Evidence based practice (EBP) is a key recommendation in healthcare delivery. It is interesting to understand barriers and facilitators to the implementation of EBP to realize optimal care outcomes. Although there may be common elements in all care settings, specific contexts may be studied further. This helps clinicians and nurses further decipher how it may be possible to integrate new interventions based on evidence for positive outcomes relating to all stakeholders involved in care delivery.
Geography: United States; Focus Area: Evidence-based practice
Definition and Typical Approach in Implementing Evidence Based Practice
According to John Hopkins Medicine Center for Nursing Inquiry, evidence-based practice involves reviewing, analyzing, and translating the latest evidence to incorporate it with patient preference and clinical experience for informed patient-care decisions. Evidence-based practice facilitates high quality care, lower costs, higher nurse satisfaction, and optimal patient outcomes.
The American Journal of Nursing explains a typical EBP process for clinical decision making. EBP takes place when an inquiry is initiated, formatted using the PICOT approach (population, intervention in area of interest, comparison intervention, outcome, time), evidence searched from available databases with chosen keywords, results combined to find pertinent literature, exclusion criteria applied, and articles appraised for validity, reliability, relevance, and applicability to the clinical question. The evidence is integrated with patient preference and clinical expertise, and outcomes of practice decisions are evaluated. Disseminating EBP results is an important aspect of avoiding duplication of effort.
Promotion: Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice Paperback – Import, 1 October 2018 by Bernadette Melnyk (Author)
Barriers and Facilitators to EBP Implementation
The barriers to implementing EBP are a lack of inclusion into nursing curriculum and a lack of internet search skills to implement EBP. Shayan and team (2019) identified that barriers were related to limited resources, information, lack of institutional support, inadequate staffing, lack of communication and teamwork, negative image about the profession, scope of practice, time constraints, and individual barriers.
Li and team (2019) identified that although nurses had a positive attitude towards EBP, unprepared implementation and insufficient knowledge was a concern. A lack of time and resources made it difficult to transform attitude and knowledge to implementation. Management function, younger age, and academic training were facilitators to EBP success.
Kilbourne and team (2019) describe a relevant concept - the learning health systems such as the US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) roadmap that incorporates implementation science and quality improvement. This approach enables stakeholder participation (consumer, clinician, health leader, administrator) to “plan, deploy, evaluate, and sustain” EBPs in a plausible manner. Barriers and facilitators may be identified and addressed for each care setting. The following section describes the dynamics of evidence-based practice for three specific contexts.
EBP Implementation Cases in Diverse Contexts
Mathieson and team (2018) discuss the implementation of evidence-based practice in community nursing through a framework of barriers, facilitators, and implementation theory in their chosen context. Community nursing has not been studied as much as other health care delivery settings. Practice innovations are not known and seldom translated into care delivery. Researchers found that a limited use of theory and lack of consistent terminology is a potential barrier. The process of implementation requires support from management for successful adoption by the individual and organization. The final decision-maker is the community nurse who influences implementation of the EBP if it has a recognized positive impact on the patient. Community nurses may be motivated by improved patient care and nurse-patient relations, interpersonal relations with healthcare professionals, and professional development. They were also more likely to adopt the innovation when there was autonomy and flexibility.
They were less likely to adopt the innovation in times of organizational change as this made them preoccupied with the ongoing change. They were resistant to the innovation if it was likely to have an adverse influence on their existing relationships. Team reorganization, working with interdisciplinary teams, patient’s unwillingness to comply with the innovation, no significant enhancement in care, and organizational goals were other probable roadblocks. On-going education was a major facilitator, but a lack of time was a barrier to engagement with the EBP.
McArthur and colleagues (2021) discussed the implementation of EBP in long-term care settings. The main barriers identified were cost, inadequate resource and staffing, lack of organizational support and teamwork. Leadership, effective strategies, protocols, and adequate resources and time. Several interventions were identified as feasible such as resident-centered care, environmental restructuring, and neighborhood team development for service reorganization and collaborative care. Change fatigue and knowledge gaps, poor job satisfaction, and work-related burnout were potential barriers. Barriers related to reflective and automatic motivation and psychological capability could be overcome through education and training.
Promotion: Evidence-Based Medicine: How to Practice and Teach it Paperback – 8 December 2010 by Straus (Author)
Finally, in a scoping review pertaining to EBP implementation in stroke rehabilitation, Juckett and colleagues (2020) examined the implementation of occupational therapy interventions for the adult stroke population. They identified that translation of research into practice remains a challenge among rehabilitation professionals. Evidence-based interventions in the domain of stroke are related to postural, functional, cognitive, behavioral, and motor impairments. The implementation of EBP in stroke rehabilitation decreases the effects of disability and enhances the quality of life of stroke survivors.
Researchers identified determinants that impeded and promoted occupational therapy practitioners for EBP implementation. They also examined implementation strategies that encouraged occupational therapy practitioners. There was a difficulty in implementing the EBP when there was inconsistent adherence to the intervention, low rate of adherence, or complexity associated with the intervention. Other barriers were lack of resources, staff, and EBP experts, logistic challenges, inadequate equipment, time constraints, inconsistent leadership engagement, decreased interdisciplinary communication, and perceived ability to implement EBPs. On an individual level, barriers included decreased confidence in utilizing the intervention, lack of knowledge of the intervention, difficulty adopting a new intervention, and an unfavorable view of an EBP.
Facilitators for implementation included electronic education, online support guides, availability of EBP experts, relationship building among stakeholders, and communication from organizational leadership. Factors that predicted successful implementation included the value that practitioners found in an EBP intervention, enthusiasm to support and adopt the intervention in rehabilitation, and a strong working knowledge of available EBP interventions and their clinical applicability. Further, patient preference and engagement strongly predicted successful implementation of the EBP intervention. Acknowledging barriers and facilitators was integral to successful implementation. Implementing the intervention was dependent on practitioner adherence, value placed by practitioner in the intervention, using multimodal knowledge translation or a combination of implementation strategies, and utilizing available EBP tools and resources.
In essence, the successful implementation and dissemination of EBP interventions in diverse contexts depends on identifying barriers and facilitators to implementation. Several stakeholders influence the successful implementation and adherence to a new innovation in EBP including patients, practitioners, the organization, healthcare leadership, and the attitudes and beliefs concerning the intervention.
Nursing, evidence-based practice, PICOT, clinical question, EBP, clinical decision-making, health learning systems, community nurses, nurse-patient relations, stroke rehabilitation, long-term care, EBP intervention, EBP implementation.
Promotion: Evidence-based Practice in Social Work: Development of a New Professional Culture (Core Concepts in Health and Social Care) Paperback – Illustrated, 20 August 2014 by Haluk Soydan (Author), Lawrence A. Palinkas (Author)
Keywords:
stroke rehabilitation, community nurses, evidence-based practice, EBP, Nursing, PICOT, long-term care, clinical question, EBP implementation, clinical decision-making, nurse-patient relations
References
Juckett, L. A., Wengerd, L. R., Faieta, J., & Griffin, C. E. (2019). Evidence-Based Practice Implementation in Stroke Rehabilitation: A Scoping Review of Barriers and Facilitators. American Journal of Occupational Therapy, 74(1), 7401205050p1. https://doi.org/10.5014/ajot.2020.035485 https://doi.org/10.5014/ajot.2020.035485
Kelly, R. (2022). Evidence-Based Practice. Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/evidence-based-practice.html#:~:text=EBP%20is%20a%20process%20used
Kilbourne, A. M., Goodrich, D. E., Miake-Lye, I., Braganza, M. Z., & Bowersox, N. W. (2019). Quality Enhancement Research Initiative Implementation Roadmap. Medical Care, 57, S286–S293. https://doi.org/10.1097/mlr.0000000000001144
Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice. Medicine, 98(39), e17209. https://doi.org/10.1097/md.0000000000017209
Mathieson, A., Grande, G., & Luker, K. (2019). Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: A systematic mixed-studies review and qualitative synthesis. Primary Health Care Research & Development, 20(20). https://doi.org/10.1017/s1463423618000488
McArthur, C., Bai, Y., Hewston, P., Giangregorio, L., Straus, S., & Papaioannou, A. (2021). Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis. Implementation Science, 16(1). https://doi.org/10.1186/s13012-021-01140-0
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. AJN, American Journal of Nursing, 110(1), 51–53. https://doi.org/10.1097/01.naj.0000366056.06605.d2
Shayan, S. J., Kiwanuka, F., & Nakaye, Z. (2019). Barriers Associated With Evidence‐Based Practice Among Nurses in Low‐ and Middle‐Income Countries: A Systematic Review. Worldviews on Evidence-Based Nursing, 16(1), 12–20. https://doi.org/10.1111/wvn.12337
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