Nursing practice isn't static. How many nurses can remember procedures learned in school that are obsolete today due to the generation of new knowledge? Many nurse leaders support the Institute of Medicine goal to have 90% of practice decisions based on evidence by 2020 to improve quality care.1-4 To achieve this goal, clinical nurses need to understand the evidence-based practice (EBP) process. Nurses must identify, access, and assess published research, practice improvement initiatives, and evidence-based reviews.2,4,5
There are numerous models designed to foster the synthesis of EBP, with the goal of identifying strong support for practice or recommending further exploration.2,5,6 It's no wonder that clinical nurses not familiar with the EBP process may find it daunting. As a Magnet(R) facility, our leadership fosters a culture of inquiry that's reinforced by a shared governance structure. Despite systemwide educational efforts, an assessment of nursing needs at our institution continues to identify EBP as a topic of interest. Strategies to address this unmet need and embed EBP in daily clinical nursing activities and special projects are multifaceted, including education, peer involvement, leveraging expertise, and ongoing evaluation.
Education
EBP isn't taught in a linear fashion at our facility. We approach education with a variety of methods to engage highly specialized nurses on different shifts who have unique levels of expertise. Education takes place in the clinical work setting, as well as in a more formal classroom setting.1,4,7
Timing, educational level, relevant topics, and supplemental resources are considerations that may impact the successful uptake of EBP by clinical nurses. The perceived importance of the topic is the first step in gaining and keeping nurses' interest. For example, discharge planning may resonate with nurses because it reflects an area of focus for the family and patient. Furthermore, best practices at the point of discharge support fiscal responsibility by avoiding preventable readmissions through planning and anticipated need for support.
Although important, even the most interesting and relevant topic won't garner the interest of nurses if education is offered when the workload doesn't permit attendance or when anxiety about meeting daily tasks haunts attendees during an educational session. Offering a variety of class options supports nurses when they can both attend and be focused on the content.
To help set the stage for professional practice and address an academic need, our nurse educators engage selected nursing faculty and senior baccalaureate nursing students in the EBP process.8 Education about the EBP project is jointly taught by the university professor and research nurse in a formal classroom setting. To provide exposure to assessing EBP, students identify a nursing procedure that's of interest to them. The student conducts a literature review and evaluation. The findings are synthesized and compared with the institution's procedure. A recommendation is made; in some cases, this is taken to the appropriate councils for further consideration. Formal poster or podium presentations of EBP projects and practice changes are shared at a conference held by the university, with hospital staff in attendance.
Members of our nursing education and research departments have embarked on an EBP scholar program to both teach and mentor EBP projects.2,4,5 A small cohort is selected from clinical nurses, with each nurse participating in education sessions and then teaching others on his or her unit. The EBP project is completed on the scholar's unit by a group of clinical nurses from the unit. The scholar leads the project and engages colleagues throughout the process. Scholars are expected to attend a full-day EBP education session and a strong foundation is planned to provide support for building skills and expertise related to EBP.
Peer involvement
Teamwork provides an opportunity to ignite nurses' passion for the EBP process and outcomes. EBP drives best nursing practices through evidence and strengthens autonomy when clinical nurses play a role in making practice decisions.
We use issue forms to identify care quality challenges, near misses, and opportunities for improvement. These forms are generated by clinical nurses and reviewed at the appropriate council. For issues requiring updated evidence, a referral to the nursing research council (NRC) is made. Our NRC meets monthly, with membership made up of clinical nurses from diverse units within the medical center. An EBP subcommittee of the NRC, under the direction of a nurse educator and PhD student, addresses issue forms and questions about current practice. The subcommittee also conducts EBP reviews.
Findings and recommendations are reported to the NRC, quality improvement council, and/or practice council as appropriate. Ultimately, outcomes are reported to the executive council to confirm current practice or recommend a change in practice based on evidence and the practice council's approval. In the absence of strong consistent findings, a research project is recommended to generate new knowledge.5
Whenever possible, issue forms that require EBP are addressed as a team. Based on high attendance, group work seems to engage nurses as they learn a new process along with their peers. Specific EBP activities related to the meetings are presented in Table 1.
Another example of peer involvement at our facility is journal clubs, which serve as a method to share and discuss published new findings. Facilitating a journal club fulfills a requirement for our clinical ladder. To tie EBP to the journal club, criteria include a discussion of the journal's level of evidence.5 If continuing education is awarded for the activity, our professional practice model (PPM) is reviewed at the onset of the session. The educator pays particular attention to the PPM and links the activity to advancing nursing excellence. This allows the clinical nurses attending journal clubs to be exposed to the importance of EBP as it relates to both practice and our institution's PPM.
Leveraging expertise
Both internal and external experts provide support for EBP while offering motivation and building confidence for our clinical nurses. For example, a full-day education program with guest speakers from Johns Hopkins was held for clinical nurses and interested professional staff throughout the system. Skills to critique evidence were taught at breakout sessions to immediately apply knowledge and internal experts were available to guide nurses through the process. And at our annual nursing research conference, motivational experts share EBP experiences with attendees.
Our practice council comprises both clinical and advanced practice nurses from various specialties. Members of the NRC sit on the practice council and review proposed practices for relevant and recent peer-reviewed references at a minimum every 3 years. Approvals of policies with minor changes are included in the process. This careful review prompts clinical nurse engagement and avoids the grandfathering of unchanged policies with outdated EBP support. Importantly, our expert librarians provide insight to target library searches and offer a critical starting point for the assessment of evidence.
Evaluation of EBP culture
Just as EBP isn't static, concerted efforts to engage nurses in EBP aren't either. Changes in education and outreach are frequently prompted by clinical nurses. After each program is conducted, attendees are asked to provide an evaluation, which includes an opportunity to write in comments. Evaluations are reviewed jointly by the nurse educators and researchers.
The EBP activities reviewed here were fashioned to address the needs expressed by nurses on our annual needs assessment survey. Group EBP projects with topics that resonate with clinical nurses have been successful at our institution based on the number of participants and completed projects, as well as participants' interest in staying engaged in a workgroup focused on final translation of the recommendations. Moving forward, we plan to monitor the needs assessment survey to see if specific approaches are impacting the confidence of clinical nurses related to EBP. We're open to the possibility that modification of current programs may be warranted or repeat sessions may better serve our nurses. We value their feedback and are committed to exploring all suggestions.
Be the spark
The triplet of clinical issues, emerging innovations, and constant generation of evidence-based publications necessitates the evolution of nursing practice. The standard for use of current EBP nursing practice has been set, along with the challenge to engage all nurses providing care. The suggestions put forth begin with engaging students in EBP in preparation for professional expectations. Various methods for educating and engaging clinical staff members provide a diverse approach, which includes cascading information throughout the institution. Group projects and the development of EBP scholars offer the opportunity for professional growth and leadership development by leveraging internal and external EBP experts. An evaluation of success should be incorporated whenever possible. Such measurement may deliver evidence to support educational practice changes or spark innovative methods to engage clinical nurses in EBP.
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