Nurse leader resistance perceived as a barrier to high-quality, evidence-based patient care

August 29, 2012 by Emily Caldwell, Ohio State University

(Medical Xpress)—A new national survey of more than 1,000 registered nurses suggests that serious barriers - including resistance from nursing leaders - prevent nurses from implementing evidence-based practices that improve patient outcomes.

When survey respondents ranked these barriers, the top five included from nursing leaders and nurse managers - a finding that hasn't been reported in previous similar studies - as well as politics and organizational cultures that avoid change.

When asked what would help them implement evidence-based practice, respondents reported education, access to information and organizational support among their top five needs.

Evidence-based practice refers to making decisions about that are based on the best evidence produced by well-designed . Numerous studies have suggested that evidence-based care of patients can reduce patient complications and decrease by as much as 30 percent.

Overall, a little more than half of respondents reported that evidence-based practice was consistently used in their organization, but only about one-third said their colleagues consistently used these practices.

The respondents with more education tended to have more confidence in implementing evidence-based practice. However, the longer nurses had been working in health care, the less interested they were in learning more about evidence-based practice.

"This was a distressing finding," said Bernadette Melnyk, the dean of the College of Nursing and chief wellness officer at Ohio State University as well as lead author of the study. "And it's a huge problem. The average age of nurses is 47, and they were educated at a time when evidence-based practice was not well integrated into educational programs. As a result, many nurses are practicing the way they were taught or steeped in tradition of the health-care system in which they work. When new who have learned to take an evidence-based approach to care are meeting these nurses in real-world settings, they encounter this prevalence of a 'this is the way we do it here' culture."

Melnyk said the findings indicate the need for widespread cultural change in health-care settings and a new direction in nursing education, where many current faculty tend to emphasize teaching rigorous research methods and critique of existing research rather than how to put research findings to use in clinical practice settings. She also said consumers should feel empowered to ask whether they are receiving evidence-based care.

The study is published in the September issue of the Journal of Nursing Administration.

Examples of care that is not based on evidence are not that hard to find, noted Melnyk, a longtime consultant with health systems on implementation of evidence-based practice and a former member of the U.S. Preventive Services Task Force. It's not uncommon for children suffering asthma attacks to receive a drug to open their airways with a nebulizer in an emergency room, when research has shown that using a metered-dose inhaler with a spacer instead leads to fewer side effects, less time in the emergency room and lower likelihood for hospitalization. And patients with depression typically receive an antidepressant prescription and nothing else despite research-based evidence that cognitive behavior therapy is more effective than medicine for mild to moderate depression.

The Institute of Medicine (IOM) issued a report in 2003 calling for health professional education programs to include evidence-based care among five core competencies. The IOM has set a goal that 90 percent of all patient-care decisions be based on evidence by 2020.

A survey of nurses in 2005 conducted by a different research group suggested that the profession wasn't ready then to adopt evidence-based care.

"Now, in 2012, they believe in it and they're ready for it," said Melnyk, also associate vice president for health promotion at Ohio State. "But there are so many barriers that continue to exist in our health-care system and our educational system.

"Another disconcerting finding in our survey was that a substantive number of nurses said their leader or manager is resistant to evidence-based practice. What I've seen as a consultant is a lot of leaders and managers will say they want their clinicians to deliver evidence-based care, but they don't walk the talk. If leaders do not role model evidence-based decision-making and they are not providing tools, education and resources for their clinicians to get the knowledge and skills they need to consistently implement this, it's probably not going to happen nor will it be sustained."

Melnyk and colleagues solicited potential participants via emails sent to 20,000 randomly selected members of the American Nurses Association. Of those, 1,015 members completed the survey.

The survey contained questions about the state of evidence-based practice from each respondent's perspective as well as two open-ended questions: what one thing prevents respondents from implementing evidence-based practice in daily clinical care, and what one thing would help them the most to implement this care.

Respondent ages ranged from 21 to 79 years, and 93 percent were female. Nearly 56 percent held master's degrees or higher, and 44 percent had earned a bachelor's, associate degree or diploma. The average number of years in nursing practice was 24, representing a range of zero to 52 years. Almost 47 percent worked in community hospitals and 23 percent practiced in academic medical centers. A quarter of respondents described themselves as nurse educators.

While 46.4 percent of respondents agreed that findings from research studies are routinely implemented to improve at their institution, more than three-quarters, 76.2 percent, indicated that it was important for them to receive more education and skills building in evidence-based practice. Fewer than a third of respondents reported that mentors were available in their health-care settings to help them learn more about how to adopt these practices.

Nurses working in hospitals with Magnet designation, awarded by the American Nurses Credentialing Center for excellence in nursing, were more likely to report the adoption of evidence-based care at their institutions, plenty of educational opportunities to gain skills in this care, and organizational cultures that supported the use of evidence in delivering care.

As for her own educational institution, Melnyk said that when she arrived at Ohio State one year ago, she held workshops on evidence-based practice with faculty "so we made sure we were talking the same language and were committed to integrating this even further throughout our curriculum. It is being strengthened all the time."

The college has also launched a Center for Transdisciplinary Evidence-based Practice to facilitate the implementation and sustainability of evidence-based practice throughout Ohio State's health-care system as well as at others across the country.

"Educational programs are behind on this. Many tend to still teach students at the bachelor's and master's levels the rigorous process of how to do research versus how to use the research that's being produced and get it into the real-world setting at a much faster pace," she said.

"Unless we have some drastic changes in both our clinical practice environment as well as our education systems, it's going to be a long haul until every clinician in this country consistently delivers evidence-based care."

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