ReviewDo educational interventions aimed at nurses to support the implementation of evidence-based practice improve patient outcomes? A systematic review
Introduction
The implementation of Evidence-Based Practice (EBP) in health care has been advocated for many years to bridge the gap between science and practice (Crabtree et al., 2016). This is aligned to the 2020 goal of the Institute of Medicine (IOM) that 90% of clinical decisions be evidence-based to improve the quality of health care (Olsen et al., 2009). Clinical nurses, working on the frontline of health care, are in a key position to question practice and use the most up-to-date research evidence in health care decision making (Cullen and Titler, 2004). Furthermore, Yost et al. (2014a) also highlighted that finding ways to promote the use of scientific evidence in nursing care is paramount, because nurses are the largest group of health care professionals. However, the translation of evidence into the clinical setting is still limited (Saunders and Vehvilainen-Julkunen, 2016). Lack of adequate EBP knowledge and skills in practising nurses has been identified as an important barrier to achieving change (Melnyk et al., 2012; Saunders and Vehvilainen-Julkunen, 2016). To address this, there have been numerous studies exploring educational interventions to encourage nurses to adopt and implement EBP within routine nursing practice (Balakas et al., 2013; Connor et al., 2016; Green et al., 2014; Milne et al., 2007).
Previous systematic reviews on educational interventions for promoting EBP with practising clinicians have focused on identifying changes in EBP knowledge and skills (Haggman-Laitila et al., 2016), multidisciplinary health care professionals such as physicians, nurses, physiotherapists, psychologists, and medical students (Fiander et al., 2015; Hines et al., 2015; Young et al., 2014), pedagogical strategies (Aglen, 2016; Phillips et al., 2014; Yost et al., 2014a, Yost et al., 2014b), and the instruments for evaluating EBP education (Shaneyfelt et al., 2006). For example, Young et al. (2014) synthesised 16 systematic reviews that evaluated the effectiveness of teaching EBP to multidisciplinary health professionals. The review included a total of 81 separate studies, and the evidence showed that conducting training programmes could lead to improvements in EBP attitude, skills, and knowledge across health professions. Furthermore, Phillips et al. (2014) investigated the methods to report educational interventions for developing EBP knowledge and skills, but most of the included articles were from the field of medicine. Haggman-Laitila et al. (2016) reviewed studies relating to practicing nurses but also focussed on the benefits of education on improving participants' EBP knowledge and skills.
Knowing that EBP education improves knowledge and skills does not tell us whether this knowledge is actually implemented in practice or whether EBP education results in improved patient care or outcomes. There is a lack of review evidence exploring whether an EBP educational intervention results in the implementation of an evidence-based approach and improved patient outcomes. This review therefore focuses on the effectiveness of EBP educational interventions in relation to improving patient outcomes within nursing practice. Firstly, changing practice and improving patient care are the ultimate purposes of implementing EBP educational programmes (Balakas et al., 2013). Staff nurses need to translate those EBP knowledge and skills into “real-world” settings and clinical practice. However, the effective implementation of EBP in routine care is often challenged by various barriers, including lack of time, lack of cultural and organisational support, competing priorities, and workloads (Melnyk et al., 2012). Secondly, the clinical environment is complex, and although nurses may have adequate EBP knowledge (Suemoto et al., 2015) it may not always be possible to successfully translate scientific evidence into nursing practice. Measuring or evaluating whether this change has been implemented is complex as it is difficult to attribute changes in patient care or outcomes to the EBP intervention itself and little is known about how best to measure these changes. As noted above, several reviews have identified that educational programmes can develop key skills for undertaking EBP such as searching and synthesising literature but limited data exists on whether conducting EBP training can change behaviour or patient outcomes (Straus et al., 2005). This may be because changes in knowledge and skills are easier to measure than the implementation of a change on patient outcomes. Educators need instruments to evaluate and document the programmatic impact of their teaching programmes (Shaneyfelt et al., 2006). Given the complexity of evaluating the effect of educational interventions to support the implementation of EBP, it is essential to provide guidance for EBP educators by highlighting suitable methods or instruments to assess patient outcomes and to make recommendations for education based on the current evaluation science. Identification of current instruments or methods to evaluate patient outcomes could help educators to understand the effects of EBP education and determine whether new methods are needed to measure the impact of EBP education on patient care.
Therefore, with a focus on practising nurses, this systematic review aimed to gather, assess, and synthesise the current available evidence on the effects of EBP education on patient outcomes. The research questions for this review were: (1) What patient outcomes have been achieved following educational interventions to support practising nurses in implementing EBP? (2) What instruments or methods have been used to determine whether EBP education improves patient outcomes?
Section snippets
Design
The PRISMA checklist (2009) guided the review methods. A protocol (available on request) was agreed at the outset amongst two of the authors (YW and AB). A PICOS statement (Moher et al., 2009) guided the search and inclusion of articles. This involved the participants (P) practising nurses, the intervention (I) any education relating to evidence-based practice, the comparison(C) other or no education, the outcome (O) would be patient outcomes (see below) and S any study design would be
Search Results
A total of 4284 articles were identified for screening, 15 of which were identified through reference and citation tracking. Of the 4284 studies, 394 duplicates were excluded. Then, the titles and abstracts of the remaining 3890 articles were screened, and 3829 were excluded according to the inclusion and exclusion criteria of the review. Furthermore, the remaining 61 articles, which could not be determined by the title and abstract alone, were assessed by the full text. Of the 61 full-text
Summary of Main Results
This systematic review is the first to explore whether providing educational interventions on evidence-based practice translates into improved patient outcomes in nursing practice. Although based on evaluation projects and qualitative data, the results suggest that positive changes on patient outcomes can be made following the implementation of specific evidence-based approaches (or projects).
The majority of the impacts of EBP interventions on patient care were found in a wide range of specific
Conclusions
In conclusion, this review provided evidence that conducting EBP educational interventions on nurses in clinical practice can have a positive impact on patient outcomes, which can demonstrate the usefulness and importance of such programmes. However, the direct impact of EBP interventions on clinical outcomes is difficult to measure because of the wide range of potential outcomes which are difficult to attribute to the results of the intervention itself. Capturing process data following the
Conflict of Interest
No conflict of interest has been declared by the authors.
Funding
This review was funded by the Nanfang Hospital, Southern Medical University, Guangzhou, PR China. The grant number is 17NJ-YB17. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Both authors contributed equally.