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Editorial: Advancing Evidence-based Practice
What is the best strategy to merge evidence-based practice (EBP) with cost reduction, quality care, and successful patient outcomes? Within the literature, no single approach immediately rises to the surface. So, how do we realistically move forward in rehabilitation nursing and neuroscience, in particular, to promote EBP?
As a result of advances in communication, technology, diagnostic procedures, pharmacokinetics, and other treatment modalities, the care of patients with neurological disorders such as stroke and Parkinson’s disease have been transformed, enabling more individuals to lead active and fulfilling lives. As rehabilitation nurses, we must recognize that EBP is not a simple process, nor readily accepted by all healthcare professionals. Although the knowledge, technology, and practice guidelines are in place for EBP in numerous practice areas, often the highest quality care is still not delivered. Studies involving countries such as the United States and Netherlands, for instance, suggest that at least 30%–40% of patients do not receive care according to current scientific evidence, while another 20% or more of the provided care is either not needed or potentially harmful to patients (Grol & Grimshaw, 2003). Other data indicate that, on average, 17 years are required for new knowledge generated by randomized control trials (the highest level of scientific evidence) to be incorporated into practice and even then the application is highly irregular (Balas & Boren, 2000; IOM, 2001).
A blend of individual, interpersonal, and system factors contribute to this delay in implementation, but there are countless actions that rehabilitation nurses can take to participate in addressing the barriers while creating incentives to embrace EBP. First, rehabilitation nurses need to maintain their creativity and pose those important questions that stimulate the research and reject the status quo when obviously it is not contributing to the patient’s well being. As part of these activities, nurses should consider a framework or model that helps to structure and evaluate the outcomes of their interventions that will help to build EBP and place it within a context. For instance, how might Social Cognitive Theory affect the research question, design, execution and interpretation of findings when applied to educating newly diagnosed diabetic patients and their families regarding insulin administration, foot care, and diet?
Along with supporting and conducting well- designed research studies, nurses must routinely publish their research, so other clinicians have access to a body of scientific literature to locate, scrutinize, and apply as appropriate to their practice settings. Astute clinicians are a vital aspect of this evidence-based equation enabling rehabilitation nursing to move to the next level. Without those dedicated nurses who diligently review and synthesize the evidence and develop practice guidelines, the likelihood of improving care will not systematically occur and those unanswered practice questions may not be identified.
However, even if there are researchers and clinicians who value EBP, there remains another daunting challenge related to implementation of EBP and sustaining these practice changes in a multi-faceted, dynamic healthcare setting among professionals who do not always readily embrace change. It is this variability (i.e., size and mission of organizations; organizational culture, skills and education of staff; volume of patients; geographic location; and many other factors) that affects the performance, continuity, acceptance, and internalization of EBP. More studies are being performed to determine specific barriers and promoters of change in particular care situations. Grol and Grimshaw (2003), for instance, in a study examining the failed implementation of evidence pertaining to hand hygiene, identified that lack of awareness, inadequate staff knowledge, absence of reinforcement regarding performance of the recommended practice, limited staff control, and varying social norms, leadership, and facilities affected adherence to the EBP standards. Studies such as these should continue as we build the science that determines strategies that contribute to EBP’s usage and sustainability.
EBP is the gold standard to which we must all aspire, but at the same time we need to accept that this scientific foundation is not static. Just as we all feel comforted by “norms” or “standards,” evidence will be subject to further refinement, which will require nurses to carefully examine the quality and applicability of current evidence affecting practice.
We all have a role in developing, as well as implementing, EBP in neuro-rehabilitation units or other practice areas. Change is difficult and requires movement out of our comfort zone. By looking ahead, rather than back, EBP offers a wonderful opportunity to improve care of patients and their families while enabling us to refine our practice. EBP is here to stay and, as professionals, we must embrace it. But we must also share the successes and failures that provide the scientific foundation for moving forward.
Balas, E.A., & Boren, S.A. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of Medical Informatics. National Library of Medicine: Bethesda, MD.
Grol, R., & Grimshaw, J. (2003). From the best evidence to best practice: effective implementation of change. Lancet, 362, 1225–1230.
Institute of Medicine, Committee on Quality of Health Care in America (2001). Crossing the quality chasm: A new health system for the 21st century (J. M. Corrigan, M. S. Donaldson, L. T. Kohn, S. K. Maguire, & K. C. Pike, Eds.). Washington, DC: National Academies Press.