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There are numerous reasons to establish an evidence-based practice (EBP) program for nursing staff at various practice sites. First, patients have complex needs, coupled with shortened in-patient lengths of stay and increases in new therapies used not only in acute settings but also in the community. Nurses must deliver care that is based on evidence of its effectiveness, safety, and currency. An EBP program is a proven way to move nursing care toward these desired outcomes (Black et al., 2015; Dols et al., 2019; Melnyk et al., 2016; Royer et al., 2018; Sonğur et al., 2018). In addition, use of EBP methods empowers nurses to address, in a systematic manner, questions and problems they encounter. Not only does it improve patient care, it also allows for dissemination both internally and to the broader nursing community (Brockopp et al., 2016).

Second, many organizations understand the positive influence that results from seeking accreditation. Ensuring that the processes and structure are in place to move toward positive outcomes allows an organization to establish, confirm, and codify goals and behaviors that result in exemplary practice. One such designation is the Magnet Recognition Program® awarded by the American Nurses Credentialing Center (ANCC). Magnet-recognized organizations have “strong leadership, empowered professionals and exemplary practice” as their “essential building blocks.” EBP not only contributes to exemplary practice but also empowers nurses to provide strong leadership (ANCC, n.d.). The use of EBP and the supports and structures needed to improve practice and contribute to the profession results in an organization that values these contributions and those who make them.

Third, the American Nurses Association (ANA) Scope and Standards of Practice describes the who, what, where, why, and how of nursing practice activities (ANA, 2015). ANA Standard 13: Evidence-Based Practice and Research states, “The registered nurse integrates evidence and research findings into practice” (2015, p. 6). This standard serves both as a benchmark and as a clear delineation that EBP is a core competency for professional nurses. This is supported by the Quality and Safety Education for Nurses (QSEN). QSEN indicates that EBP is one of the six areas of knowledge, skills, and attitudes (KSA) necessary for pre-licensure students’ education. These KSA are necessary for the nurse to use to continually improve the quality and safety of the healthcare systems in which they work. QSEN clearly defines EBP as the “integrat(ion) of best current 92evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare” (Cronenwett et al., 2007).

Fourth, in 2001, the Institute of Medicine (IOM) report, Crossing the Quality Chasm: A New Health System for the 21st Century, presented the need to improve the healthcare delivery system by providing safe, effective, patient-centered, timely, efficient, and equitable care. One of the components of this needed redesign of healthcare was the use of “evidence-based decision-making” (p. 8). Coupled with the 2001 report is the IOM’s report of 2011, The Future of Nursing, which stated that nursing is the key to improving healthcare. Three of the four key messages in the IOM report pertain to EBP. First, that nurses should practice to the full extent of their education and training, which includes the knowledge and skills needed to practice evidence-based care. Second, that nurses should attain higher levels of education and training, which addresses not only the world of academe but also the need for organizations to continually educate their staff. Third, that nurses should be full partners in redesigning healthcare, which again supports the need for nurses to be fluent in evidence-based approaches to problems.

As a result of these influencing factors, changes have occurred in both nursing education and nursing clinical practice. In academia, two key changes in educational preparation at the entry into practice level are evolving. At the baccalaureate level, the expectation of preparation for EBP is apparent as indicated by the American Association of Colleges of Nursing (AACN) Essential III: Scholarship for Evidence-Based Practice. “Baccalaureate education provides a basic understanding of how evidence is developed, including the research process, clinical judgment, inter-professional perspectives, and patient preference as applied to practice” (AACN, 2008). Thus, nursing programs have incorporated EBP into their curriculum as they focus on educating the student to use national standards based on evidence (Dols et al., 2019).

In addition, clinical nurse leader (CNL) has at its core the knowledge and ability to oversee the care coordination for a group of patients and provide direct patient care. As stated by the AACN, “this master’s degree-prepared clinician puts evidence-based practice into action to ensure that patients benefit from the latest innovations in care delivery” (AACN, 2012). As more nursing programs offer this curriculum, organizations will have CNLs as staff members.

These key changes in the education of new graduates just entering practice affect where they look for their first job as a nurse. Literature supports the importance and benefits of new nurses working in an EBP environment that fosters skills for professional development (Dols et al., 2019). This results in new graduates having the expectation that the organizations at which they seek employment will incorporate an EBP approach to the delivery of care and would support their practice and leadership through an EBP approach. As a consequence of this organizational expectation, new graduates will expect the staff with whom they work to be conversant with and use EBP in their patient-care approaches. With the emphasis on EBP for recent graduates and their expectations of the EBP approach being used in organizations, it is critical that all members of the nursing staff who have not had the opportunity to learn the EBP approach during their educational programs obtain the necessary knowledge and skills. This is further supported by the increase in the number of DNP graduates who use EBP. As DNP students, they used evidence in the development of their doctoral project and scholarly work. They have similar expectations of the workplace as being a place where EBP is integrated into practice.

As the emphasis on teamwork and interprofessional approaches to care increases, it is important that a common approach to patient-care delivery is used. It is therefore incumbent upon the nurse leader to set the EBP vision for the organization.

93■ INFRASTRUCTURE

Setting the Vision

EBP will not be successful unless it is clear that this is a priority of the organization and, most critically, the chief nursing officer (CNO) or equivalent nursing organizational leader (Brockopp et al., 2020a; Johantgen et al., 2017; Melnyk et al., 2016; Scala et al., 2016). The CNO must be the EBP champion for the organization. As with any program that is implemented, for EBP to be successful it must be part of the nursing vision for the organization. A strong and ongoing EBP program takes time to establish and integrate into the culture of how nursing functions. Without strong and visible support from the leadership, use of EBP and incorporation of the principles into the thought process of the nursing staff will not occur. The concept of continual inquiry and seeking to provide care that has been shown to result in improved patient outcomes must be interwoven into the structure and language of the organization for EBP to be successful. In addition, as indicated, the ANA (2015) describes that EBP is a core competency for professional nurses. Therefore, the use of EBP is not optional. The CNO must actively lead the organization to using an evidence-based approach to patient care.

An EBP program requires additional support from executive leadership throughout the organization. Merely including EBP as a goal is not sufficient for success. EBP needs to be a high priority in the nursing strategic plan and embedded into the organization’s strategic plan. Farahnak et al. (2019) studied the role leadership plays in the implementation of innovation, specifically EBP. The role of transformational leadership and leader attitudes was influential on staff attitudes and on the success of implementation of new practices. Farahnak et al. (2019) suggest that leadership behaviors may be more critical to innovation implementation than the leader’s attitude, thus supporting the key role the CNO plays in the implementation of EBP.

Before presenting the need for and benefits of EBP for inclusion in the organizational strategic plan, the CNO must get others on board with the vision. The creation of support requires a multipronged approach, and work at both the organizational executive level and the care deliverer’s level is necessary. Not only does the organizational executive leadership’s support need to be cultivated but nursing leadership and influential staff nurses need to be on board as well. Information and literature demonstrating the benefits of EBP must be discussed and provided to these key individuals. Multiple and disparate methods of communicating the benefits of EBP are required such as newsletters, town hall meetings, discussions with nursing staff, informational boards either electronic or paper, as well as cultivating the support and encouragement of any grassroots interest.

Having organizational executive support alone will not guarantee success, nor will strong nursing support alone result in success. Without the support of those who determine the strategic goals and what programs are funded, those who must enable the staff members to participate, and support from the caregivers who will be the ones implementing EBP, success is not ensured. All three legs to the stool need to be in place: (a) The CNO needs to establish the expectation, (b) the organizational executive leadership needs to support the use of resources for EBP, and (c) the staff need to see this as integral to how they practice nursing and not as a discrete action divorced from their professional practice. The CNO needs to present a logical and comprehensive assessment of the risk-to-benefit ratio resulting from care based on evidence. The benefits to the organization and thus to the key decision-makers must be presented and discussed. Concerns voiced during these discussions need to be considered and addressed. Organizational concerns may include the 94cost of the program, including needed personnel, support services, time away from patient care while learning, and any potential risks. Nursing leadership concerns may parallel these concerns and include issues of costs to the unit budgets, coverage for caregivers when in educational sessions, impact on staffing, seasoned staff responses, and the addition of “one more thing” to the nurses’ workload. Influential nursing staff may voice concerns about obsolescence of their skills; impact on workload; expectations of accomplishment without support to be successful; and the impact on the evaluation, reward, and compensation systems. The CNO needs to be prepared to listen and address these concerns and offer mitigating solutions.

Subsequent to creating support for EBP and the costs and requirements involved, the CNO needs to have EBP included as an organizational goal within the strategic plan. Funds are allocated based on organizational priorities, and unless EBP is an organizational priority, funding may fall on nursing alone to provide or be nonexistent. Because EBP will improve not only nursing care but also patient outcomes, organizational support is the ideal. An EBP culture provides an opportunity for interdisciplinary dialogue and information exchange, thus leading to collaborative patient care. Organizational benefits include higher quality patient care, which contributes to greater patient and family satisfaction as well as decreased lengths of hospital stay (Wu et al., 2018). Many CNOs recognize the need for an EBP facilitator, but face resistance in acquiring the financial resources needed to support such services. Given the quality and financial benefits to the entire organization, the organization needs to support an EBP program and position. It is not appropriate for a program that benefits the organization to be the financial responsibility of nursing alone.

Loss of payments for hospital-acquired conditions (HACs) and proposed incentive pay for better outcomes should be the driving force to incorporate the EBP facilitator’s role in healthcare settings as part of operational costs. The entire organization benefits by using EBP, for example by reducing the cost and rates of pneumonia, lengths of stay, and pain (Wu et al., 2018). Gilton et al. (2019) used evidence-based practice to change practice from routinely changing peripheral intravenous catheter sites to changing only when clinically indicated, all of which benefit the entire organization; thus, a case can be made that the cost of implementing and maintaining EBP is an organizational one.

Necessary Resources

Establishing and implementing an EBP environment requires essential resources, such as personnel, time, money, and space (Melnyk et al., 2018; McKinney et al., 2019). However, during times of cost containment, allocating these resources can be challenging and thereby may require creative and intentional planning (Christenbery, 2018a). The benefits of EBP include: nursing care driven by evidence improves patient care and clinical outcomes, nursing satisfaction increases as nurses become more empowered and engage in clinical inquiry to drive excellence and quality care, and the organization experiences improvement in reimbursement as patients experience fewer complications resulting in reduced resource utilization (Wu et al., 2018). Despite the well-documented benefits of EBP, nurses continue to experience difficulty incorporating EBP into daily practice because of insufficient time, lack of administrative support and mentoring, resistance to changing practice, and lack of education on the EBP process (McKinney et al., 2019; Melnyk et al., 2018).

Raising Awareness

Raising awareness and developing excitement about EBP often require a change in culture to move from tradition-based care to evidence-based care that is embraced by nurses at all levels 95of preparation. Several strategies can be implemented for building a foundation and stimulating enthusiasm for incorporating the EBP process. For instance, facilitating staff participation in EBP-related activities can be introduced through interactive sessions such as doing a version of the Great Cookie Experiment or conducting a mock trial. The original Great Cookie Experiment introduced concepts of the research process to nursing students by comparing two chocolate-chip cookies (Thiel, 1987). Student nurses gained insight into methodology, data collection, data analysis, and dissemination of research findings. Modifications of the Great Cookie Experiment have been done using other comparisons (such as hand sanitizers, lotions, breakfast bars, music, etc.) and with incorporating newer technology (Chanda, 2019; Lane et al., 2016). Nurses can become engaged in the experiment with “real-time” sequencing of events using online survey software (i.e., Survey Monkey) and data management tools (i.e., Excel), or by using audience response systems that allow for greater interaction, immediate feedback, and anonymous participation (Landrum, 2015; Thapar-Olmos & Seeman, 2018). Gaming systems, such as Kahoot (Kahoot, 2016) and Nearpod (Nearpod, n.d.) have recently emerged as alternative mobile approaches for engaging nurses in EBP educational opportunities (Calinici, 2017; Lane et al., 2016; Shatto & Erwin, 2016). Another interactive approach used to raise awareness about EBP is a mock trial. Mock trials have been used by other disciplines as an educational platform and more recently in nursing as a venue to highlight concepts of how to incorporate EBP into clinical practice (Harding et al., 2014; Mueller et al., 2017; White, 2015). For example, a mock trial can engage nurses to use available evidence when making clinical practice decisions. A topic that is relevant to all nurses, such as moral distress or safe patient handling, can be selected as a “case” to argue. To develop the pros and cons of the case, nurses gain experience reviewing literature, critiquing the evidence, and presenting an argument for or against the issue at hand. Thereby, nurses gain critical thinking skills using a problem-solving, systematic method for addressing clinical practice issues.

Education

Building an EBP infrastructure begins with staff education, which requires adequate personnel. Education promotes awareness and enables nurses to become professionally literate and develop necessary skills to critically appraise evidence before implementing findings into their practice. An advanced practice registered nurse, whether doctorally prepared or not, can serve as an EBP facilitator, whether employed by the organization or brought in as a consultant, and often has a dual appointment within a clinical and academic setting (Albert et al., 2019; Dols et al., 2019; Herron & Strunk, 2019; Lavenberg et al., 2019; Maneval et al., 2019; Monturo & Brockway, 2019; Saunders et al., 2019). The EBP facilitator enables others to initiate, conduct, and integrate EBP projects into clinical practice. The EBP facilitator serves as an educator, mentor, and change agent within the organization by (a) assessing the needs of nursing related to EBP; (b) raising awareness and developing excitement about EBP; (c) presenting EBP-related information and education in a way that is understandable and meaningful to direct-care nurses which may involve delivering content in “chunks” using micro-learning, just-in-time, or on-demand strategies; (d) building confidence and empowering nurses to engage in EBP-related activities; (e) assisting nurses with interpreting unit-specific data trends and facilitating EBP initiatives; (f) networking within the community and facilitating interdisciplinary collaboration; (g) facilitating the development of EBP proposals and project implementation; and (h) facilitating policy changes with intended plans for dissemination. Table 5.1 outlines an action plan that an EBP facilitator may use when establishing a foundation for an EBP environment.

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