What are the strategies that have worked in getting physicians and nurses to adopt evidence based practice?
“Resistance to adopting evidence-based practice is not a modern phenomenon. In his extraordinary treatise on disseminating innovations in health care (JAMA 1969;289:75), Dr. Don Berwick notes that after the discovery that sauerkraut and limes prevent scurvy, it took 147 years for that simple measure to become a matter of nautical policy” (Rubin, 2005, para. 2).
Most humans do not embrace change readily. We seem especially reluctant to do so when the change threatens to alter our personal philosophy or increases the effort needed to accomplish a task. We are creatures of habit and follow “the way we’ve always done it” as the path of least resistance regardless of the evidence presented. One need only look at the evidence between smoking or food and health issues.
Healthcare is no exception. Historically, when confronted with evidence both physicians and nurses have avoided or ignored it. That has changed somewhat in recent years. Information is more readily disseminated and new entrants to the profession are taught to value and practice according to the latest evidence.
Pham & Ginsburg (2007) frame the roots of the explosion of the use of research and EBP in healthcare to the “quiet revolution that began in the late 1980s, fueled by an expanding volume of health services research and influential reports from the Institute of Medicine on the suboptimal quality of much of the medical care in the United States” (p. 1588).
Physicians
Cultural barriers have contributed to physician opposition to evidence based practice. Historically, physicians learned under an apprenticeship model that led to a great deal of autonomy. They viewed themselves (and were viewed by the public) as “heroes” who miraculously resolved problems, much the way that current television shows such as “House” do. Physicians opposed what they perceived to be “cookbook medicine” that potentially questioned their judgment and decisions through the application of standardized procedures or protocols that took away their autonomy – and importance.
Accountability for physicians to use current evidence comes from multiple sources. First, educated consumers demand it. Online referrals and “ratings” of physicians are now more available for consumer review.
Evidence based practice has been emphasized in the training programs of the latest generation of physicians. In addition, there has been a proliferation of evidence based practice guidelines and accompanying electronic tools readily available to practicing physicians.
Physicians have been called to accountability by board certification exams that have increasingly emphasized knowledge of evidence based practices. The increased professional expectation that physicians attain and maintain board certification, has forced physicians to stay abreast of the current evidence.
Performance measurement systems and incentive programs have impacted physicians and their willingness to accept evidence based practice guidelines. Government plans, private purchasers and accrediting bodies now require physicians to practice according to current evidence or risk a reduction or loss in payment.
Finally, the health care industry is learning better how to effectively engage physicians in improving quality, i.e., IHI’s Framework for Engaging Physicians in Quality and Safety (Reinertsen, et.al, 2007). This learning is helping to drive a culture change in practitioners using the latest evidence in their practice.
Nurses
Nursing also has its barriers to implementing evidence based practice. Traditionally, nurses practice according to how they learned in nursing school (Koehn & Lehman, 2008) and lack research knowledge, skills and understanding simply because it was not taught in nursing education programs (Pravikoff, et.al., 2005). It’s hard to use research/EBP when you have to first learn how to research, on top of all of your other duties.
Institutional barriers such as financial limitations and lack of prioritization by the organization have also contributed to nursing’s slow adoption of EBP.
In addition to the regulatory push for adoption of EBP described above, I believe a major force in the adoption of evidence based practice has been Magnet designation. Magnet is seen as increasingly desirable for an organization and has some recognition as impacting an organizations bottom line through enhanced marketing. Magnet requires nurse involvement in research and EBP. The Magnet program is such that it’s not possible to merely give lip service to EBP, but it has to be instituted as a critical element in an organizational culture through the allocation of appropriate funding, leadership and time to make the practice a reality.
Today’s nurses are pursing more formal education than in prior decades. BSN education is becoming the norm in many parts of the country. With this increase in education, has come broader exposure to research/EBP concepts.
References
Koehn, M., & Lehman, K. (2008). Nurses' perceptions of evidence-based nursing practice. Journal of Advanced Nursing, 62(2), 209-215. Retrieved from CINAHL Plus with Full Text database.
Pham, H., & Ginsburg, P. (2007). Unhealthy trends: the future of physician services. Health Affairs, 26(6), 1586-1598. Retrieved from CINAHL Plus with Full Text database.
Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of U.S. nurses for evidence-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. American Journal of Nursing, 105(9), 40-52. Retrieved from CINAHL Plus with Full Text database.
Reinertsen, J.L., Gosfield, A. G, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007. Retrieved from http://www.ihi.org/NR/rdonlyres/A30445C0-6DA6-40C0-AB12-D2592A9EF1C7/0/IHIEngagingPhysiciansWhitePaper2007.pdf
Rubin, K. R. (2005, July). Resistance to evidence based practice. Emergency Medicine News, 27(7), 3, 43. Retrieved from http://journals.lww.com/em-news/Fulltext/2005/07000/Resistance_to_Evidence_Based_Practice.5.aspx
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