In the 1980s Canada's McMaster Medical School coined the term "evidence-based medicine" to describe the use of high-quality research in clinical decision making. In the 1990s the term became widely used and evolved into the broader term, "evidence-based practice." The Agency for Healthcare Research and Quality, for instance, established 13 hospitals that serve as "evidence-based practice centers" dedicated to reviewing the scientific literature on clinical and organizational topics-such as total knee replacement or bioterrorism preparedness-and producing "evidence reports," with the goal of improving the quality of care. In the past decade, nurses have begun embracing the notion of basing nursing practice on the best available and most recent evidence. Although nursing literature, schools of nursing, "evidence-based practice centers," and Magnet hospitals promote this concept, the new paradigm has yet to become a reality for nurses in all areas of practice. There are several reasons for this.
Nurses' reluctance or inability to ask questions may result from the nursing-education system itself, in which seeking the evidence to support a nursing intervention is considered "research" and is confined to the final year of training. Nurses taking their first courses could be challenged to look at recent research on falls among the elderly, medication errors, and the accuracy of tympanic thermometry-research that, in each of these areas, should be changing nursing and institutional practice. Students in my informatics classes, who have investigated practicing nurses' information-seeking behavior, asked staff nurses where they found answers to their practice questions. Repeatedly, they were told either, "I don't have any questions," or "I ask the doctor." Neither response is worthy of the professional nurse.
Time is scarce and has become, if possible, even more so as a result of severe staffing shortages and mandatory overtime. Nursing worth is measured in tasks completed rather than critical thinking done. Given nurses' current workloads, nurses have little or no time to look for research that helps them make sound clinical decisions or provide cost-effective care.
Role models are difficult to find for the first wave of nurses trained under the new paradigm of evidence-based practice. When my own students have asked about the evidence to support a certain protocol, their supervisors have replied, "You're only asking that because you are a master's student." Such responses will only change when current students are in practice and modelling new behavior to students and new nurses.
Lack of access to information is perhaps the most difficult barrier to overcome. Internet access and current literature databases must be available. Personal digital assistants can provide quick reference but aren't yet practical for most nurses, although they may become more useful in the future. While an on-site library is helpful, it's not the entire solution. Information must be available and easy to access at the point of care. This will only be possible when nurses demand it and incorporate it into their practice. Research has shown that using best practices is cost effective and reduces both complications and lengths of stay. When nurses demand tools that support their own best practice, the tools will be provided.
Although evidence-based practice is a worthy goal, it's far from being realized in many practice settings. Health care organizations, in seeking to provide high-quality and costconscious care, must provide access to, time for, and reward of evidence seeking. At the same time, nurses must become confident enough in their role to question whether common practice is best practice. These questions are best answered not by outdated textbooks or colleagues, but by sound research.
Before the nursing community realizes evidence-based practice, nurses themselves must understand the need for it. But if nurses nurture neither their natural curiosity nor their desire for self-improvement, change will never come. Nurses must demand access to literature at the site of patient contact. It's up to all of us.
When nurses demand the tools they need, tools will be provided.