Question

Nurses may be intimidated by research and by interpreting research evidence. If you were the manager or leader how would you create a culture that would support research and the use of research evidence in practice.

Answer 1

The advancement of research based practice has been a goal in nursing for many years. Evidence-based practice (EBP) provides a framework and process for the systematic incorporation of research evidence and patient preference into clinical decision making at the level of the individual practitioner and the healthcare organisation. Few well designed studies have tested the effectiveness of organisational strategies for encouraging the systematic use of research in nursing practice,1 and more research is needed into the reality and consequences of adopting EBP.2

In 1996, an acute National Health Service (NHS) hospital trust and a university department in London, UK began a joint project to increase the systematic use of research by nurses in clinical practice. EBP was selected as the approach, and the hospital-wide project began in late 1996. The project was facilitated by a senior lecturer appointed jointly by the 2 organisations, with half of his time allocated for this role. A diagnostic assessment done early in the project identified the need for the development of organisational and individual capacity to support and use EBP.3 The Evidence-Based Ward Project used action research to explore ways in which the organisation and culture of practice in a busy acute ward could be developed to make EBP part of the “normal” approach to practice. The project ran for 10 months and was coordinated by the new ward manager and the senior lecturer

Several developments occurred in the organisation and culture of practice during the project. They included:

• The introduction of team and named nursing (each patient has their own named lead nurse)

• The introduction of patient assessment and care planning using the activities of daily living model as a key activity for all qualified staff, which resulted in improved patient documentation

• The introduction of a standardised format for patient handover, including the identification of EBP questions

• Improvements in the ward environment (eg, floors were relaid and piped oxygen was connected)

• The introduction of team based and self rostering

• The introduction and enforcement of personnel management policies (eg, individual performance review).

The developments selected and methods of organisation implemented were strongly influenced by the ward manager's priorities and previous experience.

The nurses who participated in the project reported an increase in confidence in their own and their colleagues' abilities. They said that they had developed and enhanced their existing communication, organisation and management, leadership, and teamwork skills. The documentation of patient care as assessed by MONITOR scores also improved (mean difference in pre-test and post-test scores 7.6%, 95% CI 2.8 to 12.4). The average sickness rate among nurses was lower during the project than during an equivalent period in the previous year

The organisational changes that occurred during the project were sporadic, and many were not sustained. The systems that were set up to encourage the nurses to systematically question practice and find evidence-based answers to their questions (primarily the link nurse scheme) did not become fully operational. With a few exceptions, enthusiasm for and active participation in the project remained confined to change team members. To some degree, all nurses were resistant to change, but the topics about which they were resistant varied. A small group of nurses (primarily those who worked night duty, part time, or who had worked on the ward for many years) actively resisted almost all the changes agreed to by their colleagues. This group appeared to gain little if anything from the project, despite the efforts of the facilitators to get them involved. Developments on the ward since the completion of the project suggest that changes that did occur were fragile and easily reversed.