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Discussion

Developing evidence-based practice among students

Patient care must be based on the latest evidence-based practice. Student nurses should be introduced to the principles of this as part of pre-registration education

In this article…

  • How evidence-based practice has been defined
  • The benefits of using evidence-based practice to influence work undertaken in clinical settings
  • Why it is important for student nurses to be able to evaluate evidence

 

Authors

Vernel Emanuel, Karen Day and Lorraine Diegnan are senior lecturers, adult division, and Maxine Pryce-Miller is senior lecturer in Public Health; all at the School of Health and Wellbeing at the University of Wolverhampton.

Abstract

Emanuel V et al (2011) Developing evidence-based practice among students. Nursing Times; 107: 49/50, 21-23.
In response to government initiatives and the rise in patient empowerment, nurses are increasingly being challenged to deliver high-quality care supported by evidence-based practice. This can be a challenge for nurse educators providing the foundation for pre-registration student nurses.
Evidence-based practice within nursing is achieved by developing and supporting patient-centred approaches to care using the most current evidence. This facilitates the development of a questioning approach incorporating the four principles of healthcare ethics - beneficence, non-maleficence, autonomy and justice.

Keywords: Nurse education/Evidence-based practice/Pre-registration nursing

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article

 

5 key points

  1. Evidence-based practice is integral to healthcare
  2. It is a challenge for those providing nurse education
  3. It means developing and supporting patient-centred care using the most current evidence
  4. Nurses must be able to identify and evaluate evidence
  5. Evidence-based practice must be core to professional development

 

Pre-registration nurse education and the NHS aim to teach and provide high-quality healthcare that is based on the best available evidence. Evidence-based practice has evolved and is implicit in The NHS Plan (Department of Health, 2000), a range of national service frameworks (DH, 2001) and the Darzi report (DH, 2008).
Pre-registration nurse education is undergoing significant changes. As of 2013, nursing in the UK will become all-graduate entry; to this end, the Nursing and Midwifery Council (2010) has set standards and requires pre-registration nurses to achieve competencies to meet the criteria for registration upon completion of training. These standards will come into effect with the new curriculum and have implications for nurse educators.
There is a need for the curriculum to be developed further by nurse educators. The fundamentals of teaching pre-registration nurses must be based on the best available evidence to recognise and deliver high-quality patient care. This is a priority within healthcare, and professional standards, together with multiple government guidelines ensure it is delivered (NICE, 2007; Audit Commission, 2003).
There are a number of definitions of “evidence-based practice” in the literature. Barker (2010) defined it as the conscientious, explicit and judicious use of theory-derived, research-based information to make decisions about care delivery to individuals or groups of patients, taking into consideration individual needs and preferences.
The definition offered by Melnyk and Fineout-Overholt (2005) is pertinent to nurse education. This says that evidence-based practice should be a problem-solving approach to clinical practice that integrates a systematic search for, and critical appraisal of, the most relevant evidence to answer a burning clinical question. It should take into account, for example, one’s own clinical expertise, patient preferences and values.
The idea behind evidence-based practice is to ensure all healthcare is backed by firmly grounded evidence that includes the needs and preferences of individual patients (Carrier, 2009). It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
According to Kaplan et al (2003), increasing competency in information literacy is the foundation for evidence-based practice; this provides nurses with the skills to be literate consumers of information in an electronic environment. It is essential for nurses to be able to evaluate the strength of the evidence so they can determine how appropriate it is.
To gain a greater understanding about using evidence in the context of healthcare, we have to consider what counts as evidence. Reading and understanding research, being aware of current policies and procedures, and knowing about the recommendations and standards in practice are all part of the nurse’s role (Royal College of Nursing, 2007).
Upshur (2001) said that, legally, the term “evidence” can be used to either refute or corroborate an issue. In relation to healthcare, evidence can be interpreted in relation to ideas of proof. Davies et al (2000) suggested, however, that evidence is construed, and needs to be independently observed and verified. It is imperative to use appropriate evidence to inform practice and policy. In the UK, one of the bodies that informs evidence-based practice is NICE, which sets guidelines based on proven research that has been subject to scrutiny.
Other sources of evidence can also contribute to care. These include evaluative studies, patient concerns, clinical experience, best practice, clinical data and research.
Making the right decision relies on finding the right solution from whichever source is appropriate.

Literature review

Since pre-registration nurse education was reorganised in the early 1990s, there has been considerable debate regarding nurses’ fitness to practise. To determine fitness to practise, student nurses must meet clinical, theoretical and professional practice standards that have been implemented by the NMC (2010) and higher education institutions. The standards are there to ensure students meet patients’ needs by being up to date with practice. Evidence-based practice is the way to ensure that practice remains current.
It is recognised that, historically, evidence-based practice has devolved from a medical model, which is scientifically grounded (Carrier, 2009). However, the assimilation of evidence-based practice into nursing in general and as a foundation for student nurse education challenges this view. Dale (2006) suggested that “evidence-based practice is a complex concept, which is assumed to be compatible with nursing” and that, although it is now more accepted within nursing, it continues to be dominated by the medical profession. Yet to deliver a comprehensive healthcare service, all members of the multidisciplinary team are required to be committed to an evidence-based approach.
There is a traditional view that evidence-based practice should be informed solely through quantitative research. However, Ellis (2010) advocates that it is more about using various forms of information, not just research, to guide and develop practice. Ellis (2010) goes on to note that there is little agreement between professionals as to what constitutes “good evidence”.
While nurses may be motivated to approach practice from an evidence-based perspective, the literature actually suggests that evidence-based practice is rigid and prescriptive, and diminishes any professional autonomy.
Nurses work in environments that are constantly changing and evolving (Hewitt-Taylor, 2002), which may affect care. Nursing has evolved from being a series of dictated tasks to a holistic care approach, which requires evidence that is then developed into guidelines (Hewitt-Taylor 2002). These guidelines support nurses to promote an individualised approach to holistic care, moving away from ritualistic practice.
To successfully incorporate evidence-based practice into everyday practice, student nurses need to be both motivated and competent, so it is seen as a natural part of their role and not a separate concept. As such, nurses need to ensure their practice is current and that they are equipped with the necessary skills to be flexible and adaptive.
To use evidence-based practice to contribute to high-quality healthcare, professionals are required to access and integrate a number of different resources, which can be time consuming (Rycroft-Malone et al, 2003). Nurses suggest that lack of time is a major barrier when trying to access and review any of the evidence (Bertulis, 2008). Poor access to facilities and information, lack of experience and little confidence in using computers may also prevent nurses from successfully using evidence-based practice (Nicholas et al, 2005). Although information can be accessed via the internet, which is available to practitioners in many clinical areas, the quality of the resources that nurses access remains contentious (Nicholas et al, 2005).
A quantitative study by Upton and Upton (2005) examined 500 nurses’ knowledge of evidence-based practice. Respondents gave themselves the poorest ratings for IT skills, literature searches and research skills. Gerrish and Clayton’s (2004) study of 330 nurses in a large teaching hospital in the UK identified similar findings. However, they also discovered that judging the quality of information and implications for practice was a major concern. Kaplan et al (2003) said: “Establishing competency in information literacy is therefore a primary goal for the contemporary nursing professional”.
With the move to graduate-level nursing in the UK, it is suggested that the theory-practice gap could widen further. To support this educational transition, evidence-based practice should be embedded in the new curriculum (NMC, 2010). Dale (2006) said evidence-based practice means the practitioner should demonstrate skills in appraisal of evidence, self-evaluation (Sackett et al, 2000) and reflection, and reflective practice (Jasper, 2003), as well as personal growth, accountability, and lifelong learning.

Discussion

There are clear issues highlighted in the literature that need further discussion. What are the challenges for nurse educators? What is the link between graduate education and evidence-based practice? What are the challenges for nursing students? Fostering a culture of evidence-based practice in nursing is essential to delivering effective healthcare (Cleary-Holdforth and Leufer, 2008).
It is imperative that the nurse curriculum imparts fundamental knowledge on incorporating different types of the available evidence base into clinical practice. It is also important to understand that evidence-based practice should consider knowledge that has been subject to testing and found to be credible, and stems from a variety of sources. This will develop students’ confidence to inform professional practice, which will lead to the provision of individualised patient care.
Evidence exists to inform and guide practice rather than dictate it - this message must be understood. Nurse educators need to ensure they work in partnership and maintain relationships with practice areas in order to achieve this.
The link between graduate education and evidence-based practice places an emphasis on accountability and has led to the need for highly visible, well-researched guidelines for practitioners in health and social care to follow.
The responsibility of higher education institutions, hospital trusts and primary care trusts is to ensure that, through
education, standards are developed and maintained by health professionals (Care Quality Commission, 2010).
Evidence cannot be used in the absence of clinical judgement or acknowledgement of the patients’ values, concerns and preferences (Sackett et al, 2000). Support and guidance must be given to facilitate and develop student nurses so that they are able to critique literature in order to recognise the best available evidence.
Advances in IT have had a radical impact on healthcare delivery and nurse education. The use of sophisticated equipment and electronic assessment care packages require nurses to be competent in IT skills.
The challenge for student nurses is to deliver nursing care to individuals based on the best available evidence in order to ensure that high-quality care is provided. This is essential in informing patient choice in the planning and decision-making process. Rycroft-Malone et al (2003) acknowledges that, in order to practise evidence-based, person-centred care, practitioners need to draw on and integrate multiple sources of propositional and non-propositional knowledge, which has been informed by a variety of evidence bases that have been critically and publicly scrutinised.
A key reason for adopting this ethos is to facilitate, develop and foster a questioning approach, which incorporates the four principles of healthcare ethics described by Beauchamp and Childress (2007) as beneficence, non-maleficence, autonomy and justice.

Conclusion

To use evidence to underpin practice without evaluating its effectiveness is shortsighted. Health education institutions have a responsibility to encourage student nurses to promote and deliver evidence-based practice from the onset of training. In the academic setting this is encouraged and is achievable.
Integrating evidence-based practice into everyday practice is a necessity if effective patient care is to be provided; this concept is supported by current legislation (CQC, 2010; NMC, 2010).
Evidence-based practice should be viewed as an integral part of CPD and included as ongoing education for nurses, particularly in the field of leadership (DH, 2008). Nurses as leaders should use evidence-based practice and lead by example to ensure that patients receive high-quality care.

Readers' comments (5)

  • Is there just one place to search for EBP? You would think a catalogue of EBP would be available - just type in your area or query and the relevant EBP literature would appear. To trawl through umpteen journals and databases is time consuming.

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  • George Kuchanny

    Good observation anon. EBP is going to be increasingly important. I suspect thatthere is a database already - now it needs to be made available to all medical folk.

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  • As a student nurse it is impressed upon us to look for and critically appraise and evaluate our working practices. Yet in placement we see 'older' ritualistic methods being used and are expected to offer the 'new way', NMC keeping up to date etc. This is quite a daunting task in itself. Whilst I appreciate EBP may not always be best practice the rationale for not using EBP has to be supported by informed reasoning and decision making.
    If EBP is the way forward and it is not implemented, should there be a legal case asking/demanding why a task was performed a particular way, would lack of knowledge surrounding the EBP for that task be a defence? I doubt it. Therefore I would say it is imperative that a database be created. Critically Appraised Tasks(CATs) was a starting point I think??
    There is the possibility I havent looked in the right places I suppose??

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  • George Kuchanny

    There is the independent info provider at the appropriately named http://www.evidence-based-practice.net/ and we can see that Scottishclinical governance has been pushing this way forward since 1999 (pdf on this link) http://www.clinicalgovernance.scot.nhs.uk/documents/v14w16p3942.pdf

    I am expecting each and every Trust up and down the land to have a Clinical Governance Director or Director of Nursing who willl be focussed on providing information and where to get training on EBP for all - most especially students.

    Best practice should be exactly EBP not some practice 'that has always been done this way' e.g. nitro for heart problems (how old hat is that I ask?). Lean on your tutor a bit Alison and get info on support in your placement(s). Hope this helps.

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  • George Kuchanny

    Sorry Allison - misspelt your name, as you can see by the time of the post I am in busy bee mode again (when are we not I ask?)

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