In the First Quarter 2009 issue, I wrote an article titled “Technology: A gift for nursing.” In this article, I share the other half of the story or, as the late Paul Harvey would say, “the rest of the story.”

Nurses cannot advance practice with technology alone. In the first article, I asserted that technology must be intentionally designed to integrate evidence-based practice (EBP) for standardization of care, to provide clinical-decision support at the point of care and create meaningful data to measure nursing-sensitive outcomes. This article highlights the significance of evidence-based practice (EBP) and why we, as nursing leaders, must insist on the best, for both the clinicians who provide care and the patients who receive care.

“It is not enough to do your best; you must know what to do, and THEN do your best.”

—W. Edwards Deming

Deming, arguably the father of the quality movement, sets the stage for what we must pay attention to if we hope to successfully integrate technology with practice to achieve desired quality outcomes. This is where EBP becomes an obvious necessity, if nurses are to deliver the best care possible. This logic forces each of us to answer a very important and personal question: What am I doing to assure that I am practicing in accordance with the latest evidence, so I can do my best?

Living EBP
In reality, EBP is complementary to and supportive of the professional nursing process of assessment, goal planning, intervening and evaluating. It augments the nursing thought process and workflow with a step that includes the search for, and finding and evaluation of, pertinent evidence to answer defined clinical questions (Pravikoff, Tanner, & Pierce, 2005).

Sackett, Strauss, Richardson, Rosenberg and Haynes (2000) define evidence-based practice as “the integration of best research evidence with clinical expertise and patient values.” Building on Sackett, et al. and others, the Honor Society of Nursing, Sigma Theta Tau International defines evidence-based nursing (EBN) as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.”

These definitions help us move into best practices and away from traditional practices. They guide us, as a profession, away from the notion that “this is how we have always done it here” to “what is the best assessment, goal plan, intervention and evaluation we can provide to this patient at this point in the care process, based upon the latest and best evidence available?”

A landmark study (Pravikoff et al., 2005) that determined U.S. nurses were not ready for evidence-based practice revealed key insights that we must not ignore. In addition to addressing shortcomings about current sources for information available to nurses, it identified barriers that must be overcome if we are to move beyond our current realities, insist on the best for nurses and patients, and take action.

I’ve dedicated most of my nursing career to providing members of interdisciplinary teams, including nurses, with the clinical tools and infrastructures necessary to live EBP. I’ve also shown them how to leverage point-of-care technologies for clinical-decision support. That said, here are some pearls of wisdom—and evidence—from the Pravikoff study that we, as nursing leaders, should pay particular attention to.

Pravikoff et al. (2005) reported the following statistics:

• 61 percent of U.S. nurses needed clinical information at least once a week or several times a week.
• 67 percent always or frequently found the information they needed by consulting a colleague.
• 58 percent reported not using journals or other research sources to find the information they needed.
• 82 percent never used a hospital library.

These realities help us understand why we are not adequately shifting away from traditional “the way we have always done it” approaches to providing care. If I were a staff nurse seeking clinical information from a colleague, what guarantee do I have that they have incorporated the latest and best evidence into their recommendation to me, and how would this potentially affect the patient and/or family? Secondly, as nurse leaders, what do we expect from bedside clinicians with regard to accessing research in journals, hospital libraries and other sources in the fast-paced reality of daily caregiving?

We should at least expect nurses to understand the principles of EBP. Great strides have been made toward this goal by nursing leaders such as Bernadette Melnyk and Ellen Fineout-Overholt (2005). Insisting on the best includes insisting that the principles of EBP are taken to the next level by creating evidence-based clinical tools that integrate evidence into the workflow.

The Pravikoff study is a direct call for nursing leaders, around the world, to change our perceptions so that, as a profession, we can move to a point where we always insist on the very best.

The researchers also asked nurses what the primary institutional barriers were (other than time) to their use of research in practice. Here are the organizational realities nurses reported: 

• Other goals have higher priorities.
• It is difficult to recruit and retain nursing staff.
• The organization’s budget for acquisition of information resources is inadequate.
• Funds allocated for training nurses in resource use are insufficient.
• There is a perception within the organization that the nursing staff is not eager or prepared to pursue evidence-based practice.
• There is also a perception in the organization that evidence-based practice or research is not achievable in the “real world.”

It is not okay to perpetuate the perception that the nursing staff is not eager or prepared to incorporate or pursue evidence-based practice.

It’s true. In seeking to foster an evidence-based work culture and environment, nursing leaders face the organizational realities of competing initiatives and recruitment and retention challenges, as well as budget constraints. To further complicate the situation, multiple organizational variables contribute to the difficulty of overcoming these barriers. Indeed, these organizational perceptions are what most concern me. That said, they also give me the greatest hope. Why? Because we can change perceptions, and we must!

 How? Show nurses a tool designed to prepare them for incorporating evidence-based practice. Show them that this tool makes evidence-based practice achievable and that it is being used today in the “real world.”

If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead, give them a tool, the use of which will lead to new ways of thinking.

                                    —Buckminster Fuller

Point-of-care technology
This is where the world of EBP and point-of-care technology must merge to challenge current perceptions of what is possible and achievable. The responsibility of nursing leadership in an organization is to assure that clinical information systems selected for the organization support integration of evidence-based practice with electronic clinical documentation. To miss this golden opportunity to join practice with technology is to keep the bar too low and furthers the perception that EBP is not achievable in the real world, which is simply not true.

The call for creating a new paradigm that combines technology and EBP was highlighted by Belmont, Wesorick, Jesse, Troseth and Brown (2003), who identified four guiding principles for advancing practice using an intentionally designed clinical documentation system that challenges traditional ways and the status quo:

• Build a patient story that is captured in one coherent record as the patient moves through the care delivery system. In partnership with the patient, the story should be individualized and include important patient preferences.
• Empower interdisciplinary care by placing value upon and expressing appreciation for the contributions of each team member, and improve patient care and outcomes by creating clinical documentation that enables various disciplines to coordinate, communicate and integrate their services as part of a cohesive team.
• Support integrated scopes of practice for all clinicians by clarifying roles, responsibilities, competencies and evidence-based practice for which each member of the interdisciplinary team is accountable.
• Provide evidence-based information at the point of care in the form of clinical practice guidelines, risk-screening tools and clinical documentation that drive critical thinking and professional decision-making. Combine evidence-based recommendations with clinical expertise and individualized patient values to make care decisions.

Clinical practice guidelines are one of the most impactive tools we can use to live evidence-based practice at the point of care. Again, Buckminster Fuller had it right when he stated: “Give them a tool, the use of which will lead to new ways of thinking.”

Clinical practice guideline (CPG) development follows four basic methods: (1) opinion, (2) consensus, (3) evidence-based, and (4) evidence-based combined with consensual validation (Hanson, Hoss, & Wesorick, 2008). Developed CPGs are excellent clinical management tools that can be used to disseminate best practices, achieve excellence in care delivery, meet or exceed quality standards, prevent complications, reduce omissions in care and integrate successfully into electronic clinical documentation. To be useful, guidelines need frequent updating to reflect the latest evidence found in constantly changing research literature. Subsequent updating must continually occur within the point-of-care technology that nurses and other members of interdisciplinary teams use in their daily practice.

Integration of EBP and technology was further highlighted in the Technology Informatics Guiding Education Reform (TIGER) Summit and published in the TIGER Summary Report (2007) and TIGER Collaborative Executive Summary (2009). Specifically, the TIGER Usability and Clinical Application Design Collaborative determined that, to achieve excellence in clinical application design, the design must:

• Support evidence-based practice
• Enable collaborative and interdisciplinary care
• Provide seamless access to published literature and knowledge
• Support creation of new knowledge (knowledge-discovery)
• Speed translation of research into practice

 

Clinical Application Design Essentials

TIGER Usability and Clinical Application Design Collaborative

Figure adapted from the CPM Resource Center (2008) and reprinted with permission

(Staggers & Troseth, in press)

Insisting on the best
In conclusion, let me re-ask my question in an even more personal way: What are you doing to assure that every nurse with whom you work is practicing in accordance with the latest evidence, so they can do their best? What are you doing to insist on the best?

It is not okay to perpetuate the perception that the nursing staff is not eager or prepared to incorporate or pursue evidence-based practice. In my experience, I have seen the eagerness of thousands of nurses to have evidence-based tools at their fingertips when they need it, so that they can leave their shift, or episode of care, knowing that they gave the best care possible.

I have observed that, with well-designed implementation methodology and evidence-based practice tools available at the point of care, nurses successfully adopt them and express gratitude for the time and effort expended to show them how to incorporate EBP in their daily care. I have also witnessed, firsthand, the desire of nurses for effective methodology and evidence-based tools, and the satisfaction they express when these tools are shared with colleagues from other disciplines to create a truly interdisciplinary care process with equal accountability for positive patient and family outcomes.

Shame on us, nurse leaders, if we say, “The nursing staff is not ready for that level of practice.” The best-designed systems are evidence-based, and these systems are designed for use by all clinicians. They are not intended to support limited and outdated thinking, substandard practice expectations, and “this is the way we have always done it” thinking. The old ways need to pass if we have, at our fingertips, a better way of giving our patients the best, most current, most coordinated care possible.

Considering the significant advancements that have been achieved in evidence-based practice and point-of-care technology, believing that evidence-based practice or research is not achievable in the real world is unfounded. True, they must be intentionally designed and properly implemented, but there are many health care organizations that have demonstrated that evidence-based practice at the point of care can be achieved.

One exemplar is the partnership of more than 280 organizations that comprise the CPM Resource Center International Healthcare Consortium. It is now possible to walk into a number of rural, community or university settings and see nurses, respiratory therapists, dietitians, social workers, physical therapists and others all doing real-world, evidence-based practice with advanced clinical-decision support at the point of care.

Finally, with every industrialized nation engaged in various efforts to implement nationwide electronic health records (EHRs), not insisting on the best is unwarranted. With funding from the American Reinvestment and Recovery Act (ARRA), the United States is now well on the road to accomplishing this goal. An effort by the U.S. Office of the National Coordinator (ONC) to finalize criteria and measurements for “meaningful use” of health information technology by the end of this year will lead to national health information exchange via EHRs. It is vitally important to nurses and other team-based caregivers—as well as patients, families and communities—that we individually and collectively give voice to the role that EBP plays in this mandate and insist on the best! RNL

Michelle R. Troseth

Michelle R. Troseth, MSN, RN, DPNAP, is executive vice president and chief professional practice officer for Elsevier. Troseth has been an executive leader since 2001 with the Clinical Practice Model Resource Center (CPMRC), a business unit of Elsevier, headquartered in Grand Rapids, Michigan, USA.

References:
Belmont, R.L., Wesorick, B., Jesse, H., Troseth, M., & Brown, D. (2003).  Clinical documentation. Health care technology, Volume 1. San Francisco: Montgomery Research.

Hanson, D., Hoss, B., & Wesorick, B. (2008). Evaluating the evidence: Guidelines. AORN Journal, 88(2), 184-196.

Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare. Philadelphia: Lippincott Williams & Wilkins.

Pravikoff, D.S., Tanner, A.B., & Pierce, S.T. (2005). Readiness of U.S. nurses for evidence-based practice. AJN, 105(9), 40-51.

Sackett, D., Strauss, D., Richardson, W., Rosenberg, W., & Haynes, R. (2000). Evidence-based medicine: How to practice and teach EBM. London: Churchill Livingstone.

Staggers, N., & Troseth, M. (in press). The role of usability and clinical application design in health information technology adoption. In M.J. Ball, K.J. Hannah, S.K. Newbold, & J.V. Douglas (Eds.), Informatics: Where caring and technology meet (4th ed). New York: Springer.

Technology Informatics Guiding Education Reform. (2007). The TIGER Initiative. Evidence and informatics transforming nursing: 3-year action steps toward a 10-year vision. Retrieved 2 October 2009 from www.tigersummit.com

Technology Informatics Guiding Education Reform. (2009). The TIGER Initiative. Collaborating to integrate evidence and informatics in nursing practice and education: An executive summary. Retrieved 2 October 2009 from www.tigersummit.com

Troseth, M. (2009). The gift of technology to advance practice at the point of care. Reflections on Nursing Leadership, 35(1). Retrieved 2 October 2009 from http://www.reflectionsonnursingleadership.org/
Pages/Vol35_1_Troseth.aspx