Nursing researchers have come up with an answer for health care systems and professionals struggling with how to most effectively adopt evidence-based practice in their clinical settings.
In a new study, researchers have developed a list of 24 evidence-based practice competencies - a combination of knowledge and skills - for registered and advanced-practice nurses in real-world clinical settings. The authors recommend that health care institutions build these skills into employment expectations, evaluations and clinical ladder promotion systems as part of their efforts to implement and sustain evidence-based care.
Evidence-based practice refers to making decisions about patient care that are based on the best evidence produced by well-designed clinical research combined with a clinician's expertise and a patient's preferences and values. Numerous studies have suggested that evidence-based care of patients can improve quality of care, reduce medical complications and decrease health-care costs by as much as 30 percent.
"This isn't something that's just 'nice to do' anymore. This is something that we have got to do to improve quality and safety in health care and to improve patient outcomes," said lead study author Bernadette Melnyk, dean of The Ohio State University College of Nursing and chief wellness officer for Ohio State.
"We have enough studies to show that evidence-based care can produce these good results as well as fewer complications and hospital readmissions and shorter lengths of stay. But, we are talking about behavior change for clinicians, and that's not a simple process."
To arrive at the list of competencies, the researchers collected expert input from national leaders in evidence-based practice (EBP) and surveyed 80 nurses who are EBP mentors in health care systems across the United States. Within the list, 13 items apply to registered nurses (RNs) and 11 are intended for advanced-practice nurses (APNs). APNs are registered nurses with additional education (master's degree at minimum).
The competencies for RNs range from questioning clinical practices for the purpose of improving quality of care, critically appraising published research, and collecting and tracking outcomes data that can support the continued use of newly adopted practices. APNs should be expected to lead teams in applying evidence to initiate practice changes and put strategies into place to sustain a culture that fosters evidence-based practice.
All competencies point toward nurses being actively involved in shifting care from how things have always been done to care that is research-based evidence and deemed the most effective. The full list is available here: http://onlinelibrary.wiley.com/doi/10.1111/wvn.12021/full.
The study is published in the journal Worldviews on Evidence-Based Nursing.
The Institute of Medicine (IOM) has set a goal that 90 percent of all patient-care decisions be based on evidence by 2020. The Affordable Care Act calls for reimbursable treatments to adhere to recommendations made by the U.S. Preventive Services Task Force (USPSTF) - all of which are evidence-based. Despite these efforts, EBP is far from being universally embraced in many health care settings.
In the study, seven national EBP leaders used a consensus-building approach to come up with an initial set of competencies for nurses. These concepts were shared with and refined by the 80 EBP mentors in a multiround survey until those surveyed reached consensus on a final list.
Melnyk and colleagues recommend that these competencies be incorporated into health care system expectations, orientation programs, performance reviews, job descriptions and promotion protocols. Initial presentations about this study have been well-received, she said.
"People are wildly eager for this information because they haven't had a roadmap in real-world clinical settings for this before. This is going to give employers standards that they will hold their clinicians to as a way of practice," she said. "And anecdotal studies suggest that when nurses are engaged in evidence-based practice, they are more empowered and more satisfied with their roles. That's critical in an era when we're seeing so much fatigue and burnout in the nursing profession."
Examples of care not based on evidence abound, noted Melnyk, a former member of the USPSTF. Children having asthma attacks commonly receive a drug to open their airways with a nebulizer in an emergency room when research has shown that a metered-dose inhaler with a spacer leads to fewer side effects, less ER time and lower chances for hospitalization. And patients with depression typically receive an antidepressant prescription and nothing else despite evidence that cognitive behavior therapy is more effective than medicine for mild to moderate depression.
Melnyk published results from a survey of nurses about evidence-based practice in 2012 that identified barriers to its adoption. Among them: a need for a new direction in nursing education, where many faculty focus their teaching on rigorous research methods and critiques of research rather than how to put research findings to use in clinical practice. The IOM also addressed this issue, advising in a 2003 report that health professional education programs include evidence-based care among five core competencies.
"A lot of nursing educators never learned evidence-based practice. That's one of the reasons we don't have health care providers consistently practicing in this way," said Melnyk, also associate vice president for health promotion at Ohio State. "People can't do what they haven't been taught."
Ohio State is helping address this issue for current practitioners with the development of an online fellowship program to be offered by the College of Nursing's Center for Transdisciplinary Evidence-Based Practice.
The 2012 survey also suggested that widespread adoption of EBP would require extensive cultural change in health-care settings. That's a phenomenon that Melnyk has seen firsthand as a longtime consultant with health systems on implementing evidence-based practice.
"Sustainability of evidence-based practice is huge," she said. "You can have the best knowledge and skills in evidence-based practice, but if you don't practice in an environment and culture that supports it, chances are it will peter out.
"If health care systems adopt these competencies as a gold standard that sets expectations for how nurse professionals function, I think it's going to catapult the movement for EBP faster than it's moving right now."