Evidenced-Based Practice: Shocking barriers to its Implementation

Evidenced-Based Practice: Shocking barriers to its Implementation

Paula M. Grech

Department of Nursing, Eastern Michigan University

NURS 265: RN Essentials of Professional Nursing Practice

June 18, 2020

Introduction

           Despite 20 years of advocacy, the adoption of evidence-based practice (EBP) in nursing has been slow. According to Gallagher-Ford and Connor (2020), approximately 30% of healthcare decisions are evidence-based. This is far short of the goal set by the Institute of Medicine, which has established the objective for 90% of healthcare decisions to be evidence-based by 2020. Medical errors continue to be the 3rd leading cause of death in the US (Gallagher-Ford & Connor, 2020). Conducting EBP nursing research is not the problem; there is a lag in research dissemination ranging from seven to 17 years (Remus & Donelle, 2019). As of 2016, more than one-third of our hospitals were not meeting the National Database of Nursing Quality Indicators (NDNQI) evidence-based performance metrics. (Melnyk et al., 2016). EBP skills are a part of nursing education, embedded in new hire orientations, and offered to staff as professional development courses, yet organizations struggle to implement nursing EBP (McNett & Melnyk, 2019).  

           Why, despite an increase in nurse training and interest in implementing EBP, are nurses not practicing it? One reason is that there is a disconnect in the C-suite: the health organizations’ most important senior chief executives. Chief Nursing Officers (CNOs) believe EBP leads to increased quality and safety, yet many do not spend enough on EBP nor champion its use through mentors (Melnyk et al., 2016). Paradoxically, technology also holds nurses back. IT spending and data management in healthcare is among the lowest in the US (Herzlinger, 2006). Currently, EBP does not reside in the place where it can make the most impact: inside the electronic health record (EHR) at the point of care. As a result, there are two substantial consequences: 1) EBP is not dispersed and practiced at the bedside at the frequencies that it should, and 2) healthcare organizations are under-utilizing “big data” collected in the EHR. This untapped resource of health information has enormous potential to revolutionize EBP into its next iteration: “practice-based evidence.”

The Dissociation between EBP and Quality and Safety in the C-suite

           A survey of 276 CNOs found that quality and safety were listed as top priorities, but EBP was at the bottom of the list for all but 3% of the CNOs. In the same study, 74% of CNOs invested 0% to 10% of their operating budgets on building and upholding EBP in their organizations, although most CNOs stated that they believe EBP leads to high-quality care (Melnyk et al., 2016). If CNOs understand that EBP is a key driver to achieving quality and safety, why is there a disconnect? Implementation science is the study of “why”; each “why” is highly specific to each organization and dependent on contextual factors (McNett et al., 2019). 

           To start, there is no consensus on what constitutes best practice for nursing informatics governance. Nursing policies are authored by various groups within institutions, including nurses, Corporate Compliance Officers, Chief Medical Officers, and in some cases IT (Chipps et al., 2020). Policies must adhere to federal, state, and The Joint Commission’s Comprehensive Accreditation Manual for Hospitals guidelines. Sometimes, entire pages are simply copied and pasted from nursing textbooks or commercially available EBP policies into templates (PolicyMedical, n.d.). When nurses do carry out EBP research, the road to implementation is slow moving. Chipps et al. (2020) report that EBP utilization is held back by many organizational layers. The vetting process inside hospital organizations is complicated; this is compounded by a lack of EBP mentors and champions within institutions. 

           Nurse informaticists (NIs) are specially trained and particularly suited to be EBP champions within hospitals. NIs integrate nursing science using information and analytical disciplines to create, manage, and propagate EBP; they are the practitioners of implementation science within health organizations. One study reported that only 1/3 of organizations have a Chief Nursing Informatics Officer (CNIO) to help facilitate EBP (Chipps et al., 2020). CNOs must prioritize EBP and invest in NIs to sustain it. It is not enough to ask nurses to research and implement EBP to make it standard operating procedure. Transformation to an EBP culture requires mentors, champions, and an engaging team vision from leadership (Melnyk et al., 2016).

Lack of Sufficient IT Infrastructure Makes it Difficult to Innovate and Integrate

           The need for buy-in in the C-suite is only one reason nurses are behind in EBP implementation. Deficiencies of IT infrastructure and data management also make it difficult to develop and incorporate EBP. As mentioned above, healthcare spending on IT and data management is low in the US (Herzlinger, 2006). According to Diana (2020), due to the nature of their “mission-critical” work, healthcare institutions are cautious when it comes to technology innovation; most wait to see how new technologies pan out for other organizations before implementing them. However, organizations that are early adopters, like Kaiser Permanente and John Hopkins, reap valuable returns. Moreover, government regulations demand that new technology is safe, that it keeps patient information secure, and that it does what it claims at less cost than what is currently being used (Herzlinger, 2006). Relatedly, servers are run on versions of operating systems that are three releases behind (Tung, 2019), and some nursing policies and protocols remain on paper. The EBP that resides in digital databases is not often integrated into the EHR (Bonis, 2014; Gabel Speroni et. al, 2020). As a result, the standard of nursing care varies from institution to institution, and even department to department in the same hospital (Rapin et. al, 2019). A devastating amount of patient death and injury has been attributed to this fluctuation in the level of care in US healthcare systems (Gallagher-Ford & Connor, 2020).

           Nurses need to access EBP quickly and at the point of rendering care. Accordingly, EBP policy and checklist integration with the EHR is key. More than 20 studies show that integration of clinical decision support into electronic health record systems can improve nursing care (Bonis, 2014; Gabel Speroni et. al, 2020). Lack of EBP integration into the EHR decreases its use (Bonis, 2014). Chipps et al. (2020) report that part of the lack of integration stems from the fact that EHR systems are large and changes have to be implemented system-wide. Once an EBP EHR change is approved, it can take IT 6 months to 2 years to implement (Chipps et al., 2020).

           One solution is to integrate one of the several commercially-available nursing EBP databases. According to Andrea Carr, Vice President of Nursing Practice, Staff Development, and Magnet Program at Beaumont Health, licenses purchased to use Lippincott Procedure, Lippincott Advisor, UptoDate, and Lexicomp within the Epic EHR allow Beaumont nurses to tap into nursing EBP databases at the point of care. This helps nurses integrate EBP into their practices more easily (A. Carr, personal communication, May 28, 2020).

           As with the use of in-house NIs, robust IT is necessary to gather and disseminate best practices to nurses (Herzlinger, 2006). IT innovation can connect the fragmented information silos in our health care system, resulting in quality improvement and lower cost of nursing care. The use of evidence-based automated tools is promoted in the Health and Human Services “2020-2025 Federal Health IT Strategic Plan” (Golder, 2020). CNOs and chief executive of?cers need to prioritize EBP by investing in IT.

           Nursing Data Standards Will Revolutionize EBP Into Its Next Iteration: Practice-Based Evidence

           Investing in IT will also help usher in what will be the next version of EBP: practice-based evidence. Healthcare organizations are sitting on mountains of data collected through the EHR. This data has immense potential to become a clinical information system (CIS). Just as Facebook mines users’ digital data to serve them targeted ads at specific moments, CISs can support real-time, evidence-based practice decisions (Remus & Donelle, 2019). For this to work, EHRs must use consistent nursing data standards. The American Nurses Association currently supports 12 terminology standards for clinical coding purposes. These terminology standards include the International Classification of Nursing Practice (ICNP), the Nursing Minimum Data Set, and the Systematized Nomenclature of Medicine-Clinical Terminology (Remus & Donelle, 2019). Huard and Monsen (2017) surveyed 360 healthcare organizations in Minnesota. They found that while 92% of these institutions used EHRs, only 30% of them used a standardized nursing terminology inside their EHR. In other words, the lack of standard terminology to document nursing assessments, interventions, and outcomes prevents them from using their data for research.

           The field of data science can enable informatics-savvy nurses to lead the clinical transformation of evidence-based practice to practice-based evidence using EHR data (Remus & Donelle, 2019). NIs are the healthcare professionals that have the necessary informatics competencies to lead this transformation.

           In the future, nurses will be “armed” with decision support tools from the EHR that give “real-time” information to inform patient care. CNOs and NIs could be strategically positioned with real-time data to form decision-making that not only “supports fiscal mandates but also facilitates sustainable healthcare delivery” (Remus & Donelle, 2019). “Big data” is working for other industries, why couldn’t it work for ours? 

Conclusion

           Nursing EBP should be led from top-down, not from bottom-up. Nurses are educated and skilled in creating EBP; however, implementation is not easy. NI-lead EBP champions and mentors are needed to cut through the red tape and make evidence-based culture a reality. CNO and C-suite investment in powerful IT and technology systems are necessary to make EBP the foundation of care through EHR delivery (Melnyk et al., 2016). Implementing nursing EBP nationally is possible, and it will lower undesired patient outcomes, disability, and death. (Bonis, 2014; Chipps et al. 2020). Using standard nursing data sets can transform EBP into practice-based evidence. Healthcare workers — and consumers — can finally reap the rewards of “big data” made possible by data mining in EHRs (Remus & Donelle, 2019). Quality improvement and transparency will enable nurses to provide the very best care possible and allow healthcare consumers to know what they are getting.

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