Evidence-based practice (EBP) is transforming patient care in the United States, possibly on the same scale as the influence made by Florence Nightingale in the 19th century. Nightingale applied principles of cleanliness, warmth, and nutrition to patient care, and documented decreased morbidity and mortality among the soldiers she served in the Crimean War. Her observations and meticulous documentation quickly transformed nursing to a profession that made measurable improvements to the patient condition. Similarly, EBP has emerged as the preferred mechanism to integrate the best available evidence to guide nursing care and improve patient outcomes through the use of current best evidence in making decisions about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).
Although EBP projects are often focused on bringing new evidence to bear on patient outcomes, they often serve to update outdated, ritualistic, or passed-down traditions. For example, McCommons, Wheeler, and Houston (2016) reported results of their project to increase patient comfort following a colonoscopy. Nurses working in the postanesthesia care unit identified that many patients had complaints of severe abdominal discomfort following colonoscopy due to flatus from the bowel insufflation. These bedside nurses reviewed and synthesized the literature, discovering that although carbon dioxide was being routinely used in many other facilities, room air was still the standard practice in their setting. Carbon dioxide is more rapidly absorbed by the bowel than room air, and can drastically reduce the occurrence of flatus, and resulting discomfort. Because this practice would be new to the facility and beyond the scope of nursing practice, the nurses engaged a physician champion. The team used the Iowa model (Titler et al., 2001) and the PICO (Population, Intervention, Comparison, Outcome) format (Melnyk & Fineout-Overholt, 2015) to pilot the practice change, collecting data pre- and postimplementation. Not only did patient satisfaction with the procedure improve, the primary physician performing the colonoscopies reported improved visualization of the colon (McCommons et al., 2016).
Evidence-based approaches are infiltrating many fields, such as social work, education, and human resource management, because using the most current information is sensible and rational, and holds instant appeal (Trinder & Reynolds, 2000). Given the current focus on patient outcomes, nursing interventions based on the best evidence available can have a significant effect on patient care. However, the majority of nurses use less reliable resources, such as knowledge gained during their training, prejudice and personal opinion, outcomes of previous experiences, and fads. In some cases, they may not even be aware that evidence for their practice exists. U.S. hospitals expect nursing practice to be evidence-based, a need that has stimulated EBP to be added to nursing curricula. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) include EBP as the third of nine essentials. Thus, the expectation is that baccalaureate-prepared nurses participate in interpreting and implementing evidence in their daily practice. Many colleges have infused didactic courses with evidence and added a course on the process of EBP in their curriculum. This change not only meets the baccalaureate Essentials, but also prepares students for practice in settings where EBP is an expectation.
In the Latin American country of Panama, the notion of EBP in nursing education and practice is gaining momentum. Until recently, nursing practice was largely guided by oral tradition, where nursing skills, practices, and interventions were handed down from faculty to students, and thus to the clinical arena, with little evidence about the scientific basis of practices. In addition, the largely rural nature of the country and the relatively low socioeconomic demographic of the nursing student population made the acquisition of nursing textbooks and other academic materials largely unattainable. Many faculty custom-made their educational materials as handbooks, using their knowledge as clinicians in current practice and incorporating what they had been taught in their training.
The University of South Florida and the University of Panama have enjoyed a 10-year collaboration and student exchange program. This collaboration resulted in the observation of nursing education and practice between the two countries and raised questions about nursing practice procedures in both the United States and Panama. In 2015, a delegation of four University of South Florida nursing faculty and six undergraduate nursing students traveled to the University of Panama for a week-long intensive immersion into EBP principles that included comprehensive hands-on training in searching the literature for evidence. This successful venture led to the germination of a plan for introducing EBP to the nursing leaders in Panama to bring change to the existing nursing curricula, which could then be translated into changes in nursing practice and positively affect patient outcomes.
This project was designed to positively affect the current standards of nursing practice in Panama through knowledge of EBP principles and permit implementation of EBP in the University of Panama nursing curriculum. This venture was funded by an internal competitive university grant mechanism. To accomplish these goals, a train-the-trainer 4-hour workshop, as part of a regional nursing conference, was chosen as the method of information delivery. This project was the first EBP conference to be held in Panama.
The conference workshop objectives were:
- Discuss principles and models of EBP.
- Use multiple databases to search for best evidence that informs clinical questions.
- Describe mechanisms to resolve discrepancies between current clinical practice, clinical judgment, and best evidence for clinical practice.
- Apply the critical steps of the EBP process to clinical practice.
Through a series of meetings with the university faculty, the U.S. faculty were provided information concerning the Panamanian nursing curriculum and how nursing knowledge and skills were passed down from faculty to students. The use of textbooks varies by location throughout the country, with textbooks and materials more widely available in the urban versus the more rural university locations. In preparation for the conference implementation, a definitive need existed to address the language barrier. The U.S. faculty presenters spoke some Spanish and used a highly trained professional to translate the slides and materials used throughout the workshop into the Spanish language to facilitate teaching and learning. The use of an official translator using simultaneous translation from English to Spanish and from Spanish to English enabled a smooth transition and virtually no interruption in the conference scheduling. All slides and handouts were converted to Spanish prior to departure and as a take home resource for the benefit of the audience.
In this 3-day regional conference, 167 nursing faculty, students, and clinical nurses from area hospitals in Panama City, Chitré, and Chiriquí, Panama participated in didactic and hands-on EBP skill-building activities. The faculty areas of expertise included pediatrics, maternal–child health, critical care, mental health, community health, and family health nursing. The conference opening ceremony was highly rooted in tradition and included a nurse's prayer, ceremonial dance, and songs. Traditional practices are highly valued, and thus, educational and clinical practices based on tradition are pervasive.
The first part of the conference focused on building knowledge through lecture and discussion of the definitions, basic principles, and components of EBP. A discussion of common topics in patient care that contain both strong (randomized controlled trials) and weak (expert opinion) evidence for practice implementation followed. The three University of South Florida College of Nursing faculty used common health problems to demonstrate examples of EBP and how it can be applied to Panamanian nursing. A review of common clinical practices in the United States that revealed a lack of benefit despite long-term clinical use were discussed for commonalities with clinical practices in Panama.
The seven steps of the EBP process (Melnyk & Fineout-Overholt, 2015) include:
- Cultivating a spirit of inquiry.
- Formulating a question.
- Searching for the best evidence.
- Critically appraising the evidence.
- Integrating the evidence with clinical expertise and patient preferences.
- Evaluating outcomes.
- Disseminating outcomes.
The participants were taught the use of the PICO format for developing a specific clinical question and possible patient outcomes. The use of the PICO format clarifies the clinical question and guides the literature search (Bultas & McLaughlin, 2013). Levels of evidence were reviewed, and specific exemplars of both weak and strong evidence were presented.
The conference workshop then transitioned to a participant-wide hands-on demonstration of a literature search in PubMed® and CINAHL®, as both databases are available at universities in Panama. The interactive demonstration included the use of search terms, language (i.e., Spanish), application of filters, and using one topic reflecting a current health problem (e.g., Zika virus) in Panama, and was then followed by other topics of interest (e.g., mental health, childhood obesity) suggested by the participants. Handouts and instructions for conducting literature searches in Spanish and English also were provided for future reference.
Barriers to EBP
The workshop information and interactive demonstration generated much interest and questions from the participants. Understanding how to begin making changes to the nursing curriculum to influence clinical practice and the ways in which individual nurses can influence practice change are examples of questions posed by the participants. The need for extensive faculty training was the most pervasive barrier to the implementation of EBP in the nursing curriculum. When the participants were queried prior to the workshop, only four faculty members and two doctoral students knew how to conduct a literature search, despite the available library and computer resources to do so.
A second pervasive barrier to the implementation of EBP in the nursing curriculum and in clinical practice are the long-standing practice traditions on which both educators and practitioners rely. Interrupting cultural norms for education and practice is a difficult undertaking. To successfully implement EBP into the nursing curriculum and ultimately, into the practice setting, it is necessary to overcome resistance to change and the notion that changing traditional educational practices represents an inherent disrespect for past tradition. Problems that have wide appeal to nurses should be chosen. Small successful changes must be celebrated.
Finally, perceived barriers may exist to the adoption of models of education or practice that originate from an outside source, as conflicts with professional values, practice standards, and congruence with cultural norms must be considered. It is also important to obtain support from university and clinical administrators. The long-standing relationship with the University of Panama and its faculty minimized the risk of the U.S. faculty being known as experts and the Panamanian nurses as learners. In actuality, much common ground exists between the two countries, such as the need to address change to align academic curricula and health care institutions with EBP initiatives. The authors of the current study actively engaged the conference participants in identifying practice questions or clinical issues that may be addressed through EBP projects. The authors also engaged the support of the administration from the University of Panama school officials and the Gorgas Research Institute of Panama, giving legitimacy and authority to begin examining the nursing curricula and practices to infuse these areas with an evidence-based approach.
Conference Workshop Results
The 2016 EBP conference workshop attracted 167 attendees from across Panama. Nursing faculty specialty areas of clinical practice included pediatrics, maternal child health, psychiatric mental health, family health, community health, oncology, and several interprofessional health colleagues. Translation services were perceived as excellent by the audience and presenters alike. As a predominantly English-speaking faculty, this was the authors' first time presenting to a large group with a translator. Although the authors were confident in their skills as presenters, having a professional translator was of great value to both the authors and the audience.
On the Panama City campus, the nursing faculty have engaged in discussions of EBP, but this content is not presently included the formal curriculum. In fact, as the authors learned through conversations with local physicians, even patient care in medical practices is rooted in tradition, which may conflict with the best available evidence. Only several faculty and doctoral students attested to having the skill set to conduct a literature search; thus, the interactive session on searching for the evidence was needed to move Panama's EBP initiative ahead. Through presenting this workshop, the authors were able to ascertain that a spirit of inquiry was indeed present among the nursing faculty in attendance. The conference EBP workshop evaluations were favorable, and all conference workshop objectives were met.
The authors introduced EBP as part of a workshop embedded in a national research and practice conference. As in the United States, the language of EBP and research required thoughtful communication to clearly differentiate the terminology of each for thorough understanding, as these terms are often used interchangeably. As presenters, the authors realized their examples of practice improvements targeted what is commonly described as sacred cows (i.e., long-time practices that have been passed down without being questioned). Language of “how we've always done it” was used to illustrate some examples of clinical practices considered to be sacred cows. Examples from practice, such as daily bed baths, using air as a means of checking nasogastric tube placement, and patient positioning in Trendelenburg position when in shock, that are not supported by evidence were met with enthusiasm; however, it remains unclear whether these practices are still being used. It is common for practicing master's degree-prepared nurses to hold both a nursing education and a clinical practice position, bridging both worlds. However, many of the authors' examples were from acute care settings, whereas the audience members had a broader practice base within community settings.
Implementing practice change in a country where tradition is highly valued requires a more thoughtful approach, as well as the support of university officials, physicians, and the national research entity, the Gorgas Institute. The introduction of EBP into the nursing curricula represents a significant change in the questioning of clinical practice that underscores the connection between research and evidence that informs practice. The faculty and students have access to PubMed and CINAHL but were reluctant to use these databases due to inexperience and limited training. Support of efforts of the Cochrane Collaboration (von Elm et al., 2013) to ensure the translation of reviews in multiple languages for global access to best practices is essential and can be an excellent way to accelerate EBP in Panama. Surprisingly, some common terms used in the United States were unknown when discussing EBP. Terms such as patient outcomes and standard of care are not used in nursing or medical practice, according to conference participants, underscoring the need for an introduction to the vocabulary of EBP, as well as the basic principles and processes.
According to the nursing faculty present, students are beginning to question practice differences that have been observed between different hospitals, making the time for EBP ripe. In addition, an increasing number of nursing faculty are in the process of completing a doctoral program, and the conduct of research is highly respected. However, most doctoral dissertations use a descriptive design, limiting the ability to influence practice change. Because most nursing research conducted in Panama has been descriptive in nature, international studies can be used initially as a basis for changing nursing education and practice.
Finally, the need for nursing research in Panama and in all of Latin America is great, as few doctorally prepared nursing faculty exist, and only eight countries in the Latin American and Caribbean region have a doctoral program (Parmar, House, Cassiani, & Reveiz, 2015). Understanding EBP and how to search for evidence on germane topics may provide the confidence needed for nurses to publish reviews of clinical articles and gain a solid scientific grounding in a topical area as they pursue doctoral degrees or mentor doctoral students.
As a result of this conference, five Panamanian nursing faculty were matched with five U.S. nursing faculty to begin a mentorship project (Proyecto de Mentores) to identify a practice issue that would be mentor-guided through the process of the EBP steps. A review of Panamanian vaccine practices and clinical guidelines was chosen for the mentorship EBP project, a PICO question has been developed, and the literature review is complete. The authors of the current study continue to support the work of their Panamanian colleagues in confronting barriers to EBP and participated in an in-country meeting in June 2017. These efforts are quickly gaining momentum. The conference-based approach to introducing EBP was a successful first step. In the meeting, the authors discussed the most pressing practice needs in the area. Adolescent pregnancy is on the rise in this region of Panama, with consequences including increased complications from pregnancy such as eclampsia and premature birth, as well as financial consequences for the family and health care system. The next step is to develop an EBP means of addressing the increasingly high percentage of adolescent pregnancy in the region. The authors are in the process of reviewing the literature for evidence of successful interventions in decreasing early adolescent sexual encounters and reducing pregnancy in this population. After this is accomplished, the authors will outline a project proposal for implementation in the regional health centers, review the project outcomes, and disseminate the findings.
The long-term relationship of the U.S. faculty with the Panamanian nursing faculty was instrumental in moving this initiative forward, as was the willingness of the country's nursing leaders to support the education and practice changes that can improve the learning of students, raise professional nursing standards, and most important, positively influence patient outcomes.
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