Promoting excellence – Evidence-based Practice at the Bedside and Beyond
This issue focuses on the theme ‘Promoting Excellence – Evidence-based Practice at the Bedside and Beyond’. Evidence-based practice (EBP) is an approach to clinical decision making in health care that has been emphasized since the 1980s (Melnyck & Fineout-Overholt 2005). By definition, EBP is a conscientious use of current best evidence from well-designed studies which also incorporates clinician's expertise, internal evidence from patient assessments and external evidence regarding practice/context, and patient's preferences and values (Sackett et al. 2000). The scientific community and health care providers believe strongly today that implementation of EBP leads to higher quality of care, decreased variation in desired outcomes, increased safety, improved patient outcomes and decreased health care costs. Although the literature demonstrates that EBP reduces adverse outcomes such as morbidity, mortality, and medical errors, there are persistent barriers to implementation by nurses and other clinicians in health care systems (e.g. Pravikoff et al. 2005, McGinty & Anderson Anderson 2008). The international literature describes the barriers to implementation of EBP in health care institutions, such as lack of EBP knowledge and skills, a perception that EBP is time-consuming and burdensome, and non-supportive organizational culture. (e.g. Sitzia 2001, Chang et al. 2010, Majid et al. 2011)
In 2005, Pravikoff and colleagues surveyed RNs in the US regarding their preparedness for EBP. Their findings showed that the nurses were not ready to embrace or implement EBP. The most common individual barrier was lack of value for EBP and the greatest organizational barrier was lack of time for it. In 2012, 2012 and colleagues found that nurse executives strongly valued EBP but were not themselves engaged in it. The authors conclude that: ‘…if nurse executives/leaders are not engaged in EBP, serving as role models, and facilitating evidence-based care, it follows that their staff will not engage in evidence-based care, as the behaviors of nurse executives and managers influence staff behavior…’ (pg 415). In this study Magnet compared to non-Magnet institutions reported higher levels of consistent implementation of EBP, greater availability of EBP experts and more supportive organizational cultures. Melnyk and colleagues' (2012) recent study demonstrates that today nurses are ready for EBP and they do value it. However, many of the same barriers cited by nurses almost a decade ago are still in place, including lack of time and knowledge, resistance from colleagues including physicians and fellow nurses, and lack of organizational support from nurse leaders and managers. Resistance to EBP from colleagues and peers is a recurrent theme, but resistance from nurse leaders and managers is a newly identified and critical barrier, especially since their support is crucial for staff at the bedside to implement EBP. In the United States, the Institute of Medicine's goal is that 90% of the clinical decisions are evidence based by the year 2020 (Institute of Medicine 2012). It is thus highly important that nurse leaders, managers, educators and researchers increase their efforts to emphasize and invest in EBP cultures and strategies so that this goal will be achieved.
The following nineteen articles reflect an international perspective on EBP at the bedside and beyond. The authors cover many topics that provide new knowledge for a reader in decision making, risk assessment, documentation, and strategies for designing and managing care delivery throughout the continuum of care and, ultimately, promote EBP and excellence in nursing.
Knowledge, attitudes, and challenges of decision making
The first two articles from the US are reports of the attitudes of nurses and nurse managers regarding EBP and the way that managers arrive at decisions. Linton and Prasun (pp. 5–16) surveyed nurses about their attitudes and knowledge of EBP and their perceptions of organizational support for implementation. The nurses agreed that their practice was indeed based upon evidence but reported only average ability to retrieve or critically analyze evidence. Shirey and colleagues (pp. 17–30) employed a qualitative design with interview technique to study decision-making processes of nursing managers and the effects of stress on their decision making at work and at home. Findings include that managers used similar self-reflective questions to support the decision and that managers from hospitals which aspired to Magnet status, compared to those from hospitals which were not seeking this status, tended to ask the additional question: Why are we doing this?
Broader perspectives on EBP from systematic reviews and applications
The next four articles from Singapore, UK, Switzerland and US are reviews of literature synthesizing evidence for best practice. Chan and colleagues (pp. 31–46) conducted a systematic review of statistical evidence regarding the antecedents to nurses' performance on assessment of level of consciousness. The authors found that knowledge and experience are the two most significant factors in determining performance and that formal training is effective in enhancing performance. Watts' (pp. 47–57) literature review focuses on evidence regarding end-of-life care pathways. Themes which emerged from this analysis include the contribution of nursing to the content and implementation of the pathways as well as the influence of the pathways on nursing practice. Kaiser and Razurel (pp. 58–69) reviewed the literature published on risk of diabetes mellitus type 2 in individuals with gestational diabetes mellitus. Overall the authors found a low rate of compliance with healthy lifestyle recommendations. This lack of adherence did not appear to be correlated with a cognitive perception of being healthy. Social support and self-efficacy were associated with increased physical activity. Stikes and Barbier (pp. 70–78) report the results of their application of the Plan-Do-Study-Act model to overcome barriers to implementation of the kangaroo care intervention in a level III neonatal ICU. The authors studied the effect of a workshop introducing the intervention. A pre- and post-workshop comparison using survey methodology indicated that the workshop was effective in reducing the proportion of staff perceiving a barrier and in increasing the proportion of staff comfortable with kangaroo care under a wide range of clinical circumstances.
Evidence and patient care: risk assessment and safety
Four articles address the application of internal and external evidence to the assessment of risk, quality of care and assurance of safety. Edvardsson and colleagues (pp. 79–86) from Australia and Sweden report a psychometric evaluation of a scale designed to detect cognitive impairment in older people. The scale demonstrated high internal consistency and temporal stability; it can be used to predict risk of cognitive deterioration in vulnerable elders so that interventions can be planned and implemented. Andersson and Lindgren (pp. 87–93) studied the perceptions of quality of nursing care in acute hospital settings held by patients and personnel in Sweden. The patients evaluated quality of care as high but they found it difficult to get to know the staff because of the number and variety of staff categories. Langdon and colleagues (pp. 94–105) conducted a mixed method study combining a medical record audit with focus group methodology at each of two acute care facilities to evaluate the effectiveness of a tool embedded in an electronic medical record for comprehensive assessment of health risks in older adults in Australia. The authors found that although nurses perceived that the use of the tool was labor-intensive, it was fruitful in detecting health risks and enabled a more holistic approach to patient care. Fore and colleagues (pp. 106–111) report the results of implementation of the sterile cockpit model adapted from the aviation discipline to apply to medication administration on a medical/oncology unit at a mid-Atlantic Veterans Affairs hospital in the US. The use of this model had a significant impact on patient safety: the medication error rates decreased by 42.78% after implementation.
Evidence and patient care: documentation and dissemination
Two articles in this issue have a focus on documentation and internal dissemination of patient information. Karlsson and colleagues (pp. 112–120) studied 80 electronic medical records to explore documentation of health care professionals regarding the wellbeing of patients in the first 5 months following open heart surgery in Sweden. The authors assert that the records did not adequately reflect the depth of documentation necessary to reflect the complexity of the post-operative course and the impact on well-being. Johnson and Cowin (pp. 121–129) studied the perspectives of nurses regarding a bedside handover and use of a written handover sheet on medical-surgical nursing wards at three major metropolitan hospitals in Australia. The results were mixed; some were supportive of the change, others yearned for the old ways. Those who supported the change tended to value this method of increasing communication with the patient.
Context: organizational climate, interdisciplinary collaboration and leadership
The next five articles address the context for sustainable EBP. Alnes and colleagues (pp. 130–140) studied the effect of a Marte Meo counseling intervention on learning outcomes for staff caring for individuals with dementia on four separate units in Norway. The authors found that the learning climate was very important in determining learning outcomes and that support from managers was essential for creating such a climate. Struwe and colleagues (pp. 141–151) conducted a qualitative descriptive study with interview and focus group techniques to determine how staff and charge nurses organize their care of stroke patients in Denmark. The authors report that charge nurses tended to stress staff competency and commitment whereas staff nurses stressed ongoing continuity across the care spectrum. Kvist and colleagues (pp. 152–164) conducted baseline measurements with survey methodology to study the Magnet model components of transformational leadership and empirical quality outcomes on four Finnish hospitals. The authors found that nurses' awareness of the work of nursing leaders was low but the nurses' level of satisfaction was high, although their ratings of the patient safety culture were variable. Bender and colleagues (pp. 165–174) conducted a survey of the feasibility of the clinical nurse leader (CNL) role regarding improvement of interdisciplinary collaboration on a progressive care unit in the Southwest of US. The authors found that implementation and evolution of the CNL role decreased fragmentation of care by enhancing collaboration; they recommend broader implementation of the role. Wilson and colleagues (pp. 175–181) report their experience with implementation and evolution of the CNL role at a tertiary care hospital in the Northeastern U.S. The role has established its value in risk assessment, strategic quality improvement, interdisciplinary collaboration and implementation of evidence-based solutions and care. Strategies include initiation of interdisciplinary rounding and crossing units and services lines as needed to support patients throughout the care experience. The authors report improved clinical outcomes and substantial projected cost savings with the implementation of this role.
Continuity of care and community
The last two articles expand the perspective and also EBP beyond the bedside, addressing preferences and values regarding continuity of care for patients in the community. Gjevjon and colleagues (pp. 182–190) interviewed home health nurse managers in Norway regarding how they understood and assessed the concept of continuity of care. The authors assert that these managers tended to prioritize the assignment of carers in favor of those with greater need, providing them with greater continuity, with less continuity for those with lesser need. While caring in this way for patients, the managers also cared for their staffs, attempting to provide good working conditions and benefits in hopes of maintaining staffing. Gage and colleagues (pp. 191–201) employed a case study design and data collection by interviews and diaries kept by patients and nurses with case management responsibilities from three Primary Care Trusts in the United Kingdom. The authors found that community matrons, compared to other nurses with case management responsibilities, had smaller but more intensive caseloads and more patient contact time and that they cared for older patients who live alone and took more medications.
Taken as a wide selection of high quality research work, these articles are inspiring and important food for thought to all our readers. It is possible to envision that all the papers of this issue will enhance evidence-based care and excellence across settings and throughout the continuum of care, promote quality and safety, guide managers and others in responsible positions in the development of supportive strategies, and inform executives and other stakeholders in the management of a supportive organizational context for EBP. The Editors would like to thank all the authors who have contributed to the issue and wish that the readers enjoy the articles illuminating this important topic.