Getting nurses to use evidence-based practice takes culture change
Give them times, tools, and empowerment, say experts
If trends hold in 2012, it will be the 13th straight year that nurses top the Gallup poll on ethics and honesty (http://www.gallup.com/poll/151460/Record-Rate-Honesty-Ethics-Members-Congress-Low.aspx). They are widely viewed by the public as being trustworthy and caring about what they do. Indeed, no one would suggest that a nurse does anything on the job that would knowingly imperil patients. Yet many nurses do not use evidence-based practices (EBP) that are known to improve outcomes, lower costs, and reduce harm. A study in the September issue of the Journal of Nursing Administration1 surveyed more than a thousand nurses to find out what they thought of EBP, what they knew about EBP, and how much their institutions helped them to make use of EBP in their own practice. The findings were stark: Just over half agreed or agreed strongly that their facilities implemented EBP. Slightly more than a third of the respondents thought that their colleagues used EBP regularly. Just a third of the nurses felt they had adequate mentoring for EBP, and less than half thought that new research was the basis of new practice in their hospitals. Nearly three-fourths of the respondents thought they needed more education, and about 60% would be interested in participating in Web-based seminars about EBP.
The survey found several barriers to implementing EBP. The most common complaint was a lack of time — nurses already spend about 70% of their time on non-patient care activity, and they are often hard-pressed to do what they need to do within their shift. In descending order, the rest of the top 10 things that get in the way are a culture that is resistant to change; a lack of education on EBP; no access to information on EBP; managerial resistance; inadequate staffing/patient loads; nursing resistance; physician resistance; budgetary or payer issues; and lack of resources.
Some of the press since the survey was released has focused on nurses not implementing EBP, as if they have complete control over whether to implement or not. But for the last several years, Margaret "Marc" Irwin, RN, MN, PhD, a research associate at the Oncology Nursing Society in Pittsburgh, has been working with 35 organizations across the country as part of the ONS Foundation's Institute for Evidence Based Practice Change project, and in talking to nurses and organizations about EBP, she found that there was "an incredible lack of appreciation" for just how formidable the barriers to implementing EBP are to nurses.
She collected tons of data on what helps and what doesn't, what keeps organizations from implementing EBP and what encourages it. The lack of time is something people talked about again and again. "You might say that it will not take more time to do EBP, but if they do not have the information on it, if they haven't been coached in how to foster change, then it does take more time." Even if nurses have a few extra minutes, the concern is that they would be taking time away from patient care just to change the way they deliver patient care.
Organizations often have insidious ways of discouraging even those who want to do things differently, Irwin says, recalling one hospital where a team of nurses interested in EBP were told by librarians that they only did literature searches for physicians. "We were able to go in and fix that situation, but it is an example of how many do not take it seriously when nurses want to make a change," she says.
Nurses are also focused on a lot of other changes right now, says Irwin, such as the implementation of electronic medical records. Major initiatives like that get a lot of attention and make it much less desirable to bring about some other change in practice until things slow down or calm down — as if that ever happens.
Let's say you get the buy-in from a hospital and the nurses, then you need to find the resources to get baseline data, most often by doing chart reviews, Irwin says. And whoever is doing that work isn't caring for patients at the same time, so there may be a monetary cost associated with it to hire someone to do that job.
Joanne Disch, PhD, RN, FAAN, a clinical professor at the school of nursing at the University of Minnesota in Minneapolis, lumps barriers into three categories. First is institutional, dealing with the rules and regulations that might make it hard for even an enthusiastic nurse to get the information she needs to implement evidence-based care. "You may have some rule that says no iPhones or PDAs are allowed, so nurses can't call up information in a ready manner," Disch says. Changing that rule requires changing attitudes in committees that may have nothing to do with nurses.
Second is personal. Disch says that some nurses just plain do not want to change what they do. The survey found that older nurses were more likely than younger ones to care less about EBP. A 2005 study by DS Pravikoff2, which has been repeated, with results due to be published early in 2013, found that nurses were more comfortable asking their peers or looking on the Internet for information about clinical practices than they were using clinical databases or peer-reviewed literature. The value of research was lost on three-quarters of the nurses surveyed.
Third is something that might be termed philosophical barriers: when EBP butts up against a different world view. Think about smart people who do not believe in climate change, she says. "We believe things that make sense to our world. And if we do not like the evidence, we will not believe it." For instance, there are decades of proof that having open visitation in ICUs doesn't harm, but actually helps patients. Still, many nurses just will not allow it. Sometimes, the disbelief in known fact is more obviously harmful, she says, such as with nurses who persist in injecting saline in endotrachial tubes. They say it clears the tubes, but respiratory therapists will tell you it is bad patient care. "It is not about the facts for them," says Disch.
Cases like that are hard because it is the whole culture of the place that has to change, she says. If you have a facility that embraces change and provides the tools needed to implement it, it is much easier to get buy-in from just about everyone. And if you have some people who just refuse to believe, they will probably still change their actions, if not their beliefs, because everyone else is.
Getting buy-in from the top down and bottom up may come down to talking in the language each audience understands. For the C-suite, it might be about reducing costs; for physicians and nurses, it might be about improved outcomes; and for others it might be about the increased public reporting of data related to EBP and the pressure that brings to invest in quality and safety, says Disch.
Irwin says QI and patient safety managers can help by mentoring nurses and making it clear that they can come to the department for any assistance — whether it is as simple as finding literature, or as complex as understanding more about data collection and analysis. If they do not come to you, go out to them and tell them what you can offer, she says.
Find the nurses who are most interested in EBP and do a project or two with them, says Irwin. These nurses can then go preach the gospel to their peers. "Over time, we saw a lot of what we called igniting the spirit of inquiry," she says. Nurses participate in a QI project for an evidence-based practice; they see change and get excited; they want to know more and do more; they are more satisfied with their jobs. These people then go to other groups and committees. They feel more empowered and energized." They become your evangelists, Irwin says.
You may also need to help the nurses learn about how to sustain change. "You have a better understanding of issues related to how to keep from slipping back into old habits than they do," says Irwin.
Find the early adopters — the ones who are first in line for the next generation smartphone or who are always up on the latest research — says the lead author of the survey, Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor at Ohio State University in Columbus. Do not try to convince people who aren't interested.
There is a kind of "coma of complacency" among some nurses because, in part, they were never taught about EBP, says Melnyk. Giving them access to that knowledge can bring them back to the "passion and purpose" and help reduce the burnout and fatigue caused by a task-oriented, high-pressure job.
Implementing EBP can improve outcomes by up to 30%, she says. Those who use EBP are more satisfied with their jobs and more empowered in the workplace. And costs are lower. It is a no-brainer, right? But knowing and doing are two different things, says Melnyk. It takes up to 25 years right now for research to move its way into common practice — and that's not just for nurses, but for other providers and administrators as well. After all, we know that 12-hour shifts aren't the best for nurses or patients, she concludes, but we persist in having them.
For more information on this topic, contact:
- Bernadette Mazurek Menlyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, Ohio State University, Columbus, OH. Email: [email protected].
- Margaret Irwin, RN, MN, PhD, Research Associate, Oncology Nursing Society, Pittsburgh. Telephone: (412) 859-6272. Email: [email protected].
- Joanne Disch, PhD, RN, FAAN, Clinical Professor, University of Minnesota, Minneapolis. Telephone: (612) 625-1199. Email: [email protected].
References
- Melnyk BM, Fineout-Overhold E, Gallagher-Ford L, Kaplan L. The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. J Nurs Adm. 2012 Sep;42(9):410-7.
- Pravikoff DS, Tanner AB, Pierce ST. Am J Nurs. Readiness of U.S. nurses for evidence-based practice. 2005 Sep;105(9):40-51; quiz 52.
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