Nursing is probably the most holistic health-related profession. It warrants the nurse to approach one’s practice in a manner that not only focuses on the health issues of the patient but rather encompassing the whole well being of the person. Which includes the physical and physiological, mental, psychosocial, and emotional aspect of the client or service user. It is therefore necessary for the nurse to have a wide array of knowledge, skills and attitude to deal with it. In so far as knowledge and skills are concerned, the nurse can readily make use of different tools to aid his or her practice.
This essay will explore the context of evidence based practice in nursing. It will be defined based on the studies of people accounted in such work and how these changes have drawn the emergence of such. This would include its importance in the nursing profession and its contribution to healthcare. Furthermore, challenges, barriers and needs of care practitioners would be identified and elaborated. Change theory will also be discussed as change in the healthcare system is considered the catalyst in the emergence of evidence based practice and it is also the reason why evidence based practice is not yet widespread because people are hesitant to adapt to changes.
Changes in the health care system and the needs of client is unending and thus the need to update one’s profession is tantamount in order to provide proper and optimum care to the clients through continual training, formal education and seminars and the use of evidence based practice. The inclusion and implementation of evidence based practice into nursing has long been recognised as an important aspect of the development and emergence of updated quality healthcare. The aim of evidence based practice (EBP) being to help clinicians base their actions on the best current evidence.(Sacket, 1996).
As the demand of clients for better and more individualized care continues, professionals are increasingly challenged to meet the ascending expectations. This is putting an emphasis on the importance of continual improvement of practice. Practitioners now are not only tasked to be skilful and knowledgeable. Critical thinking and sensitivity are also of importance. In addition, legal and ethical obligations need to be taken into consideration. Thus, the need for continuous updating is vital.
Evidence based practice in nursing can be equated with Evidence based medicine in approach and use of evidences. Historically, the theory of evidence based medicine (EBM) originates back to mid-19th century Paris and earlier. Sackett (1996) describes EBM as: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” So, more generally, evidence based Practice (EBP) is the application of such principles across the broad field of health care. Moreover, Muir Gray (1997) describes EBP as: “an approach to decision-making in which the clinician uses the best evidence available.” As mentioned earlier, patient care must be individualized. That being the case, there is a need for the clinician to consolidate patient preference, clinical experience and thoroughly researched evidence. Appropriate care depends considerably on the needs of the patient and it varies from one individual depending on the circumstances.
Nursing profession has gone from basing interventions from traditional and ritualistic practices to a more scientifically based process. Evidence-based concepts are essential in providing care to patient problems in a particular setting and play a vital role in the nursing profession since nurses are professionally, ethically and legally accountable for the care they provide patients. (NMC, 2002) In relation to nursing, evidence-based concepts, evidences would be of great importance for the nurse in determining the suitable method of dealing with the client’s predicament.
Evidence-based nursing requires practitioners to base their practice on the best evidence available from current research rather than relying on intuition, trial and error and personal experience, the source of this evidence is from quality research, (Cormack, 2000).
New generation nurses are aware that nursing research is very essential to nursing because it challenges and tests the effectiveness of the care given. However, much nursing practice still remains rooted in myth (Walsh and Ford, 1989). To overcome this problem nurses must recognise the importance of evidence based care and the improvements to nursing practice (Parahoo, 1997).The National Health Service (NHS) Research and Development strategy launched in (1991) acknowledges the importance of developing an NHS where practice and policy is more evidence based.
The strategy is designed to create research-based health services in which scientific information is available to influence the process of health care delivery systems (Sullivan, 1998). Evidence-based practice appears to be largely derived from the concept of Evidence-based Medicine. Furthermore, Sackett et al (1996) states that this development should come as no surprise as nursing has long had an interest in identifying a clear theoretical basis for practice and considerable work and has examined the relationship between theory, practice and research.
Unlike before, twenty or so years ago the nature of nursing was rather more straightforward (Kershaw 1998) the theories, knowledge and skills, they have learnt from school may no longer be applicable in general as they were used to. Nurses today not only need to be knowledgeable and skilful, they need to be wise (Bradshaw, 2001)
Nonetheless, implementation of EBP in such specialties like mental health nursing and the change in practice it commands, is a concept of enormous merit, but as well known, an ideas merit, does not guarantee acceptance (EBMH Notebook, 1999). This notion therefore leads on to the discussion of change and change theory.
Change is nothing new and indeed has been our only constant, but change today is faster and more complex than it has ever been before (Manion, 1994). Change is a concept currently enjoying much debate and analysis within nursing (Pryjmachuk, 1996) hence one of the purposes for this essay. Change is an essential part of life, however in essence it is only likely to be welcomed if it is perceived as being necessary, rather than inevitable.
Change theory originated from Kurt Lewin in 1951. His model of change is one of the most widely promoted models. Lewin introduced the concepts of driving and restraining forces that either help or restrain the change process (Lancaster and Lancaster, 1982). He describes driving forces as those that facilitate change, by electing a change agent and moving the group with this agent. Restraining forces are those who slow the change process or stop the change from taking place. Change occurs when one force outweighs the other. Lewin states that it is important to know the driving and restraining forces in order to deal with the restraints.
Nurses in the present working climate have to accept necessary changes with open arms. Not only should they accept changes as they take place, but should also be constantly reviewing working practices and being proactive in implementing changes as and when necessary. If this does not happen, nurses will have to deal with the fallout of changes imposed on nursing by others (Ootim, 1997).
There are numerous theories that explain how and why change occurs, but Lewin (1951) identified three phases to change, unfreezing, moving and refreezing. Therefore for change to occur, the current state must be ‘unfrozen’ by people becoming aware of the problem and the necessity for change. Then the forces holding the change in equilibrium must be worked on by increasing the forces driving the change and minimising those resisting it. Finally everything must be ‘refrozen’ with the change integrated into the person, the organisation and the culture.
However a number of other models derived from sociological research attempt to explain events as the process of change unfolds. Stocking (1992) in her article ‘Managing the human side of change’ discusses promoting change in clinical care and the social interaction model based on the work of Rogers and Shoemaker (1971). This model describes the process involved when an innovation is communicated to members of a social system. Rogers and Shoemaker proposed that four factors influenced whether changes were accepted and incorporated into practice. Firstly, the advantage of a new practice and how it can improve on existing practices.
Secondly, how compatible the change is with the present practices and staff attitudes. Thirdly, the complexity of the innovation, the feasibility for easily understanding and implementing it and finally, the possibility that the innovation can be realistically tried out. Rogers (1983) observed that the factors influencing change largely revolved around the perceptions of those who were involved in introducing the innovation. Therefore innovations that demonstrate high relative advantage and compatibility, and those that lack complexity and can be tried out, are more likely to be adopted than changes that do not demonstrate these characteristics.
Individual barriers to evidence-based nursing practice include a lack of competence by nurse managers. Many lack advanced academic skills and still view nursing as a practical rather than cognitive activity. Limited ability to apply research to practice is another factor; some nurse manager try to help their nurses cope by making too few demands, people are not trained to use research for practical applications, and a large research-practice gap exists in the profession. Furthermore, heavy workloads leave nurses too exhausted to advocate for changes that could strengthen the quality of care they provide”. (Udod and Care,2004:1) To overcome these barrier, nurses must strengthen their beliefs and keep on their mind the benefits and the advantages of evidence based practice. Nurses must firstly consider that evidence based practice outcome will improve patient outcomes in order for changes in their practice to occur
Nurse Managers must also keep on their mind that they play a great role in evidence based practice. They must be a role model to the staff in demonstrating the importance of it and showing how valuable professional growth is, motivating the staff by giving or creating opportunities in research, providing support that will persuade and facilitate nurses to achieve desired competencies. Openness of communication is important so that nurse managers and staff can monitor the development of the research. Furthermore, to be able to raise up their problems, comments and suggestions towards the research. In organizational barriers, “Organizational barriers include difficulty accessing evidence, resource constraints that keep nurses’ workloads too heavy for them to learn about and implement evidence-based nursing practice, lack of funds for ongoing skill development, and management priorities that don’t include evidence based nursing practice”.( Udod and Care,2004:1).
Although management skills are important and necessary, the future requires leadership to provide the dynamics essential to challenge and lead organisations into an era where management of rapid change is the necessary key for future survival. Nursing leaders are ideally positioned to influence these changes and to play a major role in facilitating the changes (Sofarelli and Brown, 1998).
Nursing is a dynamic profession, appropriate care greatly relies on client needs, and they differ from one individual to the other depending on their situation. And the best way to provide proper, effective care is through the use of evidences, not rituals that have been used by practitioners that are now deemed irrelevant and dangerous. Nurses are accountable for their own actions and for the care they provide to their client. They are legally, ethically and professionally responsible for such care which must be rooted through best possible evidences in order to protect them from the legalities and issues of their profession.
With the emergence and development of evidence based practice, nurses and other health professionals now have a scientific, well grounded basis for the care they provide to their clients. No longer will they hesitate to provide interventions that may seem professionally, morally and legally questionable if they use the best possible evidence based resources present. Indeed, the world of healthcare has improved and changed to a level where clients can expect that the care they are given is appropriate and of the highest standard because of the utilization of evidence based practice in the nursing profession.