- evidence-based healthcare:
emphasises the use of evidence from well-designed and conducted research in healthcare decision-making
- lifelong learning:
the ongoing, voluntary and self-motivated pursuit of knowledge for personal or professional reasons
- implementation science:
all aspects of research relevant to the scientific study of methods to promote the uptake of research findings into routine settings in clinical, community and policy contexts
- research utilisation:
the movement of innovative research evidence into practice
- personal disposition:
the predominant or prevailing tendency of one’s own inclinations and preferences
- change management:
an approach to transitioning individuals, teams and organisations to a desired future state
Understanding theoretical frameworks that guide communication processes and skills development
Using frameworks that can support and guide evidence-based decision-making in lifelong learning is essential for students to be reassured that a particular evidence-based initiative is the right one in a given context. Frameworks like evidence-based practice, integrated risk management, change management and clinical reasoning are important tools for gathering the necessary factors to aid such a decision.
Healthcare professionals from a variety of disciplines realise the value of evidence transfer in evidence-based healthcare practices (Gibson, Martin, & Singer, 2004). Evidence-based practice (EBP) means healthcare professionals use patient evaluation and intervention guidelines for particular disorders and diagnostic-related groups. EBP considers the individual’s pathophysiologic knowledge of the disorder(s) being treated, their clinical expertise and the patient’s preferences for treatment (Pearson et al., 2005).
EBP is the careful and sensible use of the best available levels of evidence alongside the clinical expertise of healthcare professionals. To understand the transfer of evidence, students first need to understand the sources of best evidence – for example, published research in healthcare journals. It is also imperative for students to understand the hierarchy of evidence behind best evidence (Averis & Pearson, 2003; Pearson et al., 2005) – for example, the empirical evidence that stems from a randomised control trial or the descriptive perceptual evidence flowing from sound qualitative research. Understanding the source of evidence can also mean a student recognises a gap in the availability of sound evidence (see Figure 9.1). This can also lead to a healthcare decision based solely on expert opinion and years of clinical experience.
Figure 9.1 Spillway model
Healthcare leaders have a duty of care to implement changes that stem from a hierarchy of evidence. Shifting this evidence from knowledge to implementation in clinical practice is dependent on the aptitude of all healthcare professionals to successfully communicate the intentions of imp-lementation, and thereby ensure the long-term sustainability of the changes. However, successful communication is seldom easy to achieve, and changing the mindset of other healthcare professionals poses an ongoing challenge. Healthcare professionals must consider recognised and unrecognised barriers that impact on the transference of this evidence (Moloney, 2013). The digital age has led to additional barriers to accessing information (Moloney & Beccaria, 2009). These barriers are explored in greater depth later in this chapter and were also presented in Chapter 7. The tempo of change within the world of healthcare has also contributed to an overload of new information and a consequent inability to find and retain new information (Brown et al., 2010).
|Level of evidence||Feasibility F (1–4)||Appropriateness A (1–4)||Meaningfulness M (1–4)||Effectiveness E (1–4)|
|1||Metasynthesis of research with unequivocal synthesised findings||Metasynthesis of research with unequivocal synthesised findings||Metasynthesis of research with unequivocal synthesised findings||Meta-analysis (with homogeneity) of experimental studies (e.g. RCT with concealed randomisation)|
One or more large experimental studies with narrow confidence intervals
|2||Metasynthesis of research with credible synthesised findings||Metasynthesis of research with credible synthesised findings||Metasynthesis of research with credible synthesised findings||One or more smaller RCTs with wider confidence intervals|
Quasi-experimental studies (without randomisation)
|3||(a) Metasynthesis of text/opinion with credible synthesised findings|
(b) One or more single research studies of high quality
|(a) Metasynthesis of text/opinion with credible synthesised findings|
(b) One or more single research studies of high quality
|(a) Metasynthesis of text/opinion with credible synthesised findings|
(b) One or more single research studies of high quality
|(a) Cohort studies (with control group)|
(c) Observational studies (without control group)
|4||Expert opinion||Expert opinion||Expert opinion||Expert opinion, or physiology bench research, or consensus|
Although implementing new evidence has improved patient care standards in some instances, a gap still exists between the expansion of valued research outcomes and convenient access for healthcare professionals to improve care. Frequently, knowledge and proposed interventions revealed by evidence-based practice research remain largely unshared due to constrained resources and a scarcity of recognised utilisation intent or direction (Averis & Pearson, 2003). Efforts by the Joanna Briggs Institute (JBI) (2014a) have focused on enlarging the extent of work undertaken around increased evidence-based utilisation strategies. Initiatives like JBI Connect Plus have ensured that the needs of health consumers and the activities of research-active health professionals have a common communication platform for evidence-based practice. This modern communication platform is intended to enhance access and improve the effectiveness of strategies when implementing research findings (Metsälä & Vaherkoski, 2014).
Transference models have been well studied in the literature (Estabrooks et al., 2003; Kitson et al., 2008; Pearson et al., 2005; Rogers, 2002). Ironically, very few directly consider personal and organisational communication skills or attributes. However, some – such as the Promoting Action on Research Implementation in Health Services (PARIHS) Model (see Table 9.2) – focus on the interactions between three key elements for implementation, including establishing a context (Kitson et al., 2008). This is important to an individual or team wishing to introduce change, as understanding the willingness of an organisation to embrace change dictates the level and form of communication required to promote effective utilisation. Understanding context is a key attribute to other models, such as the Knowledge-to-Action Framework (Kastner & Straus, 2012; Straus et al., 2008), which advocates for an adaptation of knowledge to the local context. On the other hand, Rogers’ (2002) Innovation Diffusion Theory hinges on a scale of likeliness for adoption – that is, from laggards in innovation through to inspired innovators. Integral to these theories is the need to understand social knowledge – for example, the likelihood of effective social interactions with the end-users of evidence.
|Crane, 1985; CURN Project, 1981; Closs & Bryar, 2001; Funk et al., 1991||Conduct and Utilisation of Research in Nursing Project (CURN)|
〉 Problem identification
〉 Assess knowledge base
〉 Design practice change/innovation
〉 Conduct clinical trial
〉 Adopt, alter or reject change
〉 Diffuse innovation
〉 Institutional change and maintain innovation over time
〉 Outcome: change in client outcome
|Stetler 2001||The Stetler-Marram Model|
〉 Preparation phase
〉 Validation phase
〉 Comparative evaluation phase
〉 Decision-making phase
〉 Translation/application phase
〉 Evaluation phase
〉 Outcome: use of findings in practice
|Rogers, 2002||Rogers’ Innovation Diffusion Model||Some of the characteristics of each category of adopter include:|
Rogers also proposed a five-stage model for the diffusion of innovation:
〉 innovators – venturesome, educated, multiple info sources, greater propensity to take risk
〉 early adopters – social leaders, popular, educated
〉 early majority – deliberate, many informal social contacts
〉 late majority – sceptical, traditional, lower socio-economic status
〉 laggards – neighbours and friends are main info sources, fear of debt
〉 Knowledge – learning about the existence and function of the innovation
〉 Persuasion – becoming convinced of the value of the innovation
〉 Decision – committing to the adoption of the innovation
〉 Implementation – putting it to use
〉 Confirmation – the ultimate acceptance (or rejection) of the innovation
|Kleiber & Titler, 1998||The Iowa Model of Research in Practice|
〉 Expected outcomes documented
〉 Practice interventions designed
〉 Practice changes implemented
〉 Process and outcomes evaluated
〉 Intervention modified if required
〉 Outcome: improving clinical practice through research
|Jones, 2000||The Linkage Model|
〉 User system
〉 Resource/knowledge-generating system
〉 Transmission mechanism
〉 Feedback mechanism
〉 Outcome: transmission of research
|Kitson et al., 2008||Promoting Action on Research Implementation in Health Services (PARIHS) Model||This model focuses on the interactions between three key elements for implementation:|
The model asserts that successful implementation (SI) of evidence into practice has as much to do with the context or setting to which the new evidence is being introduced and how that new evidence is introduced (facilitated into practice) as it has to do with the quality of the evidence.
〉 Evidence (E)
〉 Context (C) and
〉 Facilitation (F)
There are many interpersonal communication process models that can be applied alongside such theories. An individual or group trying to establish a communication channel (the medium by which the message is delivered and received) must therefore understand the context. Barriers to communication can include noise (everything that interferes with an accurate expression or receipt of a message) and feedback (an appropriate reaction from the receiver signifying whether the message has been received in its intended form) (Moloney, 2013; Portoghese et al., 2012). Research focusing on nursing perceptions of research utilisation reveals ‘excess noise’ in nurses’ immediate and surrounding environments that restricts the ability to engage in research utilisation. This constitutes an overload of communication, leaving room for misinterpretation. The Spillway Model (Figure 9.1) highlights the need to better control this excess noise, allowing the end-user of research findings to start and finish research implementations (Moloney, 2013).
Those training to be healthcare professionals (and future leaders) are required to view communication in a different light. A student’s knowledge of appropriate communication will be based on a context of experience rather than the application of communication skills and knowledge. For example, the context of a clinical placement in an emergency room may require a different focus of communication to that in a rehabilitation ward. At the core of healthcare professional activity sits irregularity, obscurity and a risk of alternative interpretations (Rangachari et al., 2014). Thus the topic of evidence-based research utilisation is not stagnant; it has the capacity for transformation through further research – and therefore an individual’s or group’s lifelong learning. This means the seeds of learning around evidence-based practice and the communication tools required to assist in embedding new evidence need to be planted early for the student’s benefit (Lavis, Robertson & Woodside, 2003; Rangachari et al., 2014). In theory, communication flow must occur in two directions. Most transference models make no reference to this two-way communication; rather, they indirectly refer to communication – that is, the Knowledge-to-Action Framework, which considers that users of knowledge need to be included in the action or cyclic decision process to make sure any implementation meets their needs. This implies there is a two-way communication, yet never specifically advocates for it. The PARIHS framework also has an indirect communication loop, indicating that there should be interaction with the stakeholders; however, it does not elaborate on the shape of two-way communication (Kastner & Straus, 2012; Kitson et al., 2008).
Evidence implementation within an organisation requires effective communication strategies. Evidence implementation should presuppose innovation adoption: decisions typically made by senior health managers regarding changes to evidence in practice should include the staff involved in their longitudinal implementation (Rogers, 2002).
Rogers’ Diffusion of Innovation theory seems to deliver significant advantages (Table 9.2), enabling an investigation of the true root cause of why a new initiative is either adopted or not adopted, closely mimicking change strategies like the normative-reeducative strategy. The innovation diffusion theory originates from dynamic systems theory, and offers a sound platform when considering the level at which healthcare professionals should engage in research. An appreciation of the important links between theory and practice prepares these future professionals to apply knowledge and skills throughout their careers to facilitate effective change (Rogers, 2002).
Investing energy in the identification and spread of effective evidence-based practice is important. There is a need to make better use of systems like JBI Connect Plus that identify change that is having an impact, and to understand why this has occurred. It is highly recommended that students become familiar with these systems as soon as possible, and make good use of them in assignments. As the leaders of tomorrow, nursing graduates armed with these tools will be well placed to influence the necessary diffusion of new evidence into practice (Metsälä & Vaherkoski, 2014; Pearson et al., 2005). The aim should be to increase the global uptake of evidence-based practice, so receptiveness to change and improvement become built-in features of practice, supported by international, national and organisational-level structures and processes (Pearson et al., 2005).
A ‘change agent’ is recommended for effective communication in the implementation process. All students training to be part of the wider healthcare workforce should aspire to be such a change agent at one time or another. This person’s role is to influence and guide the innovation decision, and they are often external to the organisation. Having an external person driving change can often work in favour of change, as this person can remain neutral throughout the process. Their messages should be targeted to the intended audience for effective adoption of the innovation. A change agent usually has a high degree of expertise in the innovation. They are viewed as effective if they are perceived as credible, competent, reliable and empathetic. A skilled change agent will diagnose problems and determine alternatives to meet adopters’ needs, then reinforce and stabilise the new behaviour so they can leave the role of change agent (Rogers, 2002; Woodward et al., 2014). Since they are usually heterophilous to the organisation it is important to also have the support of champions and opinion leaders who are homophilous (Rogers, 2002; Woodward et al., 2014). Opinion leaders are individuals who have influence on others but not by their formal leadership role. They have large interpersonal communication networks and can be used to positively influence the diffusion of an innovation (Rogers, 2002).
the degree to which pairs of individuals who interact are different with respect to certain attributes, such as beliefs, values, education and social status
the degree to which pairs of individuals who interact are similar with respect to certain attributes, such as beliefs, values, education and social status
Research shows healthcare professionals want research engagement to be governed by risk-management prioritisation. They believe there is greater relevance to patient needs and care outcomes when targeting implementation projects (Moloney, 2013). Research also suggests that while it is essential to acknowledge that evidence-based practice adoption needs to be encouraged, recommendations also need to be refined to the patient for whom care is being provided, and the context in which that care is provided (Fallon et al., 2006). Furthermore, it is also important for an innovation to be appropriately refined to the context of the target population (Bowtell et al., 2012). It is clear that individuals or groups who are driving change must keep integrated risk management at the forefront of patient care innovations. Staff members are more likely to embrace change if they can clearly see its worth in relation to improving care standards. If staff members are to recognise and relate to any risk prioritisation, it is essential to communicate risk ‘trending’ (for example, moderate to high risk) as identified by integrated risk management systems (Vincent, 2006). Risk management and the risk trending that stems from it are valuable tools for the change agent when they need to provide evidence and justification for change.
Understanding known facilitators and barriers to research-utilisation practices
Healthcare professionals have a critical role in fostering optimal patient outcomes, and monitoring and assessing patients is a key element of this. This literature highlights mounting concern around issues of patient safety and risk of harm when a patient’s physical condition deteriorates unexpectedly (Henneman, Gawlinski & Giuliano, 2012; Odell, Victor & Oliver, 2009; Preston & Flynn, 2010). Dresser (2012, p. 110) states that ‘a turn of events unacknowledged by a healthcare professional can markedly alter the course of a patient’s condition and outcome’.
The mismanagement of a patient’s healthcare data can result in morbidity and even mortality. However, effective clinical reasoning skills can help a healthcare professional to detect and manage patient deterioration early, thus preventing adverse patient outcomes (Levett-Jones et al., 2010). Healthcare professionals are sometimes reluctant to act on adverse findings or may not know the degree of urgency if they do not understand the physiology involved in the changes they observe in the patient’s condition (Levett-Jones et al., 2010; Preston & Flynn, 2010). It is imperative to consider these staff skills in relation to any change. During the implementation of any evidence-based care standards, there will always be a reliance on skilled and knowledgeable healthcare professionals to measure indicators of change. For example, we may wish to understand whether patient recovery time has shortened or patient pain control has been vastly improved. A healthcare professional’s clinical reasoning skills therefore play a key role in the communication process throughout any implementation process (Levett-Jones et al., 2010).
Clinical reasoning skills may well present a barrier to change if cyclic patient assessment is not well performed. It is imperative for those driving change to establish the context of known and unknown barriers to change. Communication (or a lack of it) is a well-recognised barrier to change (Levett-Jones et al., 2010; van Bekkum & Hilton, 2013). Physical communication barriers in healthcare can include marked-out territories, ‘empires’ and circles of trust into which outsiders are not allowed. Closed office doors, barrier screens and divided areas for those of a different status can restrict communication. The larger the work area, the more likely it will be that these barriers may be present. Research shows one of the most significant influences in fostering unified teams is proximity (van Bekkum & Hilton, 2013).
The most likely problem to be encountered when communicating EBP is that everyone sees the world differently and there are various levels of experience. One of the main barriers to unrestricted communication is the emotional barrier. This can be a combination of fear, mistrust and suspicion. The root cause of this emotional block needs to be understood before progressing. Reflecting on one’s own emotional intelligence and that of others can unlock potential barriers to change, and thereby improve communication. A facilitator can be used to understand an individual’s emotional drivers. Most healthcare professionals are driven by patient-centric care principles because they want what is best for their patient (Davis et al., 2008; van Bekkum & Hilton, 2013).
Behavioural patterns can be ‘inherited’ due to the close nature of working in a group of healthcare professionals. It is human nature to feel a sense of belonging, and therefore it is easy to become entwined in a culture, regardless of whether it is negative or positive. Defining the context of a given culture can unveil associated cultural barriers and lead to more effective strategies for engagement. There is an increased likelihood of successful implementation within healthcare groups that are happy to accept a change agent, where that change agent is happy to conform to local parameters. However, the likelihood of success becomes lower where there are barriers to a change agent’s membership within a collective (Davis et al., 2008; van Bekkum & Hilton, 2013).
Of course, it is difficult to avoid interpersonal barriers and interpersonal conflicts within two-way communication. To decrease the likelihood of conflict, it is best for a change agent to remain flexible and neutral throughout the communication process (Davis et al., 2008; van Bekkum & Hilton, 2013).
The National Institute of Clinical Studies provides a very good overview of mainstream barriers and facilitators that can impact on the EBP implementation process (see Table 9.3). It is highly recommended that a tailored approach designed to analyse likely barriers is considered, as this will aid the change agent in focusing their efforts towards specific barriers (National Institute of Clinical Studies, 2005).
|Level||Type of barrier or enabler||Examples|
|The innovation itself|
〉 Advantages in practice
|Clinical practice guidelines may be perceived as inconvenient or difficult to use.|
Guidelines recommending the elimination of an established clinical practice, such as screening for lung cancer with chest x-rays, may be more difficult to follow than guidelines that recommend adding a new behaviour.
〉 Motivation to change
〉 Behavioural routines
|Clinicians may not agree with a specific guideline or the concept of guidelines in general.|
Clinicians may not have the motivation to change or may not feel competent to provide specific services, such as counselling about exercise or diet.
|Patients may expect certain services, such as the prescription of antibiotics for upper respiratory tract infections.|
〉 Opinion of colleagues
〉 Culture of the network
|Local opinion leaders may encourage the use of forms of care that have not been shown to be effective, such as screening for ovarian or prostate cancer.|
〉 Care processes
|Burdensome paperwork or poor communication may inhibit provision of effective care.|
|Economic and political context|
〉 Financial arrangements
|Reimbursement systems may promote unnecessary services or discourage best practice.|
You are a registered nurse who is new to an organisation. You are currently working in a very busy acute medical/surgical unit. You have noticed that there is great variation in the use of decimal points in drug dosages and the use of measurement descriptors by doctors – for example, mcg or micro. You know from previous experience that these simple differences in prescribing can lead nurses to making a medication error, potentially causing harm to a patient.
You undertake an initial search of the literature and realise that there are some national guidelines on the use of abbreviations, symbols and terminology in prescribing and administering medicines (ACSQHC, 2015). According to this, the doctors’ current prescribing habits are not in accordance with evidence best practice. You raise this issue with your nurse unit manager and state that you would like to investigate this issue further with permission, by looking into current risk-management data stemming from incident reports.
In your new workplace, you know there have been staff advocating for the use of structured communication when handing over information to others or when a nurse is seeking a patient review from a doctor. You decide to better document the situation and background, undertake an initial assessment and make some recommendations. You do not want to be authoritarian with your communication, but rather engage the nurse unit manager by presenting the facts, allowing them to engage in democratic decision-making once the evidence has been presented. You provide some examples of the discrepancies with prescriptions and the new evidence you have found that should guide practice. You outline that these types of discrepancies have historically led to errors, and that you also suspect some errors may recently have occurred in the clinical area. You say you feel it may be beneficial to determine whether there has been any recent trending stemming from incident reporting and that you feel a chart audit may be of benefit. You then ask the nurse unit manager for some advice and their opinion about the correct course of action to take. They say they are happy for you to look at incident data and to start leading a change of practice.
Most healthcare organisations have risk managers and even medication safety officers. First, you would need to seek out these individuals and present them with the evidence. The organisation would also have an integrated risk management committee, or perhaps a safe medications group. Presenting the issue with one or both of these committees would be of value. At some stage, you will require some ‘buy-in’ from the medical officers. This would need to occur beyond just your clinical area, as this issue will no doubt turn out to be broader than just your clinical unit. A meeting with a medical officer who is represented on one of the relevant internal committees and who has an interest in medication safety would be of value. The key to enabling this change in practice in accordance with evidence-based recommendations will be to enable joint support and engage many key stakeholders who would also have an interest in improving medication prescribing.
Understanding the dispositions to enable effective change management
A key emphasis of nursing care is to be patient focused and accountable in providing effective and efficient care. Care should be planned and implemented upon a strong evidence base, while taking into account the practitioner’s own clinical expertise and patients’ preferences and values. As already highlighted, a wide variety of factors can determine how evidence is translated and utilised at the point of care. While organisational factors play an important role in research utilisation and implementation, individual nurses play an even more critical role. Each nurse has their own inherited or acquired personal dispositions, some of which may contribute towards them becoming an evidence-based practice nurse. These dispositions may encompass attitudinal, behavioural and critical-thinking domains. Individual dispositions can relate to both the adoption of evidence into practice, and act as facilitators of change. Furthermore, some nurses will not only adopt and utilise evidence in practice, but will also actively engage in ways to manage and lead change processes related to practice and organisational change.
Having a positive attitude towards improving patient care and ‘making a difference’ is considered one of the key pillars of critical practice (Brechin, 2000). Nurses are often best placed to understand patient populations. As a result, they are able to identify issues and develop solutions. Having a shared common goal of wanting to improve care should be fundamental. It has been clearly identified in the literature that a negative attitude towards evidence-based practice is a major barrier when it comes to research utilisation (Fink, Thompson & Bonnes, 2005; Rycroft-Malone et al., 2004), so it is important to have a positive attitude and a belief that evidence-based practice will improve patient experiences and outcomes (Waters et al., 2009). Essentially, nurses need to be able to see a clear link between research and implications for practice in order to actively engage in evidence-based practice (Rycroft-Malone et al., 2004).
Becoming an evidence-based nurse also requires critical thinking. While there are many definitions and descriptions of critical thinking in the literature, often these include personal dispositions such as being open-minded, confident, flexible, inquisitive, information-seeking, reflective, logical and analytical (Profetto-McGrath et al., 2009; Shoulders, Follett & Eason, 2014; Wangensteen et al., 2010).
Critical thinking involves gathering and seeking information; questioning and investigating clinical practice; analysing and evaluating various sources of information and knowledge within a clinical context; and being able to problem-solve and apply theory to practice. This information-gathering may be from one’s own practice or from observing others; there can be many alternatives to solving an issue, so seeking ideas from others may help. It certainly helps to seek out and learn from others who are more experienced. Acting in the role of observer is to be expected at the transition phase between being a nursing student and practitioner; however, in order to become an independent critical thinker, it is important to move beyond this curiosity stage. It is important to develop heightened critical analysis skills by analysing situations with existing knowledge, being open-minded to others’ ideas and acquiring knowledge to fill gaps (Hunter et al., 2014; Shoulders, Follett & Eason, 2014).
Being open-minded involves receiving and considering new ideas. The ability to actively listen to others and respect their ideas is important. This may involve other nurses, but may also extend to other roles within a multidisciplinary team environment. It may be that others have previously identified similar problems and solutions. Sharing ideas can foster a greater sense of inquiry within healthcare teams, and often has the advantage of attracting interest and support from others, which may transpose to other teamwork situations (Irwin, Bergman & Richards, 2013). Having people feel involved and empowered to provide their ideas is a key aspect of change management. This can be achieved both formally and informally. In formal situations, it might involve raising issues at team meetings and allowing everyone to contribute in a safe and supportive environment. Informally, a discussion in the lunchroom might prove useful for gauging the thoughts and ideas of others.
While identifying problems or issues is important, developing ideas for solutions that fit or are likely to be successfully adopted within a work unit or organisation is even more so. For example, how well an organisation is resourced, whether the new change might ‘fit’ within current procedures and policies, and how likely it is that a change might be supported and adopted by decision-makers may all be important factors as to whether a new idea can be turned into reality (Schaffer, Sandau & Diedrick, 2013; Tagney & Haines, 2009).
A person’s own lack of confidence in appraising and using evidence in practice is another well-established barrier to research utilisation (Wallin, Boström & Gustavsson, 2012). Difficulties may arise in considering how research findings could be applied to practice, having a lack of awareness of the range of clinical issues in a speciality area, and knowing how care might best be evaluated after practice change (Fink, Thompson & Bonnes, 2005; Gagan & Hewitt-Taylor, 2004). Ritualistic practice means lacking the confidence to change practice (Savage, 2013). It is particularly important for beginning nurses to recognise these knowledge deficits, and to plan towards addressing these gaps over time.
Identifying clinical issues and potential solutions, and communicating these within the healthcare environment, may be challenging. Often the process involves identifying issues or problems within the clinical setting, and raising questions about the current situation and whether care could be provided more effectively or efficiently (International Council of Nurses, 2012). These clinical issues or questions may be related to an individual health professional’s practice, patient healthcare issues or the organisational environment – even a combination of all of these aspects.
It is not uncommon for nurses – particularly when they are transitioning from a student to a nurse – to feel unsure of their practice, knowledge and skills, and they will often rely on observing more experienced nurses. Beginning practitioners may then adopt certain practices without always critically thinking about it (Ferguson & Day, 2007). In terms of evidence-based practice, many beginning practitioners also feel limited in influencing change (Ferguson & Day, 2007; Gagan & Hewitt-Taylor, 2004; Gerrish et al., 2008). With more experience, skills and knowledge, the ability to incorporate evidence within clinical practice increases. It is important to learn from experiences by appraising each situation individually, and considering what has been learnt and what could be applicable to future situations.
Nursing knowledge is derived from many sources, yet beginning nurses have been found to place more importance on less formal mechanisms for acquiring knowledge (Gerrish et al., 2008; Mills, Field & Cant, 2009). Nursing involves a strong oral culture within which knowledge is often shared from those more experienced to those less experienced. This may mean the importance placed upon less formal ways of gaining knowledge, such as through experiential learning and interactions with other health professionals, may be judged more highly than knowledge gained from formal research journals. It is important for those mentoring beginning practitioners to be cognisant of the developmental nature of skills and knowledge, ensuring that the ‘knowledge of caring’ also incorporates a strong evidence base, or at least identifying where there may be gaps in knowledge (Anderson & Willson, 2009; Beskine, 2009).
Having an overall investigative or curious approach is fundamental in critical thinking and continued lifelong learning (Kedge & Appleby, 2009). Curiosity can stem from an innate thirst or drive for knowledge, or alternatively from the need to address an unpleasant stimulus – for example, experiencing the pressure of not knowing something and potentially feeling embarrassed among colleagues (Kedge & Appleby, 2009).
Reflective thinking is part of critical thinking. This may involve self-reflection of practice, with the goal of developing into a more critical and independent student learner (Ireland, 2008), which should have positive benefits for patient care (Dolphin, 2013). While there are many reflective models to guide nursing practice, their processes are often similar. Many processes begin by identifying and describing something that has happened or is happening, reflecting on the aspects of the situation, analysing the situation (considering other previous situations) and considering new perspectives from learning and considerations for future practice (Mantzoukas, 2008). Sharing these understandings with fellow students and healthcare colleagues has the potential to generate opportunities for further discussion and insights.
Innovation often stems from reflecting on and challenging previous knowledge and practices, including beliefs and attitudes about why things are done the way they are (Matthew-Maich et al., 2010). Within the clinical setting, engaging in reflective thinking can occur as part of a debriefing process, in discussion within professional development workshops or during formalised mentoring relationships (Beskine, 2009; Matthew-Maich et al., 2010).
Another key disposition of becoming an evidence-based nurse is being patient-focused – for example, it is important to be aware of the acquired knowledge the patient brings to a healthcare encounter and to ensure accurate information is provided. While it can be positive for patients to access health information themselves, sometimes this information may not be accurate, and subsequently patients may have high expectations about care. With the ease of access to internet-based healthcare information, patients may already feel they have an understanding of signs, symptoms and treatment options (Rodin et al., 2009). It can be a balancing act to meet the needs of the patient while communicating evidence confidently in a way that respects and maintains the integrity of the relationship (van Bekkum & Hilton, 2013). Where the evidence available is unclear, not of high quality or not contextualised to the patient’s situation, the nurse must use skills in not only the critical appraisal of evidence, but in making decisions regarding how and what to present to the patient (van Bekkum & Hilton, 2013). It is an important skill to provide clear rationales to patients. This has to be done by providing information the patient understands but that also considers the patient’s context.
Finally, being open to and engaging in change is another key disposition of becoming an evidence-based nurse. While many organisational factors are associated with change, the micro aspects of attitudes – readiness to change, openness to change, commitment to change and cynicism about change – have all been found to be important psychological factors in the change process (Choi, 2011). How change is perceived and responded to may certainly be different for each person. Change attitudes, behaviours and actions may also be dependent upon how the organisation itself supports innovation and change.
The dispositions discussed to date may not just apply to adopting evidence into practice; they may also apply to taking more proactive steps to identify ways to improve patient care and to lead the way for positive change. There is emerging literature on the role of facilitators, change agents and role models in promoting research utilisation (McCormack et al., 2013; Melnyk, 2014). This means leadership, change management and even skills in persuading and empowering others to change are all seen as necessary dispositions for effective research utilisation within the nursing profession.
Understanding team dynamics and effective change management
Studies have further suggested that group membership and dynamics are key factors in developing an evidence-based culture. The global shortage of qualified registered nurses has also been associated with poor quality communication between nurses, leading to reduced team-based problem-solving, a loss of group culture and worse patient outcomes. This is a further indication of the importance of staffing as an opportunity to increase the quality of care (Brunetto et al., 2013). The need for effective evidence-based care practices to be a group activity rather than an individual one is particularly suited to the nursing profession, where team-based care has a long-established history (Brunetto et al., 2013).
The evidence in favour of positive supervisor–nurse relationships, teamwork and well-being is of benefit to employers. It is also of benefit to nurse leaders seeking to develop and enhance the skills and knowledge of staff in their units by providing a stable workplace, as these cultural characteristics explain almost half of nurses’ commitment to their hospital or their intentions to leave. These findings suggest a leadership focus on improving the quality of workplace relationships as a first step in retaining skilled nurses. It is also the first crucial step in bringing a culture of evidence to practice settings (Brunetto et al., 2013).
Group membership and workplace culture bring clinical benefits to the ability to evaluate current practice and implement changes to improve or develop a best-practice culture, as the above findings indicate. Evidence supports groups being enabled and empowered to take a problem or issue in practice and work through to a solution where the members of the group have equally valued input and voice (Trowbridge, 2011). While these characteristics are the hallmark of healthy work environments, there is another key layer that characterises good implementation studies, and an evidence-based clinical culture.
Leadership has been described as the glue that holds a healthy work environment together (Shirey, 2006). Leadership demonstrated through collaborative practice-led change processes has been shown to have a positive impact on the development of an evidence-based culture. Programs such as the JBI Clinical Fellowship create opportunities for group engagement processes in the work environment, where the outcomes are improved practices and better patient outcomes. To effectively change practice, teams setting up clinical audit projects are using the six identified markers of leadership: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (Forsythe et al., 2013; Shirey, 2006).
While team dynamics are intrinsic to the whole project, in this case study it is Phase 2 that best demonstrates the capacity of evidence-based quality improvement projects to illustrate how complex concepts such as group productivity, social perceptions, group membership, culture and leadership can best be utilised to achieve improved patient outcomes (Trowbridge, 2011). However, changing practice is complex, requiring the support of a majority of the team, consideration of institutional policy, the types of resources needed to facilitate the change and strategies to make the change sustainable.
In a project on fall prevention and screening, Trowbridge (2011) found that barriers to best practice were identified by group process, where the results of the audit were discussed by staff involved in day-to-day care with management and policy-makers. A team-based approach was essential to this project, with equal consideration given to all ideas and suggestions for practice improvement, leading to consensus on which ideas to target first, and the development of an action plan that would engage each member of the project team.
The structure of JBI-PACES facilitates a situational analysis based on barrier identification, strategy planning, and resource implications for each agreed practice improvement strategy. Following a group process, this project identified a series of barriers and developed strategies for each, together with the resources required to achieve the practice change. As can be seen from Table 9.4, barriers can include not only tools and guides, but subjective issues such as cultural resistance, change fatigue and uptake of new practice requirements.