Supporting nurses to use research-based evidence in clinical, management, and policy decision making is a challenge in today’s complex healthcare environments.1 Evidence-informed decision making (EIDM) is the conscientious, explicit, and judicious use of evidence to make clinical, organizational, and policy decisions and includes the use of high-quality research findings.2 In community settings, EIDM involves the ability of practitioners and organizational decision makers to make complex decisions by critically appraising the evidence and basing options for interventions on contextual factors that include the client’s situation and available resources.3 With the international public demanding more effective healthcare services, EIDM is considered central to safe high-quality healthcare delivery and policy making for optimal patient, organizational, and system outcomes.4,5 Similar to other health professionals, nurses do not always use the best available evidence to make decisions, and hence patients do not always receive the best care.6 With many of the barriers to using research evidence in nursing occurring at the organizational level,7,8 building strong and supportive organizational structures and processes for nurses to find, appraise, and implement research findings into practice is necessary.8-10
The purpose of this mixed-methods intervention study was to field test and evaluate a series of organizational strategies to promote EIDM by nurse managers (NMs) and clinical leaders in home healthcare. Specific research questions were as follows: What organizational structures and processes facilitate and support EIDM by managers and clinical leaders? What are the barriers and enablers to influencing EIDM through the intervention?
Managers and clinical leaders are responsible for ensuring healthcare delivery is high quality, effective, and evidence based, and are strategically aligned to act as key facilitators to EIDM.10-13 Role modeling and building a receptive organizational context are important managerial and leadership strategies to build an organizational climate for EIDM.14,15 However, leaders and managers of healthcare organization have been slow to apply the ideas of EIDM in their own practice, despite frequently doing much to encourage clinicians to adopt evidence-based practice. Lavis et al16 revealed in a systematic review that healthcare managers lacked the knowledge and skills to retrieve, appraise, and apply published research evidence (in the form of systematic reviews) in their decision making. Findings indicated that healthcare managers lacked a systematic approach to use research evidence, basing their decisions on other factors such as budgetary and financial issues, local competition, or strategic fit.14 These findings are consistent with previous research investigating barriers to using research evidence in nursing that demonstrated nurses frequently identify lack of awareness of relevant research, isolation from knowledgeable colleagues to discuss research findings, and having poor critical appraisal skills to evaluate the quality of the research as some of the top barriers.7,16-19 Although the choices made about how to organize, structure, deliver, or finance healthcare services ultimately affects clinical work environments and patient outcomes and therefore should be based on the best available evidence,19 EIDM by managers and healthcare leaders has made slow progress.9,20-22
Limited empirical evidence exists around the types of interventions that encourage healthcare managers and policy leaders to use research evidence in their decision making.23 A recent systematic review found only 4 articles describing 2 intervention studies aimed at encouraging healthcare managers and policy makers to seek, appraise, and apply research evidence, in the form of systematic reviews, in their decision making.23 Three of the articles report data from 1 intervention that distributed 5 systematic reviews to health managers and policy makers in public health, with follow-up surveys conducted after 3 months and 2 years. The study results indicated that 23% to 63% of respondents declared they had used evidence from the the reviews in their management decisions. Significant predictors included being a manager (odds ratio [OR], 14.04; 95% confidence interval [CI], 2.22-88.96), the expectation to using the evidence in the future (OR, 19.25; 95% CI, 2.44-151.99), and the perception that reviews would overcome limited critical appraisal skills (OR, 3.36; 95% CI, 1.36-8.31).24,25 The other study, a randomized trial, found that tailored messages combined with access to an online registry of systematic reviews had a significant effect (P < 0.01) on the decisions made in programs and policies for healthy body weight promotion in the health departments.26 The intervention strategies were not able to show a significant effect on global EIDM, determined as the extent to which research evidence was considered in recent program planning decisions. The authors concluded that health departments with a strong research culture showed the greatest trend toward EIDM, offering support for organizational factors as important to promote and enable EIDM.26
While the majority of research to promote EIDM has focused on interventions directed toward clinicians,27,28 nurses typically require organizational supports to change their practice including how they acquire, appraise, adapt, and apply evidence in their decision-making process.8 Little research has been conducted to understand and evaluate the effectiveness of organizational strategies to successfully promoting the use of evidence by nurses.8 An updated Cochrane review found only 1 study that incorporated an aspect of the organizational infrastructure to promote EIDM in nursing practice.8 The included study evaluated the effects of a standardized evidence-based procedure on nursing care and found no evidence of an intervention effect at 3 months (P = 0.46). Considering the importance placed on organizational strategies to promote EIDM, the authors concluded that it is surprising that appropriately evaluated organizational infrastructure interventions are still lacking. There is a need to look more broadly at organizational strategies that promote and support EIDM in nursing at both the management and clinical levels. Interventions that target managers and clinical leaders can have far-reaching effects as they target people in positional power to influence organizational change to support and enable EIDM in nursing.
The participating organization was a large community-based healthcare organization employing approximately 2000 nurses delivering home and community healthcare throughout the province of Ontario, Canada. Management and clinical leaders from 4 of 23 units participated in the 20-week organization-focused intervention to field test the intervention. Participants included NMs, supervisors, clinical resource nurses, and specialty wound care nurses. Ethics approval was obtained from the affiliated university’s research ethics board, which operates in accordance with the Canadian policies and regulations for ethical conduct of research involving humans, in addition to organizational approval to conduct the study.
The multifaceted intervention strategy consisted of: (1) one 5-hour interactive educational workshop focusing on EIDM, (2) support from “evidence facilitators” with skills in searching and critically appraising research, (3) access to university library services, (4) information-sharing activities, and (5) encouragement and recognition activities (Table 1).
During the workshop, participants received information on the organization’s vision for EIDM and step-by-step instructions on how to incorporate research evidence into their management and clinical decision making. First, summarized chart audit results related to a clinical practice gap in nursing care for diabetic foot ulcers were provided to participants. Participants were facilitated to engage in a systematic process on how to identify questions related to management and clinical practice problems, interventions, controls, and outcomes (PICO). They then accessed and critically appraised the research literature, adapting the evidence to inform decisions related to PICO questions. As an exemplar, an action plan was developed by participants to apply the research evidence to strategies and approaches for addressing the practice gap related to diabetic foot ulcers.
The evidence facilitators were master’s degree–prepared advance practice nurses (APNs) who had received dedicated training by a university professor (B.D.) in searching and critically appraising the research literature. After the workshop, the evidence facilitators worked with intervention participants to identify priority problems and access, appraise, and adapt the research evidence to the organizational context. The evidence facilitators were deployed through e-mail or telephone when participants had PICO questions or queries in which research evidence could inform. They then searched for relevant literature and worked 1-on-1 with participants to assist them in understanding how the evidence could inform their decision making for specific situations and contexts.
All intervention participants had unlimited access to a university library for electronic database searching and acquiring of academic literature.
Organizational data from administrative databases (eg, retention and turnover of staff) and clinical chart audit data (eg, use of wound measurement rulers) were provided to participants on request, and notices of research findings from published journals were regularly disseminated via e-mail to increase exposure to different types of research and evidence.
Encouragement and Recognition
Participants’ efforts and initiatives of using EIDM to improve care were acknowledged and recognized in the organization’s employee newsletter. Attendance at research conferences was encouraged and financially supported (n = 6). Two participants copresented with organizational researchers at research conferences.
To understand if the intervention increased organizational capacity for NMs and clinical leaders to engage in EIDM, a pre/post survey was completed before and 3 months after the intervention. The instrument used was developed by the Canadian Health Services Research Foundation and is entitled: Is Research Working for You? A Self-assessment Tool and Discussion Guide for Health Services Management and Policy Organizations (available at http://www.cohred.org/downloads/priority_setting_tools/STEP1.3a_IsResearchWorkingForYou_SelfAssessment.pdf). The scale consists of 31 items, organized into 4 general categories reflecting the capacity to (1) acquire (12 items), (2) assess (5 items), (3) adapt (8 items), and (4) apply (6 items) research findings in decision making. Each item was scored on a 5-point Likert frequency scale (1 = strongly disagree or low capacity, 5 = strongly agree or well equipped), and a total score for each category calculated. The tool has shown to have good usability and strong response variability, indicating that it is valuable in assessing the skills and resources needed for research use.29 The presurvey was administered in person at the beginning of the educational workshop, and the postsurvey was mailed to participating units for distribution by the unit managers.
At the end of the intervention period, semistructured telephone interviews (n = 15) were conducted with management and clinical leaders to understand the perceived usefulness of the intervention and the barriers and facilitators to EIDM. Participants were asked to rate each of the 5 organizational strategies on a 10-point Likert scale (1 = not at all useful; 10 = extremely useful) and describe the barriers and facilitators to using the organizational strategies for EIDM in their practice.
Survey data were entered into SPSS 17.0 statistical software (New York). Descriptive statistics were used to summarize each item on the tool and total scores for each of the 4 categories; results were expressed as means, medians, and SDs. Nonparametric statistics (Wilcoxon test) were used to compare the differences in mean scores before and after the intervention. For all tests, x level was preset at .05.
Qualitative data from the semistructured interviews were analyzed using a descriptive content analysis approach.30,31 Interviews were audio recorded, transcribed verbatim by a professional transcriptionist, and entered into NVIVO 8 qualitative software (QSR International Pty Ltd, Burlington, Massachusetts). An iterative process was used to summarize the data involving deductive coding of relevant passages using the words of participants, organizing and grouping recurring ideas into response categories, displaying categories in coding matrices to identify patterns and regularities, and recoding and condensing response categories into descriptive themes.31 Demographic data and Likert scale ratings were aggregated and reported descriptively.
Thirty-two of the 33 NMs and clinical leaders (97%) who participated in the intervention completed the preintervention survey. Seventeen surveys were completed after intervention (40%). The reason provided by the research managers for the low response rate in the postintervention period was that many people in the sites were new and therefore did not feel adequately prepared to complete the survey.
Four items on the Canadian Foundation for Healthcare Improvement (CHSRF) survey displayed statistically significant increases after the intervention (P < 0.5). The items reflected the organization’s capacity for participants to acquire and apply research findings in their decision making. Specifically, after the intervention, participants reported having more resources to conduct research, having relevant staff to contribute to EIDM discussions, receiving more feedback and rationale on decisions, and being more informed about how evidence influenced decision making in the organization.
Fifteen clinical and management leaders from the 4 study sites were interviewed (Table 2). All interview participants had been involved in the organizational strategies; 13 had attended the intervention workshop. Approximately half (n = 7) were in management position, including managers, directors, and supervisors, whereas the others held clinical leadership positions, including specialty clinical nurses and clinical resource nurses (n = 8).
Ratings of the 5 organizational strategies are found in Figure 1. Strategies included: (1) EIDM workshop; (2) support from evidence facilitators; (3) library services; (4) regular dissemination of research articles and chart audit information; and (5) encouragement and recognition activities. Overall, the organizational strategies were well received, with mean ratings between 7.8 and 9.5 of 10. Support from evidence facilitators who had skill in finding, appraising, and synthesizing research evidence rated the highest (mean, 9.5/10), whereas access to “external library services” rated the lowest (mean, 7.8/10).
Barriers to EIDM
In total, 9 different barriers were identified as interfering with participants’ ability to engage in EIDM. Managers and clinical leaders predominantly believed they did not have enough time, knowledge, skills, and confidence to find, appraise, and synthesize research findings for use in their decision making. Organizational level barriers included the existence of multiple initiatives and conflicting priorities within the organization to use the intervention strategies and engage in EIDM. A national nursing shortage, experienced as chronic staff shortages, was identified as an obstacle for nurses to engage in the intervention and routinely use evidence to inform their decision making.
Strategies to Assist EIDM
Investments in continuing education, audit and feedback, and ongoing linkage and exchange activities were recommended as key strategies to encourage and support EIDM in the future. Education included searching, critically appraising, and applying research evidence, and audit and feedback included receiving organizational data on areas of care that need improvement. Linkage and exchange activities involved the continued engagement of evidence facilitators such as APNs and researchers to assist with and influence EIDM in the organization, in addition to providing opportunities to bring people together for social networking around acquiring and using evidence in their decision making. The need for more time, resources, and opportunities to work with researchers was considered important strategies, while having access to databases, Web sites, and nonjournal reports was considered less important. Table 3 shows strategies identified by participants to support future EIDM.
Exposure to the intervention may have sensitized participants to respond to the postintervention survey and qualitative interviews in ways they perceived to be socially desirable. While the CHSRF survey has shown good usability and strong response variability in previous testing, it has not been validated for internal validity. The preintervention/postintervention response rates for the CHSRF survey differed greatly (97% preintervention, 40% postintervention) and may have been a reflection of the different methods used to administer the survey (preintervention survey was administered during workshop; postintervention survey was administered by the unit managers after the intervention was completed). Finally, outcomes of EIDM such as the actual decisions made and the patient and staff outcomes that are impacted by the decisions were not included in this pilot, an important aspect of EIDM that requires further investigation.
With many of the barriers to nurses’ use of research evidence existing at the organizational level,5 the development of an organizational infrastructure that promotes and enables nurses to use research evidence in their decision making is important to optimize nursing practice and promote positive health services outcomes. After implementation of the 5 organizational strategies in our intervention, participants identified that they had more resources and were more aware of the use of research evidence in organizational decision making. Building a multifaceted EIDM infrastructure that includes staff development and a structured process to review research finding has been recognized as an important strategy for increasing the capacity of community-based organizations to incorporate EIDM.14 There is a need to further delineate and understand what organizational structures and processes improve the capacity of members to access and use research evidence in their decision making.
Access to knowledge-based networks such as electronic library services may increases nurses’ ability to acquire research evidence to support decision making in their practice32; however, in our intervention participants rated access to the library service the least. Matching information needs of nurses with computer technology that is efficient and clinically relevant is an organizational challenge with little published research on the technological infrastructure that is most effective. Furthermore, nurses in our study revealed a lack of knowledge, skills, and confidence to find and appraise research evidence, a finding that is consistent with previous barriers research that confirms nurses’ lack of knowledge and skills to finding and critically appraising the research evidence.7 With the current state of healthcare literature large, unwieldy, and highly diverse,33 the development of electronic library reference services and continuing education programs for nurses to critically appraise the research literature needs further development.14,32 The relationship between computer technology and nurse leaders’ performance in EIDM, including the computer systems and training required to search, access, and use data in their decision making is an area in need of further exploration.
Support from the evidence facilitators was the highest-rated strategy for increasing the capacity of participants to engage in EIDM, while the CHSRF survey items additionally showed that intervention participants felt they had more resources that included on-site researchers to discuss the decision-making process. The inclusion of evidence facilitators to build competency in the workforce and incorporate EIDM into nursing practice is consistent with the multifaceted strategies recently described by Ward and Mowat14 as part of a 10-year strategic direction to incorporate evidence-informed decision making in Canadian public health departments. Enlisting influential leaders and dedicated staff who role model the acquisition of new knowledge and support using evidence in the decision-making process is integral to the organizational approach for enabling and supporting EIDM.14 Our findings indicate that providing opportunities for managers and clinical leaders to work with dedicated staff who have advanced knowledge in acquiring and appraising research evidence is important to embed EIDM into organizational routines. Commitment and continued investment in physical and human resources are required to build an organizational infrastructure that supports nurses to routinely use research evidence in their operational and clinical decision making.
In addition to providing direction to acquire, appraise and use research evidence, evidence facilitators used audit and feedback data as a means to highlight organizational and unit level gaps in care to NMs and clinical leaders. Receiving regular audit and feedback data was identified by participants as useful to encourage and support EIDM. A widely used knowledge translation strategy for improving the provision of evidence-informed healthcare delivery,34 audit and feedback is a summary of clinical performance and can help identify gaps in care between recommendations for effective evidence-based care and documented actual care. Audit data can relate to the structure of healthcare delivery (eg, presence of specific equipment), healthcare processes (eg, nurses’ assessments of pain scores), or patient outcomes (eg, injuries from falls) and are commonly incorporated into quality improvement initiatives and interventions.35 Challenges exist, however, to collecting, synthesizing, and condensing clinical data into meaningful outcome measures that can be acted on. Investment is needed into data management systems that synthesize data into meaningful clinical measures that will be useful to NMs, clinical leaders, and staff in their decision making.
Encouragement and recognition activities were the 2nd most highly rated strategy from the intervention and were also identified in the qualitative interviews as important to support EIDM. These activities are consistent with senior leadership activities that create an empowering work environment for nurses36 and facilitative leadership behaviors that encourage and support nursing staff to use evidence from clinical practice guidelines in their decision making.15 Engagement and recognition activities help create an empowering work environment by recognizing the contributions made by individual nurses and enabling staff to see the contributions they make within the healthcare system.36 The engagement and recognition activities in our study indicate that EIDM is a recognized priority and that senior leadership is committed to and invested in it.
The results from this study provide valuable information for policy makers and organizational administrators about the kinds of structures and processes that can facilitate and support EIDM by managers and clinical leaders in nursing. Our study results indicated that ongoing education and linkages with researchers and dedicated facilitators can help nursing leaders acquire, appraise, and apply research evidence in their decision making and decrease their reliance on nonresearch sources of evidence. Financial investment in physical and human resources is required to develop organizational structures and processes for nurses to routinely use research evidence in their operational and clinical decision making.
Given the vast quantities of information available, it is essential that researchers conduct well-designed studies to evaluate the effectiveness of organizational interventions and generate a strong evidence base to guide policy. Consistent with recommendations from the Cochrane Effective Practice and Organization of Care Group (http://epoc.cochrane.org), robust research designs such as interrupted time series with at least 2 intervention and control sites and 3 data points before and 3 data points after the intervention should be considered.6 High-quality research evidence will then be available to inform the development of organizational infrastructures that promote EIDM in nursing.
Implications for nurse executives include creating a vision and strategy for EIDM that is well aligned with the broader organizational vision, and identifying senior leaders and local champions to promote it. In addition, investments in physical and human resources include (1) staff development to acquire the skills needed to actively practice EIDM including searching and critically appraising the research literature; (2) specialized staff to assist and mentor nurses in EIDM; (3) easy and seamless access to library resource; (4) recognition programs that acknowledge staff’s EIDM and outcomes; and (5) time to build partnership with research-focused organizations such as academic institutions and funding organizations to build capacity for EIDM and help bridge the research/practice gap.
Effective organizational infrastructures are vital to enable nurses to make complex decisions related to nursing care delivery. Findings from this study point to specific organizational strategies that promote EIDM by NMs and clinical leaders in home healthcare. Combined with knowledge from other studies that highlight the importance of EIDM, these results are useful to point the way in developing organizational infrastructures to achieve the goal of providing quality care to healthcare consumers through evidence-informed policy, management, and clinical decision making.
The authors thank Sandra Tudge and Karen Ray and the nursing managers and clinical leaders from Saint Elizabeth for their great input and participation in this study.
1. Melnyk BM, Fineout-Overholt E, Gallagher L, Kaplan L. The state of evidence-based practice in US nurses critical implications for nurse leaders and educators. J Nurs Adm. 2012; 42 (9): 410–417.
2. Sackett DL, Richardson WS, Rosenberg W, et al. Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone; 1997.
4. Canadian Nurses Association. Position Statement: Evidence-Based Decision-Making and Nursing Practice. CNA Policy Statement. Ottawa, ON: Canadian Nurses Association; 2010.
6. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003; 362: 1225–1230.
7. Hutchinson AM, Johnston L. Beyond the BARRIERS Scale: commonly reported barriers to research use. J Nurs Adm. 2006; 30 (4): 189–199.
8. Flodgren G, Rojas-Reyes MX, Cole N, Foxcroft DR. Effectiveness of organizational infrastructures to promote evidence-based nursing practice. Cochrane Database Syst Rev. 2012; 2.
9. Meagher-Stewart D, Underwood J, MacDonald M, et al. Organizational attributes that assure optimal utilization of public health nurses. Public Health Nurs. 2010; 27 (5): 433–441.
10. Gifford WA, Davies B, Edwards N, Griffin P, Lybanon V. Managerial leadership for nurses’ use of research evidence: an integrative review of the literature. Worldviews Evid Based Nurs. 2007; 4 (3): 126–145.
11. Titler MG. Translation science and context. Res Theory Nurs Pract. 2010; 24 (1): 35–55.
12. Wallin L. Knowledge translation and implementation research in nursing. Int J Nurs Stud. 2009; 46 (4): 576.
13. Cummings G, Estabrooks C, Midodzi WK, Wallin L, Hayduk L. Influence of organizational characteristics and context on research utilization. Nurs Res. 2007; 56 (4S): S24–S3.
14. Ward M, Mowat D. Creating an organizational culture for evidence-informed decision making. Healthc Manage Forum. 2012; 25: 146–150.
15. Gifford W, Davies B, Graham ID, Tourangeau A, Woodend K, Lefebre N. Developing leadership capacity for guideline use: a pilot cluster randomized control trial. Worldviews Evid Based Nurs. 2013; 10 (1): 51–65.
16. Lavis J, Davies H, Oxman A, Denis JL, Golden-Biddle K, Ferlie E. Towards systematic reviews that inform health care management and policy-making. J Health Serv Res Policy. 2005; 10 (35).
17. Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S. Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof. 2007; 27 (2): 94–102.
18. Funk SG, Champagne MT, Tornquist EM, Wiese RA. Administrators’ views on barriers to research utilization. Appl Nurs Res. 1995; 8: 44–49.
19. Gifford W, Graham ID, Davies B. Multi-level barriers analysis to promote guideline based nursing care: a leadership strategy from home health care. J Nurs Manag. 2013; 21 (5): 762–770.
20. Browman GP, Snider A, Ellis P. Negotiating for change. The healthcare manager as catalyst for evidence-based practice: changing the healthcare environment and sharing experience. Healthc Pap. 2003; 3: 10–22.
21. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q. 2001; 79 (3): 429–457.
22. Lomas J. Using research to inform healthcare managers’ and policy makers’ questions: from summative to interpretive synthesis. Healthc Policy. 2005; 1 (1): 55–71.
23. Perrier L, Mrklas K, Lavis JN, Straus SE. Interventions encouraging the use of systematic reviews by health policymakers and managers: a systematic review. Implement Sci. 2011; 6: 43.
24. Dobbins M, Cockerill R, Barnsley J. Factors affecting the utilization of systematic reviews. A study of public health decision makers. Int J Technol Assess Health Care. 2001; 17 (2): 203–214.
25. Dobbins M, Cockerill R, Barnsley J, Ciliska D. Factors of the innovation, organization, environment, and individual that predict the influence five systematic reviews had on public health decisions. Int J Technol Assess Health Care. 2001; 17 (4): 467–478.
26. Dobbins M, Hanna SE, Ciliska D, et al. A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies. Implement Sci. 2009; 4: 61.
27. Godin G, Bqlanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals’ intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci. 2008; 3 (1): 36.
28. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Int J Technol Assess Health Care. 2005; 21: 149.
29. Kothari A, Edwards N, Hamel N, Judd M. Is research working for you? Validating a tool to examine the capacity of health organizations to use research. Implement Sci. 2009; 4: 46.
30. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004; 24: 105–112.
31. Miles M, Huberman A, Saldana. Qualitative Data Analysis: An Expanded Sourcebook. 3nd ed. Thousand Oaks, CA: Sage Publications Inc; 2014.
32. Pochciol JM, Warren JI. An information technology infrastructure to enable evidence-based nursing practice. Nurs Adm Q. 2009; 33 (4): 317–324.
33. Porter-O’Grady T. A new age for practice: creating the framework for evidence. In: Malloch K, O’Grady T, eds. Introduction to Evidence-Based Practice in Nursing and Health Care. Sudbury, MA: Jones & Bartlett; 2006: 9–10.
34. Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006; CD000259.
35. Mugford M, Banfield P, O’Hanlon M. Effects of feedback of information on clinical practice: a review. BMJ. 1991; 303: 398–402.
36. Shaw S. International Council of Nurses: Nursing Leadership. Oxford, UK: Blackwell Publishing Ltd; 2007.