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INNOVATION

Improving nurses' access to healthcare evidence

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Many nurses find it difficult to access evidence on which to base their practice. A health board addressed this by regularly emailing them a selection of appropriate articles

Abstract

This article describes how the education team and library services at Betsi Cadwaladr University Health Board found a way to help nurses keep updated, and support them with the introduction of nurse revalidation in April 2016. The education team bridged the gap between nurses and library resources by delivering “5 a Month”, a small selection of current literature on chosen monthly topics from the library, to nurses at their place of work.

Citation: Anton L et al (2016) Improving nurses’ access to healthcare evidence. Nursing Times; 112: 10, 17-19.

Authors: Lyndsey Anton is nursing practice educator, nurse education team; Nia Morris is clinical librarian, Wrexham Medical Institute; Susan Ira Mahony is former clinical librarian, Glan Clwyd Hospital; all at Betsi Cadwaladr University Health Board.

Introduction

Nurses are responsible for the care they deliver to patients and need to be able to justify what they have done (McSherry et al, 2002). To do this, they are expected to reflect on high-quality healthcare evidence, ensure their clinical practice is evidence-based and consider how that evidence can be used to improve the care they offer patients. Nurses also need to use effective search strategies to locate appropriate evidence and resources (Robb et al, 2014).

Recognition of the importance of evidence-based practice has grown over recent years; it is now accepted as a necessary component of high-quality patient care and is no longer an obscure concept (Grant et al, 2012). The goal of evidence-based practice is to provide an intervention that has the greatest likelihood of success, thereby achieving the best patient outcomes at the lowest costs (Melnyk andFineout-Overholt, 2015). The procedures used should be justifiable and nurses should be able to reference authoritative evidence (McSherry, et al 2002) but many encounter barriers in seeking to use current evidence in practice including:

  • Staffing challenges, such as numbers and skill mix;
  • Demanding time commitments;
  • Identification and location of the evidence, especially if they have limited experience of this (Grant et al, 2012).

The requirement for all nurses and midwives to revalidate with the Nursing and Midwifery Council when they renew their registration every three years from April 2016 has intensified their need to use appropriate evidence to shape their practice. However, good professional practice also requires them to use the best available evidence. The NMC Code states that nurses and midwives must: “maintain the knowledge and skills you need for safe and effective practice” (NMC, 2015).

McSherry et al (2002) stated that evidence-based practice provides nurses with a sound and rational basis for decisions taken about the care being provided to patients. However, more recently Melnyk and Fineout-Overholt (2015) defined it more broadly as a lifelong problem-solving approach to clinical practice.

Continuing professional development is similarly integral to the role of nurses. Maintaining up-to-date skills and know-ledge and providing evidence-based care is paramount to ensuring standards are maintained and the Code is upheld. All nurses and midwives must act in line with the Code, whether providing direct care to individuals or groups, or bringing their professional knowledge to bear on current practice in other roles, such as education or research (NMC, 2015). The principles and values identified in it are not negotiable and can be applied to many settings.

How revalidation supports evidence-based practice

The new revalidation system replaces post-registration education and practice (PREP); from April 2016 all nurses and midwives will need to be ready to revalidate the next time their registration is due for renewal. This involves completing a range of revalidation activities and being able to demonstrate this to the person responsible for confirming this to the NMC (in most cases confirmers will be line managers).

The major differences between PREP and revalidation activities are that, in addition to undertaking 35 hours of continuous professional development and 450 practice hours (900 for those with dual registration), registrants will be required to provide their confirmer with evidence of these and of:

  • Five reflective accounts, detailing reflections on practice or professional development, and linking their learning from these reflections to aspects of the  Code;
  • Five pieces of practice-related feedback;
  • A reflective discussion with another registrant (this can be combined with the confirmation discussion).

The Code advises that nurses’ and midwives’ commitment to maintaining standards should be fundamental and a reinforcement of their professionalism. Revalidation will provide the means of demonstrating this commitment in a thorough, richer way. The Code “will become central in the revalidation process as a focus for professional reflection” (NMC, 2015).

Overcoming barriers to accessing evidence

Pape (2003) advised that the use of evidence-based practice needs to be nurtured, and creativity is required to engage nurses to use new ways of collating their evidence. To enhance the use of further evidence for reflection on topics of current interest to nurses, and to overcome some of the barriers nurses face when trying to do this, the education team reflected on strategies that would ensure nurses were regularly exposed to articles of interest and relevance that could support practice and revalidation.

An initial meeting was arranged between the education team and the library service to investigate whether providing five articles a month on a selected topic might encourage nurses to further access, read and reflect on some up-to-date literature each month. The literature would be sourced by the education team and cascaded to nurses by email.

The knowledge and skills base of nursing is diverse; it encompasses an extensive range of interventions and activities (Smith et al, 2004), so the articles selected would have to meet the wide range of needs of nurses working in any area. Such a wide remit meant the service, which became known as ’5 a Month’, could only provide a taster of the literature on a selected topic each month.

The aim would be to make it easy for staff to access further information for professional reflection, rather than give conclusive summary evidence on a topic. The purpose would be to encourage professional thought, reflection and interest rather than to synthesise or critically evaluate the evidence. Many nurses are not confident about using library databases (Robb et al, 2014) so we hoped that highlighting library services in this collaborative way would also encourage them to seek library support in accessing further evidence.

Making the most of library services

Librarians have the skills needed to locate evidence-based information, but can provide more relevant evidence when working in collaboration with clinical staff. The ideas for 5 a Month enabled the clinical librarians to work closely with the education team to develop a system that built on the strengths of both teams.

In a survey of physicians and residents in 118 hospitals in the US, respondents were asked if they had used library resources to search for information relating to a specific clinical case; 75% stated that they definitely or probably handled patient care differently using information obtained through the library (Gard Marshall et al, 2014). This highlights the positive effect library services can have on care delivery.

Further discussions between the library and education team staff also raised practical considerations. Copyright law rightly restricts the copying of some information to protect authors. It was decided therefore that only open-access articles from PubMed and Biomed Central should be used in ’5 a Month’ so they could then be viewed instantly from an email, simplifying access. However, accessibility of information neither ensures it is the best-quality evidence nor that it provides the only available perspective. To encourage wider reflection, we therefore made use of the clause in the NHS Wales copyright licence that allows storage of licensed or owned content for access by authorised users for up to 30 days.

The education team set up the ’5 a Month’ page on the nursing and midwifery information zone of the health board intranet where, for 30 days, a further five selected articles on the topic of the month, from journals paid for by NHS Wales, could be accessed. These would be automatically deleted at the end of the 30-day period and there would be a hyperlink directly to the intranet page from the ’5 a Month’ email.

For the librarians, ’5 a Month’ not only encourages dissemination of recent research or editorial opinion, but has also given them a unique opportunity to reach out to non-library users to make them aware of its services and resources without intruding on valuable staff time. The initiative has also helped to promote a closer working relationship between the library and education teams. By encouraging a better understanding of issues, such as copyright, the library has been able to offer guidance on the legality of accessing licensed works, while its role has been enhanced through working in partnership with the education team in defining nurses’ information needs and deciding how these are met.

Box 1. ’5 a Month’ topics

  • Clostridium difficile
  • Nursing documentation/record keeping
  • Patient-centred care
  • Duty of candour and patient safety
  • Revalidation for nurses
  • Hand hygiene and infection prevention
  • Nutrition and wound healing
  • Reflection on nursing
  • Continuing professional development for nurses
  • Reducing the incidence of pressure ulcers
  • Barriers to continence assessment and how to overcome them
  • Medicines management

 

How ‘5 a Month’ works

Each month the education team chooses a topic of current relevance to nurses and forwards it to the library service to undertake a search. Box 1 gives examples of topics already covered. The librarians then send a selection of relevant articles via open access and through NHS Wales licence-owned content. The education team chooses five articles from each section, trying to cover as broad a range as possible to meet the needs of nurses in as many care settings and specialties as possible, from newly qualifieds to advanced practice nurses.

Once the articles are selected, the librarians format the content into two posters that are then forwarded back to the education team to cascade by email; the library also emails all nurse Athens account holders. The first lists the open-access articles, while the second lists those paid for via NHS Wales for the intranet, which are uploaded onto the health board intranet for 30 days. Copyright declarations about use of the material are made clear in emails and on the intranet page, emphasising that the selected articles reflect only the authors’ views as a stimulant for reflection and are not given as guidelines for practice.

Feedback from staff is positive, as illustrated by the examples in Box 2. Early on in the initiative, recipients were given the opportunity to vote on whether they wanted the initiative to continue – 95% voted ’yes’. Data from the nursing and midwifery information zone of the health board intranet are also encouraging (Box 3).

Box 2. Comments from staff

  • “Fabulous idea!” (District nurse team manager, March 2015)
  • “What a great idea! I will read these articles.” (Advanced nurse practitioner, March 2015)
  • “Can I just say what a great idea this is, and extremely useful.” (Matron, April 2015)
  • “I just wanted to thank you for your time and effort regarding the ’5 a Month’ and enjoy reading the up-to-date articles. Your effort is worthwhile.” (Ward sister, May 2015)
  • “Happy to support such a worthwhile initiative and thank you for your continued interest and support.” (Matron, August 2015)
  • “This is excellent.” (Executive director, September 2015)
  • “This is a great initiative.” (Assistant director, September 2015)
  • “Great idea.” (Clinical nurse manager, September 2015)

Box 3. Views of the ‘5 a Month’ page

  • July 2015 – 71 views. An article on revalidation was the document that was viewed most
  • August 2015 – 77 views. An article on hand hygiene and infection prevention was the third most viewed document
  • September 2015 – 83 views. One of the articles on nutrition and wound healing was the third most viewed document
  • October 2015 – 48 views. The ’5 a Month’ topic was reflection for nurses, but October was busy with the Fundamentals of Care Audit, revalidation, Healthcare Standards Audit, and mentor information with a high number of views
  • November 2015 – 149 views
  • December 2015 – 103 views
  • January 2016 – 111 views

Conclusion

Initial results suggest “5 a Month” has had three benefits. It has:

  • Improved access to educational articles on a variety of topics, providing evidence in a timely manner and convenient form, enabling nurses to reflect on their practice and support their own evidence in planning for nurse revalidation;
  • Increased visibility of library services with nursing staff in a more targeted way and encourage them to seek support from library services by encouraging a culture of support through collaborative working;
  • Provided a measure for impact: not only measuring the effect of the initiative, but acting as a proxy measure for the role evidence is playing in nurses’ professional development and, ultimately, their patient care.

Grant et al (2012) pointed out that nurses’ involvement in evidence-based practice is crucial but must be balanced against barriers such as time constraints and interest. This requires focusing on small, achievable projects that offer follow-up support and have management recognition. Straus et al (2009) also described strategies that bridge the gap between knowledge and action. Although 5 a Month began as a small collaborative project between the education team and library service, it has developed and expanded and is ultimately bridging the gap between knowledge and action.

Revalidation is set to change the regulation of the nursing profession and, while nurses need to embrace the change, they must also be given the support to facilitate the transition to a new way of regulation. We hope 5 a Month has become a small step in this process for our nurses.

Key points

  • Evidence-based practice is vital to the delivery of high-quality healthcare
  • Reflection on practice is a crucial aspect of nurse revalidation, and encourages nurses to use experiences in their work to improve their future practice
  • Nurses will be required to produce evidence to demonstrate they have met their revalidation responsibilities
  • Nurses often lack the skills and/or confidence to find and evaluate evidence
  • Providing nurses with a regular selection of relevant articles makes it easier for them to access appropriate evidence 
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