for Evidence-Based Practice

Transcription

1 HOURS CE4 Cotiuig Educatio ORIGINAL RESEARCH BY DIANE S. PRAVIKOFF, PHD, RN, FAAN, ANNELLE B. TANNER, EDD, RN, AND SUSAN T. PIERCE, EDD, RN Readiess of U.S. Nurses for Evidece-Based Practice MANY DON T UNDERSTAND OR VALUE RESEARCH AND HAVE HAD LITTLE OR NO TRAINING TO HELP THEM FIND EVIDENCE ON WHICH TO BASE THEIR PRACTICE. OVERVIEW: Evidece-based practice is a systematic approach to problem solvig for health care providers, icludig RNs, characterized by the use of the best evidece curretly available for cliical decisio makig, i order to provide the most cosistet ad best possible care to patiets. Are RNs i the Uited States prepared to egage i this process? This study examies urses perceptios of their access to tools with which to obtai evidece ad whether they have the skills to do so. Usig a stratified radom sample of 3,000 RNs across the Uited States, 1,097 urses (37) respoded to the 93-item questioaire. Seve hudred sixty respodets (77 of those who were employed at the time of the survey) worked i cliical settigs ad are the focus of this article. Although these urses ackowledge that they frequetly eed iformatio for practice, they feel much more cofidet askig colleagues or peers ad searchig the Iteret ad World Wide Web tha they do usig bibliographic databases such as PubMed or CINAHL to fid specific iformatio. They do t uderstad or value research ad have received little or o traiig i the use of tools that would help them fid evidece o which to base their practice. Implicatios for ursig ad ursig educatio are discussed. KEYWORDS: Evidece-based practice, evidece, best practice, bibliographic databases, research Diae S. Pravikoff is maagig editor of the Olie Joural of Cliical Iovatios ad director of research ad professioal liaiso at Ciahl Iformatio Systems i Gledale, CA. Aelle B. Taer is regioal coordiator of the Fetal ad Ifat Mortality Review Iitiative, Louisiaa Office of Public Health, ad a adjuct faculty member at Northwester State Uiversity College of Nursig, Alexadria, LA. Susa T. Pierce is a associate professor at Northwester State Uiversity College of Nursig s mai campus, Shreveport, LA. Cotact author, Diae S. Pravikoff: dpravikoff@ciahl.com. The authors wish to ackowledge several orgaizatios that cotributed fiacially to the study: the Expert Pael o Nursig Iformatics of the America Academy of Nursig; the America Medical Iformatics Associatio s Nursig Iformatics Workig Group; Ciahl Iformatio Systems (a divisio of EBSCO Publishig); the Iteragecy Coucil o Iformatio Resources for Nursig; McKesso Corporatio; ad Skyscape, Ic. The authors of this article have o other ties, fiacial or otherwise, to ay compay that might have a iterest i the publicatio of this educatioal activity. 40 AJN September 2005 Vol. 105, No. 9

2 Cosider a hypothetical but all-too-commo real-world sceario: Nacy Adams is a 52- year-old RN i charge of a medical surgical uit i a midsize acute care facility i Souther Califoria. Oe of her patiets, a 82-year-old woma with cacer ad demetia, recetly died from asphyxiatio whe her head became trapped betwee the side rails ad the mattress o her bed. Ms. Adams had leared i ursig school to make sure that the side rails were always up o her patiets beds, ad she has emphasized that to the urses who work with her. Now she woders whether that s the right itervetio ad how to fid out. She asks several of her peers how they kow that this itervetio is best for patiets. No oe is able to provide actual evidece. It s just what they ve always bee taught to do. There is a small locked medical library i her facility used mostly by a few physicias ad o oe has ever told her where the key is. She d heard about the CINAHL database ad PubMed at a coferece she d atteded recetly, but her facility has o access to them. Besides, she has very limited computer skills. She has a computer i her office but uses it mostly for i-house ; the hospital admiistratio does t allow Iteret access because it might be abused. She s at a loss as to how to fid the iformatio she eeds. Most urses, accordig to Estabrooks, practice ursig accordig to what they leared i ursig school as well as their experieces i practice. 1 But the average age of the urse today is older tha 40 years; accordig to the Natioal Sample Survey of Registered Nurses coducted by the U.S. Health Resources ad Services Admiistratio (HRSA) i March 2000, 70 of urses graduated from ursig programs before This presets the ursig professio with a serious dilemma. O the oe had are the demads for a professioal practice, based o up-to-date iformatio, that come from govermet agecies, payers, accreditig bodies, ad patiets; o the other had are health care providers who may ot be prepared to meet these demads because they do t kow how to fid iformatio or do t have the tools to obtai it ad do t have the time to solve either of these problems. Both the iformatio ad tools to obtai it are ecessary compoets of evidece-based practice, which is characterized by the use of the best evidece curretly available for cliical decisio makig i order to provide the most cosistet ad best possible care of patiets. A frequetly quoted defiitio of evidece-based practice from Sackett ad colleagues icludes itegratig idividual cliical expertise with the best available exteral evidece from systematic research. 3 I a later defiitio, Sackett also icluded patiet prefereces as a sigificat compoet. 4 Thus, evidece-based practice is a systematic approach to problem solvig for health care providers. PURPOSE This study, which builds o kowledge gaied from recet research addressig the readiess for evidecebased practice of RNs i various work settigs, 5-7 specifically examies urses perceptios of their skills i obtaiig evidece ad their access to tools with which to do so. To uderstad the tools ad skills required for evidece-based practice, it s importat, first, to uderstad what evidece-based practice ivolves. As described by Sackett ad colleagues, evidecebased practice is a process, similar to that of ursig as it s taught to ursig studets. It etails assessig ad defiig a problem ad formulatig a specific questio. searchig for, fidig, ad evaluatig appropriate evidece. plaig ad implemetig a itervetio by itegratig the evidece ito practice. evaluatig the process ad the results. 3 It s obvious that the part of the process that icludes the search for ad evaluatio of the evidece is critical. However, persoal ad orgaizatioal barriers to the use of research ad the implemetatio of evidece-based practice are substatial. A lack of time has frequetly bee idetified as a importat barrier to applyig research to practice. BARRIERS TO EVIDENCE-BASED PRACTICE A lack of time ad access. A lack of time has frequetly bee idetified as a importat barrier to applyig research to practice Retsas, i a study of 400 urses workig i a Australia hospital, stated that, if the use of research evidece by urses is to icrease, the most importat orgaizatioal chage that eeds to occur is icreasig the time available for urses to achieve this goal. 13 Additioal time is, therefore, the first prerequisite for accessig, readig, ad evaluatig research. I additio to time, however, is the equally importat issue of access to the tools ecessary to search for the evidece. Electroic access to iformatio resources ad the appropriate skills to use the tools effectively are essetial. I a six-moth aj@lww.com AJN September 2005 Vol. 105, No. 9 41

3 Professioal literature was the most importat source cited for chages i practice, but urses foud that professioal literature was t readily available to them at the workplace. trial project published i 1994, Kig ad Carroll foud that computerized resources were accessed far more frequetly whe located o the ursig uit (as compared with the hospital library). 14 The visibility of the computer termial, the presece of a techology champio (oe who uderstads computer techology ad promotes its use), ad rewards for usig the system (such as promotio ad teure) have all cotributed to a icrease i olie searchig by urses. 15 As Kig ad Carroll poited out, access i a library provides a formal meas of commuicatio while access i a cliical settig provides a iformal tool that s more user-friedly. 14 Yet studies coducted recetly by Pierce ad by Taer (both coauthors of this report) demostrate that urses have either the skills or the resources to coduct iformatio searches. 5, 7 This is due, i part, to the amout of time most urses have bee out of school ad the fact that, for may, tools such as persoal computers, the Iteret, ad electroic databases did t yet exist whe they were i school. Pierce ad Taer each foud that urses educated after 1990 were likely to be more skilled at seekig iformatio. Marshall s importat research ad Wood ad Wright s later study demostrated that access to appropriate iformatio ca chage practice. 16, 17 I fact, while Wood ad Wright foud that 14 of 20 geeral practitioers said that the impact of the cliical iformatio they received was of at least some importace to the patiet, 96 of the physicias i Marshall s study stated that they were able to make better-iformed cliical decisios as a result of iformatio provided to them by librarias. I a survey of urses ad physicias i the Uited Kigdom that sought to idetify sources of iformatio ad the importace of these sources amog the two groups i chagig practice, Kerriso ad colleagues foud that urses perceived gaiig access to evidece-based iformatio as extremely difficult, whereas physicias foud it easier. 18 Nurses reported that access to both libraries ad electroic resources was frequetly MEDLINE vs. PubMed A RE THEY THE SAME? MEDLINE is the Natioal Library of Medicie s electroic database of citatios ad abstracts. It idexes more tha 4,800 jourals from more tha 70 coutries, from approximately 1966 to the preset. (Idex Medicus is the paper equivalet of MEDLINE.) MEDLINE is available olie ad at o cost through PubMed, or it ca be obtaied for a fee through the subscriptio database Ovid, as well as through other compaies. PubMed is the Natioal Library of Medicie s Web iterface, through which MEDLINE ca be accessed, but PubMed also icludes citatios from 1950 through 1966 (OLDMEDLINE), iprocess citatios (citatios that are available but have t yet had subject terms assiged), ad publisher-supplied citatios from jourals that were t origially chose by MEDLINE for idexig. PubMed has a greater scope tha MED- LINE ad is freely available o the Web. For more iformatio, go to pubs/factsheets/dif_med_pub.html. restricted. Professioal literature was the most importat source cited for chages i practice, but urses foud that professioal literature was t readily available to them at the workplace. The Istitute of Medicie s 2001 report, Crossig the Quality Chasm: A New Health System for the 21st Cetury, makes a strog case for the importace of iformatio techology while ackowledgig that the systematic reviews it recommeds are oly the first step i makig kowledge more usable by both cliicias ad patiets. 19 As Bakke ad colleagues poit out, exteral sources of iformatio are ofte required to provide care cosistet with the best evidece. 20 I order to take advatage of all the features of iformatio techology ad available iformatio resources, however, urses must kow how to use them. Searchig skills i a electroic eviromet. While some health care facilities have librarias to assist i obtaiig iformatio, may do t, i which case urses must have the ability to perform such activities uaided. Taer s study of a radom sample of 223 RNs ad advaced practice urses i Louisiaa ad Pierce s examiatio of 339 ursig faculty members ad graduate ad baccalaureate ursig studets, also i Louisiaa, demostrated that oly a small percetage of those surveyed were familiar with the process of evidece-based prac- 42 AJN September 2005 Vol. 105, No. 9

4 tice. 5, 7 Although approximately half of the advaced practice urses ad RNs surveyed said that they had access to the Iteret at work, fewer tha 20 of the other groups used it. Regardless of access, fewer tha 20 of urses i all groups said they were able to coduct successful literature searches with either the MEDLINE database or the CINAHL database, the two primary bibliographic databases of medical, ursig, ad allied health literature. Other researchers, icludig Russell ad Alpay, have also cocluded that urses simply have ot acquired adequate kowledge of iformatio techology. 21 (For more see Evidece-Based Practice Resources, at right, ad Makig the Most of Nursig s Electroic Resources, page 79.) Buildig o the kowledge gaied from such studies of practicig urses, we recetly coducted a pilot study that examied ursig admiistrators perceptios of the status of iformatio resources i their facilities (see Are Nurses Ready for Evidece- Based Practice? Nursig Resources, May 2003). Respodets i two states idicated that less tha 35 [of their facilities] provided access to the Iteret or computerized refereces o the cliical uits where the iformatio could be most easily ad readily used. 6 Although these ursig admiistrators believed the provisio of prit material to be at least adequate, the majority felt that olie resources were less tha adequate or completely iadequate to meet the eeds of their staff. We wated to determie whether a larger sample of U.S. urses had access to resources ad possessed skills i fidig iformatio that were comparable to those foud i our earlier studies, ad whether the availability of resources ad the skills i fidig iformatio were sufficiet for urses to implemet evidece-based practice. Specifically, we iteded to determie whether RNs were aware of their eed for iformatio ad the importace of usig evidece (icludig research) i practice. ivestigate the availability of iformatio resources to RNs at work ad at home. defie, from the RN s poit of view, the idividual ad istitutioal barriers to usig research ad other evidece i practice that are preset i the cliical eviromet. METHODS Desig. This was a descriptive, exploratory survey to examie U.S. RNs perceptios of the iformatio resources available to them ad their skills i usig those resources. Sample. Approval for the study was obtaied from the istitutioal review board of Northwester State Uiversity College of Nursig, with which two of the ivestigators are affiliated (S.P. ad A.T.). The Evidece-Based Practice Resources W HERE TO BEGIN YOUR SEARCH. The followig are some resources supportive of evidece-based practice. GUIDELINES AND BEST PRACTICES The Natioal Guidelie Clearighouse, a program of the Agecy for Healthcare Research ad Quality, U.S. Departmet of Health ad Huma Services, is a database of evidece-based cliical practice guidelies ad related documets desiged for urses, physicias, ad other health care providers. Go to The Joaa Briggs Istitute, based i Adelaide, Australia, is affiliated with Royal Adelaide Hospital ad has a large etwork of collaborators throughout the world. It produces both best-practice iformatio sheets ad systematic reviews o dozes of topics of iterest to urses. Go to practice.php. SYSTEMATIC LITERATURE REVIEWS A systematic literature review is a type of research with a defied questio or objective, a methods sectio describig the search of the literature, a sythesis of literature cocerig the questio or objective, ad a discussio of the implicatios of that sythesis. The Cochrae Collaboratio, a iteratioal oprofit orgaizatio, produces the Cochrae Database of Systematic Reviews, writte by collaborative groups of health care professioals. Topics covered are primarily biomedical, but there are may ursig topics, as well. Go to The Sarah Cole Hirsh Istitute for Best Nursig Practices Based o Evidece is a repository of systematic reviews of evidecebased practices at the Fraces Paye Bolto School of Nursig, Case Wester Reserve Uiversity. It publishes the reviews through the Olie Joural of Issues i Nursig. Go to edu/hirshistitute/reviews.shtm. Worldviews o Evidece-Based Nursig is a relatively ew joural published both i prit ad electroically by Sigma Theta Tau Iteratioal. It cotais both systematic reviews of the literature ad other articles ad abstracts. Go to www. blackwellpublishig.com/joural.asp?ref= x. The Olie Joural of Cliical Iovatios is a electroic publicatio from Ciahl Iformatio Systems ( that cotais systematic reviews of literature o key issues i patiet care, such as pai assessmet ad fall prevetio. Go to OTHER RESOURCES Evidece-Based Nursig, a quarterly publicatio of BMJ Publishig Group ad the Royal College of Nursig Publishig Compay, provides abstracted iformatio ad commetary o research studies from a wide variety of iteratioal jourals. aj@lww.com AJN September 2005 Vol. 105, No. 9 43

5 TABLE 1. Characteristics of Cliical Nurses ( = 760)* SEX () AGE IN YEARS Female 91 Male 7 Not kow RACIAL OR ETHNIC BACKGROUND White (o-hispaic) 86 Black, Africa America 4 Asia 4 America Idia or Alaska ative 1 Hispaic, Latio 2 Two or more races (o-hispaic) 1 Not kow 1 HIGHEST NURSING EDUCATION Diploma 17 Associate s degree 34 Baccalaureate 39 Master s degree 9 Doctorate 1 Not kow 1 YEAR OF MOST RECENT NURSING DEGREE earlier 41 Not kow 1 WORK SETTING Hospital 60 Nursig home 6 Commuity or public health 6 School health 4 Nohospital occupatioal health 1 Nohospital ambulatory care 12 Other 11 *Percetages may ot add up to 100 because of roudig. survey was mailed to a geographically stratified radom sample of 3,000 U.S. RNs, whose ames were geerated from a list of more tha 2 millio RNs available from a atiowide publishig compay. Because our earlier pilot study focused o oly two states Louisiaa ad New York wider geographic represetatio was desired for this study. Geographic stratificatio was based o respose percetages obtaied i the 2000 Natioal Sample Survey of Registered Nurses. For example, 10.5 of resposes to the atioal sample survey were obtaied from the Pacific regio (Alaska, Califoria, Hawaii, Orego, ad Washigto); therefore, 10.5 of the questioaires for this study were set to radomly selected RNs i that regio. Of the 3,000 surveys set, 53 were udeliverable either because of icorrect addresses or because addressees were deceased. Resposes from 1,097 (37) were retured. Of these, 987 respodets were curretly workig as RNs i admiistratio, educatio, or cliical practice, ad these composed our sample. The 760 cliical RN respodets (77 of the sample of workig RNs) are the focus of this article. Those workig solely as admiistrators or educators were excluded from this aalysis. Data from the full sample of workig RNs were preseted last September at Medifo 2004, a coferece sposored by the America Medical Iformatics Associatio, ad published i the Proceedigs of the 11th World Cogress o Medical Iformatics. 22 Istrumet. The survey used for this study, a 93- item questioaire, was origially developed for earlier studies (coducted by S.P. ad A.T.) that focused o RN faculty, graduate ursig studets, ad cliical staff i Louisiaa. 5, 7 The questioaire was modified for use i the pilot study of ursig admiistrators i Louisiaa ad New York, metioed above. 6 Cotet validity was established by experts i ursig, ursig iformatics, ad iformatio sciece. The tool was cofigured for use with Teleform techology, a high-volume, high-accuracy automated character-recogitio ad -capture techology that supports batch processig of data forms. Items were desiged i various formats. Some required respodets to aswer yes, o, or do ot kow to questios about the existece of resources (such as prit idexes, electroic databases, curret jourals, ad olie resources) ad access to them. Other items required respodets to rak terms i a provided list for example, the top three idividual barriers to usig research i practice (from a list of 10) or the top three orgaizatioal barriers (from a list of six). Because the lack of time is geerally recogized as a major problem, it was t icluded i the list of choices (respodets were istructed Besides time, rak the three primary barriers... ). 44 AJN September 2005 Vol. 105, No. 9

6 Procedure. Usig the Tailored Desig Method developed by Dillma for mailed surveys, 23 we mailed cards itroducig the survey oe week prior to mailig the questioaires. The iitial survey mailig was followed by remider postcards ad the a secod mailig of the questioaire to those from whom resposes had ot bee received. Retured questioaires were delivered to the Ceter for Nursig Research at the Uiversity of Texas at Arligto, where traied research assistats processed them. Data were aalyzed usig SPSS 12.0 software ( ( = 200) 91) RESULTS Characteristics of the 760 cliical RN respodets are described i Table (page 44). The typical respodet ( was = 200) a 40-to-49-year-old white woma who worked i a hospital, held a diploma or associate s degree i ursig, ad last atteded a degree-gratig educatioal program i 1984 or earlier. (Note that some did t respod to all questios.) Iformatio eed ad iformatio seekig. Respodets were asked how ofte they eeded iformatio to support their everyday practice. Sixty-oe percet said they eeded to seek iformatio at least oce a week or several times a week (see Figure 1, at right). Whe asked how they foud the iformatio they eeded, 67 of the respodets said they always or frequetly sought iformatio from a colleague (rather tha from a referece text or joural article) (see Figure 2, page 46). Joural articles, research reports, ad hospital libraries were seldom used as sources of iformatio. I fact, 58 of respodets reported ot usig research reports at all to support their practice; 82 ever used a hospital library (see Figure 3, page 46). Although evidece-based practice has bee widely discussed i the literature over the last several years, fewer tha half (46) of respodets said they were familiar with the term. Resource availability ad use. Fifty-seve percet of respodets said that their facility did have a medical or health scieces library, ad 5 did t kow. Most of these libraries were available to all employees ad eve the geeral public, but a small percetage of respodets (3) said that their facility s library was available oly to physicias. This percetage is a improvemet over the pilot study, i which 6 of respodets idicated that their hospital s library was available oly to physicias. 6 Iformatio seekig i today s electroic eviromet is partly depedet o oe s ability to use FIGURE 1. SURVEY ITEM: How Ofte Do You Need Iformatio to Support Your Nursig Role? (749 Respodets) 12.1 ( = 91) 28.3 ( = 212) 32.8 ( = 246) 28.3 ( = 212) resources such as computers ad search egies. Whe 32.8 asked to rate their computer skills o a 5- ( = 246) poit scale that raged from ovice (1) to expert (5), respodets were fairly cofidet i their ability to use computers (mea ratig = 3.08), the Widows operatig system (3.02), ad word processig applicatios (2.87) but less cofidet i their ability to use other programs, icludig bibliographic databases (2.58). Although 83 of respodets cosidered themselves at least somewhat successful whe searchig the Iteret or World Wide Web, oly 19 ad 36, respectively, were as cofidet i their ability to search CINAHL or MEDLINE. Sevety-six percet of respodets apparetly ever searched CINAHL, ad 58 ever searched MEDLINE. Most respodets rarely or ever sought a libraria s assistace (83), did t use the hospital library (if oe existed) (82), ad had ever received istructio i the use of electroic resources (77). Whe asked whether they had idetified a researchable problem i their practice withi the last year, Ofte (several times per week) Regularly (weekly) Occasioally (1 2 times per moth) Seldom (< oce per moth) Sevety-six percet of respodets apparetly ever searched CINAHL, ad 58 ever searched MEDLINE. Ofte (several times per week) Regularly (weekly) Occasioally (1 2 times per moth) Seldom (< oce per moth) aj@lww.com AJN September 2005 Vol. 105, No. 9 45

7 FIGURE 2. SURVEY ITEM: Whe You Need Nursig Iformatio, How Do You Fid it? I seek assistace from the libraria (737 respodets) I ask colleagues or peers (747 respodets) I search the bibliographic databases (740 respodets) I search the Iteret/World Wide Web (741 respodets) I read jourals or books (750 respodets) I atted cofereces, workshops, or programs (749 respodets) Never Rarely Sometimes Frequetly Always FIGURE 3. SURVEY ITEM: Please Idicate the Frequecy That You Persoally Seek Iformatio from Each of the Followig Sources. Referece text/maual (750 respodets) Joural article (752 respodets) Research report (751 respodets) Hospital library (748 respodets) Not at all Mothly Weekly Daily May times daily 46 AJN September 2005 Vol. 105, No. 9

8 FIGURE 4. SURVEY ITEM: I the Last Year, How Frequetly Have You Persoally Participated i the Followig Activities? Participated i research (753 respodets) Evaluated research reports (752 respodets) Idetified researchable problems (753 respodets) Not at all Oce 2 3 times > 3 times FIGURE 5. SURVEY ITEM: Overall, How Would You Rate the Followig Iformatio Resources i Your Workplace? Prit materials (737 respodets) Olie resources (733 respodets) Other iformatio resources (728 respodets) Totally iadequate Less tha adequate Adequate More tha adequate most (59) said that they had t, ad a greater percetage (72) said they had t evaluated research reports. (See Figure 4, above.) Oly 36 of respodets reported that their facilities provided access to electroic databases, ad 29 did t kow whether such access was provided or ot. Perhaps eve more importat are the resources available to urses throughout a facility, particularly at the poit of care. Of those who said that curret prit jourals were available i their facility ( = 360), oly 40 (144) had access to the jourals o ursig uits. This group represets oly 19 of the total sample of 760 cliical RNs. Similarly, 26 of the total sample said they had access to electroic databases o ursig uits, ad 49 believed they had access to the Iteret or World Wide Web o uits. Whe urses were asked whether they persoally had access to electroic resources (at home or at work), 72 said yes. Of those, 18 said they had access to the CINAHL database, 40 to MEDLINE, ad 98 to the Iteret ad World Wide Web. Fifty-three percet of the total sample had access at work. Simply because the resources are available, however, does t ecessarily mea they are adequate. Therefore, we asked respodets about the adequacy of the various resources i their istitutios (see Figure 5, above). As show i the figure, almost half (approximately 46) characterized olie resources as less tha adequate or totally iadequate. Barriers to evidece-based practice. Barriers to the use of research i practice exist at both the istitutioal level ad the idividual level. Because of aj@lww.com AJN September 2005 Vol. 105, No. 9 47

9 TABLE 2. Primary Idividual Barriers (Other Tha Time) to Nurses Use of Research i Practice, i Order of Importace 1 Lack of value for research i practice 2 Lack of uderstadig of orgaizatio or structure of electroic databases 3 Difficulty accessig research materials 4 Lack of computer skills (tied with o. 5) 5 Difficulty uderstadig research articles (tied with o. 4) 6 Lack of access to a computer 7 Lack of library access 8 Lack of search skills 9 Lack of kowledge about research 10 Lack of skills to critique or sythesize the literature (or both) TABLE 3. Primary Istitutioal Barriers (Other Tha Time) to Nurses Use of Research i Practice, i Order of Importace 1 Presece of other goals with a higher priority 2 Difficulty i recruitig ad retaiig ursig staff 3 Orgaizatioal budget for acquisitio of iformatio resources 4 Orgaizatioal budget for traiig i resource use 5 6 Orgaizatio perceives that ursig staff is ot eager or prepared to icorporate or pursue evidece-based practice Orgaizatio perceives evidece-based practice or research use as ot achievable i the real world the vast amout of literature ackowledgig that a lack of time is the greatest of all such barriers, 8-12 we assumed that lack of time would be the most importat impedimet amog our respodets ad asked them about other barriers. Respodets were asked to rak the top three barriers from a list of 10 (excludig the lack of time) that iterfere with their ow use of research (see Table 2, above); the barrier chose by the greatest umber of respodets was a lack of value for research i practice, followed by a lack of uderstadig of orgaizatio or structure of electroic databases ad difficulty accessig research materials. Other barriers such as a lack of skills to critique ad sythesize the literature, a lack of search skills, ad difficulty uderstadig research articles were also raked highly. Clearly, most RNs believe that they re ot adequately prepared to appraise research ad iterpret its usefuless for cliical decisio makig. This, coupled with how little value the urses said was placed o research i practice, reveals serious limitatios to implemetig evidece-based practice. Nurses perceptios of orgaizatioal barriers those preseted by the facility i which they work are give i Table 3 (at left). Obviously, the existece of such orgaizatioal barriers is a expressio of how much, or how little, istitutios ad their admiistrators value iformatio resources ad urses access to them. DISCUSSION The sample of cliical RNs i this study is similar to urses atioally i terms of sex, race or ethic idetity, highest degree of ursig educatio achieved, ad work settig, but they are slightly older (79 were 40 years of age or older, as compared with 68 i the atioal sample survey coducted by HRSA 2 ). The majority of the respodets i the sample survey received their basic ursig educatio before 1990, before the widespread availability of electroic iformatio resources ad persoal computers. Because of the similarities i age ad the period durig which most of the urses atteded school, it s probably safe to assume that the respodets i the atioal sample survey would have perceptios similar to those who participated i the curret study with regard to their eed for iformatio, the resources available to them, ad the cofidece they have i their skills i usig these resources. Because the umber of cliical urses i the curret study s sample was a large percetage of the total sample, the overall fidigs preseted at Medifo 2004, which icluded the resposes of admiistrators ad educators as well as cliicias, were similar. 22 However, cliical urses reported less use of bibliographic databases, less availability of istructio, less access to resources, less familiarity with evidece-based practice, ad less success i usig electroic resources tha did the total sample. Awareess. Although RNs recogized the eed for iformatio i their practice, their most frequet source of that iformatio was a peer or colleague. However, 39 of the respodets stated that they eed iformatio oly occasioally or seldom. This is alarmig whe oe cosiders the umber of chages i practice that are recommeded o a regular basis today. As Thompso ad colleagues poit out, whe decisios must be made quickly, urses trust a real perso a colleague, cliical specialist, 48 AJN September 2005 Vol. 105, No. 9

10 or supervisor more tha they do prited ad electroic resources. 24 Oe woders, however, whether this would still be the case if search ad evaluatio skills were stroger. I the group of RNs studied, a disappoitigly high percetage idetified gaps i their experiece with research appraisal (72 reported ot havig evaluated a research report withi the previous year) ad idetifyig researchable problems (59 had t doe so withi the previous year). Sevety-seve percet idicated ever havig bee traied i how to coduct bibliographic database searches. As Scolli wrote, techology is readily available to [help people] make use of resources; however, if those who ca beefit most from this techology are uaware of its existece, or do ot have the traiig, support, or access to make full use of these resources, the the beefit to ehace their kowledge is of little value. 25 It s worrisome that sources of ew iformatio, ew research, ad ew evidece for practice were used ifrequetly, if at all, by the RNs i our study. The fact that they were t usig these resources is also apparet from their lack of familiarity with the term evidece-based practice, which has appeared i the titles of hudreds, if ot thousads, of joural articles i recet years. If the term is ufamiliar, the successful itegratio of evidece-based practice ca scarcely be aticipated. Resource availability ad use. Accordig to resposes to ope-eded questios, the majority of respodets i this study were aware that their facilities had a library, but may had ever bee iside it or did t kow where it was located. I qualitative resposes, some respodets said the library was locked ad the locatio of the key or key holder was ukow. A caveat should be made i readig the results cocerig the resources available i libraries because, as fidigs of this study idicate, few RNs used the library at all. It s quite possible that respodets kowledge about the resources available withi the library was icomplete or iaccurate. The Iteret ad the World Wide Web were frequet sources of iformatio for may respodets. That search egies are easy to use ad success at retrievig results are probably two major reasos for such use. However, problems with usig the Iteret as a source of iformatio iclude the time required for olie searches ad (as has bee corroborated i several studies ) the ucertai reliability of the iformatio retrieved. While the resposes to the questios cocerig the use of computers could idicate that urses perceived themselves as havig less expertise as the complexity of the applicatio icreased, it could also mea that they simply had less experiece with other programs, icludig databases. If that s the case, greater use of such applicatios will likely result i greater expertise. I order to safely itegrate the iformatio retrieved from olie sources ito cliical practice, the urse must be skilled i evaluatig the credibility of such iformatio. Further, most urses are t adept at advaced searchig techiques that could make the time spet searchig the Iteret more productive by limitig results to specific areas of iterest. Bibliographic databases, o the other had, have may filterig optios ad are a more appropriate resource through which to examie the curret research o a give topic. I this group of RNs, 87 did t search CINAHL, the ursig ad allied health database, ad 69 did t search MEDLINE. It s worrisome that sources of ew iformatio, ew research, ad ew evidece for practice were used ifrequetly, if at all, by the RNs i our study. Barriers. The fidig that a lack of value for research i practice was the most frequetly selected barrier to the use of research i practice is of great cocer to us. It would seem that the case for the importace of research to patiet care had t bee made to our respodets i either educatio or practice. I fact, all of the major barriers ca be addressed through teachable skills, but the extet to which such skills are taught i diploma, associate s-degree, or eve baccalaureate programs varies widely. Ideed, we have bee sayig for a umber of years that as oe of us (D.P.) wrote i a 2000 editorial to stress the importace of iformatio seekig ad iformatio literacy to their studets alog with the professioal obligatio of career-log literature searchig, faculty [have] to believe it ad live it themselves. 29 CONCLUSIONS AND IMPLICATIONS FOR NURSING Accordig to this study, RNs i the cliical area geerally ackowledged that they eed iformatio for effective practice. Yet accordig to their ow resposes, they were t prepared to use the iformatio resources available to them, however adequate or iadequate. They received little or o educatio or traiig i iformatio retrieval, did t uderstad or value research, ad were geerally uprepared for a practice built o evidece. aj@lww.com AJN September 2005 Vol. 105, No. 9 49

11 Some of this ca be attributed to the techologic chages that have occurred over the last 10 or 15 years. Some of it, however, has to be blamed o the failure of ursig educatio programs to prepare studets at all levels to uderstad ad value the importace of maitaiig a practice based o more tha traditio, ituitio, ad experiece. These are importat compoets of ursig practice, of course, but searchig for ad readig curret literature, icludig research, are essetial. May thigs that we have always doe may ot be the best patiet-care practices today. The case of Nacy Adams at the begiig of this article is just oe such example. Our coclusio is that RNs i the Uited States are t ready for evidece-based practice because of the gaps i their iformatio literacy ad computer skills, their limited access to high-quality iformatio resources, ad above all, the attitudes toward research. These attributes are reiforced by their perceptio of orgaizatioal priorities. These gaps must be addressed if the largest group of health care providers i the atio is to embrace a culture of evidece-based practice as directed by health care policy ad ursig leaders. Nursig educatio s paradigm must chage so that iformatio literacy, research use, ad evidece-based practice are itegrated ito the curricula of all RN educatio programs, to istill ot oly the kowledge ad skills ecessary for evidece-based practice, but to help urses value research. Our coclusio is that RNs i the Uited States are t ready for evidece-based practice. Nurse admiistrators should lobby withi their health care orgaizatios ad facilities for the resources, time, ad traiig to support ad itegrate evidece-based practice. They will eed to idetify cost-effective, creative approaches to establishig evidece-based practice that overcome the barriers, icludig lack of time. Fially, cliicias must recogize the gaps i their ow iformatioretrieval ad evaluatio skills. look for ad obtai cotiuig educatio that ehaces the relevat skill sets. demad greater access to high-quality iformatio resources i the workplace. demostrate a commitmet to usig iformatio resources effectively to improve care. set goals for itegratig evidece-based practice that lik practice itervetios to patiet ad orgaizatioal outcomes. Itegratig evidece-based practice ito ursig requires a multifaceted approach that ivolves studets, educators, cliicias, ad admiistrators workig collectively to facilitate the chage. Neither Ms. Adams, or ay other urse, should be left at a loss whe searchig for the iformatio she eeds. REFERENCES Complete the CE test for this article by usig the mail-i form available i this issue, or visit NursigCeter.com s CE Coectio to take the test ad fid other CE activities ad My CE Plaer. 1. Estabrooks CA. Will evidece-based ursig practice make practice perfect? Ca J Nurs Res 1998;30(1): Spratley E, et al. The registered urse populatio March 2000: fidigs from the Natioal Sample Survey of Registered Nurses. Rockville, MD: U.S. Departmet of Health ad Huma Services; Sackett DL, et al. Evidece based medicie: what it is ad what it is t. BMJ 1996;312(7023): Sackett DL. Evidece-based medicie: how to practice ad teach EBM. Lodo: Churchill Livigstoe; p Pierce S. Readiess for evidece-based practice: iformatio literacy eeds of ursig faculty ad studets i a souther U.S. state [Upublished Dissertatio]. Natchitoches, LA: Northwester State Uiversity of Louisiaa; Pravikoff DS, et al. Are urses ready for evidece-based practice? Am J Nurs 2003;103(5): Taer A. Readiess for evidece-based practice: iformatio literacy eeds of urses i a souther U.S. state [Upublished Dissertatio]. Natchitoches, LA: Northwester State Uiversity of Louisiaa; Fuk SG, et al. BARRIERS: the barriers to research utilizatio scale. Appl Nurs Res 1991;4(1): Hayes RB. Some problems i applyig evidece i cliical practice. A N Y Acad Sci 1993;703:210-24; discussio Omery A, Williams RP. A appraisal of research utilizatio across the Uited States. J Nurs Adm 1999;29(12): Parahoo K, McCaugha EM. Research utilizatio amog medical ad surgical urses: a compariso of their self reports ad perceptios of barriers ad facilitators. J Nurs Maag 2001;9(1): Royle JA, et al. Literature search ad retrieval i the workplace. Comput Nurs 1995;13(1): Retsas A. Barriers to usig research evidece i ursig practice. J Adv Nurs 2000;31(3): Kig BA, Carroll P. Nurses as ed-user searchers of the literature o CD-ROM. J Nurs Staff Dev 1994;10(6): Ash JS. Factors affectig the diffusio of olie ed user literature searchig. Bull Med Libr Assoc 1999;87(1): Marshall JG. The impact of the hospital library o cliical decisio makig: the Rochester study. Bull Med Libr Assoc 1992;80(2): Wood F, Wright, P. The impact of iformatio o cliical decisio-makig by geeral medical practitioers. Iformatio Research: A Iteret Electroic Joural 1996;2(1) Kerriso S, et al. People ad paper: iformatio for evidece-based practice ad the differig eeds of doctors ad urses. J Iterprof Care 1999;13(3): AJN September 2005 Vol. 105, No. 9

12 19. Istitute of Medicie Committee o Quality of Health Care i America. Crossig the Quality Chasm. Washigto, DC: Natioal Academies Press; Bakke S, et al. Promotig patiet safety ad eablig evidece-based practice through iformatics. Med Care 2004;42(2 Suppl):II Russell A, Alpay, L. Practice urses traiig i iformatio techology: report o a empirical ivestigatio. Health Iformatics Joural 2000;6(3): Taer A, et al. Readiess for evidece-based practice: iformatio literacy eeds of urses i the Uited States. I: Fieschi M, et al., editors. Proceedigs of the 11th World Cogress o Medical Iformatics. Amsterdam, Belgium: IOS Press; p Dillma D. Mail ad Iteret surveys: the Tailored Desig Method. 2d ed. New York: Joh Wiley ad Sos; Thompso C, et al. Research iformatio i urses cliical decisio-makig: what is useful? J Adv Nurs 2001;36 (3): Scolli P. A study of factors related to the use of olie resources by urse educators. Comput Nurs 2001;19 (6): Crocco AG, et al. Aalysis of cases of harm associated with use of health iformatio o the Iteret. JAMA 2002;287 (21): Jadad AR, Gagliardi A. Ratig health iformatio o the Iteret: avigatig to kowledge or to Babel? JAMA 1998;279(8): Schloma BF. Now you see it, ow you do t: the ephemeral ature of digital iformatio. Olie J Issues Nurs 2003;8(2): Pravikoff D. O the iformatio highway, or sittig o the curb? J Nurs Educ 2000;39(3): HOURS CE4 Cotiuig Educatio GENERAL PURPOSE: To afford registered professioal urses a opportuity to review a study of urses perceptios of their access to tools used to obtai evidece o which to base cliical practice ad their ability to use those tools. LEARNING OBJECTIVES: After readig this article ad takig the test o the ext page, you will be able to: describe the backgroud iformatio relevat to the authors study of urses perceptios ad abilities related to the use of evidece i practice. discuss the authors methodology ad the statistical results of this study. outlie the authors coclusios ad recommedatios for improvig urses use of evidece i practice. To ear cotiuig educatio (CE) credit, follow these istructios: 1. After readig this article, darke the appropriate boxes (umbers 1 17) o the aswer card betwee pages 48 ad 49 (or a photocopy). Each questio has oly oe correct aswer. 2. Complete the registratio iformatio (Box A) ad help us evaluate this offerig (Box C).* 3. Sed the card with your registratio fee to: Cotiuig Educatio Departmet, Lippicott Williams & Wilkis, 333 Seveth Aveue, 19th Floor, New York, NY Your registratio fee for this offerig is $26. If you take two or more tests i ay ursig joural published by Lippicott Williams & Wilkis ad sed i your aswers to all tests together, you may deduct $0.75 from the price of each test. Withi six weeks after Lippicott Williams & Wilkis receives your aswer card, you ll be otified of your test results. A passig score for this test is 13 correct aswers (76). If you pass, Lippicott Williams & Wilkis will sed you a CE certificate idicatig the umber of cotact hours you ve eared. If you fail, Lippicott Williams & Wilkis gives you the optio of takig the test agai at o additioal cost. All aswer cards for this test o Evidece- Based Practice must be received by September 30, This cotiuig educatio activity for 4 cotact hours is provided by Lippicott Williams & Wilkis, which is accredited as a provider of cotiuig ursig educatio (CNE) by the America Nurses Credetialig Ceter s Commissio o Accreditatio ad by the America Associatio of Critical-Care Nurses (AACN , category O). This activity is also provider approved by the Califoria Board of Registered Nursig, provider umber CEP11749 for 4 cotact hours. Lippicott Williams & Wilkis is also a approved provider of CNE i Alabama, Florida, ad Iowa, ad holds the followig provider umbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas ursig cotiuig educatio requiremets as Type 1. *I accordace with Iowa Board of Nursig admiistrative rules goverig grievaces, a copy of your evaluatio of this CNE offerig may be submitted to the Iowa Board of Nursig. aj@lww.com AJN September 2005 Vol. 105, No. 9 51