Oct 1 2012

Do Nurses Resist Implementing Evidence-Based Improvements to Patient Care?

Recently, Nurse.com covered a new study conducted by Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN. Published in the September issue of the Journal of Nursing Administration, the study of more than 1,000 registered nurses found that resistance from nursing leaders and other barriers prevent nurses from implementing evidence-based practices, even when those practices could improve patient outcomes.

Mary Naylor Mary Naylor

In a recent post for the American Journal of Nursing’s Off the Charts blog, Mary Naylor, PhD, FAAN, RN, program director for the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative (INQRI) program, weighed in on the topic, discussing the complexities of today’s health care system.  Naylor noted that, “administrative and workflow inefficiencies limit hospital nurses from spending more than about 30 percent of their time on direct patient care.” 

Given the challenges and barriers noted by Melnyk and the limited amount of time that nurses actually get to spend with patients, how can nurses influence the delivery of evidence-based practices? Project investigators from the INQRI program commented on some of the challenges associated with translating research into practice.

Barbara Resnick Barbara Resnick

Barbara Resnick, PhD, CRNP, FAAN, FAANP, professor at the University of Maryland School of Nursing, notes that “there is a well-known lag in the implementation of evidence-based findings into real world clinical settings with the average length of time from discovery of a drug intervention, for example, to implementation into practice taking approximately 13 years.”

“Similarly,” Resnick notes, “there continue to be individuals who do not benefit from simple and well established interventions such as pneumonia vaccines or exercise interventions. Currently there is a need to better understand the effectiveness of dissemination and implementation approaches and the science that underlies implementation research.  It is only in this manner that we will truly change care at the bedside.”

Joanne Disch Joanne Disch

Joanne Disch, PhD, RN, FAAN, clinical professor at the University of Minnesota School of Nursing, says the common organizational and leadership barriers noted in Melnyk’s articles “are real, and have to be dealt with.  However, we also need to pay attention to the role that nurses themselves play in choosing which evidence-based practices they will implement.”

In an editorial in Nursing Outlook earlier this year, Disch pointed out several evidence-based practices nurses do not routinely  implement (e.g., routine oral care, open visitation) and several practices that nurses persist in using despite the fact that they are not evidence-based and may, in fact, be detrimental (e.g., injecting saline before suctioning, 12-hour shifts). 

file Nancy Hanrahan

“The issue of implementing evidence-based practice is complex, multifactorial, and requires interventions at all levels to assure that patients receive the care they deserve,” Disch says.

It’s a support issue, according to Nancy Hanrahan, PhD, RN, CS, FAAN, the Dr. Lenore H. Kurlowicz Term associate professor of nursing at the University of Pennsylvania School of Nursing.  She suggests that the culture clash Melnyk noted between nurses who were educated to use an evidence-based approach and those who were not reflects a paradigm shift occurring throughout health care in which we are moving toward greater accountability for the quality and outcomes of health care services. 

According to Hanrahan: “Nurses, being the largest [sector] of the health care workforce, have the most face-to-face time with patients when compared with other providers.  Changing the nursing practice paradigm could have a large return if organizations, agencies and government programs supported the appropriate educational and mentoring programs.  But, as Melnyk reports, nurses do not experience support.  So often nurses are held responsible for change but managers and hospitals do not provide the time or resources. Magnet hospitals are exemplar places for nurses to work with high standards for nursing practice.  Nurses can emphasize to their administrators that magnet would be good for the facility brand and good for nurses and patients.  Thus, here is a way to support the paradigm shift to achieve better work environments for nurses and better care for patients.” 

Resnick points out that more support is needed not only for clinicians, but for nurse researchers.  Until recently, the National Institutes of Health has not focused on research dissemination or implementation.

“There is now, however, a National Center for Advancing Translational Sciences and the Institute of Implementation Science in the Division of Cancer Control and Population Sciences at the National Cancer Institute.  Although still limited, there are increased resources toward this type of science.  It is critically important that nurses have the knowledge and skills to disseminate and/or implement their findings into real world settings and participate in the development of the growing science around dissemination and implementation,” Resnick says.

The successful translation of knowledge to improve nursing care and patient outcomes is a core part of the INQRI program’s mission. In its final funding round, INQRI sought proposals focused on projects that would promote ways to implement successful evidence-based strategies and practices.  The six projects selected in 2010 included: the creation of a nurse manager development program to increase patient safety; the dissemination and implementation of evidence-based methods to measure and improve pain outcomes; and the implementation of a risk-specific fall prevention intervention to reduce falls in hospitals.  In addition, INQRI grantees have received additional support from other funders to implement what they learned through their INQRI projects.
Resnick recently completed a dissemination project funded by the Stulman Foundation.  With this grant, she was able to implement the Function-Focused Care for Assisted Living Residents intervention which was tested under the purview of her INQRI grant.

Resnick notes that, “through a combined face- to-face and email based intervention, we established champions in 20 assisted living settings and were able to change the philosophy of care in these settings.  The findings and successes of the intervention through this type of dissemination were impressive and we found that the facilities taking early responsibility for the intervention and care approach led to much better long-term success than can be seen in traditional effectiveness research.  While there is a place and need for both effectiveness and controlled randomized studies, implementation research is greatly needed to establish the best ways in which to spread our many successful interventions.”

Tags: Health Care Quality, Interdisciplinary Nursing Quality Research Initiative, Nurses and Nursing