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Understanding Evidence-Based Practice
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Susan Stillwell is adamant: "evidence-based practice matters." And she should know. As an expert mentor in the field, Stillwell is currently the Associate Director of the Center for the Advancement of Evidence-based Practice in the College of Nursing and Health Innovation at Arizona State University. Her aim is to advance the integration of evidence-based practice (EBP) in healthcare practice through educating students and faculty in the field and "to help shift their paradigm to approach their disciplines with using the evidence to improve safety, quality care, and outcomes of individuals, providers, and organizations."
In addition to her significant contribution to the field at the University, Stillwell has acted as a consultant in evidence-based health with schools and hospitals, not only in the United States, but all over the world. She considers herself fortunate to have been influenced by many important role models and mentors whom she says helped shape her career when she was studying for her post-master's certificate in EBP at the College of Nursing and Health Innovation. These included Alyce Schultz, Anne Wojner Alexandrov, Ellen Fineout-Overholt, and Bernadette Melnyk. Thinking back, Stillwell notes, "These individuals thought differently, which fueled my spirit of inquiry and influenced my professional path." However, she is also quick to point out it was her interaction with those she terms as "evidence-users" that provided the "tipping point" in her career.
In 2010 Stillwell wrote an article entitled: "National survey shows the majority of nurses use very little research in the first 2 years after their graduation, highlighting a gap between research and clinical practice," which was cited in a study by Forsman H, Rudman A, Gustavsson P, et al., entitled: "Use of research by nurses during their first two years after graduating" (J Adv Nurs 2010;66:878-90). While this focused on the use of evidence in nursing in Sweden, Stillwell is quick to point out "the gap between research and clinical practice still exists in the United States and other countries." Even so, she thinks some U.S. hospitals are better placed with their integration of evidence in their procedures, noting that this might be due to hospitals seeking to attain and maintain Magnet status.
Stillwell fears graduates under stress with multiple priorities may struggle to find time to actively seek evidence-based research, citing nursing educator Patricia Benner's observation that it takes 2 to 3 years for nurses to become "competent" and therefore confident enough to focus on adequately incorporating evidence-based research into practice. However, she says belief in evidence-based practice research does not necessarily translate into effective implementation. Stillwell says nurses require the right "background knowledge" to be able to frame the correct PICOT question, and further asserts that "faculty need to be knowledgeable and feel comfortable with EBP in order to foster a culture of curiosity in their students and support students to ask questions - a necessary foundation for EBP." (For the uninitiated, PICOT is an acronym for patient population [P], intervention/issue of interest [I], comparison intervention/issue of interest [C], outcomes of interest [O], and time taken for intervention to reach outcomes [T].)
Stillwell says for an organization to have a successful culture of evidence-based practice it needs three key features. The first, she says, is support from within the organization's administration, suggesting that if they make it a priority then "barriers to EBP will be mitigated." She claims the second key factor is having "intraprofessional teams" with a "shared vision" for both the delivery of healthcare and sound patient outcomes. Stillwell sees the patient as the "core recipient of health services" and feels there needs to be a "synergy" between the different people involved in the treatment process to progress the use of evidence-based practice and teamwork. Finally, she states there needs to be a "critical mass" of people who have skills in evidence-based practice and who can serve as mentors in the field. She goes on to explain that there is "no magic number for a critical mass. Freshwater (2005) describes a critical mass as individuals who share the passion and similar ideals, the same goal, and are willing to act on what they believe."
Stillwell warns that both not using evidence and not testing or questioning evidence in use is risky because of the potential for patients to be "adversely affected" by substandard healthcare. She states: "For nursing, as a discipline, not practicing based on evidence invites the status quo or even worse. In fact, Florence Nightingale believed nursing to be an art - a progressive art - and believed that standing still would mean going backward. If nurses do not embrace the EBP paradigm, I believe they will risk providing quality care to their patients, their families, and receiving quality care themselves. Nursing is a caring profession, but it is also a profession based on science. To not use evidence in our practice risks the existence of professional nursing practice."
Importantly, Stillwell makes it clear that just using evidence alone does not mean that the "evidence-based practice paradigm" is being met. She states the preferences and values of the patient need to be an important consideration in their treatment, otherwise they may choose not to follow recommended advice, which could result in a poor outcome.
Stillwell reasons that the development of skills in evidence-based practice for graduate nurses begins with educational programs run by faculty who have expertise in the area. She says concepts and principles of evidence-based care should be integrated into the nursing curriculum, in both didactic and clinical courses. Significantly, she notes, "using the language of the paradigm is critical to fostering a culture of EBP. For example, using 'evidence' in conversations, patient preferences, and values in assessment of patients, and the use of the word 'appraise' is a start in shifting the paradigm." She also thinks that connections can be built between academic and clinical practice partnerships so that it can be demonstrated that nursing science has relevance for actually providing care to clients.
According to Stillwell, nurses should be expected to question practice and work in an environment where this is viewed as an acceptable and normal part of effective procedure. To her, curiosity is an important attribute for nurses to develop through education, and suggests that nurses can be encouraged to ask PICOT questions as well as share research findings on a daily basis so that it becomes ingrained in their work mindset. She says the education of graduate nurses should incorporate assessment of their knowledge of evidence-based practice and their comfort levels with regard to this, so that their specific training can be modified accordingly. Stillwell suggests that specific sessions be set aside to focus on evidence-based practice as part of nurse training, with a view to how this will help the broader implementation of evidence-based practice in healthcare.
She says there is a role for clinical leadership in this process, suggesting, "if it takes on average two to three years for the graduate nurse to become 'competent,' perhaps clinical leadership can create an innovative residency to include the competency of evidence integration as part of professional development." She says clinical leadership can be a vital part of "transforming the healthcare setting" and encouraging the development of a culture of evidence-based practice. She says the clinical leader can also identify barriers to evidence-based practice and find ways to overcome and eliminate them.
In her role at Arizona University, Stillwell has overseen the education of a wide range of students, many of whom will enter the workforce with strong skills in evidence-based healthcare. She says evidence-based practice is integrated in all nursing courses at the University, but is the central focus of one course offered early in the undergraduate program. She says in this course there is a move to "differentiate the EBP paradigm from the process" and emphasize the importance and the responsibility involved in lifelong learning rather than focusing too much on specific procedures. Interestingly, Stillwell uses storytelling as a method to ensure teaching can have greater "clinical relevance" for the student. She cites explaining the link between hand washing and mortality rates as an example of "bringing history alive," therefore making coursework more engaging for students. She says questioning students and asking if they can improve an intervention or procedure is a good way to make them reflect upon their work and is another important way for them to make sense of their education. She also thinks having a set time for students to question each other in an environment where they feel comfortable doing so is another vital part of the learning process and "encourages a spirit of inquiry."
Stillwell has a more innovative mindset when it comes to the way students are conditioned to learn: "Traditionally, educational systems have focused on students providing the right answers, thus, we might want to shift that paradigm to having students ask questions." She says to ensure this happens such strategies are specifically scheduled into classes rather than being loosely incorporated into teaching. She notes that as there are competing priorities in Arizona State University's nursing program, repetition is used to assist students in absorbing information and there is an emphasis on ensuring study materials have enough relevance to the field.
She says, "A prescribed time is provided for students to develop PICOT questions based on clinical scenarios or to change research questions into PICOT questions throughout the semester. Students practice searching databases to find evidence to answer the question." Stillwell emphasizes that, as mentioned before, these are specifically scheduled activities. She adds that the students gain experience in the field by interviewing nurse managers about the outcomes they are monitoring and the way they implement evidence-based practice, and "by the end of the course, the students demonstrate the EBP process, from PICOT question to Dissemination, based on a personal clinical issue of interest." She says the end of the course is marked by a presentation from a clinical partner of the university who outlines the impact of changes in practice on patients and healthcare costs. She says the "presentation provides the students with an opportunity to validate the relevancy of their coursework with direct application to the clinical setting."
Stillwell says that strategies to keep up with evidence are vital, especially given the amount of time it has taken to get research into practice (she says historically this has been around 17 years). She hopes that the current speed of technological advancement will mean nurses will have instantaneous access to knowledge. She does however caution that any change implemented will need to be subject to constant evaluation and monitoring to ensure or determine its success. Further, she advises that evidence-based practice is an ongoing process and any change is never permanent. So, she insists that monitoring outcomes and reviewing literature for the most up-to-date evidence is vitally important. She also suggests healthcare organizations develop comprehensive ongoing plans for updating practices, which detail procedures, responsible persons involved, and resources required. She says as librarians have expertise in sourcing evidence they should be part of the "intraprofessional team."
Stillwell insists that collaboration is an essential part in the wider implementation of evidence-based healthcare. "EBP champions, knowledge brokers, EBP mentors should be considered as key resource individuals in the strategic plan. There will no doubt be opportunities for entrepreneurs to develop new services and deliverables to update healthcare delivery practices and maybe nurses should lead the way."
As for her own legacy, Stillwell hopes that her students become lifelong learners who strive to make a real difference to those in their care.
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