How do you support your staff? Promote EBP

Nurse managers' attitudes toward evidence-based practice (EBP) influence the early adoption of best practices by their staff. The nurse manager has a pivotal role in providing opportunities for staff nurses to access, understand, and use EBP. Staff nurses who are involved in EBP projects have the opportunity to strengthen critical-thinking skills and build team competencies as they work with colleagues to identify practice questions, search for and critique evidence, and translate their findings into practice. The EBP novice needs support and help overcoming the many barriers that may derail an EBP project. But with the nurse manager's help and support for the process, staff nurses' renewed enthusiasm and engagement benefit the unit team and patient care.

Your role in supporting EBP

The important relationship of nurse manager support to positive work attitudes and behaviors, staff satisfaction and engagement, a healthy work environment, and positive patient outcomes is well established. Anecdotally, nurse managers understand how their priorities influence the priorities of their staff. There has been limited exploration of the role of the nurse manager in implementing a culture of EBP and its impact on the nursing unit. Most often, the EBP literature speaks broadly of the role of nurse leaders in allocating resources and establishing the infrastructure needed to support EBP in a healthcare organization. There are few published descriptions of how nurse managers can advance EBP at the bedside.

Kramer et al. studied the clinical nursing environment and the nurse manager's role in promoting a professional practice environment over a number of years.¹ They developed and used an Essentials of Magnetism tool to measure eight attributes viewed by staff nurses as essential to an excellent work environment, one of which is nurse manager support. In 2007, they conducted a national research study combining quantitative and qualitative techniques to better understand the concept of nurse manager supportive behaviors. They administered an investigator-developed Nurse Manager Support Scale to more than 2,000 staff nurses in eight Magnet® hospitals, and followed this survey with interviews of selected staff nurses, managers, and physicians on the highest scoring units. Among their findings, they discovered that the item "stimulate and guide staff in research and evidence-based practice activities" contributed more significantly to staff nurse perception of the nurse manager support for career development than any of the other career development items. However, only 44% of the staff nurses reported their nurse managers exhibited this behavior.

Although many other items were viewed as more important by staff nurses and were also more frequently performed by nurse managers, the contribution of support for EBP to staff nurse perceptions of support for career development is a provocative finding. Other, more traditional, career development activities such as encouragement of specialty certification and coaching didn't have as strong an influence. Interestingly, this same item in the research instrument also affected hospital-level data. Three of the eight hospitals in the study scored significantly lower on nurse manager's support for career development because of low scores on the item describing nurse manager support of EBP. Analysis showed that this reflected organizational differences among the eight hospitals with respect to support for EBP. The authors commented the results indicated that staff nurses' perceptions of supportive nurse manager role behaviors are affected by hospital and departmental organization and expectations.

An example from one organization illustrates the importance of nurse manager support for staff nurses participating in EBP projects.² Pediatric nurses on the adolescent medical-surgical unit were concerned about how distractions and interruptions affected medication administration safety. A team was assembled to ensure that members had the knowledge, skills, and experience in project management needed for a successful project. The nurse manager supported the team as an active member and encouraged collaboration beyond the unit to access additional resources. She provided information about the project to other unit staff, the department, and across the hospital. Her support and enthusiasm helped motivate staff to work on the project, and she was able to allocate dedicated project time for the team members. As the project evolved, the nurse manager provided input on the feasibility of the time line. She played a critical role in creating the action plan to implement the team's recommendations.

These strategies demonstrated the manager's commitment to her staff having the opportunity to experience the EBP process. The outcomes of a project such as this occur on many levels. The project changed practice, but it also built lasting skills and a sense of accomplishment and pride among the staff. For the nurse manager, involving her staff in a unit-based EBP project was a unique opportunity to nurture professional practice and collaborative teamwork.

Barriers to EBP

Organizational differences do exist. Some healthcare organizations have successfully integrated EBP, whereas others are still struggling. A number of barriers to EBP have been well-described in the literature. They include individual characteristics, such as lack of knowledge and skill; limited organizational resources; and healthcare environments that don't value nursing autonomy and collegial relationships. Nurse managers may have particular difficulty supporting and promoting EBP if their own knowledge and skills in the EBP process are limited. Until recently, few nurses had the opportunity to learn the EBP process in academic programs, and healthcare organizations often focused EBP education and resources toward practitioners rather than managers.

Gale and Schaffer surveyed a convenience sample of staff nurses and nurse managers from eight acute care and critical care units in one hospital. They found agreement between staff nurses and nurse managers that insufficient time, lack of staff, and not having the right equipment or supplies available were the most significant barriers.³ Staff nurses were more likely to agree with the statement that EBP doesn't take account of limitations in the practice setting, and nurse managers were more likely to agree that sufficient information could be accessed for questions about the practice change. These findings suggest that dialogue exploring the challenges of a specific unit's work environment could help nurse managers and staff nurses identify and overcome barriers.

Strategies to promote EBP

What strategies can nurse managers use to engage staff in EBP? These are likely to vary based on the organizational EBP infrastructure and culture, but even in a setting with limited resources you can still use a variety of strategies to encourage asking questions about practice and create a learning environment. Table 1 lists examples of unit-based activities that can help nurse managers build an EBP culture on their units.

Table 1: Unit-based strategies to promote EBP

Fostering EBP within organizations requires resources, infrastructure, and champions. Nurse managers are often at the interface of policy and practice, with accountability for successful unit implementation of organizational initiatives and practice changes. They have an equally important role representing their staff and patient needs to higher levels of administration. Your role as a frontline manager, with all that implies for the quality and safety of patient care, makes you an ideal candidate to be an EBP champion in your organization.

Champions need competencies. Many nurse managers already have expertise in communication, critical thinking, managing change, monitoring practice, project management, and leading a team. These are examples of skills that contribute significantly to the success of an EBP project. You also need familiarity with the EBP process, ideally taking advantage of your organization's EBP resources and education to ensure your own competency. Some free introductory online educational programs about EBP are also available. For example, there are courses provided by the West Virginia University School of Nursing (http://www.hsc.wvu.edu/Charleston/son/Continuing-Education/EBPDescription.aspx) and the Penn State University Libraries (http://www.libraries.psu.edu/psul/tutorials/ebpt.html).

Many healthcare organizations have adopted a formal EBP model to guide their work. Examples include the CURN Model (originally published in 1983), Iowa Model (1994, 1998, 2001), and models developed by Stetler (1994, 2001) and by Rosswurn and Larrabee (1999). The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model was developed by its nurses, nurse leaders, and nursing faculty to provide nurses at all levels with the opportunity to use EBP and participate in EBP projects.⁴ The JHNEBP Model and its accompanying guidelines and tools are designed to be user-friendly and relatively easy to teach and implement. To date, about 80 hospitals and schools of nursing have used the JHNEBP Model. Nurses at The Johns Hopkins Hospital have been using this model for almost a decade to improve bedside practice. The JHNEBP Model guides nurses at all levels in the organization to think critically about their practice, and gives nurse managers a structure and well-defined process to support the professional development of their staff and ensure quality patient care.