Why do we need supporting structure for evidence-based practice?
The need for evidence-based practice (EBP) is emphasized in health care. Many barriers relating to EBP are identified, among them lack of time and skills for searching evidence (Kajermo et al. 2008). In addition, there exists a misunderstanding concerning the process of utilizing evidence. Nurses may think, as was previously taught in evidence-based courses, that they have to define the problem by themselves, search for the evidence, appraise its methodological quality, interpret it and make conclusions before applying the evidence into practice (Heiwe et al. 2011). Such misunderstandings keep up barriers to EBP due to an ever-increasing workload and simultaneous shortage of staff.
Expertise in nursing – different titles, roles and tasks
The titles, roles and tasks of different type of experts in healthcare are inconsistent both nationally (Finland) and globally. Lack of consistency creates barriers to utilization of experts’ competencies. Consequently, this inhibits the evaluation of the effect of expertise position on patients’, staffs’ and organizational outcomes (Donald et al. 2010). In the table attached, different kinds of titles, descriptions and rationales for the experts’ roles are introduced based on international literature. The aim of the table is to introduce the issues for further discussion in order to enhance descriptions relating to the roles, tasks and rationales for different expert positions in Finnish social and health care.
The Action Model of Expertise (Fin AME)
The current understanding relating to evidence-based practice is based on collaboration between people with different competencies (Medves et al. 2010). In Finland, the Ministry of Social Affairs and Health (2009) published the National Nursing Action Plan for the years 2009-2011 with the aim of increasing the effectiveness and attraction of nursing by means of management. In the Action Plan an Action Model of Expertise (Fin AME) was introduced as a means of facilitating evidence-based health care.
Fin AME consists of the roles of four different types of experts, their core competencies, emphasis on competency and actions in implementation of EBP.
Operational Model for EBP (OMEBP)
There is a need to reform management practices in health care services in national, regional and local levels to supporting the development of evidence-based nursing and midwifery. To produce, dissaminate and implemenet knowledge. As well as develop consistent practices to ensure the continuing development of nurses’ and midwifes competence in the OMEBP.
Responsibilities at different levels of healthcare system for developing consistent evidence-based practices seen in figure below:
International cooperation along with national improvements create structures that support the development of evidence-based healthcare and make evidence available for transfer and implementation. However, there is a need to reform the management practices within healthcare services at the national, regional and local levels towards supporting the development of evidence-based nursing and midwifery.
National level collaboration is required to ensure consistent structures in the development of evidence generation and consistent requirements for curriculum development. The utilisation of synthesised evidence that has been produced in international cooperation requires national strategies and multidisciplinary collaboration prior to evidence dissemination and implementation. The further responsibilities of national institutions and organisations in regards to the production of clinical practice guidelines and other forms of evidence should be agreed upon.
Collaboration at the local level enables the effective knowledge transfer of best practices and identification of the local needs for development. It is recommended that healthcare organisations and educational institutions actively participate in collaboration in order to improve knowledge base and care outcomes in the region. At the regional level, managers in nursing and midwifery decide upon the strategic directions in the development of consistent evidence-based practices and coordinate the implementation of national strategies.
Organisations have the responsibility to establish the necessary structures that support EBPs, to ensure the competency of health professionals, to collect information on the outcomes of care and to change practices if needed. Responsibilities include the development of evidence-based tools to receive feedback as managers need information of compliance with EBPs. The central factor in the successful dissemination of evidence is to have effective communication channels within in the organisation. The development of consistent, evidence-based practices in nursing and midwifery requires that nursing and midwifery staff is aware of evidence-based clinical practice guidelines, systematic reviews and recommendations that form the basis for consistent practices and good patient care.
There are various kinds of models that have been developed for evidence dissemination and implementation (van Achterberg, Schoonhoven, & Grol, 2008; Wang, Kao, & Lin, 2015; Stevens, 2013). In the present study, the Operational Model for Evidence-Based Practices (OMEBP) is used as a framework for consistent practice development, see figure below:
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, Ylönen, Jalonen, & Holopainen, 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; Langlois et al., 2018).
It is described below how evidence-based consistent practices are developed at unit or ward level. After the practise is developed, it helps in decison-making between patient and nurse.
Figure: The Operational Model for Evidence-Based Practices, OMEBP (Holopainen, Korhonen, Miettinen, Pelkonen, & Perälä, 2010, translated from Finnish).