Implementing the new essential evidence-based practice competencies in real-world clinical and academic settings: moving from evidence to action in improving healthcare quality and patient outcomes.

Abstract

It has been a little over a year since the first set of essential evidence-based practice (EBP) competencies for practicing nurses and advanced practice nurses (APNs) were published in Worldviews on Evidence-Based Nursing (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). In the initial year after publication, there were over 13,000 downloads of this paper, which indicates the great interest worldwide in these new competencies. However, dissemination of evidence alone, including these competencies, does not typically result in changes in real-world practice and academic settings. Dissemination of evidence must be taken a step further by acting upon the evidence that is published to make changes to improve health care and health outcomes. Now that there is a landmark set of research-based, essential EBP competencies for practicing registered nurses and APNs, we must take action to implement them in the real world to ultimately improve healthcare quality and patient outcomes as well as to reduce costs. Competence is often described broadly as a concept that incorporates knowledge, skills and attitudes, and the ability to do something well (Ilic, 2009; Melnyk et al., 2014). A variety of health professions have used competencies as a mechanism to determine whether clinicians are providing high-quality safe care (Gallagher-Ford, Buck, & Melnyk, 2014; Williams et al., 2010). As an example in the nursing profession, the Quality and Safety Education for Nurses (QSEN) Project is a global initiative that developed six competencies for nursing education to prepare students with the knowledge, skills, and attitudes to improve quality and safety. The QSEN competencies include: (a) patient-centered care, (b) teamwork and collaboration, (c) EBP, (d) quality improvement, (e) safety, and (f) informatics. Other healthcare disciplines, such as medicine, have developed and implemented competencies, such as essential geriatrics competencies for internal medicine and family medicine, developed in 2010 through a consensus-building process that included leadership and members of key stakeholder organizations. There are very few validated tools that exist to measure competency in EBP. The three tools that do exist, the Berlin questionnaire, the Fresno tool, and the Assessing Competency in Evidence based medicine (ACE) tool, have focused on medical students and graduates from medical school (Ilic, 2009). The Berlin tool is a 15-item, self-report knowledge assessment tool that was created to measure EBP knowledge in medical professionals (Fritsche, Greenhalgh, Falck-Ytter, Neumayer, & Kunz, 2002). However, a major limitation is that the Berlin tool only assesses step 3 in the EBP process (i.e., critical appraisal of evidence; Ilic, 2009). The Fresno assessment tool also was developed to measure medical professionals’ EBP competence, specifically knowledge and skills in EBP (Ramos, Schafer, & Tracz, 2003). The Fresno tool is a standardized objective measure of EBP, which is comprised of two clinical scenarios with open-ended questions that tap four steps in the EBP process to which participants respond. The ACE tool is a 15-item assessment of EBP competency, including knowledge, attitudes, skills and behaviors (Ilic, Nordin, Glasziou, Tilson, & Villanueva, 2014). It contains a short patient scenario from which a clinical question is presented followed with a search strategy and a hypothetical article extract. Participants taking the ACE assessment answer 15 “yes” or “no” questions that represent four steps of EBP, including forming the clinical question, searching the literature, critical appraisal, and application of the evidence to the patient (Ilic et al., 2014). Items 1 through 11 on the ACE tool assess EBP knowledge and skills, and items 12 to 15 assess attitudes toward implementing EBP in the clinical setting. As these three tools were developed specifically to measure EBP competence in the medical profession, there is a tremendous need to develop additional valid and reliable tools that are applicable to other professions, including practicing nurses and APNs. Now that the new EBP competencies for practicing nurses and APNs exist, there is a tremendous window of opportunity to develop an objective valid and reliable assessment based on these competencies. The new research-based EBP essential competencies provide leaders with another tool that can assist them in taking action and moving their organizations toward high quality safe care. They can be implemented in a broad range of applications. The EBP competencies should be set as an expectation of performance in organizations. They should be introduced during the onboarding process for all new hires and clearly incorporated into job descriptions and performance appraisals for all new and practicing nurses and APNs in healthcare systems across the globe. They also can be used as a tool for conducting assessments of practicing nurses’ and APNs’ knowledge and skills in EBP to identify gaps where targeted continuing education and skills building workshops are needed. Until all practicing nurses and APNs achieve all of these competencies, they can be built into clinical ladder systems to provide an incentive for nurses to become more proficient in their EBP knowledge and skills. They also can be integrated into expectations for members of shared governance councils to ensure that decisions and recommendations from councils are based in evidence as opposed to tradition. The new EBP competencies also can be used as a guide for educators to prepare students in the necessary knowledge and skills they need to leave academia and function competently in EBP as practicing nurses and APNs in real-world practice settings. One academic barrier to the preparation of students to achieve these competencies is that many faculty across the United States and globe have excellent research skills, but do not have comparable EBP knowledge or skills needed to teach students the seven-step EBP process and how to rapidly translate findings from research into healthcare settings to improve care and outcomes because they themselves were taught rigorous research instead of an evidence-based approach to care (Melnyk, 2013). Further, many educators in academia have the misperception that it is essential for students to first learn research before they can be taught EBP. These barriers often create negative attitudes toward research and a lack of foundational understanding of EBP in students that further slow its implementation in the real world (Melnyk, 2013). In those institutions that do provide an outstanding education in EBP, it is critical that students enter healthcare settings that value and emphasize EBP instead of care that is steeped in tradition (e.g., that is the way it is done here). Practice and academia need to be in sync with each other so that what students learn in academia and how they experience real-world practice are aligned for the best outcomes to be achieved. This requires that partnerships be forged between all academic and practice settings. There are healthcare systems in the United States that have already begun to implement the new EBP competencies. For example, The Ohio State University Health System in the Midwest, USA, has begun to incorporate the EBP competencies into its clinical ladder system and their onboarding program. Nationwide Children's Hospital in Columbus, Ohio, USA, is integrating the competencies into its policy and procedure committee. This transdisciplinary committee participated in a self-assessment using the EBP competencies, which provided data that informed the development of targeted education sessions for the group to increase EBP knowledge and skills. Ongoing mentoring also has been provided to develop and build EBP skills so the competencies can be achieved. In addition, Flagstaff Medical Center, a member of Northern Arizona Healthcare in Flagstaff, Arizona, USA, has integrated the EBP competencies into its clinical educator and clinical nurse specialty positions and is beginning to integrate them into all nursing positions. We would like to hear from others who have begun the process of integrating the new competencies in clinical or academic settings. In conclusion, it is terrific that there is finally a set of research-based EBP competencies for practicing nurses and APNs. However, if these competencies are not used in actual practice, they will be added to the plethora of other evidence-based interventions and research findings that are published but not implemented in the real world to improve healthcare quality and patient outcomes. A quote by Stephen R. Covey (1989) is “To know and not to do is not to know.” Having so much knowledge that never gets translated into real-world settings is not acceptable in this high stakes situation; people around the world deserve the best health outcomes. Moving health care to an evidence-based approach to care can no longer be an academic exercise or something to be done on top of other role responsibilities. EBP must be in the DNA of all transdisciplinary practicing clinicians and the foundation of care that is delivered. It is only when this happens that we will have a healthcare system free of complications, errors, and wasteful spending along with a healthier world for people across the globe.