issues in research

Evidence-based nursing practice: what US nurse executives really think
This article by Dariene Sredl considers qualitative statements from US nurse executives about their belief in and implementation of evidence-based nursing practice. Their statements suggest uncertainty about the way forward
• • • • evidence-based nursing practice nurse executives qualitative statements implementation

Introduction
Health care is undergoing rapid changes, and outcomes drive processes. While the basis for the integrated approach we now know as evidence-based practice was established centuries ago, only since the 1990s has evidence-based medicine (EBM) and evidence-based nursing practice (EBNP) emerged as a viable framework for positive clinical outcomes built on a substantial research base (Melnyk et a/2004, Mishel and Braden 1987). Much of the momentum towards using evidence-based practice in the United States comes from cost-containment efforts spurred by payer and healthcare facility administrators eager for healthy profit margins and healthy healthcare consumers of their services (Youngblut and Brooten 2001). The huge growth in computerised information has enhanced the healthcare knowledge base of consumers who realise that EBNP is increasingly synonymous with the perception of high-quality patient care (Melnyk and Fineout-Overholt 2005, Youngblut and Brooten 2001). Evidence-based nursing also results in time-saving nursing care streamlined to eliminate useless, outdated practices and rituals, while adopting practices that result in desired outcomes (Youngblut and Brooten 2001).

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To be effective. few studies have examined the EBNP comprehension level among nurse executives (Le May et al 1998. all nurses. Comprehension of EBNP by nurse executives The gap between availability of best-practice evidence and use ofthat evidence can be traced to comprehension levels of nurse executives (Sredl 2005).200 practising nurses found that only 21 per cent had implemented evidence gleaned from research into their practice within the six months prior to the study. Although several studies have examined comprehension levels of EBNP among staff nurses and nurse clinicians such as advanced practice nurses.issues in research A major responsibility of nurse executives is to provide nursing care in a creative and cost-effective way to the institution's healthcare consumers (Perra 2000). Practice culture differs from management culture (Le May ei al 1998). 4 . If a 'receptive' environment can help nurses accept EBNR how does a 'facilitating' environment evolve? And. One study (Bostrom and Suter 1993) conducted with 1. Sredl 2005). 15. Australia and Canada. Titles for these top-level nursing managers vary in different institutions and include: director of nurses: chief nursing officer: chief nurse executive: clinical manager: and. while much has been published and discussed rhetorically concerning EBNP there is little published evidence that nurses and nurse 52 NURSERESEARCHER 2008. must embrace the change. I will call them 'nurse executives'. who brings about this change? Is change in one facility enough? Is change in one state's facilities or in one nation's facilities enough? Evidence-based nursing is a global meta-paradigm. Unfortunately. the EBNP philosophy allows for this creativity in an atmosphere of costeffectiveness if supported by top-level nursing management (Perra 2000). if in a school. If nurse executives understand and employ the steps inherent in EBNR they may encourage similar attempts by the nurses working with them. For the purpose ofthis article. if an environment favourable to EBNP does evolve. These titles may be similar to the responsibilities of nurses working in nursing managerial positions in the UK. dean. A qualitative study with a phenomenological approach undertaken by Rodgers (1994) found nurses working in receptive environments more amenable to the use of EBNP in terms of individual and organisational attitudes. While there is no agreement on exactly how this is to convert into practice. especially nurse executives.

There is a paucity of research into how well nurse executives understand EBNP and if they comprehend the difference between the medical and the nursing EBM models (Sredl 2005). tradition. 15. Sredl 2005). nurse executives may not have collectively assembled a cohesive point of view on EBNP It is vital that they do so. clinical. the evidence-based nursing process does not try to repudiate the medical model's reliance on RCTs. and they are at the forefront of the shift. new competencies require new training. folk medicine and other holistic forms of time-honoured remedies. patient advocacy. Old patterns of thought restrict nurses to mere handmaidens. The shift to EBNP is creating uncertainty in healthcare (Sredl 2005). eastern. Sackett et a/1996). New roles require new competencies. preferences and beliefs Oacobs 2001. Contemporary nurses are nurse executives. and patient values. greatly overextending the influence of one form of evidence over all others (Anderson 1995. Daines 1997. 4 53 . NURSERESEARCHER 2008. Conceptual competence is as important as managerial. Zeitz and McCutcheon 2003. To remain at the forefront of this shift. assumption. Instead it encompasses quantitative and qualitative research. educators and researchers. such as informatics. much less use it (MacPhee 2002. as well as western therapies. educational or technical competence (Porter-O'Grady and Krueger Wilson 1995). A dichotomy exists between medicine and nursing regarding the interpretation of the term 'evidence-based' (Engebretson 1997). Rush and Harr 2001. new training requires new technology. clinical specialists. The medical model uses randomised controlled clinical trials (RCTs) as the gold standard of evidence. healthcare benefits are decreasing. clinician expertise. EBNP differs from the medical model of evidence-based practice in many ways (Sredl 2005). Literature review Healthcare costs are rising. new technology requires new thought (Sredl 2005).executives can understand EBNP. to develop competencies. In a healthcare venue concerned with efficiency and cost-containment. MacPhee and Sredl 2004. Launer 2003). however since leadership involves influencing others to accomplish goals (Huber etal 2000). In contrast. Management innovations tend to occur in a fluid work environment marked by rapid-paced innovative change. Lee et al 2002.. nurses must embrace training and technology.

Synthesised literature reviews on EBNP are also found in the CINAHL Clinical Innovations Database (Androwich 1999). while 'evidence-based nursing process' yielded only seven. 'Evidence-based nursing practice' yielded 355 citations in these databases. acknowledges uncertainty and bases outcomes on choosing the conclusion that best exemplifies the expected patient benefit (Freedman 1996. Charles Peirce. The first of these is Bayes' Theorem. Sredl 2005). 54 NURSERESEARCHER 2008.issues in research An analysis To get a better understanding of EBNP I conducted a bibliometric analysis of the literature (Sredl 2005). Bayesian Theory starts with observed past differences accumulated into 'prior. Lancet Archive.536 citations. The Cochrane Collaboration library holds numerous titles devoted to the study of EBNP but can be accessed by subscription only. Medline. Theoretical framework The theoretical underpinnings of the evidence-based nursing process flow from five distinct postulates (Sredl 2005). The Bayesian method requires the establishment of prior probability. One key assumption of bibliometric mapping is that published research papers represent knowledge produced by genuine scientific research. Estabrooks et al 2004). The second distinct postulate that led to the development of EBNP was the acknowledgement of new ways of 'knowing' in scientific circles (Janesick 2000).695. While 'nursing practice. with estimates of research productivity represented by topic count (Estabrooks etal 2003. evidencebased') yielded 2. Marten 2002). wrote about four ways of knowing (Carper 1975. many of the citations reviewed were treatment-oriented articles addressing a specific patient condition or disease process. or posterior probabilities'. Peirce identified tenacity. This assumption is not always accurate (Sredl 2005). 4 . Searches on CINAHL. 'Evidence-based medicine' produced 21. 15.536 citations. and Medline In-Process and non-indexed citations databases on Medline with the keyword 'evidence-based nursing' (which became 'nursing practice. Very few articles addressed topics of executive or administrative significance in nursing. Sigma Theta Tau International recently launched a new journal entitled Worldviews on EvidenceBased Nursing. A nineteenth century American philosopher. evidence-based' resulted in 2.

linguistic. 1978. authority. thereby qualifying as a meta-paradigm (Brodie 1984. According to Kuhn.that the dissolution of an old paradigm occurs when the old paradigm can no longer answer new pertinent questions. more 'fitting' paradigm emerges to replace it. In contrast. Carper's ways of knowing included empirics. these major paradigm shifts are usually preceded by periods of pronounced professional insecurity since paradigm shift involves a disruptive change in the evolution of existing scientific thinking. the scientific revolution. interpersonal and intrapersonal. or ways in scientific communities of looking at scientific facts. is the third theoretical construct. which involves a 'covering' or universally accepted law (Hempel and Oppenheim NURSERESEARCHER 2008. though unidentified as such at that time. known as the 'multiple intelligence construct'. 15. Interrelated concepts and theories undergo metamorphosis over time to yield newer metaparadigms more applicable to the societal and environmental changes that have occurred (Parse 1999). aesthetics. bodily-kinesthetic. Different worldviews generate different variations on existing knowledge bases (Mclntyre 1995). Gardner's theory. or the common sense approach. Kuhn's 'paradigms'. is actually a composite of theories. 4 55 . Gardner listed four to ten ways of knowing by asserting that a human being has 'multiple intelligences' (Walters and Gardner 1984). Kuhn went on to proclaim an even more novel concept . Meta-paradigms arise from the blending of a series of theories or paradigms (Thompson 1985). and science. originally identified seven manifestations of human intelligence. While Peirce and Carper limited themselves to only four ways of knowing. musical. spiritual intelligence and existential intelligence (Gardner 1999). Fawcett 1984. and when a new. logicalmathematical. His theory later evolved to include naturalist intelligence. Nursing science. The fourth theoretical construct is Hempel's covering law model. Newman 1992). spatial. Although introducing the concept of paradigms was novel in itself. intuition. ethics and personal (intuitive) knowledge in nursing (Carper 1975. was already well under way. traditional approach. or the expert approach.or the unquestioned. or the controversial and inquisitive approach (Marten 2002). White 1995). When Thomas Kuhn published his classic work The Structure of Scientific Revolutions (Kuhn 1962). by virtue of the human needs it seeks to care for.

Design This article is concerned with qualitative questions embedded in a larger exploratory descriptive study (Sredl 2005) that used mailed survey instruments. Rogers' innovation-diffusion theory examines the process of change and the adoption and acceptance of technological innovations by a given profession (Hilz 2000. leaders skilled at implementing change strategies and improving healthcare outcomes by energising nurses to accept change. while cognisant that the change may produce anxiety or a feeling of threat (Buonocore 2004). This article contains open-ended qualitative data from nurse executives' responses to two questions (Sredl 2005). change occurs very slowly (Sredl 2005). 'Do you have any additional comments (relative to EBNP)?' The second was. please explain. 15. The fifth theoretical postulate involves the embrace of change. or meta-paradigm as we now know it. In healthcare and other social reforms. 4 . change agents can help activate the change process in the group (Hilz 2000). The law must be broad in scope. remains in effect until a more inclusive covering law takes effect (Klemke et al 1998). The first question was. According to this theory. The contemporary healthcare market requires effective nurse executives. the EBN Beliefs Scale and the EBN Implementation Scale developed by Melnyk and Fineout-Overholt (2003).issues in research 1948). The qualitative part of the study discussed in this article was accomplished by the subjects' invitation to com56 NURSERESEARCHER 2008. Valente and Rogers 1995). The profession of nursing has committed itself to the development of a research base to support practice (Cavanagh and Tross 1996). 'Do you foresee any problems in the global nursing implementation of EBNP? If so. but also universally appropriate in content. This 'covering law'. Methodology Aim Nurse executives need to be skilled at finding and appraising research if they are to activate change (Huber et al 2000).' Many of the respondents chose this opportunity to divulge their thoughts on EBNP The resultant qualitative data greatly enhanced findings from the quantitative part of the survey (Sredl in press).

of this number.píete two open-ended qualitative questions in an effort to broaden the base of EBNP comprehension from the nurse executive's viewpoint so that coded keywords describing the nurse executives' viewpoint towards EBNP could be further defined. The 154 responses were returned by first class mail. Questionnaires were formatted to specifications designed to yield high response rates (Salant and Dillman 1994). Research questions The qualitative research questions that were explored included asking the nurse executives to comment on their perceptions of EBNP and any additional comments they might offer regarding anticipated problems with global implementation of EBNP Sample A stratified randomised list of nurse executives employed in key upper management positions in healthcare facilities in the 50 states of the US and the District of Columbia was purchased from the American Organization of Nurse Executives (AONE) and the American Hospital Association (AHA). Data were tabulated according to indicated statistical analysis. No identifying information was sought. This meant the project would not require quarterly review by the board. since I did not need access to confidential information. addressed return envelope were included in the packet mailed to each participant but potential subjects were allowed the convenience of responding by telephone. I then obtained permission to use and slightly modify EBNP opinion surveys developed and copyrighted by Melnyk and Fineout-Overholt. 134 were mailed back and 20 were returned via other media routes. A total of 951 mailings were sent for a total of 917 valid questionnaires. A covering letter and stamped. email and telephone. No 'thank you' letters with results were sent since the data were received with no identifiers. 4 57 . 15. Human rights were protected in accordance with the guidelines devel- NURSERESEARCHER 2008. email or fax. fax. Procedures The institutional review board of the sponsoring institution first gave me "exempt status review".

The qualitative research methodology supports the uncovering of facts as they are believed by the subjects (Lincoln 2001). such as critical theory. 58 NURSERESEARCHER 2008. The epistemology of what can be known is inordinately influenced by how we come to know it. post-structuralism era brought about alternative paradigms in social sciences and research methodology that matched the alternative modes of critical analysis. to Bayes' Theorem (Smith eta/ 2000). The advent and decline of the post-modern. as established by the National Research Act of 1974 (Burns and Grove 1993). Confidentiality of data Every effort was made to maintain the confidentiality of the data that these subjects provided. Risks and benefits There were no perceived risks to this study. as Gardner (1999) professed. there are as many varieties of recognised and accepted ways to measure validity as there are methodologies.issues in research oped by the National Commission for the Protection of Human Subjects of Biomédical and Behavioral Research. 1 5. feminist and sexual orientation models and heueristic modes of inquiry such as phenomenological methods (Denzen and Lincoln 2000). General standards regarding validity testing for qualitative studies conform. Validity and reliability The exploratory descriptive nested mixed-methodology design of the larger study was necessary to describe and delineate a movement in nursing that has broad consequences for the discipline. Benefit to risk ratio is positive and strong. participatory research modes. 4 . The essence of the meaning of validity is to assimilate the research findings so that the results can be trusted enough to act on (Lincoln 2001). compiled then destroyed. Study benefits included the professional satisfaction of contributing to a broader nursing knowledge base of EBNP among subjects who have not been studied in any great number to date. Information was aggregated without identifiable tracers. racial and ethnic studies. in large part. Abstract and obtuse methodological arguments to the contrary.

The degree of agreement among nurse executives in my study is tallied in the heueristic unit profiling. supporting or contradicting the interpretation of data. My larger study supports the interrelationship of multiple data sources including the Likert scale replies to the quantitative questions. that in qualitative research validity should ultimately reside in meaning and understanding (Mishler 1990. and Maxwell concurred. Mishler suggested. the principal investigator is challenged to ensure an appropriate fit between the research question and: data collection procedures. Qualitative studies are not conducive to the psychometric rigours employed in quantitative study validity establishment (Sredl 2005). Elliot Eisner. and assessing the comprehensiveness of the research as a whole (Smith et al 2000. There is a commonality among many of the responses that is apparent even without statistical analysis. This form of validity is demonstrated in critical awareness . structural corroboration. remaining cognisant of prior knowledge that has a bearing on the issue under scrutiny. Lincoln 2001). as such. the widely respected methodological theoretician. who have taken a two-year degree with no research NURSERESEARCHER 2008. and. open to alternative philosophical versions of validity (Denzen and Lincoln 2000. proposed three forms of validity for qualitative research. 4 59 . the heuristic unit composites of the verbatim responses to the qualitative questions. The qualitative models of inquiry are alternative paradigms of research. Lincoln 2001). 'Structural corroboration' refers to the ways in which multiple data types are interrelated. Maxwell 1992). consensual validation and referential adequacy (Eisner 1991).a mindfulness of self and others (Sredl 2005).In the Bayes' Theorem form of validity testing. maintaining compliance with internal and external value constraints. 'Referential adequacy' speaks to the enlargement of understanding that an individual criterion prompts. Many responding nurse executives feel associate degree nurses (ADNs). 15. appropriately analysing the dataset. 'Consensual validation' refers to the composite opinions of the subjects and the extent to which an agreement exists. according to Denzen and Lincoln. and the graphical profiling of the data processed in response to the profile analysis via multidimensional scaling response to data depicted in a representational model.

Future studies should attempt to replicate this one using a larger number of participants. 4 . in their own experience and expertise. 15. as such knowledge is used in their perceived implementation of EBNP in their respective workplaces. • Community outreach organisations and extended-care facility nurse executives were not included in this study.issues in research courses. • Not including a question about the subject's job so that statistics broken down by executive position could be calculated. • Only nurse executives who are members of AONE and/or employed at AHA member hospitals were sought as potential subjects for this study. the two qualitative questions included in this study meet the alternative non-psychometric paradigm of validity. Results Qualitative research embodies the observations about themes and patterns that arise from the data (Janesick 2000). Future nursing studies replicating the methods of this study may lead to global EBNP information dissemination to all levels of practising nurses (Sredl 2005). on the topic of EBNP based on their ways of knowing. offering 60 NURSERESEARCHER 2008. They ask the nurse executive subjects to expand. quality adds a special dimension to research (Sredl 2005). if they wish. These observations reveal the human element inherent in all research. The insight provided by the respondent who likened EBP to being 'part of a toolkit for excellence' certainly provided an enlargement of understanding of the meta-paradIgm of EBNP Towards these ends. are task-oriented. In a world not confined to quantity. and to project these ways of knowing about EBNP onto a global schema of their creation. The subject of evidence-based nursing is one topic replete with understandings and misunderstandings. Limitations • The relatively limited response rate of this study (n=154). there for the mining. Qualitative inquiry offers rich repositories of ideas. Strengths The major strength of this research is the addition of knowledge of EBNP among nurse executives In the US. are a barrier to the implementation of EBNP (Sredl 2005).

it is the way we think'. with several recurrent underlying themes.' Other answers indicate strong personal beliefs about and in support of EBNP Exemplars describing the beliefs of the nurse executives on these points include. at present. conjuring notions and representations that are not. many were unsure of how to implement it through an EBNP initiative in their facility. 'Our pain initiative is a perfect example of EBP Also our work with pre-op antibiotics . Eorthis reason. EBNP [requires] 'a difficult culture change process'. 'Although all our policies and procedures are evidence-based. NURSERESEARCHER 2008. such as. The second qualitative question asked nurse executives if they could foresee any problems in the global nursing implementation of EBNP The responses received to this were so varied that a frequency analysis was not feasible. The responses varied. Qualitative questions Respondents who chose to answer the two qualitative questions wrote succinct responses to one or both. An exemplar is. Individual responses are used as exemplars throughout the remainder of text. Results exemplars Results indicate that while most respondents thought EBNP was a good idea whose time had come. The qualitative questions prompted the subjects to add additional comments on any question or aspect of EBNP of special interest to them. 15. found in any of the literature (Sredl 2005). '[We are] actively involved in promoting EBP and assessing outcomes of relationship nursing models in acute psych setting'. The first qualitative question was an invitation to offer additional comments regarding the respondent's opinion on EBNP. 'I don't think EBP is difficult but the culture change and process of getting there maybe is. 4 61 .guidance yet divergence. this study included two open-ended questions about the subject's particular understanding of EBNP The following are verbatim responses to each of the two questions. where that particular insight helps expand the subject under discussion. we are still working on a level of quality nursing care to ensure EBP at the bedside'. 'is complicated to understand' and 'is hampered by a predominance of associate degree nurses who have limited understanding of the process'.

'Over 68 per cent of my staff has either a diploma in nursing or ADN. and 'Difficult to implement EBNR large per cent of the staff are AD grads. 'I don't know that much about evidence-based nursing'. Exemplar statements include. '99 per cent of our nurses are associate degree prepared.. and have little to no exposure of EBP They are so task-oriented. facility will take three years'. Exemplar statements on these issues include. so staff nurses will have training in how to read and use the research literature' (Sredl 2005). I believe this is an added challenge'. Other results represent a cautious partial understanding of beliefs in EBNR with exemplars including. and 'Over 68 per cent of my staff has either a diploma in nursing [three-year non-college affiliated] or ADN. no matter what their level of EBNP acceptance. Respondent exemplars identifying problems and perceiving difficulties in understanding EBNR problems that can act as effective barriers to starting an EBNP programme. Some respondents raised the issues of using EBNP to change practice. including the original study (Melnyk et al 2004). 15. top administrative support is necessary for EBNP implementation since support personnel such as medical reference librarians are 62 NURSERESEARCHER 2008. I believe this is an added challenge'.issues m research 'think EBP is crucial to the profession'. 4 . emphasis in tasks'. and 'Currently 60 per cent of staff nurses do not have bachelor's degrees. include.' Corroborating the studies cited earlier. 'Time constraints'. and 'Any related increase in expense or manpower would not be welcomed.it is our professional responsibility'. 'I think it's more difficult for nurses to buy in'. and 'We have to engage in EBNP . To implement in our. This is a major impediment to EBNP We must insist that the entry into practice is a bachelor's degree at the minimum.. The supporting qualitative data suggest that contemporary nurse executives do believe in the concepts inherent to the EBNP process. The repeated contention that ADN nurses cannot function within an EBNP dynamic was made even more poignant by such statements as. and 'Time is unfortunately more of the issue than anything'. These observations point to time thresholds that may not be present in the day-to-day responsibilities of contemporary nurse executives. and 'EBNP is something I have a vague idea about but it's not being implemented here'. evaluate outcomes of a practice change and change practice based on patient outcome data respectively.

Budgeting for EBNP must also include access to databases and online or hard copy information sources of best evidence. The supporting qualitative data suggest that although contemporary nurse executives believe in the concepts inherent in EBNP and feel confident in their ability to effect change in their respective organisations. ie MDs'. 'Depends upon compliance with standards of practice'. These databases. articles and standards of practice as we dialogue with colleagues . If using evidence-base means more cost in countries with nothing more to give.integral to an effective evidence-based nursing regimen (Sredl 2005). especially having master's prepared nurses'. 'Do you foresee any problems in the global nursing implementation of EBNP? If so. Exemplar statements related to this issue include. and 'Lack of emphasis on EBP by academic makes this a difficult process to convince staff it adds value'. 15. Exemplars highlighting this point include. education. and 'Although all our policies and procedures are evidence-based we are still working on a level of quality nursing care to ensure EBP at the bedside'. like the first. Information revealed in the qualitative responses also indicates a lack of nurses prepared at masters and doctorate level. 'Physician buy-in = Champions'. are expensive and a facility subscription is necessary for access (Sredl 2005). please explain. such as the Cochrane Collaboration. money. availability of research data'.one of the data sources integral to the EBNP process (Prelec 2004). It's based on text.don't know. and 'Tradition. and 'Healthcare approaches are regional in nature'. and 'Culture barriers specific to roles of the various care givers. 'Although 1 believe [the care that my nurses deliver is evidence-based] I do not have proof.other hospitals'. elicited responses so varied that a frequency analysis was not feasible on it either. I see bigger dichotomy between haves and have nots'. resources. 4 63 . Exemplars examining the source of this expert opinion include.' This question. NURSERESEARCHER 2008. The subjective qualitative data resulting from this research can be considered expert opinion -. may hurt. they are unsure how to implement the steps involved in EBNP The second qualitative question was. 'Time. 'GlobalInternational . As Smith etal (2000) contend. failure to take this information into account in making a differential diagnosis can lead to a serious misrepresentation of the evidence. Exemplar statements include.

If EBNP is indeed to be the emphasis of nurses in a worldwide collective effort towards practice homogeneity. and 'I consult with various small hospitals and can assure you that they cannot spell EBP and don't plan to learn'. The nurse shortage. Evidence-based nursing processes establish best evidence practices and positive clinical outcomes (Sredl 2005). As one subject stated. EBNP courses should be developed and taught at all levels in schools of nursing. is severely compromised by the shortage of nurse educators prepared at master's and doctoral levels.' Implications for nursing education and research Data analysis in this study reveals a nurse executive collaborative structure hesitant and often inconsistent in proclaiming understanding of evidencebased nursing and the steps inherent in the evidence-based nursing process. how to critique research and how to retrieve outcome data should all be emphasised as part of an increased emphasis on nursing informatics courses. 'I am sure evidence-based guidelines can improve clinical care for the population . 15. '[We are] actively involved in promoting EBP and assessing outcomes of relationship nursing models in acute psych setting. Courses on how to search for 'best evidence' and 'positive clinical outcomes'. Exemplars include. combined with the ageing of America's professional workforce. undesirable and expensive alternative outcomes (Sredl 2005). nurses need to understand evidencebased nursing and the evidence-based nursing process. means that nurses must do more with less and in a more efficient way (Block and Sredl 2005). Using evidence-based practice guidelines also eliminates stress and frustration for staff nurses attempting to reinvent the wheel in applying their basic education to state-of-the-art patient care problems and new technology. Using this evidence by incorporating it into care plans can decrease costs associated with patient care by avoiding repetitious. Emphasis on curriculum development based on EBNP should be given funding priority from the US National Institute for Nursing Research. Curricula developed around one espoused nursing theory is too limited. 64 NURSERESEARCHER 2008. 4 . This shortage. in turn.not necessarily for any given individual'.Implications for nursing practice US nursing practice in the 21st century has been severely compromised by its current nurse shortage.

18. despite the bravado exemplified in the responses to the Beliefs Scale (Sredl 2005). 5. Data suggest that when EBNP is championed by nurse executives. 4 1 2 ^ 1 5 . Individual attitudes and organisational climate can greatly influence a nurse executive's propensity towards adopting a positive attitude toward EBNP. 96. 1. Journal of Nursing Staff Development. others in the organisation adopt positive attitudes toward EBNP (Melnyk et al 2004. RN is associate professor of nursing. Sredl D (2006) Nursing eduation and professional practice: a collaborative approach to enhance retention. 1. Block V. While Kuhn (1962) and Hempel and Oppenheim (1948) realised the need for this structure and the impiications that this structure would have. 4 65 . Sredl 2005). 3. Cost savings to hospitals using EBNP can include: lower nursing attrition rates due to increased job satisfaction and performance self-efficacy. but only if the nurses have been educated to understand the construct of EBNP • Darlene Sredl PhD. 23-30. 22. 28-34. B o s t r o m J. This structure is in place largely due to taxonomies such as the Cochrane database and the US's National Guidelines Clearinghouse. NURSERESEARCHER 2008. A n d r o w i c h I M (1999) Evidence-based practice: harvesting the evidence. US This article has been subject to double-blind review : < A n d e r s o n R (1995) Patient empowerment and the traditional medical model. Evidence-based nursing has global implications for nursing. Sirter W N (1993) Research utilization: making the link to practice. 9. Chart. future studies can measure nurse executives' effectiveness at implementing EBNP in healthcare organisations. St Louis MO. and confirmation (Hilz 2000). Now that baseline data have been established. A case of irreconcilable differences? Diabetes Care. improved patient outcomes: lower morbidity-mortality ratios: and reductions in noncovered inpatient hospital days. Journal for Nurses in Staff Development. the qualitative results of this study do not demonstrate such a clear understanding of the EBN process.Future studies will determine if nurse executives move through the last three stages of the innovation diffusion process: decision. University of Missouri at St Louis. 15. implementation. 2. Conclusion Nursing science has structure.

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