Donna Ciliska, RN, PhD
Professor, McMaster UniversityEditor, Evidence-Based Nursing
This text is based on the Joanna Briggs Oration, given at the 2005 Joanna Briggs International Conference, Adelaide, Australia.
This paper provides an opportunity to reflect on evidence-based nursing. Where have we been? How far we have come? What are the current issues and where are we going in terms of incorporating high quality evidence into clinical, education, management and policy decisions? Was evidence-based nursing just a passing fad, or does it contribute to quality, efficient health care?
Where we have been?
While the use of evidence is often recommended in relation to health care reform, institutional change, health care practitioner competence or health care practitioner education, opponents argue that there is no evidence that evidence-based health care makes a difference. There are no sensitive system indicators; health care costs are highly influenced by adoption and spread of technology; mortality and morbidity are also influenced by a multitude of factors. Yet, evidence-based health care should impact on all three indicators; we just do not have solid data to link them.
More specific reviews are often used to support the move to evidence-based nursing in clinical areas. An older, much cited review sought to determine the impact of research-based nursing practice on patient outcomes (Heater, Becker & Olson, 1988). They reported finding 84 relevant studies which showed "sizeable gains" in patients in behavioral, knowledge, physiologic, and psychosocial outcomes, compared with patients who received routine nursing care. However, evidence-based nursing is more than research utilisation. More recently, Thomas and colleagues updated their review of the use of guidelines by health care practitioners other than physicians. They found 18 studies of 467 health care providers (participants were nurses in all but one study). While reporting of methods was poor in all included studies, three out of five studies observed improvements in at least some processes of care and six out of eight studies observed improvements in outcomes of care when care was based on guidelines rather than no guidelines (Thomas, Cullum, McColl, et al, 2005).
Much research has focused on barriers nurses face to evidence-based practice (EBP). Dicenso and colleagues (2005) collated literature on the topic. Barriers included: lack of time; lack of access to search engines, databases and research articles; lack of skills in critical appraisal or understanding of research language; lack of sense of control over practice or confidence to implement change; and difficulty seeing applicability or generalisability of results from different institutions or clinical units (DiCenso, Ciliska & Guyatt, 2005). In addition, nurses identified institutional lack of leadership, motivation, vision, strategy or direction among managers (DiCenso, Ciliska & Guyatt, 2005).
Another body of research concerns changing health care practitioner behavior; what strategies can be used to change practitioner behavior in light of research evidence?
The Cochrane Effective Practice and Organisation of Care Group reviewed 41 systematic reviews, and found that most of the studies of practitioner behavior change was carried out with physicians; the most effective strategies involved one-to-one contact, such as academic detailing, audit and feedback, and use of opinion leaders. Less effective strategies have been impersonal/passive communications such as written materials, continuing education, workshops or conferences. A range of interventions have been shown to be effective in changing professional behavior in some circumstances. The review of reviews concluded that multifaceted interventions targeting different barriers to change are likely to be more effective than single strategies, and that a diagnostic analysis should be done to identify factors likely to influence the proposed change (Grimshaw, Shirran, Thomas, et al, 2001).
The reality is, we have little evidence that EBP makes a difference, and in most institutions, there is still a considerable gap in between what is known in the research evidence, and what happens in practice.
How far we have come?
If health care costs, and population mortality and morbidity are not currently sensitive outcomes to track to assess the impact of EBP, are there other macro indicators to assess climate change? Are practitioners and policy makers "warming" to EBP beyond lip service? Dedicated publications, centres and web sites may be macro indicators. There are at least five recently published, English texts regarding evidence-based nursing or EBP within nursing. With respect to journals, Evidence-Based Nursing started in 1998. It contains abstracts of high quality articles of relevance to nurses, and includes a commentary about the clinical implications of the results. It now has over 9000 individual subscribers. The website has over 30,000 unique visitors each month with around 100,000 full article downloads per month. Furthermore, a second dedicated journal, Worldviews on Evidence-Based Nursing began in 2004, and is a high quality source of primary studies, reviews and theoretically-based articles about research dissemination and utilisation in clinical, policy and educational arenas. Sales of the texts, and subscriptions to these two journals indicate quite a high level of interest in evidence-based nursing.
Evidence-based nursing centres around the world were highlighted in an editorial in 1999 (Ciliska, DiCenso & Cullum, 1999). At the time, the Joanna Briggs Institute (JBI) had five collaborating centres, plus there were four other known centres in the world: UK, Canada, Germany and US. Now JBI has nursing centres in seven different countries, plus seven other centres of nursing with midwifery, and other multidisciplinary sites. There are multiple other centres. Again, as a very rough indicator, a Google search on center AND evidence AND nursing in November, 2005, resulted in 8,710, 000 hits. Granted, this could represent multiple publications from a few centres, but there were many different centres represented in the first few pages of hits. Still, this search would miss many centres which have different, but related titles, such as the Center for Advancement of Evidence-Based Practice at Arizona State University (http://nursing.asu.edu/caep/); Academic Center for Evidence-Based Practice (http://www.acestar.uthscsa.edu/About.htm), or the Knowledge Utilization Studies Program (http://www.nursing.ualberta.ca/kusp/) at the University of Alberta.
As another macro indicator, a PubMed search of titles and abstracts, using evidence and nursing, resulted in 1075 hits for the entire database before 1998, and 2336 hits from 1998 to the present. While this seems a big increase in the last seven years, the similar search of evidence and medicine yielded 1689 and 5664 hits, respectively; a far greater increase in medicine over nursing in the same time period. Taken as a group, these macro indicators indicate considerable growth in interest in evidence-based nursing.
What are the current issues?
What are the current issues in research, clinical practice, education and management/policy development? Regarding research, some of our current funded research has jumped into randomised trials of interventions, such as various dissemination strategies, and knowledge brokers. It is difficult to impact on patient outcomes, and we may need an intermediate step of assessing change in practice or utilisation of evidence. However, valid and reliable tools are not yet available, but are under development by Estabrooks and colleagues at the University of Alberta. Further, we may not know enough about particular interventions, such as knowledge brokers, how they see their role, how they function, and what are the barriers and facilitators to this role. We need more descriptive studies of such interventions. Current research is also trying to understand the kinds of decisions that nurse make (Thompson, Cullum, McCaughan, et al, 2004) and what information sources nurses use to make clinical decisions (Estabrooks, Chong, Brigidear, & Profetto-McGrath, 2005; Thompson, et al, 2004). Others are studying nurses' understanding of EBP. Banning (2005), found that nurses had difficulty differentiating EBP from the research process; that EBP was equated with the research process.
In clinical practice, who needs to know about EBP? Does every nurse in the institution or agency? Can the institution afford to educate every bedside care-giver in EBP? If not, then should EBP be in the job description and performance appraisals of the nurse educators? The clinical specialists? The advanced practice nurses? With more undergraduate programs requiring courses and expecting students to be able to function as evidence-based practitioners, a critical mass of staff will have the skills at some future point. However, many educational programs continue to be evidence-based, without teaching EBP. Content taught is based on current, high quality research, but faculty may not teach the students how to find, critique and apply the evidence for themselves. Further, at the Masters' level, most curricula include research skills, but not the EBP process. Graduates may know about how to design studies, but not necessarily how to critique and utilise research results (Ciliska, 2005).
What is needed to practice in an evidence-based way? Many institutions have policies, procedures, best practices or guidelines that utilise high quality evidence in their development. If this is true, the staff who follow the guidelines will be practicing in an evidence-based way, without knowing the EBP process. This may be a short-term strategy while educating staff in the process, and waiting for the critical mass to be built.
In order to be utilised, the reviews (which form the basis of the guidelines) must be perceived as being done by "credible" people, and accessed by someone in the workplace who can help translate the language of research (Ciliska, Hayward, Dobbins et al, 1999).
Does teaching EBP change anything? Coomarasamy and Kahn (2004) conducted a systematic review of 23 studies; all involved postgraduate trainees in medicine. Eighteen studies evaluated stand-alone classroom courses, which resulted in improved knowledge but not skills, attitudes or behavior; five studies evaluated clinically integrated teaching, which improved knowledge, skills, attitudes and behavior. While it is not possible to generalise to nurses, particularly undergraduates, it is an area of important research. Strauss and colleagues (2004) have offered a framework to guide evaluation of teaching of evidence-based medicine. It involves an evaluation matrix around learners, interventions and outcomes. They classify learners as doers (do all steps of the EBP process), users (ask the clinical questions and go directly to the pre-appraised literature) or replicators (trust and follow recommendations of others considered to be leaders). This framework could have considerable relevance for evaluating nursing education.
At the management and policy level, an appreciation of the EBP process is necessary to support a culture of evidence-based care. Several pilot projects have been undertaken, with little published as yet. For example, in Canada, the Executive Training for Research Application (EXTRA) fellowships are provided in order to give health care managers the skills to better use research, as a way to increase evidence-based decision-making within the health system. It is supported by a group of national organisations including the Canadian Health Services Research Foundation, the Canadian College of Health Service Executives, the Canadian Nurses Association, and the Canadian Medical Association (http://www.chsrf.ca/extra/index_e.php). The first graduates of the two year program will occur this spring (2006). Each fellow must do a project within their own institution using evidence and evaluating the policy results, and/or dissemination and uptake. It involves tremendous commitment from institutional management executive and governing boards of the fellow's institution.
What are priorities for next few years?
Now for some crystal ball gazing: The vision for 2010 is that we have successfully bridged the research transfer gap. We have 30-second access to the best information available, including pre-appraised information in easily searched databases. We use research evidence in decision-making - for clinical practice, management and policy decisions.
What are the priorities in order to help us get to that vision?
While the list looks short, each item is actually a large field of research. Within these practice and research priorities, there is a lifetime of work for each of us!
Don't be too timid and squeamish about your actions. All life is an experiment. The more experiments you make the better!
Ralph Waldo Emerson
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