Supporting structures of EBP

Why do we need supporting structures for evidence-based practice?

The need for evidence-based practice (EBP) is emphasized in health care, but many barriers relating to EBP are identified. Among them are limited resources in health care and health professionals’ skills for searching evidence (e.g. Shafaghat et al. 2021). In addition, there exists a misunderstanding concerning the process of utilizing evidence. Nurses may think, as was previously taught in evidence-based courses, that it is their duty to define the clinical problem and search for the research literature by themselves, appraise its methodological quality, interpret the results and make conclusions before applying the evidence into practice. These kinds of expectations are not realistic and they hold up the barriers to EBP due to an ever-increasing workload and simultaneous shortage of staff. Instead, nurses need to know where to find reliable synthesized evidence and how to implement it into practice. (e.g. Warren et al. 2016).

Two models, the Action Model of Expertise (FinAME) and Model for Developing Evidence-Based Practices (OMEBP), were developed to support evidence implementation and EBP in nursing.

References:

Shafaghat T, Nasab MHI, Bahrami MA, Kavosi Z, Montazer MRA, Zarchi MKR, Bastani P. 2021. A mapping of facilitators and barriers to evidence-based management in health systems: a scoping review study. Systematic Reviews 10:24.

Warren JI, Lothschuetz Montgomery K, Friedmann E. 2016. Three-year pre-post analysis of EBP integration in a Magnet-Designated community hospital. Worldviews on Evidence-Based Nursing 13:1, 50-58.

The Action Model of Expertise - FinAME

The titles, roles and tasks of different type of experts in healthcare are inconsistent both nationally (Finland) and globally. The inconsistency creates barriers to utilization of experts’ competencies in evidence-based healthcare (EBHC). The AME model describes the roles of four different types of nursing experts and their core competencies in EBHC. The aim of the model is to introduce the issues for further discussion in order to enhance descriptions relating to the roles, tasks and rationales for different nursing expert positions in Finnish social and health care.

The first draft of the model (formerly known as AME) was developed in Oulu University Hospital in Finland. The FinAME was further developed in a Steering Group for Development of Nursing Care set up by the Ministry of Social Affairs and Health (Finland) and published in the Action Plan ‘Increasing the effectiveness and attraction of nursing care by means of management’ by the Ministry of Social Affairs and Health (2009). In recent years, the Nursing Research Foundation (NRF) has further developed AME which is nowadays known as FinAME. Currently in cooperation with the University of Oulu and an expert group coordinated by the Finnish Nurses Association the model has been expanded to describe also the core competencies of nursing educators, managers and clinical researchers in EBHC based on the JBI model of EBHC (including global health, evidence generation, evidence synthesis, evidence transfer, evidence implementation; publication of the updated model in process).

Consistent Nursing Practices - A Model for Developing Evidence-Based Practices (OMEBP)

The realization of the EBP requires implementation of the best available evidence into practice, and thus, the development of consistent evidence-based practices. The aims of evidence-based consistent practices are to decrease unjustified variations in clinical care and improve quality of care. Thus, the consistent practices enable healthcare consumers to receive the best possible care regardless of where they live and who is the care provider. (Jylhä et al. 2017.)

Responsibilities in the development of consistent evidence-based practices at different levels of the healthcare system are presented in the table below:

Table 1. Responsibilities at different levels of health-care systems for developing consistent EBP

International cooperation along with national improvements are important in the establishment of evidence-based healthcare (EBHC). Researchers at international and national level conduct reliable studies for evidence synthesis and make evidence available for transfer and implementation.

At the national level collaboration is required between nursing/midwifery leaders to create a supportive organizational culture and ensure consistent structures for evidence-based practices (EBP) in healthcare organizations, such as in different kind of special healthcare and primary care context, third sector organizations (e.g., Mathieson et al. 2019, Shafaghat et al. 2021). In addition, collaboration between educators is needed to ensure utilization of the best available evidence in the development of curricula for training competent staff for EBHC (e.g., Horntvedt et al. 2018). The utilization of synthesized evidence requires national strategies and structures prior to evidence dissemination and implementation. Further, it is important to make an agreement which (national bodies) are responsible for producing and disseminating reliable clinical guidelines or other forms of evidence at the national level.

Collaboration at the local level enables effective knowledge transfer of the best practices, and identification of the local context and development needs. It is recommended that healthcare organizations and educational institutions actively participate in collaboration to improve EBPs in local settings. At the local level, leaders in nursing and midwifery decide the strategic directions of the development of consistent EBPs and coordinate the implementation of national strategies.

Organisations have responsibility to establish the necessary structures that support EBPs to ensure competency of the healthcare professionals, to collect information on the outcomes of care and to improve practices if needed. Responsibilities also include the development of evidence-based tools to receive feedback and information for leaders about professionals’ compliance with EBPs. The development of consistent EBPs in nursing and midwifery requires that nurses and midwifes are aware of the evidence-based clinical practice guidelines, systematic reviews and recommendations that form the basis for consistent practices and good patient care. Thus, one central factor in the successful dissemination of evidence is effective communication channels within the organizations.

The Operational Model for Developing Evidence-Based Practices (OMEBP) is used as a framework for consistent practice development, see figure below:

Figure 1. A Model for Developing Evidence-Based Practices (©Nursing Research Foundation)

The model consists of four main phases:

(1) assessing development needs for current practice to assess whether the current practice is in line with the best evidence (e.g. clinical guidelines);

(2) creating a plan to make the practice consistent with the evidence, and changing the current practice according to the best evidence if needed;

(3) describing consistent EBP and then disseminating and implementing the new practice during decision-making to improve the consistency between practice and the best evidence;

(4) continuing to evaluate and follow up on the practice to establish the best evidence in practice and to ensure that no unjustified variation in practice occurs.

(Jylhä et al., 2017; Suhonen et al., 2019)

The main point is that consistent EBP represents evidence in the decision-making. In addition, decisions should consider the patients’ context, circumstances and preferences, and clinical context (setting), resources and circumstances. Practitioners (e.g. nursing staff) use all this information when they make decisions with patients about their care in multidisciplinary collaboration (Jylhä et al., 2017).

It is described below (Figure 2) how consistent EBPs are developed at unit or ward level. After the EBP is developed, it helps in decision-making between patient and nurse/midwife.

Figure 2: Developing EBP at unit or ward level

 

References:

Holopainen A, Korhonen T, Miettinen M, Pelkonen M, Perala M-L. Hoitotyön käytannöt yhtenäisiksi – toimintamalli näyttöön perustuvien käytäntöjen kehittämiseksi [Consistent nursing practices – a model for developing evidence-based practices]. Premissi 2010; 1:38–45 (in Finnish).

Horntvedt M-ET, Nordsteien A, Fermann T, Severinsson E. 2018. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Medical Education 18(1): 172.

Jylhä V, Oikarainen A, Perälä M-L, Holopainen A. 2017. Facilitating evidence-based practice in nursing and midwifery in the WHO European Region. Geneva, Switzerland, World Health Organization.

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: e6.

Shafaghat T, Nasab MHI, Bahrami MA, Kavosi Z, Montazer MRA, Zarchi MKR, Bastani P. 2021. A mapping of facilitators and barriers to evidence-based management in health systems: a scoping review study. Systematic Review 10:24.

Suhonen R, Ylönen M, Jalonen L, Holopainen A. 2019. Leading Evidence-Based Practice in Finnish Healthcare. In: Hafsteinsdóttir H, Jónsdóttir H, Kirkevold M, Leino-Kilpi H, Lomborg K, Rahm Hallberg I. (Editors). Leadership in Nursing: Experiences from the European Nordic Countries. Springer, Switzerland, 83-98.