Implementation forum Building a foundation for evidence-based practice: experiences in a tertiary hospital

The aim of this article is to report on the creation and early innovations of an evidence-based nursing committee in a tertiary hospital. During a post-merger transitional period, the Evidencebased Nursing (EBN) Committee conducted a number of projects, which included selecting an evidence-based practice (EBP) model for nursing; developing a process for prioritising and disseminating research findings to healthcare programmes; and evaluating an important EBP application in direct patient care. Hamilton Health Sciences (HHS), a 1157 bed tertiary hospital providing inpatient and outpatient acute and long term care across several health programmes, is a recent merger of 2 hospitals at 4 sites in a large city in southern Ontario, Canada. Approximately 2900 nurses (2550 Registered Nurses and 380 Registered Nursing Assistants) are employed by HHS in either full or part time positions in health programmes that range from infertility services and obstetrical care to a large and progressive cardiac surgery programme. HHS provides regional services to 2.2 million people in Hamilton and Central South Ontario. In 2000, the Nursing Practice Committee (NPC), a nursing body that represents direct care nurses, sets the general direction for nursing, and is accountable to the Chief Nursing Officer, identified 3 priorities for development. One of these priorities was to develop the use of EBP by nurses at the bedside. Therefore, with accountability to the NPC, the EBN Committee was created and given themandate of developing the use of EBP at the patient care level and recommending processes that would promote EBP among direct care nurses. In 2002, the mandate and responsibilities were expanded (see table 1). Under the co-leadership of a clinical nurse specialist (BK) and a school of nursing faculty member with a track record in health services research (EAM), the EBN Committee membership was established taking the following factors into account: c hospital sites c healthcare programmes c major representation of direct care Registered Nurses and Registered Practical Nurses c academic and research representation fromMcMaster University School of Nursing c links to community care Two hour EBNCommittee meetings were scheduled monthly after NPCmeetings for the convenience of members serving on both committees. At the outset, funds were provided for direct nursing staff replacement costs, so that EBN Committee members could complete preparatory work and attend meetings. In the spring of 2002, replacement costs stopped because of fiscal cutbacks to Ontario hospitals. From the beginning, several barriers to the implementation of EBP by nurses were recognised and taken into account when planning change. Firstly, direct care nurses on inpatient units have little control over their workloads, which can hamper involvement in non-direct care activities, such as learning about EBP or participating in evidence-based clinical projects. Compounding this, a continuing nursing shortage resulted in the reliance on many overtime nursing hours. The merger of 4 different healthcare facilities brought differing cultures and organisational challenges to the fledgling, albeit large, hospital. Furthermore, the merger itself created an imperative of forging a unified organisation, and numerous merger goals became priorities for action. New organisational priorities, such as re-developing organisational structures that were no longer suitable after the merger, superseded those of the nursing staff so that goals, such as the promotion of EBP by nurses, were placed on hold. Another barrier to the implementation of EBP was the limited access to research journals and other research resources within or close to the clinical areas of the hospitals. Even if research resources are readily available, as Funk et al found, most nurses lack the training and skills in effective literature searching and critical appraisal. Furthermore, experiential knowledge is often favoured by nurses over empirical evidence. A critical issue, identified by Newman and Papadopoulos, is lack of support by ward managers for the concept or application of EBP. Some HHS nursing staff reported a lack of support, although infrequently. In these cases, nursing staff reported that information seeking and critical appraisal are not valued as a part of the nursing culture on the unit, and limited access to computer resources exacerbates the problem. Communication with nursing staff across the 4 sites was problematic because of the lack of a common electronic communication system and incomplete electronic address listings for nursing staff. Finally, the complexities of modern healthcare organisations can create a formidable barrier to creating change in clinical practice. The sound administration of today’s healthcare organisation depends on the interrelatedness of administrative bodies within the agency. This interrelatedness creates professional interdependencies that require considerable communication, negotiation, and collaboration and can result in protracted change processes that are both energy and time consuming. Despite these barriers, several opportunities for change were identified: c the nursing organisation had identified EBP as a priority for planning and action