CHAPTER 3 Developing a culture of inquiry to sustain evidence-based practice
After reading this chapter, you should be able to:
3.2 Introduction
Culture does not change because we desire to change it. Culture changes when the organisation is transformed; the culture reflects the realities of people working together every day (Hesselbein 2002:2).
Evidence-based practice (EBP) is having a significant effect on the health service environment. It constructs a language that bridges the healthcare disciplines and the clinical and managerial components of health services. Most experienced clinicians in nursing, medicine and allied health now recognise that the contemporary healthcare environment calls for our practice to be justified by sound, credible evidence. There is pressure on all clinicians to accommodate innovation, while at the same time ensuring their practice is effective, safe and efficient (Forbes & Griffiths 2002). Consequently, EBP in healthcare is having a profound effect on nursing and the way we think about nursing.
3.3 Evidence-based practice in healthcare
EBP has been thoroughly defined in Chapter 1. In summary, EBP is making clinical decisions using the best available evidence, in conjunction with clinical expertise, and judgment and knowledge of the patient. Essentially, EBP is about reducing uncertainty in clinical care, leading to efficient and effective service delivery. It is about asking questions of our practice, systematically searching for answers to these questions, applying the best possible evidence from this search at the clinical interface and then evaluating the effect of this evidence-informed care.
However, evidence-based decision making is not as easy as following a five- or six-step recipe. First, clinicians are not born with the skills to be evidence-based practitioners. Second, the ‘evidence’ is, quite often, inaccessible, unreadable, invalid, not available, not applicable or lacking in quality (Bryar et al 2003, Funk et al 1991, Kajermo et al 1998, Miller & Messenger 1978, Parahoo & McCaughan 2001, Retsas 2000). Although healthcare organisations acknowledge the promotion and support of EBP, few provide the infrastructure, resources, support and incentives necessary to develop and sustain a culture of inquiry (Osborne, unpublished work, 2009).
Tranmer et al (1998) suggest that i) there is lack of organisational support to develop EBP and research the utilisation knowledge and skills of nurse clinicians; and ii) in the absence of evidence, there is lack of organisational support to generate nurse-initiated evidence for practice through the conduct of research. Organisations that can enable the culture by building infrastructure and developing EBP competency in staff will create a professional practice environment that fosters personal and professional staff development as well as developments and improvements in the quality of care delivered to patients (Newhouse et al 2005, Newhouse 2007).
3.4 Culture and organisation in healthcare
…a pattern of shared basic assumptions that the group learned as it solved its problems of external adaptation and internal investigation, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems (Schein 1992:12).
In any organisation, however, the organisational culture also contains a number of subcultures that ascribe to a pattern of basic assumptions based on a shared perspective. In healthcare, those shared perspectives can be based on discipline (e.g. nurses or medical doctors), gender, age, geographical location (e.g. ward or unit, acute facility or community outreach clinic), experience (e.g. novice nurses or expert nurses) or specialty field (e.g. acute care or critical care; orthopaedics or oncology). Supporting an organisational culture of inquiry happens in a cultural environment made up of individual clinicians and subgroups of individual clinicians, each with their own values, beliefs, assumptions and behaviours. Therefore, before we can expect an organisational cultural change, we must first effect an attitude change in the individual clinician. By making organisation synonymous with culture, cultural change involves altering or transforming the basic assumptions of the organisation. If the basic assumptions of the subcultures make up the organisational culture, then cultural change will have to begin with the subcultures and, more basically, with the individuals that make up the subcultures. Given that definitions determine actions, thoughts and perceptions (Bate 1994:9), we must conceptualise an evidence-based culture or, more aptly, a culture of inquiry, before we can discuss and recognise a ‘cultural change’.
3.5 What is a culture of inquiry?
Learning has been described as being on a continuum, which, if reinforced over time, will lead to permanent changes in behaviour (Webb et al 1996). Thus, a culture of inquiry is a learning culture that encourages interrogation of practice by providing the necessary resources to formulate questions, search for answers and evaluate the answers in practice. Such a culture recognises the value of research and the integration of research findings into practice by providing the necessary infrastructure, resources, support and incentives to enable nurse clinicians to fully engage in the EBP agenda.
Healthcare occurs in a multidisciplinary and multidimensional environment. Therefore, a culture of inquiry tolerates diversity and promotes true collaboration in the decision-making process on issues regarding patient care. Such a culture also has particular attributes associated with a participative management, such as a flat versus hierarchical management framework and decentralised administration (Havens & Vasey 2003). Organisational strategies that enhance nurse involvement in decision making provide nurses with a voice in both patient care decisions and in nursing work decisions. Such involvement in decision making has implications for positive patient outcomes (Havens & Vasey 2003), such as lower patient morbidity and mortality (Aiken et al 1994, Baggs et al 1999), shorter mean length of stay (Aiken et al 1999), and fewer patient complaints (Havens 2001).
In addition to valuing collaboration and involvement in decision making, a culture of inquiry values and supports autonomy and authority in decision making in areas of expertise. Autonomy has been defined as ‘an individual’s ability to independently carry out the responsibilities of the position without close supervision’ (Blanchfield & Biordi 1996:43). Authority has been defined as ‘sanctioned or legitimate power to make decisions’ (Blanchfield & Biordi 1996:43). Thus, a culture of inquiry recognises the legitimate authority of nurse clinicians, values professional nurse autonomy and encourages nurse involvement in healthcare decision making, thus providing support for change and innovation in practice.
There are benefits to having a culture of inquiry for both patients and nurses. It was demonstrated more than two decades ago that patients who are the recipients of nursing care that is based on research have better outcomes. Heater et al (1988) conducted a meta-analysis of nurse-conducted experimental research and found that patients who are the recipients of research-based nursing interventions can expect 28% better outcomes than patients who receive standard nursing care. This early study supports the assumption that engagement in the EBP and research agenda improves patient outcomes.
Benefits to nurses working in an organisation that values EBP and nurses’ contribution to healthcare have also been demonstrated in the literature. Several authors reported strong associations between autonomous decision making in clinical practice, job satisfaction and perceived productivity in organisations where the nurse leader values education and professional development of all nurses (Kramer & Schmalenberg 2003a, 2003b; Scott et al 1999). EBP is a great equaliser because the role of authority and opinion is no longer a sufficient basis for decisions about healthcare (Osborne & Gardner 2004). Rather, rules of evidence take precedence in clinical decision making (Osborne & Gardner 2004).
3.6 Development towards a culture of inquiry
Organisational leaders must develop strategies to achieve a receptive context for the kind of culture and climate that supports and enables EBP, innovation and change (Greenhalgh et al 2004, Thiel & Ghosh 2008). Changing to a culture of inquiry can be problematic. Without simultaneous change at both the macro (organisation) level and micro (nurse clinician) level, cultural change will not be sustainable. Change in the culture of an organisation requires commitment to change by the individual members of the organisation’s subcultures. However, to gain and maintain this commitment to change, the organisation must fully support its individual members throughout the change. Organisational support for a culture of inquiry is required to remove identified barriers to research utilisation, to build capacity to engage in the EBP agenda, and to encourage and support innovation in practice by recognising and supporting authority and autonomy for clinicians to effect practice change.
3.6.1 Removal of well-identified barriers
Research is still perceived by most nurse clinicians as external to practice, and implementing research findings into practice is often difficult. Barriers to research utilisation by nurses have been discussed in the international nursing literature for more than three decades (Bryar et al 2003, Funk et al 1991, Kajermo et al 1998, Miller & Messenger 1978, Parahoo & McCaughan 2001, Retsas 2000). In 1978, the most frequent problems encountered when trying to put research findings in place included:
Although the quantity and quality of nursing research has improved since then, the use of research findings in practice remains low. In 1991, Funk et al found the two greatest barriers reported by nurses were ‘nurses not feeling they had enough authority to change patient care procedures’ and ‘insufficient time on the job to implement new ideas’. Both are barriers of the organisational setting (Funk et al 1991). Moreover, most of the other barriers in the ‘top 10 list’ were those related to the organisational setting, including lack of cooperation and support from physicians, other staff and administration, inadequate facilities for implementation, and insufficient time to read research (Funk et al 1991). Barriers reported in the past vary little from barriers reported today. In general, aspects of the organisational setting and aspects of the research itself continue to represent the greatest problem areas. Lack of time to read and apply findings, lack of organisational support, lack of peer support, and lack of authority to change practice continue to rank highest in the list (Brown et al 2009, Bryar et al 2003, Fink et al 2005, Kajermo et al 1998, Parahoo & McCaughan 2001, Retsas 2000). A recent integrative review of 45 studies using the BARRIERS Scale found no evidence to support the theory that the identification of barriers to nurses’ use of research influenced nursing practice, and concluded that research is needed to investigate whether there is a relationship between perceptions of barriers and nurses’ use of research and EBP (Carlson & Plonczynski 2008). To achieve successful cultural change towards a culture of inquiry, organisations must not only recognise these barriers but also put strategies in place to reduce or eliminate them.
3.6.2 Capacity building in evidence-based practice and research utilisation
Difficulty in not only understanding but also accepting research findings is widespread (Bryar et al 2003, Funk et al 1991, Kajermo et al 1998, Miller & Messenger 1978, Parahoo & McCaughan 2001, Retsas 2000), and presents a serious challenge for the promotion of EBP in nursing. This is an issue not easily solved and in part is related to the nursing culture. Nursing is an old profession. Our beginnings are steeped in rituals, traditions and folklore. Despite the fact that nursing has changed in recent years and the context of nursing practice has changed dramatically, for too many nurses these rituals, traditions and folklores persist (Holland 1993, O’Callaghan 2001, Strange 2002, Winslow 1998). This creates an environment that resists change, does not question and does not look to science to inform practice. In this environment, research skills will not be valued. In conjunction with this historical cultural background is the varying quality of research education in undergraduate nursing programs and varying support from organisations for postgraduate research training for nurses.
The skills necessary to conduct EBP are easily identified and relate to competencies such as searching and retrieval of research literature, critical appraisal of research reports, and a level of skill in the design and conduct of epidemiological research. The skills and attitudes necessary to sustain a culture of inquiry are less easy to acquire and have been identified as having a professional pride and vision to build the evidence base for practice, being motivated and having the willingness, energy, enthusiasm, tenacity and ability to initiate change, being aware of own strengths and limitations, and having commitment to continuous learning (Bland & Ruffin 1992, McCormack & Garbett 2003, Scott et al 1999). Clinical academic positions that are joint appointments between a tertiary institution and a healthcare facility can play a major role in achieving change in this area by role modelling, promoting collaboration, supporting change agents and empirically demonstrating the value of EBP.
Enabling EBP within organisations is important for promoting positive outcomes for nurses and patients. Fostering EBP is a long-term developmental process within organisations, not a static or immediate outcome (Newhouse et al 2005). Once the question of ‘Why aren’t nurses using research?’ is attended to and barriers are removed, organisations need to ask the questions, ‘how?’ and ‘what?’. Implementation requires multiple strategies to cultivate a culture of inquiry where nurses generate and answer important questions to guide practice (Newhouse et al 2005). Organisations need to ask ‘how we can shift the culture forward beyond exploration and towards integration of evidence with decision making?’ and ‘what do nurses need to effect change in practice?’
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