Despite the Institute of Medicine's call for improving patient safety in the publication To Err is Human, and its 2001 recommendation for all professionals to deliver patient-centered care emphasizing evidence-based practice (EBP), struggles to implement and sustain EBP continue to exist.1 Daily challenges plague managers regarding urgent operational issues and increasing budgetary and resource constraints. However, managers remain in the ideal position to create and support an environment that provides evidence-based care.
Nurse managers play a major role in establishing a unit-based culture in which nursing practice is guided by evidence. To do this, we must establish expectations supported by departmental policy that encourage clinical nurses to actively incorporate evidence into daily decision making. This can produce challenges for the often overburdened manager who must overcome the frequently sited barriers to EBP implementation: lack of time, inadequate knowledge and skills, lack of EBP mentors, and resistance to change.2
Utilizing a participative leadership style in which decisions are made with the most feasible amount of participation from those who are affected by the decisions, in addition to support at the organizational level (top down) and the unit level (bottom up), the nurse manager can have significant influence in overcoming these barriers and role model opportunities for seamless incorporation of new practice behaviors.3 The nurse managers at the National Institutes of Health (NIH) Clinical Center have formalized the role of the manager in designing a unit culture to facilitate EBP for clinical staff.
Help from the top
Organizational support for the adoption of EBP is a prerequisite for implementation throughout the organization. It's becoming more evident through the research that the leadership behaviors of nurse managers and administrators play an important role in successfully transferring research evidence into clinical nursing.4 Because responsibility for the practice environment rests with the nurse manager, we must first demonstrate an understanding and appreciation of EBP to foster an environment that promotes its implementation and adoption.
One study found that clinical nurses observed the most significant managerial support to take place when the manager was aligned with the organization and exhibited behaviors of stimulating and guiding staff in research and EBP activities.5 Looking first to the organization for support, the NIH Clinical Center incorporated EBP expectations into the annual nursing performance evaluation, noting accomplishments of staff members choosing to take on more responsibility as they teamed up with clinical nurse specialists (CNSs) or nurse managers to improve practice. The inclusion of an EBP element on the clinical nurses' annual performance plan highlights the importance of EBP in their practice and holds the clinicians accountable for this practice.
Another significant contribution from the organizational level was a five-level competency developed by the EBP steering committee. This competency was tiered based on the novice-to-expert framework and was required for all nurses within the department to complete at least to level III. The CNSs and nurse managers were required to complete the competency at the more advanced levels IV and V, with the expectation that they would guide the projects and take on a champion role. The competency provided the framework for working through the steps of EBP and provided a resource for staff to refer back to for reference. The development and validation of the competency helped foster the adoption of EBP and has provided a way for all new staff to experience a standardized process for learning the EBP steps.
Learning as part of the culture
An organization's ability to devote the required educational resources in this fiscally challenging environment is yet another impediment to the adoption of EBP. Some institutions have offered workshops specifically aimed at the nurse manager that allow them to learn among their peers and focus on managerial issues that potentially apply on other units. We contracted an expert from a local university who provided monthly classes on appraising the literature, synthesizing findings from the literature, and other pertinent topics to strengthen staff members' EBP skills. These in-services supported a group process of appraising literature findings and allowed for rich discussion of key points within the research articles. The skill of literature appraisal is still noted to be one of the areas of competence with which most staff members require assistance.
Once again, it's the manager's challenge to ensure that staff members have the opportunity to gain exposure to the education available. To help facilitate this, some in-services were brought to the unit specifically by the library informationist who helped staff learn how to find and search the databases. Additional classes for locating and searching the databases were held in the library, with continuing-education credits offered for added incentive to attend.
So much to do, so little time
Providing adequate staffing to enable the nurses to engage in an EBP culture and have sufficient time to access the research continues to be an ongoing challenge for managers. However, this becomes increasingly important with expanding workloads pulling managers farther away from the bedside. One strategy that our managers have used to address this is to encourage the participation of staff in the shared governance committees, specifically the clinical practice committee that leads the process of adopting EBP and provides opportunities for clinical nurses to gain experience incorporating synthesized evidence into standards of practice.
This experience of serving on a shared governance committee allows for enhancement of EBP skills and knowledge, which are then applied on the unit level. One study noted that some of the most supportive actions that a nurse manager can offer include a greater presence in the clinical areas, more explicit communication about EBP, and more specific delegation of EBP responsibilities.6 These actions allow the manager to observe firsthand some of the clinical issues that need to be addressed and an opportunity to support EBP projects to improve outcomes.
For example, in the pediatric clinic, the nurse manager was notified by staff that the patients were experiencing undue pain and anxiety with I.V. needle sticks. The nurses brought forward the idea of implementing a new practice and looked at measures to utilize for pain and anxiety reduction with the hopes of improving the patient experience. Because pain and anxiety management in the pediatric clinic is a priority, the manager was able to support the project as a clinical issue that warranted time and attention.
Leaders as coaches and mentors
As we shift our focus to evidence and quality care, we realize that the old styles of leadership are no longer the best approach. To achieve the best outcomes through quality care, we must utilize all available talent to inspire, involve, empower, coach, and lay the foundational expectation that everyone is to participate. Coaching supports and facilitates staff to embrace opportunities as they arise, helps shift the culture toward looking for continuous ways to improve, fosters practice autonomy, and contributes to an environment in which practice is based on research and evidence. Autonomy and control over nursing practice have been associated with increased nurse satisfaction and improved patient outcomes, which is ultimately the goal of EBP.7
Characteristics of this leadership style should mirror and support nurse managers, as well as institutional philosophies regarding the importance and need for EBP. In addition to the cultivation of the "spirit of inquiry," unit managers can provide scheduled workdays or designated project time for staff to participate in educational courses or one-on-one mentoring with managers or advanced practice nurses. (See Figure 1.)
Everyday EBP
With all of these considerations in addition to daily responsibilities, the best option is to work opportunities for EBP into daily practice. After all of the staff members are thinking along the same path of providing the best care, you'll then play an active and supportive role through participative daily practice.
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