Barriers, challenges, and strategies Essay

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Most clinical health care workers are aware that achieving the paradigm of evidence-based practice (EBP) is the gold star standard that one strives for in his/her clinical practice. EBP is expected of healthcare clinicians and has become a synonym for quality care both by the institution of healthcare and its consumers (Brim & Schoonover, 2009). This essay will define EBP for nurses. The barriers, challenges and strategies to implementing evidence-based nursing practice (EBNP) will be discussed with reference to relevant and authoritative literature. As well, the relevance and the links that EBNP has with the clinical area of Intensive Care will be discussed. EBP is the integration, by clinicians, of clinical expertise which is meticulous, explicit and uses current clinically appraised professional knowledge (Eizenberg, 2011; Kenny, Richard, Ceniceros, & Blaize, 2010).

EBP accommodates patient preferences, views and values; while also guiding, supporting, validating and answering health care workers clinical judgements, practices, and questions (Eizenberg, 2011; Kenny et al., 2010; Matula, 2005; Wolf, 2005). EBP is a process of asking a clinical question; searching for clinical evidence; critically appraising this evidence and then expertly integrating this evidence with patients values, views and preferences; evaluation of how the changes to practice have had on outcomes; and finally disseminating the results that the EBP or change had on patient outcomes (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010). The definition of EBP and EBNP and the implementation of EBNP appear to be straightforward and easily accomplished; however, EBNP implementation is far removed from being easy (Brim & Schoonover, 2009; Cullen, Titler, & Rempel, 2011; Eizenberg, 2011; Kenny et al., 2010; Tolson, Booth, & Lowndes, 2008). Nursing research has uncovered numerous challenges and barriers which the implementation of EBNP faces. These challenges and barriers can be classified as a research, a clinician, an organisational, a nursing professional barrier, and not least patient barriers (Fernandez, Davidson, & Griffiths, 2008; Gerrish et al., 2011; Hutchinson &Johnston, 2006; Ross, 2010).

Eizenberg (2011), Gerrish et al. (2011), and Ross (2010) found that nurses face research and clinician barriers that include not having the time, skills and knowledge to critically critique and/or synthesise research literature, unable to effectively use and search databases electronically, hold negative views toward research and feel research is too complex, as well research at times is not clear on how to implement the findings and findings can be contradictory. Due to these barriers, nurses tend to rely on synthesised evidence such as evidence-based protocols, policies and procedures (Gerrish et al., 2011). Eizenberg (2011) and Gerrish et al. (2011) also found that nurses prefer to acquire information through third parties such as their colleagues, the workplace, through patient care experience, and the knowledge they received from their nursing education. Eizenberg (2011) found that the organisation is the greatest factor in successful EBNP implementation.

The organisation controls access and the budget to and for evidence resources such as computers with internet access, a well-equipped library, and access to educational opportunities in EBNP procedures and theory (Eizenberg, 2011). The barrier of not having the authority to change a nursing practice also lies with the organisation a nurse may have the necessary research knowledge and experience to effectively change practice but cannot implement practice change due to the organisation not giving him/her the authority to instill change (Eizenberg, 2011). Few nursing staff members are given the opportunity to participate in the development of evidence-based policies and procedures; therefore, most nurses are not engaged to support EBP.

Ross (2010) further found organisational barriers such as the organisation giving priority to other goals (for example excess sick leave) over EBNP, the organisation may perceive that the staff are not ready or willing to implement EBNP, and that the organisation believes EBNP is unachievable. These organisational barriers prevent EBNP being accomplished and to the greater extent of not being implemented. A barrier of nursing profession relates to the medical dominance of healthcare; as such, nurses are not afforded the power, authority, autonomy and respect from colleagues for nursing practice that the status of being a profession decrees (Brim & Schoonover, 2009; Eizenberg, 2011; Gerrish et al., 2011).

A further nursing profession barrier is it can be difficult to instill enthusiasm or information about an EBNP if turnover is high; there is a shortage of experienced nurses; and support from colleagues is lacking (Gerrish et al., 2011; Mark, Latimer, & Hardy, 2010). Due to high turnover and staff shortages, nurses are unable to leave the bedside and have limited time to participate in EBNP projects such as journal clubs, or to attend training in EBP, PICO (Population/Intervention/Comparison/Outcome), and database searches (Brim & Schoonover, 2009; Brown, Johnson, & Appling, 2011). Nurses, as Kenny et al. (2010) found were hesitant to change their practice if the change would perceivably increase an already heavy workload. Brim & Schoonover (2009) found that some nurses believed EBNP to be an optional course of action as they were never shown a clear direction of what EBNP is essential to nursing and his/her practice. One of the main premises of EBNP is that the evidence and the values and beliefs of the patient/s are synthesised together to form an EBNP which is foremost favourable for a positive outcome for the patient/s (Fernandez et al., 2008).

Such factors as treatment, travel, and prescription costs; denial of diagnosis; inadequate knowledge level of disease and strategies to decrease risk factors; lack of social support; and cultural issues can all potentially become barriers to implementing an EBNP for a patient or patients (Fernandez et al., 2008). The high acuity of an intensive care unit (ICU) patient significantly affects a nurses ability to search a database for answers (Brim & Schoonover, 2009; Kenny et al., 2010). An answer to a question is usually needed immediately or momentarily; therefore, ICU nurses rely on experience, colleagues, and knowledge of evidence-based policies, procedures and guidelines (Eizenberg, 2011; Gerrish et al., 2011). I know I rely heavily upon in-services, experience, and speaking with the ICU Clinical Nurse Educators and Nurse Educators who will do a literature search to acquire information or answers to a question I have posed but once again this evidence/information has been synthesised by others and is third hand and I have not fully practiced EBN (Eizenberg, 2011; Gerrish et al., 2011).

To try and challenge this barrier I do try and read the clinical information the educator obtained at a later date usually at home or on a break. Strategies to overcome these challenges and barriers abound from EBP and EBNP journal articles and books. Some of the leading strategies are for the organisation to fully support EBNP through infrastructure, strong leadership from nurse managers and/or advanced practice nurses, and by ensuring a context in which EBNP can flourish (Gerrish et al., 2011; Tolson et al., 2008). The infrastructure needs to provide access to a computer which can access online databases. Infrastructure needed to be in place includes a staffed evidence based nursing library with a librarian able to educate nurses on the process of EBNP (Pochciol & Warren, 2009). The added challenge is to have EBNP info accessible to the nurse at the patients bedside (Pochciol & Warren, 2009).

Nursing leaders need a Masters degree or above, as studies show that leaders with these credentials read and implement more research literature; are more confident; and they consider themselves more competent in supporting others through the EBNP process (Eizenberg, 2011; Gerrish et al., 2011). Leaders, as suggested by Cullen et al. (2011), hold the responsibility to provide support; to build, to create, and maintain an organisational culture that has the capacity to support EBP at both a clinical and administration level. Leaders must be given the power, authority, and support to introduce change without this authority change cannot occur (Eizenberg, 2011). Scholars agree that if EBNP is to succeed and be sustainable nurses need to be educated and mentored on the implementation process of EBNP (Brim & Schoonover, 2009; Brown et al., 2011; Eizenberg, 2011; Gerrish et al., 2011; Pochciol & Warren, 2009; Ross, 2010; Tolson et al., 2008).

EBNP education of nurses needs to begin at orientation to the hospital and is essential that this education is continually built upon and supported with extra education given to nurse managers, educators and advanced practice nurses (Pochciol & Warren, 2009 & Tolson et al, 2008). Ross (2010) suggests nurses information literacy be improved to ensure nurses are able to practice EBN. Information literacy is the ability to competently recognise, locate, and evaluate the fundamental information required at a given point (Ross, 2010). The ICU, where I am employed, has undergone significant changes to the staff and managerial side of the unit. At one point the Clinical Nurse Specialists ratio decreased to less than 5% of nursing staff and there was not a permanent full time Clinical Nurse Consultant. Without the necessary support acquired from these roles the education of ICU nurses and the implementation of new practices, policies and procedures decreased significantly.

These barriers significantly halted EBNP from occurring in the ICU as there were very few highly educated leaders available to support EBNP. As suggested by Eizenberg, (2011), Gerrish et al. (2011), and Cullen et al. (2011), educated leaders and managers are needed to keep and instill EBNP to an institution. To obtain Magnet Status hospitals must ensure that EBNP is in place, is supported, and is sustained by the organisation (Brown et al., 2011). To procure nurse interest in EBNP, and maintain Magnet Status, some hospitals have linked participation in EBNP to clinical ladder advancement and a monetary reward in the form of a wage increase with advancement up the ladder (Whitmer, Aver, Beerman, & Weishaupt, 2011). To hold their position on the clinical advancement ladder the nurse must show, yearly, that he/she is supporting, or implementing, or participating in EBNP within the setting they are employed (Whitmer et al, 2011).

The benefits of practicing EBN includes: patients ability to access effective evidence based treatment information; facilitates consistent improvement, through decision making, to healthcare systems; facilitates decisions based on up-to-date evidence and technologies; and reduces variances in nursing care from one nurse to another standard and competencies are evidence based and consistent; through evidence based competencies the professional status of nursing is elevated to higher heights (Gerrish et al., 2011; Eizenberg, 2011). In conclusion, the challenges/barriers, barrier strategies, and benefits of EBNP has been discussed. Little discussion on EBNP within an ICU was attempted as the ICU nurses face the same situations, challenges/barriers, strategies and benefits as nurses in other areas of healthcare (Sciarra, 2011). Nurses must be given organisational support, education and knowledge needed to participate proficiently in EBNP.

Brim, C. B., & Schoonover, H. D. (2009). Lessons learned while conducting a clinical trial to facilitate evidence-based practice: the neophyte researcher experience. The Journal of Continuing Education in Nursing, 40(8), 380-384. DOI: 10.3928/00220124-20090723-06 Brown, C. R., Johnson, A. S., & Appling, S. E. (2011). A taste of nursing research: an interactive program, introducing evidence-based practice and research to clinical nurses. Journal for Nurses in Staff development, 27(6), E1-E5. DOI: 10.1097/NND.0b013e3182371190 Cullen, L., Titler, M. G., & Rempel, G. (2011). An advanced educational program promoting evidence-based practice. Western Journal of Nursing Research, 33(3), 345-364. DOI: 10.1177/0193945910379218

Eizenberg, M. M. (2011). Implementation of evidence-based nursing practice: nurses personal and professional factors? Journal of Advanced Nursing,
67(1), 33-42. DOI: 10.1111/j.1365-2648.2010.05488.x

Fernandez, R. S., Davidson, P., & Griffiths, R. (2008). Cardiac rehabilitation coordinators perceptions of patient-related barriers to implementing cardiac evidence-based guidelines. Journal of Cardiovascular Nursing, 23(5), 449-457. Gerrish, K., Guillaume, L., Kirshbaum, M., McDonnell, A., Tod, A., & Nolan, M. (2011). Factors influencing the contribution of advanced practice nurses to promoting evidence- based practice among front-line nurses: findings from a cross-sectional survey. Journal of Advanced Nursing, 67(5), 1079-1090. DOI: 10.1111/j.1365-2648.2010.05560.x Hutchinson, A. M., & Johnston, L. (2006). Beyond the BARRIES Scale: commonly reported barriers to research use. Journal of Nursing Administration, 36(4), 189-199. Kenny, D. J., Richard, M. L., Ceniceros, X., & Blaize, K. (2010). Collaborating across services to advance evidence-based nursing practice. Nursing Research, 59(1S), S11-S21. Mark, D. D., Latimer, R. W., & Hardy, M. D. (2010). Stars aligned for evidence-based practice. A TriService initiative in the Pacific. Nursing Research, 59(S1), S48-S57. Matula, P. (2005). Evidence-based practice at the bedside: Igniting the spirit of inquiry. The Pennsylvania Nurse, Dec, 22.

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). The seven steps of evidence-based practice. Following this progressive, sequential approach will lead to improved health care and patient outcome. The American Journal of Nursing, 110(1), 51-53.

Pochciol, J. M., & Warren, J. I. (2009). An information technology infrastructure to enable evidence-based nursing practice. Nursing Administration Quarterly, 33(4), 317-324. Ross, J. (2010). Information literacy for evidence-based practice in perianesthesia nurses: readiness for evidence-based practice. Journal of PeriAnesthesia Nursing, 25(2), 64-70. DOI: 10.1016/j.jopan.2010.01.007

Sciarra, E. (2011). Impacting practice through evidence-based education. Dimensions of Critical Care Nursing, 30(5), 269-275. DOI:
10.1097/DCC.0b.013e318227738c Tolson, D., Booth, J., & Lowndes, A. (2008). Achieving evidence-based nursing practice: impact of the Caledonian development model. Journal of Nursing Management, 16, 682-691. DOI: 10.1111/j.1365-2834.2008.00889.x

Whitmer, K., Aver, C., Beerman, L., & Weishaupt, L. (2011). Launching evidence-based nursing practice. Journal for Nurses in Staff Development, 27(2), E5-E7. DOI: 10.1097/NND.0b013e31820eefd2
Wolf, Z. R. (2005). Clinical challenges and evidence based nursing practice. The Pennsylvania Nurse, Dec, 20.

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