nurse included the components of clinical expertise and patient values when describing the term.
Under the predetermined sensitizing concepts, the investigators identified over 50 substantive codes. Clustering these codes, seven major themes emerged (see Table 2), which were then organized under two major categories: (1) individual knowledge and attitudes; and (2) structural characteristics of the workplace. Discipline-specific quotations are noted as psychiatrists (P), nurses (N), and dental hygienists (DH).
Table 2. Major Themes and Related Impact on Disciplines
|Individual characteristics||All disciplines||All disciplines||Willingness to change; high external locus of control|
|Views of evidence||All disciplines (particularly P)||All disciplines||Quality and credibility of available evidence; mistrust of evidence|
|Commitment levels||All disciplines (weak endorsed)||All disciplines (strongly endorsed)||Practice hours; additional training; conviction to practice|
|Hierarchical practice structure||N, DH||All disciplines||Lack of autonomy; lack of authority|
|Practice philosophy||All disciplines (strongly endorsed, especially DH and N)||All disciplines (weakly endorsed)||Underutilization of nonreimbursable services; comfort of providers; tradition|
|Resources||All disciplines (strongly endorsed)||All disciplines (weakly endorsed; more with P,N)||Practitioner workload; lack of equipment; practice location|
|Practice characteristics||All disciplines (weakly endorsed)||All disciplines (strongly endorsed)||Colleague attitudes to evidence; leadership example; link to teaching institution|
Individual Knowledge and Attitudes
Individual factors appeared to be largely attitudinal while demographics played a smaller role in shaping the implementation of EBP. Three major themes were revealed across disciplines contributing both as enhancers and barriers to EBP: individual characteristics, views about evidence, and commitment level.
Individual characteristics such as age, experience, and attitudes to practice were identified as both potential enhancers and barriers to implementing EBP. For example, an individual's willingness to change was reported across disciplines. One nurse articulated the challenges that change presents:
… it took a while for people to get comfortable … there was a lot of talking with other staff members. “I don't know if I want to do it, etc.”… (N3)
Further, one's knowledge, experience, and attitude were reported across cases/across disciplines with experience and attitude being reported unanimously across all cases and disciplines. Individuals who were open to change and interested in continuing education had an orientation that enhances the implementation of EBP while opposing attitudes were perceived as barriers. A nurse and a dental hygienist shared:
There is a wide range in nurses' ability to read articles, to interpret results.
some of us go to more continuing education … and will bring that back and discuss it with everybody else.
Views and attitudes about evidence
Issues surrounding evidence were diverse and included factors surrounding its quality, credibility and availability. These issues were perceived as both enhancers and barriers to EBP. The psychiatrists were most articulate about the perceived limitations to the evidence and this was viewed as a significant barrier to their implementation of EBP. Across cases, psychiatrists reported the challenge in reading and applying the overwhelming amount of literature made available.
All psychiatrists had some level of mistrust of research publications and the “evidence.” This mistrust was centered on funding of studies by pharmaceutical companies and negative research findings not being published (publication bias). The published material therefore could be misleading. This view was consistent across cases within this discipline, as exemplified by this quote:
I actually have some very serious concerns … that [medical] evidence may be really flawed at the moment because we don't have access to all the information … some of the studies that were published were misleading, in that they did not disclose all of the information …
Only the psychiatrists made mention of the perception that EBP diminished the “art” of care, that there was a lack of evidence for many therapies and that too much weight was placed on randomized controlled trials (RCTs) to the neglect of other forms of research and evidence. One psychiatrist shared his views:
… if you restrict this to RCTs then clearly evidence-based medicine would be a limited field … you're going to have to … accept that there's going to be a variety of forms of evidence in order to truly apply it in a comprehensive clinical way to all clinicians everywhere.
Across disciplines, nurses and psychiatrists both mentioned a lack of quality evidence, and all three disciplines noted a difficulty in applying evidence to practice.
Conversely, the availability of evidence, particularly with the advent of online resources, was reported as an enhancer for all psychiatrists and also across disciplines with some of the nurses noting enhanced accessibility.
Despite the limitations reported previously, the overall quality and presentation of the evidence was also described across cases of the psychiatrists as an enhancer for practicing according to evidence. For example, the use of review articles, conference presentations, and grand rounds reportedly enhanced EBP.
Study participants' commitment level to work was another important theme that emerged from the data. The most common enhancer was an individual's commitment to continuing education activity, which was reported across all three disciplines. A nurse describes an example:
We had many older nurses who would come in to journal club even on their days off as they were very committed. They would come in on their own time.
The remaining commitment enhancers were isolated within cases. For example, one dental hygienist felt that full-time work increased one's commitment and enhanced EBP. An individual nurse reported that young nurses were more committed to EBP and the changes that are required.
Conversely, a lack of commitment to work was viewed as a barrier, but examples of this were isolated within cases. For example, one dental hygienist reported that part-time practitioners had lower commitment levels to their careers and to EBP. One nurse felt that younger practitioners with young families were too busy and less committed to EBP. Interestingly, while some participants extolled committing after-work hours to research and continuing education, two nurses and one psychiatrist felt that this poses a barrier to EBP and that “down time” is needed to reduce stress and prevent burn out.
Structural Characteristics of the Workplace
While individual characteristics and attitudes were identified as important enhancers and barriers to EBP, often these characteristics reflected adaptation to one's workplace culture. Four themes emerged falling within the Structural Characteristics category that appeared to have a significant impact on EBP: practice hierarchy, philosophy and characteristics, and resources. These themes operated as both enhancers and barriers to EBP.
Hierarchical practice structure
The practice hierarchy had a differential impact on practitioners based on their location within the hierarchy. While some of the dental hygienists and nurses raised this as a barrier to EBP, the psychiatrists did not. For the dental hygienists, their autonomy was not only reportedly diminished by an employing dentist, but also by nonclinical support staff. For nurses, physicians were viewed as having authority over nurse behaviors. A dental hygienist and a nurse state:
I'm told by the office manager at times how I'm supposed to do things. And we've had instances where I've told her she's not clinical, so she has no right to tell me how to treat my patients … even the assistants have told me what to do sometimes …” DH I “I think the problem is what our doctors order, we have to do what they order … because we're not getting that from them then we're not free ourselves to go and do it.
Practice philosophy was often perceived as a barrier to EBP but only by nurses and dental hygienists. Once again, location in the hierarchy and autonomy in practice influenced practitioners' perceptions. Dental hygienists experienced great challenges in this area. For example, they felt nonreimbursable preventive services and therapies were underutilized, and there was a reliance on tradition.
Dental hygienists also reported that there was an overwhelming preoccupation with production-oriented care as opposed to client-centered care, which minimized utilization of evidence. One dental hygienist shared:
It's just automatic that you use the full [billing of a procedure] … because it's something more that [the employer/dentist] can bill … that's pretty much the number one barrier … you don't even need it, but you just do it anyways because it's a charge that goes through for the patient to get money for the dentist.
Nurses and dental hygienists both reported that practice philosophy was influenced by the comfort level of providers with certain procedures rather than on evidence. Conformity was valued as a practice regardless of whether the behaviors were evidence based or not. This is reflected in the following statement:
I think there is an idea … it's just easier to keep doing something the way that we do it. It's more work to change.
In fact, all three professions reported practice philosophies that valued tradition and maintaining the status quo. This was particularly consistent with dental hygienists and nurses who described a reluctance in others to changes in practice.
Practice philosophy was also viewed as an enhancer to EBP in some circumstances. For example, some dental hygienists and nurses reported that their workplace held overall goals of client-centered care and this was influential in supporting EBP.
Also, all nurses, some dental hygienists and one psychiatrist mentioned that when staff goals were philosophically congruent with EBP, it was further supported. A psychiatrist explained:
I am blessed with the luxury of working in a teaching hospital where I and my colleagues share information from conferences and from journals ….
A lack of resources was commonly identified as a barrier to implementing EBP. Understaffing and heavy workloads impede innovation and change. This was found with all of the nurses and across disciplines with some of the psychiatrists and a dental hygienist. One nurse described this situation:
… staff is so overworked right now. They are so stressed out with the heavy level of care that they are just at the level where they are burned out … many of these things [learning towards EBP] are expected to be done on work-time, but in this day and age, they are already overloaded with their work.
Other resource barriers, found across disciplines, included a lack of equipment or financial support. In addition, a dental hygienist and a nurse, respectively, reported that remote practice locations and a lack of support for change were barriers.
While staffing and workload constituted a major barrier, access to computers enhanced the implementation of EBP. Access to specialty services and clinical nurse specialists were also viewed as enhancers of EBP. While it was noted that nurse educators were increasingly being used to do more general nursing duties as opposed to research, education, and implementing change, they were still perceived as facilitating EBP and change.
There was considerable agreement over what practice characteristics enhanced the participants' ability to provide EBP. All but one participant indicated that favorable collegial attitudes to EBP represented one of the greatest enhancers. Included in this were leadership, common goals among staff, and a perception of “strength in numbers” for supporting EBP. A nurse reported:
… other staff members saw that it was effective, by actually using it and trialing it … That helped the modelling.
Practice linked in some way to a teaching institution was associated with EBP, and this was found across all disciplines. Both working in a respectful workplace and having open communication enhanced the application of EBP across cases and across disciplines. All of the nurses and most of the dental hygienists felt that good staff morale supported EBP, and these factors improved the sense of teamwork within the practice and contributed to EBP.
Practice characteristics that acted as barriers to EBP were fewer and less universally recognized by participants. Interestingly, none of the barriers reported were found across all three disciplines and psychiatrists did not note any. Dental hygienists and nurses indicated that lack of leadership represented a barrier. Belonging to a staff of a small size, a lack of respect, staffing issues, poor staff attitudes, and morale were each reported in nursing and dental hygiene as barriers to EBP.
Discussion and Concluding Remarks
The unique aspect of this study is the comparison of participant's experiences with EBP across three distinct health professions. This study reveals many individual characteristics and attitudes and the important role of workplace culture that act as enhancers and barriers to EBP and, while saturation was not attempted, the findings are consistent with those of others (Melnyk & Fineout-Overholt, 2005; Pepler et al., 2005). These findings call attention to the complex interplay between individual characteristics and structural features suggesting that further research, and ultimately healthcare quality, would benefit from exploring the impact of this dynamic on the introduction of EBP initiatives.
Within the first major category, individual characteristics and attitudes, the substantial difference that emerged between professions was attitude to evidence. All the psychiatrists had some level of mistrust of research publications and the “evidence.” However, participants in the other two professions did not voice these concerns.
Other differences between professions emerged within the second major category when respondents reflected on the impact of structural characteristics of the workplace. Two primary distinguishing structural factors were revealed: (1) Practitioner's position in the workplace hierarchy; (2) the profession's location in the public or private sector. The higher the practitioners' position in the workplace hierarchy, the fewer impediments they encountered in implementing EBP. Thus, nurses and dental hygienists had to negotiate with practice superiors to introduce evidence-based changes while psychiatrists did not encounter this barrier. In the case of dental hygienists, the only profession practicing primarily in the private sector, it was a case of double jeopardy; they were lower in the practice hierarchy and sometimes encountered a profit motive impediment to EBP.
Regarding similarities between professions, individual characteristics such as positive attitudes and a commitment to continuing one's education emerged as common enhancers to EBP. Of the structural characteristics, three factors had a similar impact on practitioners in all professions. These factors were location in a teaching environment, resources, and supportive colleagues and practice conditions. All practitioners who were associated with a teaching hospital indicated that this affiliation substantially enhanced EBP. Similarly, practitioners in all three professions identified resources as a critical factor in their ability to introduce EBP changes. Finally, all practitioners cited supportive colleagues and common goals as enhancers for EBP. Practice philosophies that valued tradition and maintaining the status quo were barriers to EBP for all professions.
In identifying both individual and structural factors that influence practitioner's ability to introduce EBP, this exploratory study has revealed the complex interaction between personal attitudes to change and work place culture. These findings suggest that the creation of a positive EBP work culture may have a significant impact on individual attitude and capacity to change.
Recognizing that the implementation of EBP typically requires changes to practice, one idea that threaded through many of the major themes was the identification that change requires hard work. Regardless of the potential improvements to quality healthcare delivery, continuing with existing practice and conforming to expectations is less demanding for healthcare workers who already have arduous work days. Considering the volume and intensity of barriers working against implementing EBP in many cases, it is not surprising that EBP has not been more fully embraced. The enhancers to implementing EBP that were identified by the study participants will need to be particularly compelling to influence changes in practice. Perhaps the best place to begin this ambitious task is reflecting on how to create a multidiscipline work culture open to and supportive of evidence-based change.
While the main limitation of this study is the small sample size, as an exploratory study our findings are instructive for future research. This study demonstrates that multiprofession research can provide insight into diversity in barriers and enhancers experienced by each professional group. Accompanying the inherent differences in these disciplines are also the associated educational backgrounds, practice structures and cultures, socialization processes and gender mixes. Given the interdisciplinary nature of today's healthcare settings, understanding the differences, similarities, and interface between disciplines will reveal critical elements and processes to promote EBP and improve healthcare delivery and outcomes.
Joanna Asadoorian, AAS (DH), BScD (DH), MSc, is an Associate Professor in the School of Dental Hygiene, Faculty of Dentistry, University of Manitoba, Winnipeg, MB, Canada. Joanna teaches theory and pathology to dental hygiene students. Joanna's research interests focus on self-assessment, reflection, and clinical decision making in the broader context of continued competence and quality assurance of healthcare providers. She publishes and presents her research locally, nationally, and internationally.
Brenda Hearson, RN, MN, CHPCN(C), Clinical Nurse Specialist, Winnipeg Regional Health Authority Palliative Care Program, and Canadian Virtual Hospice, Winnipeg, MB, Canada. Brenda works as a clinical nurse specialist in palliative care. Currently her practice includes working with the Winnipeg Regional Health Authority Palliative Care Program as well as working online with the Canadian Virtual Hospice, a national bilingual Website dedicated to providing information and support related to end-of-life and bereavement care. Prime interests focus on the well-being of family caregivers and patient, family and professional education in palliative care.
Satyendra Satyanarayana, BSc, MSc, MD, FRCPC, Staff Psychiatrist, Centre for Addiction and Mental Health, Assistant Professor of Psychiatry, University of Toronto, Toronto, ON, Canada. Satyendra is currently a staff psychiatrist in the Mood and Anxiety Program at the Centre for Addiction and Mental Health. His research interests include public health aspects of mental health.
Jane Ursel, PhD, Associate Professor, Department of Sociology, Faculty of Arts, University of Manitoba, Winnipeg, MB, Canada. Jane is also the director of a tri-provincial research institute on interpersonal violence, RESOLVE. Jane is currently principal investigator of two longitudinal studies: an 18-year study of the Winnipeg Family Violence Court and a 5-year study of 600 women in the prairies who have been abused by their intimate partner.