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What is Evidence-Based Practice in Nursing?

5 min read • June, 01 2023

Evidence-based practice in nursing involves providing holistic, quality care based on the most up-to-date research and knowledge rather than traditional methods, advice from colleagues, or personal beliefs. 

Nurses can expand their knowledge and improve their clinical practice experience by collecting, processing, and implementing research findings. Evidence-based practice focuses on what's at the heart of nursing — your patient. Learn what evidence-based practice in nursing is, why it's essential, and how to incorporate it into your daily patient care.

How to Use Evidence-Based Practice in Nursing

Evidence-based practice requires you to review and assess the latest research. The knowledge gained from evidence-based research in nursing may indicate changing a standard nursing care policy in your practice Discuss your findings with your nurse manager and team before implementation. Once you've gained their support and ensured compliance with your facility's policies and procedures, merge nursing implementations based on this information with your patient's values to provide the most effective care. 

You may already be using evidence-based nursing practices without knowing it. Research findings support a significant percentage of nursing practices, and ongoing studies anticipate this will continue to increase.

Evidence-Based Practice in Nursing Examples

There are various examples of evidence-based practice in nursing, such as:

• Use of oxygen to help with hypoxia and organ failure in patients with COPD 
• Management of angina
• Protocols regarding alarm fatigue
• Recognition of a family member's influence on a patient's presentation of symptoms
• Noninvasive measurement of blood pressure in children 

Improving patient care begins by asking how you can make it a safer, more compassionate, and personal experience. 

Learn about pertinent evidence-based practice information on our  Clinical Practice Material page .

Five Steps to Implement Evidence-Based Practice in Nursing

Evidence-based nursing draws upon critical reasoning and judgment skills developed through experience and training. You can practice evidence-based nursing interventions by  following five crucial steps  that serve as guidelines for making patient care decisions. This process includes incorporating the best external evidence, your clinical expertise, and the patient's values and expectations.

• Ask a clear question about the patient's issue and determine an ultimate goal, such as improving a procedure to help their specific condition. 
• Acquire the best evidence by searching relevant clinical articles from legitimate sources.
• Appraise the resources gathered to determine if the information is valid, of optimal quality compared to the evidence levels, and relevant for the patient.
• Apply the evidence to clinical practice by making decisions based on your nursing expertise and the new information.
• Assess outcomes to determine if the treatment was effective and should be considered for other patients.

Analyzing Evidence-Based Research Levels

You can compare current professional and clinical practices with new research outcomes when evaluating evidence-based research. But how do you know what's considered the best information?

Use critical thinking skills and consider  levels of evidence  to establish the reliability of the information when you analyze evidence-based research. These levels can help you determine how much emphasis to place on a study, report, or clinical practice guideline when making decisions about patient care.

The Levels of Evidence-Based Practice

Four primary levels of evidence come into play when you're making clinical decisions.

• Level A acquires evidence from randomized, controlled trials and is considered the most reliable.
• Level B evidence is obtained from quality-designed control trials without randomization.
• Level C typically gets implemented when there is limited information about a condition and acquires evidence from a consensus viewpoint or expert opinion.
• Level ML (multi-level) is usually applied to complex cases and gets its evidence from more than one of the other levels.

Why Is Evidence-Based Practice in Nursing Essential?

Implementing evidence-based practice in nursing bridges the theory-to-practice gap and delivers innovative patient care using the most current health care findings. The topic of evidence-based practice will likely come up throughout your nursing career. Its origins trace back to Florence Nightingale. This iconic founder of modern nursing gathered data and conclusions regarding the relationship between unsanitary conditions and failing health. Its application remains essential today.

Other Benefits of Evidence-Based Practice in Nursing

Besides keeping health care practices relevant and current, evidence-based practice in nursing offers a range of other benefits to you and your patients:

• Promotes positive patient outcomes
• Reduces health care costs by preventing complications 
• Contributes to the growth of the science of nursing
• Allows for incorporation of new technologies into health care practice
• Increases nurse autonomy and confidence in decision-making
• Ensures relevancy of nursing practice with new interventions and care protocols 
• Provides scientifically supported research to help make well-informed decisions
• Fosters shared decision-making with patients in care planning
• Enhances critical thinking 
• Encourages lifelong learning

When you use the principles of evidence-based practice in nursing to make decisions about your patient's care, it results in better outcomes, higher satisfaction, and reduced costs. Implementing this method promotes lifelong learning and lets you strive for continuous quality improvement in your clinical care and nursing practice to achieve  nursing excellence .

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• Anne Mulhall , MSc, PhD
• Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

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Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research …

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• OJIN Homepage
• Table of Contents
• Volume 18 - 2013
• Number 2: May 2013
• Impact of Evidence-Based Practice

The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas

Dr. Stevens is STTI Episteme Laureate, Professor and Director of the Academic Center for Evidence-Based Practice (ACE) and Improvement Science Research Network (ISRN) in the University of Texas Health Science Center School of Nursing San Antonio. She holds the UT System Chancellor’s Health Fellowship in interprofessional health delivery science. Her multi-site research on team collaboration and frontline engagement in quality improvement is conducted through the national collaboratory, the ISRN.

The impact of evidence-based practice (EBP) has echoed across nursing practice, education, and science. The call for evidence-based quality improvement and healthcare transformation underscores the need for redesigning care that is effective, safe, and efficient. In line with multiple direction-setting recommendations from national experts, nurses have responded to launch initiatives that maximize the valuable contributions that nurses have made, can make, and will make, to fully deliver on the promise of EBP. Such initiatives include practice adoption; education and curricular realignment; model and theory development; scientific engagement in the new fields of research; and development of a national research network to study improvement. This article briefly describes the EBP movement and considers some of the impact of EBP on  nursing practice , models and frameworks , education , and research . The article concludes with discussion of the next big ideas in EBP , based on two federal initiatives, and considers opportunities and challenges as EBP continues to support other exciting new thinking in healthcare.

Key words: EBP, quality improvement, education, research network, translational science, Institute of Medicine

Over the past decade, nurses have been part of a movement that reflects perhaps more change than any two decades combined. The recommendation that nurses lead interprofessional teams in improving delivery systems and care brings to the fore the necessity for new competencies, beyond evidence-based practice, that are requisite as nurses transform healthcare.   Directions in nursing education in the 1960s established nursing as an applied science. This was the entry of our profession into the age of knowledge. Only in the mid-1990s did it become clear that producing new knowledge was not enough. To affect better patient outcomes, new knowledge must be transformed into clinically useful forms, effectively implemented across the entire care team within a systems context, and measured in terms of meaningful impact on performance and health outcomes. The recently-articulated vision for the future of nursing in the Future of Nursing report ( IOM, 2011a ) focuses on the convergence of knowledge, quality, and new functions in nursing. The recommendation that nurses lead interprofessional teams in improving delivery systems and care brings to the fore the necessity for new competencies, beyond evidence-based practice (EBP), that are requisite as nurses transform healthcare. These competencies focus on utilizing knowledge in clinical decision making and producing research evidence on interventions that promote uptake and use by individual providers and groups of providers.

This discussion highlights some of the responses and initiatives that those in the profession of nursing have taken to maximize the valuable contributions that nurses have made, can make, and will make, to deliver on the promise of EBP. A number of selected influences of evidence-based practice trends on nursing and nursing care quality are explored as well as thoughts about the “next big ideas” for moving nursing and healthcare forward.

The EBP Movement

EBP is aimed at hardwiring current knowledge into common care decisions to improve care processes and patient outcomes. Evidence-based practice holds great promise for...producing the intended health outcome.  Following the alarming report that major deficits in healthcare caused significant preventable harm ( IOM, 2000 ) a blueprint for healthcare redesign was advanced in the first Quality Chasm report ( IOM, 2001 ). A key recommendation from the nation’s experts was to employ evidence-based practice. The chasm between what we know to be effective healthcare and what was practiced was to be crossed by using evidence to inform best practices.

Evidence-based practice holds great promise for moving care to a high level of likelihood for producing the intended health outcome. The definition of healthcare quality ( Box 1 ) is foundational to evidence-based practice.

Box 1. Definition of Quality Healthcare

The phrases in this definition bring into focus three aspects of quality : services (interventions), targeted health outcomes, and consistency with current knowledge (research evidence). It expresses an underlying belief that research produces the most reliable knowledge about the likelihood that a given strategy will change a patient's current health status into desired outcomes. Alignment of services with current professional knowledge (evidence) is a key goal in quality. The definition also calls into play the aim of reducing illogical variation in care by standardizing all care to scientific best evidence.

The EBP movement began with the characterization of the problem—the unacceptable gap between what we know and what we do in the care of patients ( IOM, 2001 ). In the report, Crossing the Quality Chasm ( IOM, 2001 ), IOM experts issued the statement that still drives today’s quality improvement initiatives: “Between the health care we have and the care we could have lies not just a gap but a chasm” ( IOM, 2001 , p. 1) and urged all health professions to join efforts for healthcare transformation.

Development of evidence-based practice is fueled by the increasing public and professional demand for accountability in safety and quality improvement in health care.  A major part of the proposed solution to cross this chasm was “evidence-based practice.” Experts continue to generate direction-setting IOM Chasm reports ( IOM, 2003 ; IOM, 2008a ; IOM, 2008b ; IOM, 2011a ); each report consistently identifies evidence-based practice (EBP) as crucial in closing the quality chasm. The intended effect of EBP is to standardize healthcare practices to science and best evidence and to reduce illogical variation in care, which is known to produce unpredictable health outcomes. Development of evidence-based practice is fueled by the increasing public and professional demand for accountability in safety and quality improvement in health care.

Leaders in the field have defined EBP as “Integration of best research evidence with clinical expertise and patient values” (Sackett et al, 2000, p. ii). Therefore, EBP unifies research evidence with clinical expertise and encourages individualization of care through inclusion of patient preferences. While this early definition of EBP has been paraphrased and sometimes distorted, the original version remains most useful and is easily applied in nursing, successfully aligning nursing with the broader field of EBP. The elements in the definition emphasize knowledge produced through rigorous and systematic inquiry; the experience of the clinician; and the values of the patient, providing an enduring and encompassing definition of EBP.

The entry of EBP onto the healthcare improvement scene constituted a major paradigm shift.  The EBP process has been highly applied, going beyond any applied research efforts previously made in healthcare and nursing. This characteristic of EBP brought with it other shifts in the research-to-practice effort, including new evidence forms (systematic reviews), new roles (knowledge brokers and transformers), new teams (interprofessional, frontline, mid- and upper-management), new practice cultures (just culture, healthcare learning organizations), and new fields of science to build the “evidence on evidence-based practice” ( Shojania & Grimshaw, 2005 ). The entry of EBP onto the healthcare improvement scene constituted a major paradigm shift. This shift was apparent in the way nurses began to think about research results, the way nurses framed the context for improvement, and the way nurses employed change to transform healthcare.

Impact on Nursing Practice

In this wide-ranging effort, another significant player was added…the policymaker. For EBP to be successfully adopted and sustained, nurses and other healthcare professionals recognized that it must be adopted by individual care providers, microsystem and system leaders, as well as policy makers. Federal, state, local, and other regulatory and recognition actions are necessary for EBP adoption. For example, through the Magnet Recognition Program ® the profession of nursing has been a leader in catalyzing adoption of EBP and using it as a marker of excellence.

A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice.  In spite of many significant advances, nurses still have more to do to achieve EBP across the board. A recent survey of the state of EBP in nurses indicated that, while nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in employing it in practice (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). One example of implementation of EBP points to the challenges of change. The evidence-based program, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS ® ) ( AHRQ, 2008 ) carries with it proven effectiveness of reducing patient safety issues and the program is available with highly-developed training and learning materials. Yet, because of the change necessary to fully implement and sustain the program across the system supported by organizational culture, a sophisticated implementation plan is required before the evidence-based intervention is adopted across an institution. While agency policy may be set, implementation and sustainment of TeamSTEPPS ® remain challenging.

Impact on Nursing Models and Frameworks

Early in the EBP movement, nurse scientists developed models to organize our thinking about EBP. A number of EBP models were developed by nurses to understand various aspects of EBP. Forty-seven prominent EBP models can be identified in the literature.  These frameworks guide the design and implementation of approaches intended to strengthen evidence-based decision making. Forty-seven prominent EBP models can be identified in the literature. Once analyzed, these models can be grouped into four thematic areas: (1) EBP, Research Utilization, and Knowledge Transformation Processes; (2) Strategic/ Organizational Change Theory to Promote Uptake and Adoption of New Knowledge; and (3) Knowledge Exchange and Synthesis for Application and Inquiry ( Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010 ). Listed among models in Category 1 is the ACE Star Model of Knowledge Transformation ( Stevens, 2004 ); this model is the exemplar for the present discussion of the impact of EBP on nursing models and frameworks.

The ACE Star Model of Knowledge Transformation ( Stevens, 2004 ) was developed to offer a simple yet comprehensive approach to translate evidence into practice. As explained in the ACE Star Model, one approach to understanding the use of EBP in nursing is to consider the nature of knowledge and knowledge transformation necessary for utility and relevance in clinical decision making. Rather than having clinicians submersed in the volume of research reports, a more efficient approach is for the clinician to access a summary of all that is known on the topic. Likewise, rather than requiring frontline providers to master the technical expertise needed in scientific critique, their point-of-care decisions would be better supported by evidence-based recommendations in the form of clinical practice guidelines.

The ACE Star Model of Knowledge Transformation highlights barriers encountered when moving evidence into practice and designates solutions grounded in EBP. The model explains how various stages of knowledge transformation reduce the volume of scientific literature and provide forms of knowledge that can be directly incorporated in care and decision making. The ACE Star Model emphasizes crucial steps to convert one form of knowledge to the next and incorporate best research evidence with clinical expertise and patient preferences thereby achieving EBP. Depicted in Figure 1 , the model is a five-point star, defining the following forms of knowledge: Point 1 Discovery, representing primary research studies; Point 2 Evidence Summary, which is the synthesis of all available knowledge compiled into a single harmonious statement, such as a systematic review; Point 3 Translation into action, often referred to as evidence-based clinical practice guidelines, combining the evidential base and expertise to extend recommendations; Point 4 Integration into practice is evidence-in-action, in which practice is aligned to reflect best evidence; and Point 5 Evaluation, which is an inclusive view of the impact that the evidence-based practice has on patient health outcomes; satisfaction; efficacy and efficiency of care; and health policy.

Figure 1. ACE Star Model of Knowledge Transformation

Copyright Stevens 2004 . Reproduced with permission.

Quality improvement of healthcare processes and outcomes is the goal of knowledge transformation. Important new knowledge resources have been developed and advanced owing to the EBP movement. The importance of Point 2 and Point 3 forms of knowledge has been underscored by several recent reports on the role of systematic reviews ( IOM, 2008a ; IOM, 2008b ; IOM, 2011b ) and clinical practice guidelines ( IOM, 2008a ; IOM, 2008b , IOM, 2011c ) in "knowing what works in healthcare." As an important new form of knowledge, systematic reviews are characterized as the central link between research and clinical decision making (IOM, 2008). Likewise, the function of clinical practice guidelines is to guide practice (IOM, 2008). Important new knowledge resources have been developed and advanced owing to the EBP movement. While resources were available for Point 1, only recently have resources been developed for the knowledge forms on Point 2, 3, 4, and 5 of the Model. These resources are outlined in Table 1 .

Impact on Nursing Education

Following the influential Crossing the Quality Chasm report ( IOM, 2001 ), experts emphasized that the preparation of health professionals was crucial to bridging the chasm ( IOM, 2003 ). The Health Professions Education report ( IOM, 2003 ) declared that current educational programs do not adequately prepare nurses, physicians, pharmacists or other health professionals to provide the highest quality and safest health care possible. The conclusion was that education for all health professions were in need of “a major overhaul” to prepare health professions with new skills to assume new roles ( IOM, 2003 ). This overhaul would require changing way that health professionals are educated, in both academic and practice settings. Programs for basic preparation of health professionals were to undergo curriculum revision in order to focus on evidence-based quality improvement processes. Also, professional development programs would need to become widely available to update skills of those professionals who were already in practice. Leaders in all health disciplines were urged to come together in an effort for clinical education reform that addresses five core competencies essential in bridging the quality chasm:  All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team emphasizing evidence-based practice, quality improvement approaches, and informatics ( IOM, 2003 ). Table 4 presents details of each competency.

From this core set, IOM urged each profession to develop details and strategies for integrating these new competencies into education. With a focus on employing evidence-based practice, nurses established national consensus on competencies for EBP in nursing in 2004 and extended these in 2009 ( Stevens, 2009 ). The ACE Star Model served as a framework for identifying specific skills requisite to employing EBP in a clinical role. Through multiple iterations, an expert panel generated, validated, and endorsed competency statements to guide education programs at the basic (associate and undergraduate), intermediate (masters), and doctoral (advanced) levels in nursing. Between 10 and 32 specific competencies are enumerated for each of four levels of nursing education which were published in Essential Competencies for EBP in Nursing ( Stevens, 2009 ).   These competencies address fundamental skills of knowledge management, accountability for scientific basis of nursing practice; organizational and policy change; and development of scientific underpinnings for EBP ( Stevens, 2009 ).

A measurement instrument was developed from these competencies, called the ACE EBP Readiness Inventory (ACE-ERI). The ACE-ERI quantifies the individual’s confidence in performing EBP competencies. The ACE-ERI exhibits strong psychometric properties (reliability, validity, and sensitivity) and is widely used in clinical and education settings to assess nurses' readiness for employing EBP and measuring impact of professional development programs ( Stevens, Puga, & Low, 2012 ). The ACE Star Model, competencies, and ERI have been adopted into practice settings as nurses strategize to employ EBP. These resources have also been incorporated into educational settings as programs are revised to include EBP skills.

Curricular efforts were also underway. To stimulate curricular reform and faculty development, the IOM suggested that oversight processes (such as accreditation) be used to encourage adoption of the five core competencies. Initiatives that followed included the new program standards established by the American Association of Colleges of Nursing, crossing undergraduate, masters, and doctoral levels of education ( AACN, 2013 ). The AACN standards underscored the necessity for nurses to focus on the systems of care as well on the evidence for clinical decisions. This systems thinking is crucial to effect the changes that are part of employing EBP.

Another curricular initiative became known as Quality and Safety Education in Nursing Institute (QSEN) ( QSEN Institute, 2013 ). Through multiple phases, this project developed a website that serves as a central repository of information on core QSEN competencies, knowledge, skill, attitudes, teaching strategies, and faculty development resources designed to prepare nurses to engage in quality and safety.

Educating nurses in EBP competencies was catapulted forward with the publication of  Teaching IOM.  Educating nurses in EBP competencies was catapulted forward with the publication of Teaching IOM ( Finkleman & Kenner, 2006 ). While the materials presented were in existence in other professional literature, the book added great value by synthesizing what was known into one publication.  This resource was accessible to every faculty member offering teaching strategies and learning resources for incorporating the IOM competencies into curricula across the nation. The resource continues to be updated and expanded through subsequent editions and versions ( Finkleman & Kenner, 2013a ; 2013b ). The strength of these resources is that the approaches and strategies remain closely aligned with the Institute of Medicine’s continuing progress toward better health care. This close alignment reflects the appreciation that nursing must be part of this solution to effect the desired changes; and remaining in the mainstream with other health professions rather than splintering providers into discipline-centric paradigms.

Impact on Nursing Research

Nascent fields are emerging to understand how to increase effectiveness, efficiency, safety, and timeliness of healthcare; how to improve health service delivery systems; and how to spur performance improvement.  Nursing research has been impacted by recent far-reaching changes in the healthcare research enterprise. Never before in healthcare history has the focus and formalization of moving evidence-into-practice been as sharp as is seen in today’s research on healthcare transformation efforts. Nascent fields are emerging to understand how to increase effectiveness, efficiency, safety, and timeliness of healthcare; how to improve health service delivery systems; and how to spur performance improvement. These emerging fields include translational and improvement science, implementation research, and health delivery systems science.

Investigation into uptake of evidence-based practice is one of the fields that has deeply affected the paradigm shift and is woven into each of the other fields. Investigation into EBP uptake is equivalent to investigating Star Point 4 (integration of EBP into practice). Several notable federal grant programs have evolved to foster research that produces the evidential foundation for effective strategies in employing EBP. Among the new research initiatives are the Clinical Translational Science Awards and the Patient-Centered Outcomes grants.

Clinical and Translational Science Awards

When the public cry for improved care escalated, rapid movement of results into care was brought into sharper focus in healthcare research. The National Institutes of Health (NIH), including the National Institute for Nursing Research (NINR), developed the Clinical Translational Science Award (CTSA) program to speed research-to-practice by redesigning the way healthcare research is conducted ( Zerhouni, 2005 ). The term, translational science, was coined, and the definition was provided by NIH ( 2010 ): “Translational research includes two areas of translation. One [“T1”] is the process of applying discoveries generated during research in the laboratory, and in preclinical studies, to the development of trials and studies in humans. The second area of translation [“T2”] concerns research aimed at enhancing the adoption of best practices in the community. The comparative effectiveness of prevention and treatment strategies are [sic] also an important part of translational science” (Section I, para 2).

Nurses are involved in each of the 60 CTSAs that were funded across the nation...  Nurse scientists have been significant leaders in the CTSA program, conducting translational research across these two areas. Nurses are involved in each of the 60 CTSAs that were funded across the nation, contributing from small roles and large roles, ranging from advisor and collaborator to principal investigator. As part of the CTSAs, nurse scientists conduct basic research and applied research, adding significantly to the interprofessional perspectives of the science. In relation to EBP, nurses are valued contributors to the “T2” end of the continuum of translational science, applying skills in mixed methods and systems settings.

Patient-Centered Outcomes Research

As evidence mounted on standard medical metrics...it was noted that metrics and outcomes of particular interest to patients and families... were understudied.  Another recent and swooping change in healthcare research emerged with a focus on patient-centered outcomes research (PCOR). As evidence mounted on standard medical metrics (mortality and morbidity), it was noted that metrics and outcomes of particular interest to patients and families (such as quality of life) were understudied. In 2010, attention was drawn to the need to produce evidence on patient-centered outcomes from the perspective of the patient. Congress founded and heavily funded the newly-formed Patient-Centered Outcomes Research Institute (PCORI) with the following mission: “The Patient-Centered Outcomes Research Institute (PCORI) helps people make informed health care decisions, and improves health care delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from research guided by patients, caregivers and the broader health care community” ( PCORI, 2013 , para. 1).

Likewise, some of the most recent calls for research from the Agency for Healthcare Research and Quality (AHRQ) are also focusing on PCOR. These calls encourage early and meaningful engagement of patients and other stakeholders in stating the research question, conducting the study, and interpreting results ( AHRQ, 2013 ). This new direction in healthcare research will produce evidence that is co-investigated by patients and families in partnership with health scientists, increasing relevance so that EBP reflects the patient’s viewpoint.

The Next Big Ideas

Two additional federal initiatives exemplify what may be called the next big ideas in EBP—each underscoring evidence-based quality improvement. The initiatives call for better use of the knowledge that may be gained from quality improvement efforts. Both initiatives emanate from the NIH and both focus on generating evidence needed to make systems improvements and transform healthcare. The first is NIH’s expansion of the program on Dissemination and Implementation (D&I) science; the second is the development of the research network, the Improvement Science Research Network (ISRN).

NIH Dissemination & Implementation (D&I) Grants

A call for increased emphasis on implementation of evidence-based practices brought forth a federal funding program. In January of 2013, the NIH initiative in dissemination and implementation was expanded across 14 institutes, including NINR. In this call for research proposals, implementation is defined as “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings” ( NIH, 2013 , Section I, para 11). This research initiative will add to our understanding of how to create, evaluate, report, dissemination, and integrate evidence-based strategies to improve health ( Brownson, Colditz, & Proctor, 2012 ). Because of the central role that nurses play across all healthcare settings and clinical microsystems, research in this field is highly relevant to the profession.

D&I research offers nurses opportunities to guide health care transformation at multiple level.. .   This field of science moves beyond the individual provider as the unit of analysis and focuses on groups, health systems, and the community. D&I research offers nurses opportunities to guide health care transformation at multiple levels, thereby addressing recommendation from the Future of Nursing. For example, one emphasis in the field is discovering and applying the evidence for the most effective ways to speed adoption of evidence-based guidelines across all health care professionals in the clinical unit and in the agency. To date, nurse scientists are minimally engaged in D&I research. A recent survey of seven years of NIH projects indicated that only four percent of these were awarded to nurse scientists ( Tinkle, Kimball, Haozous, Shuster, & Meize-Grochowski, 2013 ).

Improvement Science Research Network

The overriding goal of improvement science is to ensure that quality improvement efforts are based as much on evidence as the best practices they seek to implement.  Continuing work with using the ACE Star Model as a framework laid a pathway to one of the “next big ideas:” to move from EBP to the study of strategies for achieving EBP ( Stevens, 2012 ). In many instances, studies about single innovations on Star Point 4 were often not rigorous or broad enough to produce credible and generalizable knowledge ( Berwick, 2008 ). As a new field, improvement science focuses on generating evidence about employing evidence-based practice , providing research evidence to guide management decisions in evidence-based quality improvement. The overriding goal of improvement science is to ensure that quality improvement efforts are based as much on evidence as the best practices they seek to implement.

Recognizing that pockets of excellence in safety and effectiveness exist, there is concern that local cases of success in translating research into practice are often difficult to replicate or sustain over time. Factors that make a change improvement work in one setting versus another are largely unknown. To fill this gap, the Improvement Science Research Network (ISRN) was developed ( Stevens, 2010 ). The ISRN is an open research network for the study of improvement strategies in healthcare. The national network offers a virtual collaboratory in which to study systems improvements in such a way that lessons learned from innovations and quality improvement efforts can be spread for uptake in other settings. The ISRN was developed in response to an NIH call for projects that build infrastructures to advance new fields of science.

The ISRN supports rigorous testing of improvement strategies to determine whether, how, and where an intervention for change is effective. The following shortcomings in research regarding improvement change strategies have been noted: studies do not yield generalizable information because they are performed in a single setting; the improvement intervention is inadequately described and impact imprecisely measures; information about sustainability of change is not produced; contexts of implementation are not accounted for; cost or value is not estimated; and such research is seldom systematically planned ( IOM, 2008b ).

The primary goal of the network is to determine which improvement strategies work as we strive to assure effective and safe patient care. Through this national research collaborative, rigorous studies are designed and conducted through investigative teams. Foundational to the network is the virtual collaboratory, fashioned to conduct multi-site studies and designed around interprofessional academic-practice partnerships in research. The ISRN offers scientists and clinicians from across the nation opportunities to directly engage in conducting studies. “No hospital too small, no study too large” is one of the guiding principles of ISRN collaboration (ISRN Resource List, n.d., para. 28). ISRN Research Priorities were developed via stakeholder and expert panel consensus and are organized into four broad categories: transitions in care; high performing clinical microsystems; evidence-based quality improvement; and organizational culture ( ISRN, 2010 ). The research collaboratory concept has proven its capacity to conduct multi-site studies and is open to any investigator or collaborator in the field.

The new NIH D&I grant resources and the ISRN collaboratory are “the next big ideas” in advancing EBP today. These will provide the scientific foundation for the rapidly expanding efforts to make healthcare better. Nurses will take advantage of these EBP advances to address opportunities and challenges.

Opportunities and Challenges

...the story of EBP in nursing is now long, with many successes, contributors, leaders, scientists, and enthusiasts. Much has been done to make an impact; much remains to be accomplished.  From this admittedly selective overview of EBP, it is seen that the story of EBP in nursing is now long, with many successes, contributors, leaders, scientists, and enthusiasts. Much has been done to make an impact; much remains to be accomplished. Opportunities and challenges exist for clinicians, educators, and scientists.

Those leading clinical practice have willing partners from the academy for discovering what works to improve health care. Such evidence to guide clinical management decisions is long overdue ( Yoder-Wise, 2012 ). While there are benefits to both as the evidence is gathered and applied, the true benefit goes to the patient. Clinical leaders have unprecedented opportunity to step forward to transform healthcare from a systems perspective, focusing on EBP for clinical effectiveness, patient engagement, and patient safety.

Those leading education have great advantages offered from a wide variety of educational resources for EBP. The rich resources offer students a chance to meaningfully connect their emerging competencies with clinical needs for best practices in clinical and microsystem changes. As they emerge from formal education, students will see great enthusiasm for employing EBP in today’s clinical environments.

Those leading nursing science have access to new funding opportunities to develop innovative programs of research in evidence-based quality improvement, implementation of EBP, and the science of improvement. Readiness of the clinical setting for academic-practice research partnerships brings with it advantageous access to clinical populations and settings and an eagerness for utilization of the research results.

The challenges for moving EBP forward spring from two sources: nurses becoming powerful leaders in interprofessional groups and nurses becoming powerful influencers of change. Therefore, adopting the following habits hold promise for moving us ahead:

• Redesigning and/or investigating the redesign of healthcare systems through creativity and mastery of teamwork.
• Persistence in educating the future workforce, and retooling the current workforce, with awareness, skills, and power to improve the systems of care.
• Laying aside comfortable programs of research and picking up programs of systems research.
• Insistence on multiple perspectives and sound evidence for transforming healthcare.

The nursing profession remains central to the interdisciplinary and discipline-specific changes necessary to achieve care that is effective, safe, and efficient. New in our vernacular and skill set are systems thinking, microsystems change, high reliability organizations, team-based care, transparency, innovation, translational and implementation science, and, yes, still evidence-based practice. Let us move swiftly to make these new ideas and skills commonplace.

Acknowledgment

Portions of this work were supported by the National Institutes of Health, National Institute of Nursing Research NIH (1RC2 NR011946-01, PI K. Stevens), and NIH CTSA (UL1TR000149, PI R. Clark).

Correction Notice

On September 3, 2013, the Acknowledgment was modified from the original publication date of May 31, 2013. Additional information has been added at the request of the author.

Kathleen R. Stevens, EdD, RN, ANEF, FAAN E-mail: [email protected]

Agency for Healthcare Research and Quality (AHRQ). (2013). Funding and grants . Retrieved from: www.ahrq.gov

© 2013 OJIN: The Online Journal of Issues in Nursing Article published May 31, 2013

Agency for Healthcare Research and Quality (AHRQ). (2008). TeamSTEPPS national implementation project 2008. Retrieved from: http://teamstepps.ahrq.gov/

American Association of Colleges of Nursing (AACN). (2013 ). Essentials series. Retrieved from: www.aacn.nche.edu/education-resources/essential-series

Berwick, D.M. (2008). The science of improvement. Journal of the American Medical Association , 299 (10), 1182-1184.

Brownson, R.C., Colditz, G.A., & Proctor, E.K. (2012). Dissemination and implementation research in health: Translating science to practice . New York: Oxford University Press, Inc.

Finkelman, A & Kenner, CA. (2006). Teaching IOM: Implications of the IOM reports for nursing education . Washington, DC: American Nurses Association.

Finkelman, A & Kenner, CA. (2013a). (3 rd Ed). Teaching IOM: Implications of the IOM reports for nursing education . Washington, DC: American Nurses Association.

Finkelman, A & Kenner, CA. (2013b). Learning IOM: Implications of the IOM reports for nursing education . Washington, DC: American Nurses Association.

Improvement Science Research Network (ISRN) (n.d.) ISRN resource list. Retrieved from www.isrn.net/ISRNResourceList

Improvement Science Research Network (ISRN). (2010). Research priorities. Retrieved from www.isrn.net/research

Institute of Medicine (IOM). (1990). Medicare: A strategy for quality assurance. (Lohr, KN, Ed.). Washington, DC: National Academy Press.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21 st century . Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academies Press.

Institute of Medicine. (2003). Greiner, AC & Knebel, E (Eds.). Health professions education: A bridge to quality . Washington, DC: National Academies Press.

Institute of Medicine. (2008a). Knowing what works in health care: A roadmap for the nation . Washington, DC: National Academies Press.

Institute of Medicine (IOM). (2008b). Training the workforce in quality improvement and quality improvement research. IOM Forum Workshop. Washington, DC: National Academies Press.

Institute of Medicine. (2011a). The future of nursing: Leading change, advancing health [prepared by Robert Wood Johnson Foundation Committee Initiative on the Future of Nursing]. Washington, DC: National Academies Press.

Institute of Medicine. (2011b). Finding what works in health care: Standards for systematic reviews. [Committee on Standards for Systematic Reviews of Comparative Effective Research; Board on Health Care Services]. Washington, DC: National Academies Press.

Institute of Medicine. (2011c). Clinical practice guidelines we can trust [Committee on Standards for Developing Trustworthy Clinical Practice Guidelines]. Washington, DC: National Academies Press. Retrieved from: www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx .

Institute of Medicine. (2013). Announcement. Crossing the quality chasm: The IOM health care quality initiative . Retrieved from: www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx

Mitchell, S.A., Fisher, C.A., Hastings, CE, Silverman, L.B., Wallen, G.R. (2010). A thematic analysis of theoretical models for translational science in nursing: Mapping the field. Nursing Outlook, 58 (6), 287-300.

National Institutes of Health (NIH). (2010). Institutional clinical and translational science award (U54)  Retrieved from: http://grants.nih.gov/grants/guide/rfa-files/RFA-RM-10-001.html#SectionI

National Institutes of Health (NIH). (2013). Dissemination and implementation research in health . PAR 10-038. Retrieved from: http://grants.nih.gov/grants/guide/pa-files/PAR-10-038.html

Patient-Centered Outcomes Research Institute (PCORI). (2013). Mission and vision . Retrieved from: www.pcori.org/about/mission-and-vision/

Quality and Safety Education in Nursing Institue (QSEN). (2013). About QSEN. Retrieved from http://qsen.org/about-qsen/

Shojania, K.G., & Grimshaw, J.M. (2005). Evidence-based quality improvement: The state of the science. Health Affairs (Millwood), 24(1), 138-150.

Stevens, K.R. (2004). ACE star model of knowledge transformation. Academic Center for Evidence-based Practice. University of Texas Health Science Center San Antonio. www.acestar.uthscsa.edu

Stevens, K.R. (2009). Essential evidence-based practice competencies in nursing. (2 nd Ed.) San Antonio, TX: Academic Center for Evidence-Based Practice (ACE) of University of Texas Health Science Center San Antonio.

Stevens, K.R. (2012). Delivering on the promise of EBP. Nursing Management, 3 (3). Philadelphia: Lippincott, Williams & Wilkins, Inc.

Stevens, K.R., Puga, F., & Low, V. (2012). The ACE-ERI: An instrument to measure EBP readiness in student and clinical populations. Retrieved from: www.acestar.uthscsa.edu/institute/su12/documents/ace/8%20The%20ACE-ERI%20%20Instrument%20to%20Benchmark.pdf

Tinkle, M., Kimball, R., Haozous, E.A., Shuster, G., & Meize-Grochowski, R. (2013). Dissemination and implementation research funded by the US National Institutes of Health, 2005–2012. Nursing Research and Practice, Article ID 909606, 15 pages.

Yoder-Wise, P. (2012). The complex challenges of administrative research for the future. JONA, 42 (5), 239-241.

Zerhouni, E.A. (2005). Translational and clinical science—time for a new vision . New England Journal of Medicine, 353 (15), 1621-3.

May 31, 2013

DOI : 10.3912/OJIN.Vol18No02Man04

https://doi.org/10.3912/OJIN.Vol18No02Man04

Citation: Stevens, K., (May 31, 2013) "The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 4.

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Research in Nursing Practice

Yates, Morgan BScN, RN

Morgan Yates works as an RN in the ED of Surrey Memorial Hospital, Surrey, British Columbia, Canada. Contact author: [email protected] . The author has disclosed no potential conflicts of interest, financial or otherwise.

Bridging the gap between clinicians and the studies they depend on.

Research provides the foundation for high-quality, evidence-based nursing care. However, there isn't a direct flow of knowledge from research into practice. When I ask nurses where the “evidence” to guide the development of “evidence-based care” comes from, I get an interesting array of answers, from “researchers” to blank stares, as if there's no connection between the worlds of researchers and bedside nurses.

If research evidence informs our nursing practice, why doesn't it come from all of us? Nurses are inquisitive, think critically about their patients’ care, and want to know the best treatments for their patients—all of which makes them perfectly suited for research. Though the majority of nurses don't have the training to conduct research projects without assistance, they know how to ask questions and they know which questions need answering.

Yet research is often perceived as something undertaken by others far removed from the front lines of nursing practice. I believe that many nurses’ notions about who does or doesn't do research are rooted in our identity as nurses, which often manifests in a belief that “good” nurses are not researchers but instead have excellent clinical skills and can manage any crisis on a unit. A 2007 study by Woodward and colleagues in the Journal of Research in Nursing found that nurse clinicians engaged in research often perceive a lack of support from nurse managers and resentment from colleagues who see the research as taking them away from clinical practice.

The distinction often drawn between nursing research and clinical practice is mirrored in the inconsistent translation of research evidence into practice. Despite widespread promotion of evidence-based practice in nursing, creation of new translational research roles for nurses in major medical centers, and Medicare reimbursement policies in the United States tied to implementation of specific evidence-supported practices, studies continue to suggest much room for improvement. In a September 2014 article in this journal, Yoder and colleagues noted that researchers have consistently found that “nurses who valued research were more likely to use research findings in practice.” Such observations suggest a need for a much stronger link between nurse clinicians and the development of research into best practices. Though this has been discussed for years, I do not yet see research as having infiltrated fundamental views of what constitutes “nursing work.”

My discussions with frontline nurses and nurses involved in research have led me to ask three key questions that need addressing before we can fully integrate research into our professional identity. These are:

• How can nurses strive for high-quality research without focusing on randomized controlled trials?
• What are the barriers to and challenges of being involved in research and how can we address these?
• How can nurses at varying education levels be involved in research?

Nurses could turn many quality improvement (QI) projects into research. Research may be viewed as a continuum, with formal projects at one end and QI projects somewhere along the continuum. Though nurses may not think that QI projects would be of interest to others, with increased understanding of the research process and greater institutional support, some QI projects could easily become research projects.

More bedside nurses are likely to engage in research if

• nursing education is strengthened.
• time away from direct care is allocated for conducting research activities.
• consultant resources such as methodologists and biostatisticians are available to staff.
• institutional and organizational support of research are strengthened.

Many nurses are intimidated by research, but change is possible if we stop seeing research as someone else's job and start making it a part of who we are and what we do. This will pave the way to evidence-based practice truly becoming the norm.

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• You are here: Hospital nurses

How research can improve patient care and nurse wellbeing

07 September, 2020

Research evidence can inform the delivery of nursing practice in ways that not only improve patient care but also protect nurses’ wellbeing. This article, the first in a four-part series, discusses four studies evaluating interventions to support the delivery of compassionate care in acute settings recommended by the findings of the Francis Inquiry report

This article, the first in a four-part series about using research evidence to inform the delivery of nursing care, discusses four studies that were funded following the two Francis inquiries into care failings at Mid Staffordshire NHS Foundation Trust. Each study evaluated an intervention method in an acute hospital setting that aimed to improve patient care and protect the wellbeing of nursing staff; these included a team-based practice development programme, a relational care training intervention for healthcare assistants, a regular bedside ward round (intentional rounding), and monthly group meetings during which staff discussed the emotional challenges of care. The remaining articles in this series will explore the results of the studies and how they can be applied to nursing care during, and after, the coronavirus pandemic.

Citation: Bridges J et al (2020) Research that supports nursing teams 1: how research can improve patient care and nurse wellbeing. Nursing Times [online]; 116: 10, 23-25.

Authors: Jackie Bridges is professor of older people’s care, University of Southampton; Ruth Harris is professor of health care for older adults, King’s College London; Jill Maben is professor of health services research and nursing, University of Surrey; Antony Arthur is professor of nursing science, University of East Anglia.

• This article is open access and can be freely distributed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
• Click here to see other articles in this series

Introduction

When asked what would make their working life easier or how they could be better supported to deliver the care to which they aspire, nurses most often say “better staffing”, according to a body of research evidence linking nurse staffing with staff wellbeing, care quality and patient outcomes (Bridges et al, 2019; Aiken et al, 2012). What is not always given much attention by nursing teams and managers is the ‘taken-for-granted’ context in which individual nurses work – the way nursing care is organised, the learning opportunities available to the team and the attention paid to staff wellbeing. It may be possible to change these to support nurses and the care on which they lead and deliver, but opportunities may be missed to think differently about them. The evidence base is growing in this area but does not always reach those nurses who are managing and delivering care.

This is the first in a series of four articles highlighting nursing research findings that can directly inform the management and delivery of nursing care in acute hospital settings. The articles highlight four studies that were funded after publication of Francis’ (2013; 2010) reports on the independent and public inquiries into care failings at Mid Staffordshire NHS Foundation Trust. However, as this series will argue, the inquiries’ findings have relevance for nursing practice during, and beyond, the coronavirus pandemic, as nursing teams regroup and reset what they do in response to a rapidly changing care environment.

Using research evidence to improve patient care

Change in the complex, adaptive system of healthcare is usually incremental, rather than transformative, and it is unusual for events to lead to a ‘phase transition’, in which radical and transformative change occurs (Braithwaite et al, 2017). Arguably the coronavirus pandemic has stimulated a phase transition in healthcare (and in wider society), disrupting certainties about healthcare and how it should, and can, be delivered. As we move through this system shock, there are opportunities to think about new ways of working; however, it is also important to retain the valuable knowledge gained from other events that have affected the healthcare system.

The lessons learned from the care failings at Mid Staffordshire NHS Foundation Trust during the late 2000s and the inquiries that followed had an important impact on hospital nursing and the wider system, stimulating reflection, innovation and research to improve nursing care quality. The evidence generated as a result, some of which is explained below, is a reminder of aspects of care that are at risk of being overlooked during the current pandemic. These include the:

• Complexities of caring for older people;
• Importance of nurses’ relational work;
• Importance of nursing care, especially when there is no surgical/medical ‘cure’.

In the absence of a cure for Covid-19, nursing is at the forefront of the supportive care needed by people with the most severe symptoms. As such, it is important to draw on evidence that supports good nursing care and how best to support nurses’ wellbeing, which can be negatively affected by their caring work.

Research studies investigating intervention

The research world responded to the Francis inquiries: the National Institute for Health Research (NIHR) funded several studies to inform policy and practice improvements in this area. The research delivered through four such studies (Box 1) – each of which was led by an author of this article – is summarised below.

Box 1. The four studies

Creating Learning Environments for Compassionate Care (CLECC)

This study trialled a pilot intervention focusing on team building and understanding patient experiences. Participants felt it improved their capacity to be compassionate.

Chief investigator: Jackie Bridges

Full study report available here

Older People’s Shoes

This study trialled an interactive programme to help healthcare assistants (HCAs) get to know older people and understand the challenges they face. The programme was well received by participants, especially as HCAs’ training needs are often overlooked.

Chief investigator: Antony Arthur

Intentional Rounding

This study aimed to evaluate how intentional rounding works in diverse ward and hospital settings. Participants expressed concern that rounding oversimplifies nursing, and favoured a transactional and prescriptive approach over relational nursing care.

Chief investigator: Ruth Harris Full study report available here

Schwartz Center Rounds

This study aimed to understand the unique features of Schwartz Rounds, comparing them with 11 similar interventions. Attending rounds increased staff members’ empathy and compassion for colleagues and patients, and improved their psychological health.

Chief investigator: Jill Maben

Study 1: Creating Learning Environments for Compassionate Care

Bridges et al (2018) investigated the feasibility of implementing a team-based practice development programme into acute care hospital settings. Under the Creating Learning Environments for Compassionate Care (CLECC) programme, all registered nurses and healthcare assistants (HCAs) from participating teams attended a study day, with a focus on team building and understanding patient experiences. A senior nurse educator supported the teams to try new ways of working on the ward, including holding regular, supportive discussions on improving care. Each ward manager attended learning groups to develop their compassionate care leadership role, and two team members received additional training in carrying out observations of care and feeding back to colleagues.

The programme was piloted on four wards in two English hospitals, with two control wards continuing with business as usual. Researchers interviewed staff and observed activities related to the project to understand whether these could be easily put into practice and whether changes were needed. They also tested evaluation methods, including ways to measure compassion and ensuring enough older patients could be recruited to a future study.

The study found that the CLECC programme can be made to work with nursing teams on NHS hospital wards and that staff felt it improved their capacity to be compassionate. Researchers also learned they could improve the programme to help staff continue using it, for example, by helping senior nurses to understand their role in supporting staff with this.

Study 2: Older People’s Shoes

Arthur et al (2017) studied the feasibility of a relational care training intervention for HCAs to improve the relational care of older people in acute hospitals. They initially conducted a telephone survey of acute NHS hospitals in England to understand what training HCAs received. They undertook group interviews with older people and individual interviews with HCAs and staff working with them to establish what participants thought should be included in HCA training. Training was highly variable and focused on new, not existing, staff; relational care was not a high priority.

In response to their findings, the study team designed and produced an innovative interactive training programme called Older People’s Shoes, which aimed to encourage HCAs to consider how to get to know older people and understand the challenges they face. A train-the-trainer model was used to allow the intervention to be viable beyond the testing sites. To see whether they could formally test this new training, the team conducted a pilot cluster-randomised trial in 12 wards from three acute hospitals; it concluded that a larger study to examine whether changes in patient outcomes could be observed would be challenging, but possible.

Older People’s Shoes was well received by participants. This was particularly so for the HCAs, whose training needs were often overlooked or restricted to mandatory requirements, where the focus is almost exclusively on safety.

Study 3: Intentional Rounding

Originating in the US, intentional rounding is a timed, planned intervention that aims to address fundamental elements of nursing care through a regular bedside ward round. Harris et al’s (2019) study aimed to explain which aspects of intentional rounding work, for whom and under what circumstances. It aimed to do this by exploring how intentional rounding works when used with different types of patient, by different nurses, in diverse ward and hospital settings, and whether and how these differences influence outcomes. The study methods included:

• An evidence review to create a theory of why intentional rounding may work;
• A national survey of how intentional rounding had been implemented;
• A case study evaluation exploring the perspectives of senior managers, health professionals, patients and carers;
• Observations of intentional rounding being undertaken;
• An analysis of costs.

The national survey found that 97% of NHS trusts had implemented intentional rounding, although with considerable variation: fidelity to the intentional rounding protocol was observed to be low. All nursing staff thought intentional rounding should be tailored to individual patient need and not delivered in a standardised way. Few felt intentional rounding improved either the quality or frequency of their interactions with patients; they perceived the main benefit of intentional rounding to be the documented evidence of care delivery, despite concerns that documentation was not always reliable. Patients and carers valued the relational aspects of communication with staff, but this was rarely linked to intentional rounding. It is suggested these results should feed into a wider conversation and review of intentional rounding.

Study 4: Schwartz Center Rounds

These were developed in the US to support healthcare staff to deliver compassionate care by helping them to reflect on their work. Schwartz Rounds are monthly group meetings, in which staff discuss the emotional, social and ethical challenges of care in a safe environment. The number of organisations hosting Schwartz Rounds has increased markedly over recent years.

Maben et al (2018) conducted a study to evaluate Schwartz Rounds and understand how the system works. The study used mixed methods, including:

• An evidence review to understand the unique features of Schwartz Rounds;
• A comparison with 11 other similar interventions, such as action learning sets;
• A national survey of 48 staff running Schwartz Rounds in 46 organisations, using telephone interviews to discuss how these had been implemented;
• A survey of 500 staff in 10 organisations to examine how Schwartz Rounds affect work engagement and wellbeing;
• A case study evaluation investigating the perspectives of people who shared their stories at Schwartz Rounds (panellists), audience members who listened and contributed, facilitators, and people who did not attend.

The researchers also observed preparation meetings, actual Schwartz Rounds and steering group meetings to determine how the rounds worked, and under which circumstances they worked optimally.

Their survey found psychological health improved in those attending Schwartz Rounds but not in those who did not attend. Participants described Schwartz Rounds as interesting, engaging and supportive. How they were run varied, creating different levels of trust and safety, and who attended varied – frontline staff found attendance difficult.

It was concluded that Schwartz Rounds are a ‘slow intervention’ that increases its impact over time and creates a safe, reflective space for staff to talk together confidentially. In the staff observed, attending Schwartz Rounds increased their empathy and compassion for colleagues and patients, supported them in their work and helped them make changes in practice.

Applying research findings

The findings from the above studies not only tell us about the impact of each of these four interventions, but also highlight the changes required to better support nursing teams to deliver high-quality care. Written by nursing professors, who were the chief investigators on each of these studies, this series will bring together the findings from the four studies to:

• Highlight the impact of care organisation and related learning opportunities on nurses and on care delivery, as well as the need for staff wellbeing interventions to support nurses;
• Signpost to practical, evidence-based ways in which individuals and teams can improve support for nurses and nursing care;
• Pose questions that individuals and teams can ask in the context of the coronavirus pandemic to optimise support for nurses and care.

The series is part of a collaboration funded by the NIHR to bring the findings of the individual studies to a wider audience; more details about the collaboration and the individual projects can be found at go.soton.ac.uk/cn4. This work will culminate in an event, due to be held in spring 2021, to engage a range of stakeholders in considering how nursing policy and practice should respond to the findings. Readers interested in finding out more can register their interest at Bit.ly/NursingTeams.

The series aims to provide evidence to support nursing teams as they work to recover from the coronavirus pandemic, review ways of working to retain the better areas of nursing care that existed before it took hold and, also, to embrace any lessons learned through their experiences during the pandemic.

• Care failings at Mid Staffordshire NHS Foundation Trust generated the need for evidence about how to improve patient care
• In response to this, four studies have each investigated a different intervention method in acute hospital settings
• The studies’ findings highlight changes that can help nursing teams to deliver high-quality care and protect nurses’ wellbeing

Also in this series

• Learning opportunities that help staff to deliver better care
• Research that supports nursing teams, part 3 of 4
• Nursing interventions that promote team members’ psychological wellbeing
• The four featured studies were funded by NIHR Health Services and Delivery Research programme. The views and opinions expressed are those of the authors and do not necessarily reflect those of the Health Services and Delivery Research programme, NIHR, NHS or the Department of Health and Social Care.

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Usefulness of nursing theory-guided practice: an integrative review

Affiliations.

• 1 School of Nursing, Memorial University of Newfoundland, St. John's, NL, Canada.
• 2 Shifa College of Nursing, Islamabad, Pakistan.
• 3 Clinical Nursing Instructor, Nipissing University, North Bay, ON, Canada.
• PMID: 30866078
• DOI: 10.1111/scs.12670

Background: Nursing theory-guided practice helps improve the quality of nursing care because it allows nurses to articulate what they do for patients and why they do it. However, the usefulness of nursing theory-guided practice has been questioned and more emphasis has been placed on evidence-based nursing and traditional practice. Therefore, an examination of experimental studies was undertaken to analyse the extent of use and usefulness of nursing theories in guiding practice. We reviewed experimental studies because in this era of evidence-based practice, these designs are given more weightage over other research designs. This examination would corroborate the usefulness of nursing theory-guided practice compared to traditional practice.

Methods: An integrative review was conducted. Literature search was performed within multiple databases, and 35 studies were reviewed and appraised.

Results: Majority of the studies were from Iran, the United States and Turkey and used Orem's self-care model, Roy's adaptation model and Peplau's theory of interpersonal relations. The effect of theory-guided interventions was evaluated in improving quality of life, self-efficacy, self-care and stress of patients with chronic, acute, cardiac and psychological illnesses. The quality rating was judged to be strong for three studies, moderate for 25 studies and weak for seven studies. All of the strongly rated studies found nursing theory-guided interventions useful. Overall, nursing theory-guided interventions improved all of studied outcomes in 26 studies and at least one outcome in nine studies. None of the studies reported that nursing theory-guided interventions as not useful.

Conclusion: Nursing theories have guided practice in both eastern and Western countries, and theory-guided practice has been found useful compared to traditional nursing practice. Therefore, nurses should continue to guide their nursing practice through the lens of nursing theories and should continue to evaluate the effectiveness of nursing theory-guided practice.

Keywords: experimental studies; nursing theories; nursing theory-guided practice.

© 2019 Nordic College of Caring Science.

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• Nursing models and self-concept in patients with spinal cord injury--a comparison between UK and Taiwan. Chen HY, Boore JR, Mullan FD. Chen HY, et al. Int J Nurs Stud. 2005 Mar;42(3):255-72. doi: 10.1016/j.ijnurstu.2004.06.012. Int J Nurs Stud. 2005. PMID: 15708013
• Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme. Edfeldt K, Nyholm L, Jangland E, Gunnarsson AK, Fröjd C, Hauffman A. Edfeldt K, et al. BMC Nurs. 2024 Apr 7;23(1):233. doi: 10.1186/s12912-024-01877-1. BMC Nurs. 2024. PMID: 38584285 Free PMC article.
• Psychometric Testing of the Slovene Version of the Perceived Inventory of Technological Competency as Caring in Nursing. Krel C, Vrbnjak D, Štiglic G, Bevc S. Krel C, et al. Healthcare (Basel). 2024 Feb 28;12(5):561. doi: 10.3390/healthcare12050561. Healthcare (Basel). 2024. PMID: 38470672 Free PMC article.
• Nursing theories in the care of stroke patients: a scoping review. Lima JN, Lima LR, Cavalcante EGR, Quirino GDS, Pinheiro WR. Lima JN, et al. Rev Bras Enferm. 2023 Oct 6;76(5):e20220791. doi: 10.1590/0034-7167-2022-0791. eCollection 2023. Rev Bras Enferm. 2023. PMID: 37820129 Free PMC article. Review.
• The effect of telephone counseling based on Orem's model on adherence to treatment and resilience of patients with coronary angioplasty: a randomized clinical trial. Rostami K, Maryami M, Rambod M. Rostami K, et al. BMC Cardiovasc Disord. 2023 Oct 4;23(1):489. doi: 10.1186/s12872-023-03529-9. BMC Cardiovasc Disord. 2023. PMID: 37794373 Free PMC article. Clinical Trial.
• State of the Art on Family and Community Health Nursing International Theories, Models and Frameworks: A Scoping Review. Gasperini G, Renzi E, Longobucco Y, Cianciulli A, Rosso A, Marzuillo C, De Vito C, Villari P, Massimi A. Gasperini G, et al. Healthcare (Basel). 2023 Sep 18;11(18):2578. doi: 10.3390/healthcare11182578. Healthcare (Basel). 2023. PMID: 37761774 Free PMC article. Review.
• McCarthy CT, Aquino-Russell C. A comparison of two nursing theories in practice: Peplau and Parse. Nurs Sci Q 2009; 22: 34-40.
• Gournay K. Mental health nursing in 2001 - what happens next? J Psychiatr Ment Health Nurs 2001; 8: 1-3.
• McKenna HP, Slevin OD. Nursing Models, Theories and Practice. 2008, Blackwell, Oxford.
• McCrae N. Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. J Adv Nurs 2012; 68: 222-9.
• Bond AE, Eshah NF, Bani-Khaled M, Hamad AO, Habashneh S, Kataua H, Al-Jarrah I, Abu Kamal A, Hamdan FR, Maabreh R. Who uses nursing theory? A univariate descriptive analysis of five years’ research articles. Scand J Caring Sci 2011; 25: 404-9.

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Why should I participate in nursing research?

By Marian Altman, PhD, RN, CNS-BC, CCRN-K Jul 14, 2020

• Orientation

Add to Collection

Added to Collection

When someone mentions research, do some of the following thoughts come to mind? Nursing research is important, but I don’t have time. Nursing research is vital to move the profession forward, but I think it’s boring. Nursing research contributes to the empirical body of knowledge, and the criteria necessary for professional status, but research is too complicated and I don’t really understand it. If so, you are not alone.

Nursing research started with Florence Nightingale. She measured illness and infection rates among wounded soldiers in the Crimean War and used those results to petition the British government to improve conditions.

Think about it…Without research, Flo wouldn’t have been able to convince others that sanitation was important to surviving sepsis. This is one reason that research, especially nursing research, is important. Through research, we demonstrate our contribution to health and wellness, answer questions about our practice and confirm our knowledge. The purpose of nursing research from her time until today is to provide empirical evidence to support nursing practice and help us provide excellent patient care.

Participation Barriers

Personal and environmental barriers to participating in nursing research include the following:

• I’m too busy with work.
• Nursing research is for graduate-prepared nurses.
• There’s too much math and statistics.
• I don’t understand research methodology.
• My organization’s culture doesn’t support clinical nurse research participation.
• I don’t work at a Magnet hospital, so I don’t need to know about research.
• I have other priorities.
• I’m not interested in the research.
• I won’t use nursing research.

Participation Benefits

Here’s how nursing research impacts you, our nursing community and ultimately patients and families:

• Improves nursing activities, interventions or approaches to enhance professional practice
• Addresses current issues such as COVID-19
• Helps improve patient outcomes, reduce the length of stay in hospitals and costs
• Helps improve your quality of life, your work environment and your health
• Shapes health policy and the healthcare model to optimize the health and well-being of all populations, which helps prevent, diagnose and cure diseases
• Improves the health and well-being of people around the world
• Offers possible compensation for your participation
• Ensures nursing practice remains relevant and supportive, and protects our patients.
• The ANA Code of Ethics, Provision 7 , encourages nurses to participate in the advancement of the profession through knowledge development, evaluation and application to practice.

You can support research by participating in a study. Access AACN's webpage, Participate in Research Studies , which lists a variety of nursing research opportunities. Select a study that speaks to you and your values and participate if you can. You can also bookmark this page and check it regularly, as new studies are added frequently. We can help improve nursing practice and the patient experience by participating in nursing research.

Please tell us about the research you are supporting in your unit, your organization or elsewhere.

I've been enrolled in the Covid Symptom Study since March. I think it is pretty reputable as it was sent to me by a longitudinal cancer study I have b ... een enrolled in for several years (initially presented through the hospital where I work) Presently over 4 million people enrolled, but they ask for more people to report to give more data. So far from their data, they have revealed six distinct "types" of Covid-19. They say: "Please help by taking 1 min daily to report how you feel 🙏. You also get an estimate of COVID in your area. Download the app https://covid.joinzoe.com/us COVID Symptom Study - Help slow the spread of COVID-19 Help slow the spread of COVID-19 by self-reporting your symptoms daily, even if you feel well. Join millions of people supporting scientists to fight the virus. Help identify (a) How fast the virus is spreading in your area (b) High-risk areas (c) Who is most at risk, by better understanding symptoms linked to underlying health conditions. covid.joinzoe.com" Read More

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• Nursing General
• Introductions to Nursing

Notes On... Nursing Research

ISBN: 978-1-394-23016-7

December 2024

Wiley-Blackwell

Dominic Roche , Clare L. Bennett

Generate and apply high-quality research in a nursing context with this accessible guide

The production and application of rigorous, effective research can have a significant impact on nursing care. Notes On… Nursing Research offers an overview of nursing research, its relationship with clinical practice and patient outcomes, and its positive effects on the nursing professional. Beginning with an introduction to the fundamental principles of nursing research, it moves through the stages of designing and conducting research studies before concluding with specific applications of research to clinical practice and patient care. Part of the Notes On… Nursing series, it is a valuable resource for trainee and qualified nurses, as well as for nursing researchers.

Notes On… Nursing Research readers will also find:

• A step-by-step guide to formulating and answering a research question
• Detailed discussion of research methodologies including data collection and analysis, inferential statistics, multivariate statistics, evidence synthesis, and much more
• Specific examples showing how research has improved patient care and outcomes

Notes On… Nursing Research is ideal for undergraduate nurses, as well as a valuable resource for qualified and practicing nurses and other health professionals looking to develop their understanding of research.

Dominic Roche, PhD is Senior Lecturer in Adult Nursing at the School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, UK.

Clare Bennett, D.Nurs is Reader in Knowledge Translation and Health Improvement and Co-Director of the Wales Centre for Evidence-Based Care at the School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, UK.

The Impact of Education on Nursing Practice

The American Association of Colleges of Nursing (AACN), the national voice for academic nursing, recognizes that education has a significant impact on the knowledge and competencies of the nurse clinician, as it does for all healthcare providers. Clinicians with a Bachelor of Science in Nursing (BSN) degree are well-prepared to meet the demands placed on today's nurses. BSN nurses are prized for their skills in critical thinking, leadership, case management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings. Nurse executives, federal agencies, the military, leading nursing organizations, healthcare foundations, Magnet hospitals, and minority nurse advocacy groups all recognize the unique value that baccalaureate-prepared nurses bring to health care.

AACN encourages employers to foster practice environments that embrace lifelong learning and offer incentives for registered nurses (RNs) seeking to advance their education to the baccalaureate and higher degree levels. We also encourage BSN graduates to seek out employers who value their level of education and distinct competencies.

Download Fact Sheet [PDF]

Different Approaches to Nursing Education

There are three routes to becoming a registered nurse: a 3-year diploma program typically administered in hospitals; a 3-year associate degree usually offered at community colleges; and the 4-year baccalaureate degree offered at senior colleges and universities. Graduates of all three programs sit for the same NCLEX-RN© licensing examination.

Baccalaureate nursing programs encompass all course work taught in associate degree and diploma programs plus a more in-depth treatment of the physical and social sciences, nursing research, public and community health, nursing management, and the humanities. The additional course work enhances the student’s professional development, prepares the new nurse for a broader scope of practice, and provides the nurse with a better understanding of the cultural, political, economic, and social issues that affect patients and influence healthcare delivery. The BSN prepares nurses to practice the full scope of nursing responsibilities across all healthcare settings (NASEM, 2021). For more than two decades, policymakers, healthcare authorities, and practice leaders have recognized that education makes a difference when it comes to nursing practice.

• In March 2024, the U.S. Health Resources and Services Administration (HRSA) released findings from its 2022 National Sample Survey of Registered Nurses which found that for the first time, the baccalaureate was the most common degree for nurses seeking initial licensure as an RN. The latest data show that 45.4% of RNs entered the workforce with a baccalaureate degree. More than two-thirds of the RN workforce (69%) are prepared at the baccalaureate and graduate degree level.   
• In April 2023, results from the 2022 National Nursing Workforce Survey show that the percentage of RNs with a BSN or higher degree in the US workforce exceeded 70% for the first time (71.7%).  Most nurses now enter the workforce with a BSN or entry-level master’s degree (51.5%). This survey is administered every two years by the National Council of State Boards of Nursing and the National Forum of State Nursing Workforce Centers.  
• Issued in November 2022, findings from the  CGFNS Nurse Migration Report 2022  point to an international shift toward baccalaureate education as the preferred pathway into the nursing profession. The latest data show the majority of nurses who migrated to the U.S. in 2022 were educated at the baccalaureate or higher level, which is consistent with how most new nurses are prepared in U.S. schools of nursing.  
• In March 2019, AACN approved a position statement on Academic Progression in Nursing , which called for preparing all RNs with a baccalaureate degree, at minimum, offered by an accredited four-year college or university. AACN supports the many pathways available to assist nurses in advancing their education, including expanding articulation agreements and concurrent enrollment options with community colleges.  
• In December 2017, the governor of New York signed legislation into law requiring future registered nurses graduating from associate degree or diploma nursing programs in the state to obtain a baccalaureate in nursing within 10 years of initial licensure. The legislators found that given “the increasing complexity of the American healthcare system and rapidly expanding technology, the educational preparation of the registered professional nurse must be expanded.”  
• In the September-October 2014 issue of Nurse Educator , a research team led by Dr. Sharon Kumm from the University of Kansas published findings from a statewide study , which showed clear differences in outcomes from BSN and associate degree in nursing (ADN) programs. The study showed that 42 of 109 baccalaureate outcomes were met in ADN programs. The 67 outcomes that were not met were in the areas of liberal education, organizational and systems leadership, evidence-based practice, healthcare policy, finance and regulatory environments, interprofessional collaboration, and population health.  
• In September 2013, the Robert Wood Johnson Foundation (RWJF) released an issue of its Charting Nursing’s Future newsletter titled The Case for Academic Progression , which outlined how patients, employers, and the profession benefit when nurses advance their education. Articles focus on the evidence linking better outcomes to baccalaureate and higher degree nurses, educational pathways, and promising strategies for facilitating academic progression at the school, state, and national levels.  
• In September 2012, the Joint Statement on Academic Progression for Nursing Students and Graduates was endorsed by the American Association of Colleges of Nursing, American Association of Community Colleges, Association of Community College Trustees, National League for Nursing, and the Organization for Associate Degree Nursing. This historic agreement represents the first time that leaders from the major national organizations representing community college presidents, boards, and administrators joined with representatives from nursing education associations to promote academic progression in nursing. With the goal of preparing a well-educated, diverse nursing workforce, this statement represents the shared view that nursing students and practicing nurses should be supported in their efforts to pursue higher levels of education.  
• In October 2010, the Institute of Medicine released its landmark report on The Future of Nursing: Leading Change, Advancing Health , initiated by the Robert Wood Johnson Foundation, which called for increasing the number of baccalaureate-prepared nurses in the workforce to 80% by 2020. The expert committee charged with preparing the evidence-based recommendations in this report state that to respond “to the demands of an evolving healthcare system and meet the changing needs of patients, nurses must achieve higher levels of education.”  
• In May 2010, the Tri-Council for Nursing (AACN, ANA, AONL, and NLN) issued a statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. In the statement titled Education Advancement of Registered Nurses , the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe patient care. The Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.”  
• In December 2009, Dr. Patricia Benner and her team at the Carnegie Foundation for the Advancement of Teaching released a study titled Educating Nurses: A Call for Radical Transformation , which recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure. The authors found that many of today’s new nurses are “undereducated” to meet practice demands across settings.  
• In February 2008, the Council on Physician and Nurse Supply , which is based at the University of Pennsylvania, called for increasing nursing school graduations by 30% and for increased federal support to enable more nurses to complete the BSN.  
• In March 2005, the American Organization of Nurse Executives (AONE) – today known as the American Organization for Nursing Leadership (AONL) - released a statement calling for all RNs to be educated in baccalaureate programs to adequately prepare clinicians for their challenging, complex roles. AONL’s statement, titled Practice and Education Partnership for the Future, represents the view of nursing’s practice leaders and a desire to create a more highly educated nursing workforce in the interest of improving patient safety and nursing care.  
• The National Advisory Council on Nurse Education and Practice (NACNEP) has urged that at least two-thirds of the nurse workforce hold baccalaureate or higher degrees in nursing. In a 2000 report , NACNEP found that nursing’s role calls for RNs to manage care along a continuum, to work as peers in interdisciplinary teams, and to integrate clinical expertise with knowledge of community resources. To meet scope of practice expectations, RNs must have critical thinking and problem-solving skills; a sound foundation in a broad range of basic sciences; knowledge of behavioral, social and management sciences; and the ability to analyze and communicate data. Among the three types of entry-level nursing education programs, NACNEP found that the BSN, with its broader and stronger scientific curriculum, best fulfills these requirements and provides a sound foundation for addressing the complex healthcare needs of today in a variety of nursing positions. Baccalaureate education provides a base from which nurses move into graduate education and advanced nursing roles.  
• Currently, there are 706 RN-to-BSN and 179 RN-to-MSN programs that build on the education provided in associate degree and diploma programs and prepare graduates for a broader base of practice (AACN, 2024). In addition to hundreds of individual agreements between community colleges and four-year schools, state-wide articulation agreements exist in most states to facilitate advancement to the baccalaureate. These programs further validate the unique competencies gained in BSN programs.  
• RNs work as part of an interprofessional team with colleagues educated at the graduate level. These professionals, including physicians and pharmacists, recognize the complexity involved in providing care and the need for higher education. Because nurses are primarily responsible for direct patient care and care coordination, these clinicians should not be the least educated member of the healthcare team.

Recognizing Differences Among Nursing Program Graduates

There is a growing body of evidence that indicates BSN graduates bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.

•   In March 2022,  Nursing Outlook  published an article from Dr. Joshua Porat-Dahlerbruch, Dr. Linda Aiken, and colleagues that explored “ Variations in Nursing Baccalaureate Education and 30-day Inpatient Surgical Mortality .” The authors found that having a higher proportion of baccalaureate-prepared nurses in hospital settings, regardless of educational pathway, is associated with lower rates of 30-day inpatient surgical mortality.  
• In the July 2019 issue of  Health Affairs , Dr. Jordan Harrison, Dr. Linda Aiken, and their colleagues from the University of Pennsylvania published findings from a study, which found that each 10% increase in the hospital share of nurses with a BSN was associated with 24% greater odds of surviving to discharge with good cerebral performance among patients who experienced in-hospital cardiac arrest.  
• In the March 2019 issue of The Joint Commission Journal of Quality and Patient Safety , Dr. Maya Djukic and colleagues from New York University released details from a study, which found that baccalaureate-prepared RNs reported being significantly better prepared than associate degree nurses on 12 out of 16 areas related to quality and safety, including evidence-based practice, data analysis, and project implementation. The authors conclude that improving accreditation and organizational policies requiring the BSN for RNs could help safeguard the quality of patient care.  
• In the July 2017 issue of BMJ Quality and Safety , Dr. Linda Aiken and colleagues reported findings from a study of adult acute care hospitals in six European nations, which found that a greater proportion of professional nurses at the bedside is associated with better outcomes for patients and nurses. Reducing nursing skill mix by adding assistive personnel without professional nurse qualifications may contribute to preventable deaths, erode care quality, and contribute to nurse shortages.  
• In the October 2015 issue of Global Qualitative Nursing Research , Dr. Allison Brandt Anbari published a qualitative meta-synthesis of studies on practice differences identified by graduates of RN to BSN programs. Nurses completing the programs reported enhanced assessment and critical thinking skills, improved communication abilities, and better patient outcomes. Findings were consistent with a 1988 study published by Dr. Joyce Johnson in Research in Nursing and Health .  
• In a study published in the October 2014 issue of Medical Care , researcher Dr. Olga Yakusheva from the University of Michigan and colleagues found that a 10% increase in the proportion of baccalaureate-prepared nurses on hospital units was associated with lowering the odds of patient mortality by 10.9%. The authors also found that increasing the amount of care provided by BSNs to 80% would result in significantly lower readmission rates and shorter lengths of stay. These outcomes translate into cost savings that would more than off-set expenses for increasing the number of baccalaureate-prepared nurses in hospital settings.  
• In the May 2013 issue of Medical Care , researchers from the University of Pennsylvania, led by Dr. Matthew McHugh, found that surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and 12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The study authors conclude that these better outcomes were attributed in large part to investments in highly qualified and educated nurses, including a higher proportion of baccalaureate-prepared nurses.  
• In an article published in the March 2013 issue of Health Affairs , nurse researcher Dr. Ann Kutney-Lee and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients—and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients.  
• In the February 2013 Journal of Nursing Administration , Dr. Mary Blegen and colleagues published findings from a study of 21 University HealthSystem Consortium hospitals on the association between RN education and patient outcomes. Hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower rates of congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis as well as shorter lengths of stay.  
• In a January 2011 article published in the Journal of Nursing Scholarship , Drs. Deborah Kendall-Gallagher, Linda Aiken, and colleagues released the findings of an extensive study of the impact nurse specialty certification has on lowering patient mortality and failure to rescue rates in hospitals. The researchers found that certification was associated with better patient outcomes, but only when care was provided by nurses with baccalaureate-level education. The authors concluded that “no effect of specialization was seen in the absence of baccalaureate education.”  
• In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates. The authors conclude that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”  
• In a study released in the May 2008 issue of the Journal of Nursing Administration , Dr. Linda Aiken and colleagues confirmed the findings from her landmark 2003 study, which show a strong link between RN education level and patient outcomes. Titled “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes,” the researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.  
• In the January 2007 Journal of Advanced Nursing , a study on the “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that BSN-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, a team of Canadian researchers studied 46,993 patients admitted to the hospital with heart attacks, strokes, pneumonia, and blood poisoning. The authors found that “hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates.” Findings indicated that a 10% increase in the proportion of BSN nurses was associated with 9 fewer deaths for every 1,000 discharged patients.  
• In a study published in the March/April 2005 issue of Nursing Research , Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate-prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, titled “The Impact of Hospital Nursing Characteristics on 30-Day Mortality,” confirms the findings from Dr. Linda Aiken’s landmark study in September 2003.  
• In a study published in the Journal of the American Medical Association (JAMA) on September 24, 2003, Dr. Linda Aiken and colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5%. The authors recommend that public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. They also call for renewed support and incentives from nurse employers to encourage RNs to pursue baccalaureate and higher degree levels.  
• Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 – one by the state of New York and one by the state of Texas – clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level. These findings are consistent with findings published in the July/August 2002 issue of Nurse Educator by Dr. Cheryl Delgado that reference studies conducted in Arizona, Colorado, Louisiana, Ohio, and Tennessee that also found that nurses prepared at the associate degree and diploma levels make the majority of practice-related violations.  
• Chief nurse officers (CNOs) in university hospitals prefer to hire nurses who have baccalaureate degrees, and nurse administrators recognize distinct differences in competencies based on education. In a 2001 survey published in the Journal of Nursing Administration , 72% of these CNOs identified differences in practice between BSN-prepared nurses and those who have an associate degree or hospital diploma, citing stronger critical thinking and leadership skills (Goode et al., 2001). A strong preference for hiring new RNs with a BSN was confirmed in a study released by NCSBN in 2002.  
• Research shows that RNs prepared at the associate degree and diploma levels develop stronger professional-level skills after completing a BSN program. In a study of RN-to-BSN graduates from 1995 to 1998 (Phillips et al., 2002), these students demonstrated higher competency in nursing practice, communication, leadership, professional integration, and research/evaluation.  
• Data show that healthcare facilities with higher percentages of BSN nurses enjoy better patient outcomes and significantly lower mortality rates. Magnet hospitals are model patient care facilities that typically employ a much higher proportion of baccalaureate prepared nurses when compared to other hospitals. In several research studies, Dr. Marlene Kramer (1988), Dr. Linda Aiken (2013) and others have found a strong relationship between organizational characteristics and patient outcomes.  
• The fact that graduates of baccalaureate, associate degree, and diploma nursing programs can pass the NCLEX-RN©, the national licensing exam for RNs, is not proof that no differences exist among graduates. The NCLEX-RN© is a multiple-choice test that measures the minimum technical competency for safe entry into basic nursing practice. Passing rates should be high across all programs preparing new nurses. This exam does not test for differences between graduates of different entry-level programs. The NCLEX-RN© is only one indicator of competency, and it does not measure performance over time or test for all knowledge and skills developed through a BSN program.

Public and Private Support for BSN-Prepared Nurses

The federal government, the military, nurse executives, healthcare foundations, nursing organizations, and practice settings acknowledge the unique value of baccalaureate-prepared nurses and advocate for an increase in the number of BSN nurses across clinical settings.

• The nation’s Magnet hospitals , which are recognized for nursing excellence and superior patient outcomes, have moved to require all nurse managers and nurse leaders to hold a baccalaureate or graduate degree in nursing.  
• The National Advisory Council on Nurse Education and Practice (NACNEP), policy advisors to Congress and the Secretary for Health and Human Services on nursing issues, and the National Academy of Science, Engineering, and Medicine recognize the unique contributions of baccalaureate-prepared nurses to high quality, safe, and effective patient care.  
• In the interest of providing the best patient care and leadership by its nurse corps officers, the U.S. Army , U.S. Navy, and U.S. Air Force all require the baccalaureate degree to practice as an active-duty Registered Nurse. Commissioned officers within the U.S. Public Health Service also must be baccalaureate prepared.  
• The Veteran's Administration (VA), the nation's largest employer of registered nurses, has established the baccalaureate degree as the minimum preparation its nurses must have for promotion beyond the entry-level.  
• Minority nurse organizations, including the National Black Nurses Association , Hispanic Association of Colleges and Universities , and National Association of Hispanic Nurses , are committed to increasing the number of minority nurses with baccalaureate and higher degrees.  
• Based on a nationwide Harris Poll conducted in June 1999, an overwhelming percentage of the public – 76% – believes that nurses should have four years of education or more past high school to perform their duties.  
• The Pew Health Professions Commission in a 1998 report called for a more concentrated production of baccalaureate and higher degree nurses. This commission was an interdisciplinary group of healthcare leaders, legislators, academics, corporate leaders, and consumer advocates created to help policymakers and educators produce a workforce able to meet the changing needs of the American healthcare system.  
• Countries around the world are moving to create a more highly educated nursing workforce. Canada, Sweden, Portugal, Brazil, Iceland, Korea, Greece, and the Philippines are just some of the countries that require a four-year undergraduate degree to practice as a registered nurse.

Fact Sheet References

Aiken, L. H., Sloan, D., Griffiths, P. et al. (2017). Nursing skill mix in European hospitals: association with mortality, patient ratings, and quality of care. BMJ Quality & Safety , 26(7), 559- 568. DOI: 10.1136/bmjqs-2016-005567.

Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T., & Cheney, T. (2008, May). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration , 38(5), 223-229. DOI: 10.1097/01.NNA.0000312773.42352.d7.

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association , 290, 1617-1623. DOI :  10.1001/jama.290.12.1617 .

American Association of Colleges of Nursing. (2023). 2022-2023 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.

American Association of Colleges of Nursing. (2019). Academic progression in nursing: Moving together toward a highly educated nursing workforce. Position statement. Available at https://www.aacnnursing.org/Portals/42/News/Position-Statements/Academic-Progression.pdf .

American Association of Colleges of Nursing. (2019). Articulation agreements among nursing education programs. Fact sheet. Available at https://www.aacnnursing.org/News-Information/Fact-Sheets/Articulation-Agreements .

American Association of Colleges of Nursing, American Association of Community Colleges, Association of Community College Trustees, National League for Nursing, National Organization for Associate Degree Nursing. (2012, September). Joint statement on academic progression for nursing students and graduates. Available at https://www.aacnnursing.org/NewsInformation/Position-Statements-White-Papers/Academic-Progression .

American Organization of Nurse Executives. (2005). Practice and education partnership for the future. Washington, DC: American Organization of Nurse Executives.

Brandt Anbari, A. (2015, January-December). The RN to BSN transition: A qualitative systematic review. Global Qualitative Nursing Research, 2, 1-11. DOI: 10.1177/2333393615614306.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2009). Educating Nurses: A Call for Radical Transformation. Carnegie Foundation for the Advancement of Teach. San Francisco: Jossey-Bass. DOI: 10.3928/01484834-20120402-01.

Blegen, M.A., Goode, C.J., Park, S.H., Vaughn, T., & Spetz, J. (2013, February). Baccalaureate education in nursing and patient outcomes. Journal of Nursing Administration , 43(2), 89-94. DOI: 10.1097/NNA.0b013e31827f2028.

CGFNS International (2022). Eds. Bakhshi, M., Álvarez, T.D., & Cook, K. CGFNS nurse migration report: Trends in healthcare migration to the United States. Online Report. Available at http:// www.cgfns.org/2022nursemigrationreport .

Delgado, C. (2002, July/August). Competent and safe practice: a profile of disciplined registered nurses. Nurse Educator , 27(4), 159-61. DOI: 10.1097/00006223-200207000-00005.

Djukic, M., Stimpfel, A.W., & Kovner, C. (2019, March). Bachelor's degree nurse graduates report better quality and safety educational preparedness than associate degree graduates. Joint Commission Journal on Quality and Patient Safety , 45(3), 180-186. DOI: 10.1016/j.jcjq.2018.08.008.

Estabrooks, C.A., Midodzi, W.K., Cummings, G.C., Ricker, K.L., & Giovanetti, P. (2005, March/April). The impact of hospital nursing characteristics on 30-day mortality. Nursing Research, 54(2), 72-84. DOI: 10.1097/00006199-200503000-00002.

Fagin, C.M. (2001). When care becomes a burden: Diminishing access to adequate nursing. Millbank Memorial Fund, New York, NY. Available at https://www.milbank.org/publications/when-care-becomes-a-burden-diminishing-access-to-adequate-nursing.

Friese, C.R, Lake, E.T., Aiken, L.H., Silber, J.H., & Sochalski, J. (2008, August). Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research, 43(4), 1145-1163. DOI: 10.1111/j.1475-6773.2007.00825.x.

Goode, C.J., Pinkerton, S., McCausland, M.P., Southard, P., Graham, R., & Krsek, C. (2001). Documenting chief nursing officers' preference for BSN-prepared nurses. Journal of Nursing Administration, 31(2). 55-59. DOI: 10.1097/00005110-200102000-00002.

Graff, C., Roberts, K., & Thornton, K. (1999). An ethnographic study of differentiated practice in an operating room. Journal of Professional Nursing , 15(6), 364-371. DOI: 10.1016/s8755-7223(99)80067-2.

Harrison, J.M., Aiken, L.H., Sloane, D.M., Brooks-Carthon, J.M., Merchant, R.M., Berg, R.A., & McHugh, M.D. (2019, July). In hospitals with more nurses who have baccalaureate degrees, better outcomes for patients after cardiac arrest. Health Affairs , 38(7), 1087-1094. DOI: 10.1377/hlthaff.2018.05064.

Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health . Washington, DC: National Academies Press. DOI: 10.17226/12956.

Johnson, J. (1988). Differences in the performance of baccalaureate, associate degree and diploma nurses: A meta-analysis. Research in Nursing and Health , 11, 183-197. DOI: 10.1002/nur.4770110307.

Kendall-Gallagher, D., Aiken, L., Sloane, D.M., & Cimiotti, J.P. (2011, January). Nurse specialty certification, inpatient mortality, and failure to rescue. Journal of Nursing Scholarship , 43(2), 188- 194. DOI: 10.1111/j.1547-5069.2011.01391.x.

Kramer, M. & Schmalenberg, C. (1988). Magnet hospitals: Part I, Institutions of excellence. Journal of Nursing Administration , 18(1), 13-24. DOI:10.1024/1012-5302/a000216.

Kumm, S., Godfrey, N., Martin, D., Tucci, M., Muenks, M., & Spaeth, T. (2014). Baccalaureate outcomes met by associate degree programs. Nursing Educator , 39(5), 216-220. DOI: 10.1097/NNE.0000000000000060.

Kutney-Lee, A., Sloane, D.M., & Aiken, L. (2003, March). An increase in the number of nurses with baccalaureate degrees is linked to lower rates of post-surgery mortality. Health Affairs , 32(3), 579-586. DOI: 10.1377/hlthaff.2012.0504.

McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M., & Aiken, L.H. (2013, May). Lower mortality in magnet hospitals. Medical Care , 51(5), 382-8. DOI: 10.1097/MLR.0b013e3182726cc5.

National Academy of Science, Engineering, and Medicine. (2021). The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity . Washington, DC: The National Academies Press. DOI: https://doi.org/10.17226/25982.

National Advisory Council on Nurse Education and Practice (2000). Report to the Secretary of the Department of Health and Human Services on the basic registered nurse workforce. Washington, DC: United States Department of Health and Human Services, Health Resources and Services Administration.

National Council of State Boards of Nursing (2002). 2001 Employers survey. Chicago: Author. Available at https://www.ncsbn.org/public-files/RBrief_Employer_053.pdf.

Phillips, C.Y., Palmer, C.V., Zimmerman, B.J., & Mayfield, M. (2002). Professional development: Assuring growth of RN-to-BSN students. Journal of Nursing Education , 41(6), 282-283. DOI: 10.3928/0148-4834-20020601-10.

Porat-Dahlerbruch, J., Aiken, L.H., Lasater, K.B., Sloane, D.M., & McHugh, M.D. (2022, March). Variations in nursing baccalaureate education and 30-day inpatient surgical mortality. Nursing Outlook , 70(2), 300-308. DOI: https://doi.org/10.1016/j.outlook.2021.09.009.

Smiley, R.A., Allgeyer, R.L., Shobo, Y., Lyons, K.C., Letourneau, R., Zhong, E., Kaminski-Ozturk, N., and Alexander, M. (2023, April). The 2022 National Nursing Workforce Survey. Journal of Nursing Regulation , 14(Supplement), S16-S17. DOI: https://doi.org/10.1016/S2155-8256(23)00047-9.

Tourangeau, A.E, Doran, D.M., McGillis Hall, L., O'Brien Pallas, L., Pringle, D., Tu, J.V., & Cranley, L.A. (2007, January). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing , 57(1), 32-41. DOI: 10.1111/j.1365-2648.2006.04084.x.

Tri-Council for Nursing. (2010, May). Educational advancement of registered nurses: A consensus position .

U.S. Health Resources and Services Administration. (2024). National Sample Survey of Registered Nurses .

Yakusheva, O., Lindrooth, R., & Weiss, M. (2014, October). Economic evaluation of the 80% baccalaureate nurse workforce recommendation: A patient-level analysis. Medical Care , 52(10), 864-869. DOI: 10.1097/MLR.0000000000000189.

Updated: June 2024

Robert Rosseter [email protected]

Baccalaureate-Prepared Nurses are Essential to Quality Health Care   Impactful Nursing 

Discover how nursing education elevates patient outcomes and why BSN-educated nurses play a pivotal role in ensuring healthcare quality. This document is a must-read for healthcare advocates and stakeholders, shedding light on the vital role of baccalaureate-prepared nurses. 

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The Queen's Nursing Institute Scotland

Promoting excellence in community nursing across Scotland

Strengthening nurse-led community research

8th August 2024

Research Fellows, Ben Bowers and Caroline Dickson, discuss the importance of research within nursing, and how to embed it in practical and innovative ways.

Research within nursing is generally considered a Marmite concept – you either love it or hate it!

That said, nurses are curious, questioning, have considerable abilities to use evidence to make decisions and to advocate for patients and their families. They can evaluate current practice and identify ways to make patient and staff experiences better. Nurses do research! Community and primary care nurses do research! It’s not a case of love or hate, it’s about recognising and articulating what counts as research… and building community and primary care nurses’ confidence in driving forward research that matters.

Educators in community and primary care are seeking to find innovative ways to include research in their curricula, ways that help nurses to embed research into daily practices and encourage them to consider how they can lead on developing much needed evidence to support community nursing practice.

Increasing numbers of community nursing researchers are role modelling ways of incorporating research into clinical and academic roles.  Forums such as the Queen’s Nursing Institute Scotland and the Queen’s Nursing Institute are committed to supporting UK-based nurse researchers and research engagement, through skills training, networking and providing opportunities for community and primary care nurses to be involved in research. These activities are happening concurrently with the UK Government showing a commitment to developing research capacity and capability in nursing within its strategic plans, and government-funded schemes that support clinical academic careers and research activity. However, community and primary care nurse-led research remain very under-represented (Bowers and Evans 2022).

The problem remains, there is not enough nurse-led research to inform evidence-based community practice. So, we created the QNI Community Nursing Research Forum (click here for more)  to strengthen community-based nursing research through peer support, mentorship and supporting personal development and research opportunities across the United Kingdom.

The idea for the Forum is simple and is proving to be effective. It brings together novices and experts alike, to network, learn, share ideas and develop research and development within their clinical role as well as in research-related careers. The Forum now has 900 members from across the UK. We come together as a community for online Masterclasses, drop-in sessions and webinars. We also have a growing private Facebook group for members to ask research related questions and get advice. We continue to build innovative web resources (click here for more)  based on members’ requests and development needs.

There is great appetite for engaging with research within community and primary care nursing and we want to support members in developing their skillsets, networks and research interests. There are considerable benefits from being part of an inclusive, dynamic community of like-minded peers interested in research, and the UK-wide focus is hugely helpful in bringing people together and supporting one another to grow and access support within their specialties and beyond.

Taking up opportunities to engage in research may not seem like a priority when much of the workforce is understaffed and clinical practice demands are high. However, engaging in research provides a chance to recharge and grow. Conducting and engaging in research requires many different skills and abilities. It also allows nurses to communicate and collaborate closely with like-minded peers involved in research, something that can be limited when working in relative isolation in community settings. So, we invite you to join us!

These are the key reasons why you should join the Community Nursing Research Forum:

• There are similar opportunities and challenges for nurses working in the community and primary care, regardless of specialties and geographical location
• Organisations do not always provide the support needed to engage with research
• Peer support is invigorating
• Opportunities to generate ideas, learn about research, methodologies and methods
• Mentorship scheme

Dr. Caroline Dickson is Senior Fellow of the Higher Education Academy, Director of Person-centred Practice – International Community of Practice, a Fellow of Queens Nursing institute Scotland, a Member of the CPcPR and Co-founder of CAKE (click here to find out more)

Ben Bowers is a Wellcome Post-Doctoral Fellow, a Nurse Consultant – Palliative Care, a Research Consultant at the Queen’s Nursing Institute, and Honorary Associate Professor.

31 Castle Terrace Edinburgh EH1 2EL

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If you’re interested in identifying best practices and finding new and better ways to support patient care, scientific study and clinical research need nurses to serve in a variety of roles, including PhDs, DNPs, nurse researchers, and direct-care clinical nurses. In fact, all nursing roles contribute to the research cycle, speakers said during a 2024 ONS Congress ® session about the integration of and collaboration between nursing researcher roles.

“All types of scholarly work are interdependent and interconnected,” Kristen Fessele, PhD, RN, AOCN ® , a nurse scientist at Memorial Sloan Kettering Cancer Center (MSKCC) in New York, NY, said. The process of taking research studies and analyzing data to the point of actual implementation in clinical care is complex and can take years. “It’s too much for one person to do alone, so we need different kinds of training that emphasize our skill sets so we can get all of this to our patients,” Fessele said.

Nursing Roles in Research

Research has a variety of roles for nurses for a reason: Each has a specific purpose. Nurse researchers, usually PhD prepared, focus on the generation and dissemination of knowledge, DNP-prepared nurses emphasize the application of research to clinical practice, and clinical nurses implement the new practices in direct patient care, observe side effects, identify challenges or obstacles, and provide insights and data back to nurse researchers to inform future studies.

Uniting those roles around a clinical topic is essential to solving clinical problems together, Fessele said. “It’s not until we implement the evidence in our different clinical practice, policies, procedures, workflows, clinical settings, and patient groups that we start to improve outcomes.”

That third factor is critical: Nurses are key to helping researchers understand how an innovative approach or technique works for different populations. “Especially as we start to look at scholarly work through a health equity lens, this becomes even more important,” Fessele said. “We need to ask, is it working for everyone? Is every clinician following the practice that we think is the best, and are they evolving as new evidence comes along? We need evidence and we need implementation, or we’re not going to improve the clinical problem.”

Although most research is “very regimented,” Fessele said, it will not change practice or contribute to new standards of care until the findings are implemented in direct care. And that’s where the DNP role comes into play.

The American Association of Colleges of Nursing (AACN)  approved the first DNP program in October 2004. DNP education prepares “nurse leaders at the highest level of nursing practice to improve patient outcomes and translate research into practice,” AACN said.

Cheryl Le Huquet, DNP, MSN, RN, NE-BC, project manager of hospital operations at  UCLA  Health in Los Angeles, CA, and James Simmons, DNP, AG/ACNP, acute care nurse practitioner and founder of Ask the NP and Simmons Medical, were in the first DNP cohort at UCLA. Le Huquet said that she and Simmons have been working on socializing DNPs and PhDs since 2020. 

“This is not a one-and-done situation,” she explained. “Personal relationships are required to build trust and are foundational to the working relationships.”

Why DNPs Should Consider Research

Le Huquet described herself as very process-oriented, so when she was initially finding her place in research, she knew it would be in application. “I don't need to generate more research. I need to apply what’s already out there,” she said.

Simmons’ pathway was similar: He recognized that his area of interest already had established evidence and models, but he wanted to find a new way to apply them. 

“I knew I wanted to implement the science, see with my own eyes if it worked in a community that I care about, and then give that information back to the researchers because that information was missing. So once I figured this out, the check for DNP was pretty easy,” Simmons said.

The  distinction between PhD and DNP roles in research can be vague, and collaboration can be challenging across roles and settings. However, working together can improve the research process, facilitate faster implementation and improvement, and identify additional projects to improve patient care. 

PhDs and DNPs Team Up to Conduct Better Clinical Cancer Research

As DNPs, Le Huquet and Simmons needed to collaborate with PhD researchers to accomplish their goals. In 2020, they convened a meeting of nurses interested in research at UCLA. Simmons said they had a vision that “building a collaborative scholarly PhD–DNP community will advance nursing science and improve patient outcomes.” 

Based on the concept of speed dating, the UCLA program participants come to each meeting prepared to pitch their areas of clinical interest to someone else. Simmons described the meetings as a “DNP–PhD immersive experience” and “where nurse scientists meet practice change.” 

Simmons said the original goal was to start small and use experiential learning to grow the program. However, the community was so excited about the program that it expanded organically. Word spread and the concept grew, and now participants meet virtually once a month, with in-person meetings once per quarter. The program has also evolved to allow participants to share their elevator pitch by video to distribute within or beyond the group for ideas, resources, or other support.

One topic that the group has addressed is the difference between what PhDs and DNPs do. “It was a really lovely opportunity to have some folks understand these career paths—not in a formal but in a really casual environment,” Simmons said. “The value of that has been the different perspectives that people can bring.” He said that many participant connections have led to exciting collaborations, and he is currently creating a website to expand the program and connect PhDs and DNPs around the world to talk about their interests and projects. 

Fessele implemented a similar meeting concept at MSKCC, which is called a “monthly mingle.” She said the meetings bring together the “doctorally prepared and the doctorally curious,” with about 160 people invited to the Interprofessional and Doctorally Educated Allied Scholars (IDEAS) meeting. IDEAS features speakers, networking, and ideas sharing, and Fessele said that the meetings have led nurses to create more formal collaborations around common interests.

Another benefit of research partnerships is potentially shrinking the timeline from analysis to implementation, and Fessele said that she is now prioritizing implementation science through DNP collaborations on the research team. She said that DNPs and other implementation specialists help to test interventions, plan how to launch the results, speed up timelines, and identify direct care obstacles or barriers before launch.

Initial Findings From ONS’s PhD–DNP Think Tank

ONS is leading national work to expand collaboration among nursing research roles. In April 2024, the Society convened a PhD–DNP think tank at ONS Congress that brought together 30 PhD and DNP nurses to discuss collaboration opportunities and obstacles and develop an action plan to leverage both roles. The group is currently analyzing insights from the conversations and plans to publish the findings. 

According to the participants, barriers to collaboration between PhDs and DNPs include funding, role confusion, lack of organizational support and infrastructure, time limitations, and competition for positions. The benefits, participants said, include improved patient outcomes, efficiencies, more pragmatic and clinically relevant studies, promotion of the profession, faster translation of research to practice, and more diverse skill sets. 

Do You Want to Get Involved in Nursing Research?

ONS develops research priorities designed to advance patient care, scientific inquiry, clinical applications, and the field of oncology nursing (see sidebar). They can serve as a starting point for nurses interested in developing research projects.

However, some aspects of nursing research apply to all roles. In fact, getting involved in nursing research doesn’t necessarily mean obtaining an advanced degree. “All nurses participate in evidence-based practice (EBP),” Le Huquet said. “By documenting their care in the electronic health record, each nurse is contributing to the data collection required as a baseline for EBP projects or as data for a nursing study.”

For those interested in becoming more involved in nursing research, Le Huquet provided these tips:

• Learn how to collect and present data.
• Read the literature and understand the methods and analysis, not just the results.
• Understand your organization’s goals so you can move your system forward.
• Work with a leader (often a DNP) to build the business case to support the change in your institution. 
• Build relationships with PhD- and DNP-prepared nurses. “This is an underrecognized skill in nursing but essential in the business world,” she said. “Health care is a business.”

Simmons added, “Find your passion! Nurses can leave a lasting legacy on the healthcare issues they care most about through a focus on generating new knowledge or on using the principles of implementation science to apply best practices from the literature. 

“Imagine doing what you love every single day—while changing the world? It’s entirely possible in nursing science!”

• Oncology Nursing Roles

The impact of covid-19 on the regulation of nursing practice and education

Research output : Contribution to journal › Article › peer-review

ASJC Scopus Subject Areas

• Research and Theory
• Leadership and Management
• Fundamentals and skills
• Nursing Education
• Nursing Law
• Nursing Regulation

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• 10.1016/j.teln.2022.01.004

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T1 - The impact of covid-19 on the regulation of nursing practice and education

AU - Smith, Sherrill J.

AU - Farra, Sharon L.

N1 - Publisher Copyright: © 2022 Organization for Associate Degree Nursing

PY - 2022/7

Y1 - 2022/7

KW - COVID-19

KW - Nursing Education

KW - Nursing Law

KW - Nursing Regulation

KW - Pandemic

UR - http://www.scopus.com/inward/record.url?scp=85125118466&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85125118466&partnerID=8YFLogxK

U2 - 10.1016/j.teln.2022.01.004

DO - 10.1016/j.teln.2022.01.004

M3 - Article

AN - SCOPUS:85125118466

SN - 1557-3087

JO - Teaching and Learning in Nursing

JF - Teaching and Learning in Nursing

• Open access
• Published: 07 August 2024

The present situation of the nursing practice environment and its influence on nursing quality in a post-epidemic era: a cross-sectional study

• Xiaotong Liu 1 , 2 ,
• Yabin Guo 1 , 2 ,
• Yang Zhou 2 &
• Yang Zhou 1 , 2  

BMC Nursing volume  23 , Article number:  543 ( 2024 ) Cite this article

11 Accesses

Metrics details

Nursing Practice Environment is an important index to improve nursing quality and patient outcome. To explore the nursing practice environment in the COVID-19 ward during the period of COVID-19 and its impact on nursing quality to provide reference for setting up supporting nursing team in epidemic area in the future.

A cross-sectional survey was conducted among 251 nurses working in COVID-19 ward in Shanghai, Hainan and Hunan in December 2022 through stratified proportional sampling. Structured questionnaires, including general information questionnaire, professional practice environment scale and nursing quality questionnaire, were used to investigate the patients. Pearson correlation was used to analyze the correlation between nursing practice environment and nursing quality, and multiple linear regression analysis was used to analyze the influencing factors of nursing quality in the COVID-19 ward.

The professional practice environment scale score was (3.34 ± 0.40), the nursing quality questionnaire score was (9.47 ± 0.81), both at a high level. Single factor analysis showed that nursing quality was related to educational background, physical condition, professional title, grade of the original hospital and composition of nursing staff in supported departments. Nursing quality were positively correlated with each nursing practice environment dimensions (in addition to teamwork). The results of regression analysis showed that the nursing practice environment in the COVID-19 ward had a positive impact on nursing quality.

Conclusions

The nursing practice environment and nursing quality of nurses in the COVID-19ward is generally very high. The education, working hospital level and nursing practice environment of nurses are the important factors influencing nursing quality. The relationship between nursing practice environment (include leadership and autonomy in clinical practice, staff relationships with physicians, control over practice, communication about patients, handling disagreement and conflict, internal work motivation and cultural sensitivity) and nursing quality is positive. It is suggested that the hospital should pay special attention to and improve nursing practice environment in order to improve nursing quality when setting up temporary ward in the future epidemic period of infectious diseases, ensure patient safety.

Impact on clinical practice

Research shows that an active nursing practice environment can improve the quality of care, and nursing managers create and maintain an active practice environment to improve the quality of care and ensure patient safety.

Peer Review reports

Introduction

The professional practice environment is defined as the organizational characteristics of a nursing practice environment that promotes or restricts professional nursing practice [ 1 ]. A positive professional practice environment can make nurses put into professional practice, enhance communication and cooperation between doctors and nurses, and promote healthy patient outcomes [ 2 ]. At the same time, a good environment of professional nursing practice also helps to reduce burnout, improve nurses’ job satisfaction, and improve the quality of patient care [ 3 , 4 ]. On the contrary, a poor practice environment for nurses will make nurses dissatisfied with their profession, fatigue, burnout and intention to leave in nurses working, resulting in reduced anticipation of and sensitivity to potential dangers and increased more missed nursing care events, affecting patient safety [ 5 , 6 , 7 , 8 ]. The study found that the working environment of nurses was directly related to nurse satisfaction and patient safety [ 6 , 9 ]. Hence, creating a safe and loving practice environment for nurses can help nurses become more motivated and reduce existing concerns about the quality of care.

The emergence of the human coronavirus SARS-CoV-2 strain plunged the world into a new infectious disease pandemic in 2019. As the first country to detect COVID-19, China has effectively controlled the epidemic in 2020 and implemented normalize management of the epidemic. It has entered the post-epidemic period, which is characterized by frequent outbreaks of small intensity [ 10 , 11 ]. In the post-epidemic era, hospitals should not only continue to undertake routine diagnosis and treatment, but also have to be in a state of readiness to combat outbreak of COVID-19. By the end of the 2021, our nurses had reached 5.018 million, according to the National Health Commission of the People’s Republic of China [ 12 ]. When the epidemic breaks out, the Chinese government will organize nurses from all over the country to support local hospitals, and patients will be arranged in specialized COVID-19 ward. The deterioration of the working environment as a result of the COVID-19 (e.g. increased risk of infection, increased psychological burden, physical discomfort caused by prolonged wearing of protective gear, etc.) and the critical condition of patients lead to the excessive work pressure of nurses, making them more likely to develop negative emotions such as fatigue, insomnia and psychological stress, affect the quality of care and patient safety [ 13 , 14 ]. Good professional nursing practice environment can help reduce burnout, improve nurse job satisfaction, improve patient care quality [ 3 , 4 ]. Therefore, it is necessary to provide high-quality care supported by experience and research, strengthening of basic nursing measures, and overall enhancement of nursing services in the COVID-19 Ward, reduce the length of hospital stay and reduce the morbidity and mortality of COVID-19 pneumonia.

However, as we known researchers did not study how the nursing practice environment in the COVID-19 ward of designated hospitals in China had concrete impact on the quality of care. Chen et al. [ 15 ] noting the changes in the nursing environment brought about by COVID-19 and nurses’ views, but this study is not a quantitative survey on the effect of nursing practice environment on nursing quality. The purpose of this study is to describe the nursing practice environment of nurses in the novel coronavirus ward, improve the current situation of the nursing practice environment in the novel coronavirus ward, so as to promote the improvement of nursing quality, better play the important role of nurses in the COVID-19 ward, and provide reference for the occurrence of similar major infectious diseases in the future.

Study design

This study followed the STROBE guidelines for cross-sectional study. This cross-sectional survey in which nurses were invited to fill out a COVID-19 ward care quality questionnaire through a questionnaire website. ( https://www.wjx.cn/ )

Participants and sample size

This study selected hospitals in Hainan Province, Hunan Province and Shanghai City, three regions with severe epidemics in the country (one hospital in each region), the total number of anti-epidemic nurse in the three hospitals was 534. After obtaining the informed consent of the hospital and participants, a proportionate stratified sampling technique was conducted according to the strata of different departments on nurses on the COVID-19 ward from December 21 to 27, 2022. A complete list of qualified nurses (for sampling purposes) was first provided by the nursing department to determine the proportion of nurses to be drawn from each hospital. Subsequently, the number of nurses drawn from each department was then determined by the ratio of the number of nurses in each hospital department to the total number of nurses in the hospital. Inclusion criteria include; (1) Nurses holding nursing certificate; (2) Now or ever worked in the COVID-19 ward, with working hours ≥ 4 h per day for at least two weeks; (3) Participants gave informed consent and were able to cooperate with the study. The nurses who quit after filling in the form of informed consent were excluded.

The Cochran formula for estimating sample size was used, where t = 1.96, p  = 0.5,d = 0.05. The formula is as follows;

The sample size was calculated by the Cochran formula to be 223, considering a 10% non-response rate, and finally the required sample size was calculated to be at least 245 cases.

Measurement tool

This research questionnaire consists of three parts: general information questionnaire, Professional Practice Environment scale(Professional Practice Environment scale, PPE)and the nursing quality questionnaire.

General information questionnaire

The questionnaire was constructed by consulting domestic and foreign literatures and clinical experience, collected the gender, age, marital status, physical status, education, work experience (years), professional titles and positions, composition of nursing staff in supported departments, whether the nurse has intensive-care unit working experience, grade of the original hospital.

Professional Practice Environment scale(PPE)

Professional Practice Environment scale is used to measure the current situation of nursing practice environment, Constructed in 2004 by Erickson, Duffy, Mary et al [ 1 ]. A total of 38 items were used to measure occupational practice environment characteristics. The scale consists of eight dimensions, including leadership and autonomy in clinical practice(5 items), staff relationships with physicians (2 items), control over practice (7 items), communication about patients (2 items), teamwork (4 items), handling disagreement and conflict (8 items), internal work motivation (7 items) and cultural sensitivity (3 items). Each item is divided into 4 options, from 1 point “strongly disagree” to 4 “strongly agree”. The average score range of each dimension and its items is 1 to 4. The higher the score, the better the professional practice environment. PPE scale has been used in various studies and proved to have good reliability and validity. This research adopts the Wang Xia [ 16 ]. The Cronbach’α coefficient of the revised scale was 0.89 after cultural adjustment. Previous Study [ 17 ] have utilized a critical value of 3.0 to describe the work environment for nurses in China, which accurately assessed working environment of nurses. Therefore, this study selected a 3.0 dimensions score to describe the status of nursing perceptions of the professional practice environment.

The nursing quality questionnaire

The nursing quality questionnaire was developed based on the nursing sensitivity index system of respiratory medicine department, which was established by Cui Jin-rui et al [ 18 ]. The total Cronbach α coefficient was 0.884. This is a self-assessment questionnaire, categorized into seven distinct dimensions(55 items): ward management(8 items), nursing risk assessment and implementation(5 items), nursing practice(12 items), nursing operation technique(13 items), important examination and test indicators(7 items), health education(5 items) and doctor-nurse-patient cooperation(5 items). Each dimension score is the average of the sum of the scores of all entries within that dimension, each dimension ranged from 0 to 10. The total scale score is the average of 55 items. The higher the score, the better of nursing quality.

Data collection

The project leader provided uniform and standardized training to nursing administrators in three hospitals before the start of this study, instructing them to clarify the exclusion criteria and important considerations before distributing the questionnaires. The survey questionnaires were distributed by the nursing administrators of each hospital to the nurses online. Participants were invited to complete the COVID-19 Quality of Ward Care Questionnaire online via a questionnaire website. ( https://www.wjx.cn/ ). Once the data collection was completed, the researcher exported and organized the data collected from the online questionnaire into Excel tables. After deleting the invalid data, the organized data from these Excel tables were imported into SPSS for analysis.

Data analysis

SPSS version 26.0 software was used to analyze the data. The measurement data were expressed as mean and standard deviation, and the counting data were expressed as frequency and percentage. T-test, analysis of variance, Pearson correlation analysis, and multivariate Regression analysis nursing quality were used to analyze the influencing factors, and the differences were statistically significant with P  < 0.05.

Quality control and ethical considerations

This study was reviewed and approved by the Ethics Committee of Xiangya Hospital, Central South University(No.202211250), and it strictly adheres to the ethical guidelines as outlined in the Declaration of Helsinki. Firstly, We invited the nursing managers ( n  = 10) of the COVID-19 ward to work together to develop the quality of care questionnaire, after three rounds of meetings to discuss the questionnaire to determine the entries, the questionnaire was filled out by 15 nurses on line prior to the formal survey, and after filling out the questionnaire, a one-on-one interview was conducted, and 15 nurses agreed that the questionnaire was clearly expressed, free of ambiguity, and easy to understand, and the questionnaire was finally finalized to ensure the usability of the questionnaire. The questionnaires were only to be filled out after the participants had fully understood the study and provided their consent, either orally or in writing. After obtaining participants consent to distribute the online questionnaire, an informed consent form was set up on the first page of the questionnaire, and if the participant chose “No”, the survey was automatically closed. Participants was clearly communicated that they had the right to withdraw from the study at any time, without facing any repercussions. All the collected information is encrypted on questionnaire website, The researcher logged into after obtaining an account and password through the authorization of the project leader to view the questionnaire collection.

Participant characteristics

A total of 252 questionnaires were collected. After excluding those with missing data, a total of 251 questionnaires were included in the calculation, with an effective recovery rate of 99.6%. The average age of the participants was (32.97 ± 6.61). There were 222 female participants. 77.7% of the nurses had more than 6 years working experience. In terms of education, 72.1% of the nurses had a bachelor’s degree, and 80.5% of the COVID-19 ward were composed of supported nurses from several hospitals. A univariate analysis showed that, there were significant differences in nursing quality among nurses with different educational background, physical condition, professional title, grade of the original hospital and composition of nursing staff in supported departments. ( p  < 0.05) (Table  1 ).

Components of nursing quality questionnaire

The average score of nursing quality questionnaire of nurses in the COVID-19 ward was (9.47 ± 0.81), and the scores of all dimensions in descending order were as follows: nursing operation technique (9.65 ± 0.77), ward management (9.58 ± 0.79), nursing practice (9.50 ± 0.91), important examination and test indicators (9.47 ± 0.98), nursing risk assessment and implementation (9.46 ± 0.99), health education (9.39 ± 1.09), doctor-nurse-patient cooperation (9.26 ± 1.12).

Components of professional practice environment scale

Table  2 shows the mean and standard deviation of the total PPE scale scores and dimensions for all participants. As shown in Table  2 , the average score of PPE scale for nurses in the COVID-19 ward was (3.34 ± 0.40), nurses generally believed that the working environment was good.

Correlation analysis between the nursing quality dimensions of nurses in COVID-19 ward and nursing practice environment

Table  3 showed the results of Pearson correlation analysis, the total mean score of professional practice environment was positively correlated with the total mean score of nursing quality ( r  = 0.46, p  < 0.01). The seven dimensions of the professional practice environment(leadership and autonomy in clinical practice、staff relationships with physicians、control over practice、communication about patients、handling disagreement and conflict、internal work motivation and cultural sensitivity)was a positive correlation between the score and nursing quality ( p  < 0.01).Moreover, the results showed teamwork ( r  = 0.12, p  = 0.06) has no significant correlation.

Results of multiple linear regression of nursing quality in COVID-19 wards

Multiple linear regression was used to explore the influence of different population characteristics and nursing practice environment on nursing quality. The assignment table is shown in Table  4 . As shown in Table  5 , multiple linear regression showed that grade of the original hospital ( β  = 0.128, p  = 0.021), education ( β =-0.179, p  = 0.001) and professional practice environment( β  = 0.458, p <0.001) were influencing factors of nursing quality, explained 25.8% of the variance in nursing quality scores.

The purpose of this study was to explore the present situation of nursing practice environment and its influence on nursing quality. The results of the study showed that the nursing practice environment in the COVID-19 ward was good, and the nursing practice environment had an impact on the nursing quality, specifically as follows:

The status of nursing practice environment in COVID-19 ward

The results of this study showed that the average PPE score was (3.34 ± 0.40). Among them, the dimension of staff relationships with physicians had the highest score (3.53 ± 0.53), it shows that the medical cooperation in the COVID-19 ward is close and the harmonious relationship has been established. However, the teamwork dimension has the lowest average score(3.01 ± 0.68),and “This ward can not get the cooperation it needs from other wards” and “The lack of close cooperation with other departments of the hospital limits the effective development of work in this ward” had low scores, indicated the bad cooperation between the nurses in the ward. Good doctor-nurse relations but low scores for teamwork are consistent with a work environment for retired nurses in China [ 19 ]. In addition handling disagreement and conflict dimension score is also low, At the same time, “Everyone ignores or avoids disagreement between members” is the lowest, This indicates that the cooperation between nurses and the communication between nurses and other wards needs to be strengthened. On the one hand, faced with the risk of cross-infection during a pandemic, the COVID-19 ward is under closed management, there is a lack of effective communication between departments. Previous studies also have pointed out that physical barriers (i.e., personal protective equipment) and spatial barriers (i.e., social distance) implemented during the pandemic disrupted workflow and communication and affected teamwork [ 20 , 21 ]. On the other hand, a study pointed out that health care workers in COVID-19 critical care were more likely to frequently work with each other than those in non–COVID-19 critical care [ 22 ]. 85.2% of the nurses ( n  = 92/108) in the ICU ward came from different hospitals in our study. Due to the different age, geography, and cultural level of nurses in each area, as well as the difficulty of establishing effective teamwork in a short period of time in a temporarily formed team, which leads to unsuccessful teamwork. Effective teamwork is facilitated by timely, frequent, accurate, problem-solving communication based on shared knowledge, common goals, and mutual respect [ 23 ]. Therefore, nursing managers should pay attention to the relationship between doctors and nurses, encourage the exchange of important clinical information between nurses and doctors, and strengthen the cohesion and teamwork of the whole team.

At the same time, we found that the internal work motivation dimension scores were at the top. Moreover, “I feel a high degree of personal responsibility for the work I do.” and “My discipline controls its own practice” also rank at the top, it indicated that the nurses thought that the working conditions of the COVID-19ward were better and the nurses had a high sense of responsibility, which made the nurses mobilize their own enthusiasm. Research shows that individual factors (e.g., emotional intelligence, self-reflectiveness, confidence, communication style), attitudinal factors mediated by the team (e.g., accountability, commitment, values or enthusiasm), and lastly socio-economic factors (e.g., education, culture) were all found to influence individual’s attitudes and behaveours vis-à-vis colleagues, impacting the work environment in which teamwork occurred [ 24 ]. Organizing teamwork training and clarifying team roles can improve team relationships [ 25 ], It is suggested that the manager should carry out team cooperation according to the situation of the ward, and make clear the nursing responsibility of each nurse, attach importance to the opinion of each nurse, and jointly create a harmonious and mutual help working environment.

The status of nursing quality in COVID-19 ward

According to the results of this study, the nursing quality of Chinese nurses during the COVID-19 period was relatively high, and the average score of nurses in the COVID-19 ward was (9.47 ± 0.81).Based on previous research [ 26 ], we believe that is related to higher standards, stringent ward environment in the COVID-19 ward and to the increased professional competence of nurses.

Nurse characteristics have relationship between high nursing quality and patient results [ 27 ]. A total of 88.4% female nurses participated in the study, 60.6% were between 26 and 35 years old, and 31.1% had worked for 6 to 10 years. The results showed that the front-line nurses were all experienced nurses, which enabled them to provide quality care. In addition, a shocking the nursing quality scores for associate degrees or below are higher than those for bachelor’s, which may be because of the It may have to do with the fact that highly educated nurses demand more from their own development. The more educated nurses are, the more demand for your own development, thus scoring lower on the self-assessed quality of care scores.

We showed that the highest score dimension was nursing operation technique (9.65 ± 0.77), which indicated that all nurses performed the operation according to the ward standard. And the dimension with the worst score is “doctor-nurse-patient cooperation” and “health education”. This may be due to the busy clinical work of nurses, long working hours, heavy tasks of epidemic prevention leading to insufficient attention and assessment to patients. Moreover, nurses may reduce direct contact with patients and doctors at work due to fear of infection, thus resulting in poor health education for patients and communication with doctors Meanwhile, patients felt anxious and reluctance to communicate with medical and nursing staff due to the disease. Therefore, hospitals should strengthen the knowledge related to 2019 coronavirus disease pneumonia training so that nurses can receive timely, accurate, precise and comprehensive education on health knowledge and disease assessment, and relieve patients’ tension and anxiety through humanistic care and health education so that they can actively cooperate with treatment and care.

Nursing quality on COVID-19 wards is influenced by multiple factors

The regression analysis showed that the nursing quality was influenced by the degree of education and the rank of Nursing Hospital, which is consistent with the study by Fitzpatrick et al [ 28 ]. This may be related to the fact that highly educated nurses have a more systematic knowledge of nursing and are more likely to work in higher-level hospitals, and that examinations are more frequent in level 3 hospitals than in level 2 and lower hospitals. In China, hospitals are classified into three levels from small to large based on their scale (staffing, hardware facilities, research capabilities, etc.) [ 29 , 30 ]. Among them, the third-level hospitals are representative of the large comprehensive hospitals in our country, often possessing more advanced large medical equipment and medical technology, and are responsible for important tasks such as the treatment of critical illnesses and specialized diagnosis and treatment [ 29 ]. Nursing quality is an important indicator for evaluating the level of hospitals, so nurses in higher level hospitals tertiary hospitals tend to face high level of work requirements, which poses a higher challenge to the nurses’ own competence. Previous studies [ 31 , 32 ] have shown that nurses in tertiary hospitals have stronger professional competencies such as information competency and emergency management competency than nurses in secondary and lower hospitals. This shows that it is necessary for nursing managers to focus on the cultivation of nursing professional skills, particularly for nurses at the secondary level and below hospital, which is ensures the quality and efficiency of nursing services. The results of this study show that education was a negative variable of nursing quality. This may be due to the fact that healthcare workers with higher academic qualifications may have a heavier workload, not only needing to complete clinical frontline medical and nursing care, but also different roles such as teaching, scientific research, management, and so on, which gives them a higher sense of responsibility for their patients, resulting in a greater work pressure [ 33 ], and thus impacting on the quality of their care. In addition, the number of nurses with Master degree or above in this study was only 11 (4.4%), so it is necessary to continue to expand the sample in the follow-up study for further in-depth analysis.

Numerous studies have demonstrated that a better professional nursing practice environment can lead to higher nursing quality [ 34 , 35 , 36 ]. The results of correlation analysis showed that the nursing practice environment all other dimensions except teamwork, were positive related to nursing quality. We hypothesized that it may be due to the particularity of the setting of the COVID-19 ward. The better the nursing practice environment was, the higher level of nursing quality in the COVID-19 ward was. Zelauskas et al [ 37 ]showed that environment of professional nursing practice means that the nurse in nursing service, through authorized managers have more autonomy, and responsibility to work environment. A study of 69 hospitals in 217 Chinese provinces found that the longer nurses worked in COVID-19 ward, the worse the quality of care [ 38 ]. At the same time, Cheng et al [ 15 ] showed that COVID-19 had brought positive changes to the nursing practice environment. For example, nurses have a greater say in the organization and work more closely with doctors. However, there are also some problems, such as the difficulty of ward management and increased occupational risks, and the safety and comfort of the ward environment need to be improved. Therefore, it is suggested that managers should arrange shift patterns scientifically, optimize and rationally allocate personnel, provide adequate rest time, and reduce the workload of nurses, ward managers need to develop simple and standard management patterns, establish good ward facilities and rest environment.

This study has some limitations. First of all, this study aimed at the cross-sectional investigation in the post-epidemic period, is a specific environment. It is not applicable after the COVID-19 pandemic, provides reference for similar outbreaks of infectious diseases in the future. Second, the data in this study were the result of nurses’ self-report, so there may be bias. However, this study can provide a reference for nursing managers to improve the quality of nursing care from the perspective of improving the working environment during the outbreak of infectious diseases.

Our study participants were nurses in the COVID-19 ward of designated hospitals, our evidence and recommendations will contribute to improved care practices.

The results showed that the working environment of the nurses in the COVID-19.

ward was good, and the nursing practice environment was much improved compared with the previous studies, especially the leadership ability, autonomy and cultural sensitivity in the clinical practice. However, team cooperation is not good enough. COVID-19 wards require multidisciplinary teamwork, so we should focus on training nurses’ team cooperation ability to promote the friendly development of the ward. In addition, nurses’ clinical practice ability affects nursing outcomes. Among the seven dimensions of nursing quality, doctor-nurse-patient cooperation scored the lowest, which also indicates that doctor-nurse-patient communication needs to be improved. The quality of nursing is influenced by grade of original hospital, nursing education and nursing practice environment. Therefore, sending excellent nurses and training local nurses, promoting good cooperation between medical and nursing staff, and improving the working environment of nurses can effectively improve the quality of care.

Even though we are a temporary team, the nursing practice environment and nursing quality of nurses in the COVID-19 ward are still at a high level in the post-epidemic period, the level of nursing quality was different with different characteristics (grade of the original hospital, education). In addition, the nurse practice environment has proven to have a positive impact on the quality of care. PPE scale score (include leadership and autonomy in clinical practice、staff relationships with physicians、control over practice、communication about patients、handling disagreement and conflict、internal work motivation and cultural sensitivity)was correlated with nursing quality score. In order to improve nursing quality, it is suggested that nursing managers should adopt supportive management, arrange human resources reasonably, authorize appropriately, cooperate with each other to create a good working environment, to enable nurses to have a better working state to deal with ward nursing matters, thus improving the quality of clinical care.

Data availability

The data generated in this study can be obtained from the corresponding author through reasonable demand.

Erickson JI, Duffy ME, Gibbons MP, Fitzmaurice J, Ditomassi M, Jones D. Development and psychometric evaluation of the Professional Practice Environment (PPE) Scale. J Nurs Scholarsh. 2004;36(3):279–85. https://doi.org/10.1111/j.1547-5069.2004.04050.x .

Article   PubMed   Google Scholar  

Spence Laschinger HK, Zhu J, Read E. New nurses’ perceptions of professional practice behaviours, quality of care, job satisfaction and career retention. J Nurs Adm Manag. 2016;24(5):656–65. https://doi.org/10.1111/jonm.12370 .

Article   Google Scholar  

Boamah SA, Read EA, Laschinger HKS. Factors influencing new graduate nurse burnout development, job satisfaction and patient care quality: a time-lagged study. J Adv Nurs. 2017;73(5):1182–95. https://doi.org/10.1111/jan.13215 .

Porter-O’Grady T, Weston MJ, Clavelle JT, Meek P. The value of nursing Professional Governance: researching the Professional Practice Environment. JONA: J Nurs Adm. 2022;52(5):249–50. https://doi.org/10.1097/nna.0000000000001141 .

Rivaz M, Tavakolinia M, Momennasab M. Nursing professional practice environment and its relationship with nursing outcomes in intensive care units: a test of the structural equation model. Scand J Caring Sci. 2021;35(2):609–15. https://doi.org/10.1111/scs.12877 .

Ribeiro O, Trindade LD, Fassarella CS, Pereira SCD, Teles P, da Rocha CG, et al. Impact of COVID-19 on professional nursing practice environments and patient safety culture. J Nurs Adm Manag. 2022;30(5):1105–14. https://doi.org/10.1111/jonm.13617 .

Zeleníková R, Jarošová D, Plevová I, Janíková E. Nurses’ perceptions of Professional Practice Environment and its relation to missed nursing care and nurse satisfaction. Int J Environ Res Public Health. 2020;17(11):3805.

Article   PubMed   PubMed Central   Google Scholar  

Xie T, He W, Jiu Z, Li Q, Huang C, Liu J, et al. Overwork among ICU nurses: identification of risk factors. JONA: J Nurs Adm. 2023;53(5):271–6. https://doi.org/10.1097/nna.0000000000001282 .

Zelenikova R, Jarosova D, Plevova I, Janikova E. Nurses’ Perceptions of Professional Practice Environment and Its Relation to Missed Nursing Care and Nurse Satisfaction. Int J Environ Res Public Health. 2020;17(11). https://doi.org/10.3390/ijerph17113805 .

Zhou T, Xu C, Wang C, Sha S, Wang Z, Zhou Y, et al. Burnout and well-being of healthcare workers in the post-pandemic period of COVID-19: a perspective from the job demands-resources model. BMC Health Serv Res. 2022;22(1):284. https://doi.org/10.1186/s12913-022-07608-z .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Li L, Yu P, Liu Z. The dynamic evolution mechanism of public health risk perception and the choice of policy tools in the post-epidemic era: evidence from China. Int J Disaster Risk Reduct. 2022;77:103056. https://doi.org/10.1016/j.ijdrr.2022.103056 .

China NHCPR. Transcript of the 11 May 2022 press conference by the NHSRC. http://www.nhc.gov.cn/xcs/s3574/202205/521fc41948544e00a9ffe886eaac1496.shtml Accessed.

Turale S, Meechamnan C, Kunaviktikul W. Challenging times: ethics, nursing and the COVID-19 pandemic. Int Nurs Rev. 2020;67(2):164–7. https://doi.org/10.1111/inr.12598 .

Lee H, Choi S. Factors affecting fatigue among nurses during the COVID-19 pandemic. Int J Environ Res Public Health. 2022;19(18):11380.

Jingxia C, Longling Z, Qiantao Z, Weixue P, Xiaolian J. The changes in the nursing practice environment brought by COVID-19 and improvement recommendations from the nurses’ perspective: a cross-sectional study. BMC Health Serv Res. 2022;22(1):754. https://doi.org/10.1186/s12913-022-08135-7 .

WANG X. The Study of Correlation between Nurses’Burnout and Nurses’Professional aPractice Environment in changsha. Central South University; 2006.

Cao Y, DiGiacomo M, Salamonson Y, Li Y, Huai B, Davidson PM. Nurses’ perceptions of their professional practice environment: a cross-sectional study. J Clin Nurs. 2015;24(23–24):3441–8. https://doi.org/10.1111/jocn.12953 .

Jinrui C, Ying C, Rong X, Su-qin X. Development of a nursing-sensitive quality indicator system in respiratory medicine departmerlt. Chin J Nurs. 2016;51(11):1285–91.

Google Scholar  

Liu P-C, Zhang H-H, Zhang M-L, Ying J, Shi Y, Wang S-Q, et al. Retirement planning and work-related variables in Chinese older nurses: a cross-sectional study. J Nurs Adm Manag. 2018;26(2):180–91. https://doi.org/10.1111/jonm.12532 .

Hayirli TC, Stark N, Bhanja A, Hardy J, Peabody CR, Kerrissey MJ. Masked and distanced: a qualitative study of how personal protective equipment and distancing affect teamwork in emergency care. Int J Qual Health Care. 2021;33(2). https://doi.org/10.1093/intqhc/mzab069 .

Terwilliger IA, Manojlovich M, Johnson JK, Williams MV, O’Leary KJ. Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study. BMC Health Serv Res. 2022;22(1):1379. https://doi.org/10.1186/s12913-022-08795-5 .

Yan C, Zhang X, Gao C, Wilfong E, Casey J, France D, et al. Collaboration structures in COVID-19 critical care: Retrospective Network Analysis Study. JMIR Hum Factors. 2021;8(1):e25724. https://doi.org/10.2196/25724 .

Mahboube L, Talebi E, Porouhan P, Orak RJ, Farahani MA. Comparing the attitude of doctors and nurses toward factor of collaborative relationships. J Family Med Prim Care. 2019;8(10):3263–7. https://doi.org/10.4103/jfmpc.jfmpc_596_19 .

Schilling S, Armaou M, Morrison Z, Carding P, Bricknell M, Connelly V. Understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: a systematic review of reviews. PLoS ONE. 2022;17(8):e0272942. https://doi.org/10.1371/journal.pone.0272942 .

Rehder KJ, Adair KC, Eckert E, Lang RW, Frankel AS, Proulx J, et al. Teamwork before and during COVID-19: the Good, the same, and the Ugly horizontal ellipsis. J Patient Saf. 2023;19(1):36–41. https://doi.org/10.1097/pts.0000000000001070 .

Zhang X, Sheng Q, Wang X, Cai C. The experience of frontline nurses four months after COVID-19 rescue task in China: a qualitative study. Arch Psychiatr Nurs. 2021;35(4):358–63. https://doi.org/10.1016/j.apnu.2021.05.007 .

Bock L. Nurse characteristics and the effects on Quality. Nurs Clin North Am. 2020;55(1):97–. https://doi.org/10.1016/j.cnur.2019.10.007 .

Fitzpatrick JM, While AE, Roberts JD. Key influences on the professional socialisation and practice of students undertaking different preregistration nurse education programmes in the United Kingdom. Int J Nurs Stud. 1996;33(5):506–18. https://doi.org/10.1016/0020-7489(96)00003-X .

Article   CAS   PubMed   Google Scholar  

Shen Y, Jian W, Zhu Q, Li W, Shang W, Yao L. Nurse staffing in large general hospitals in China: an observational study. Hum Resour Health. 2020;18(1):3. https://doi.org/10.1186/s12960-020-0446-5 .

China NHCPR: Interpretation of the Accreditation Standards for Tertiary Hospitals (, Rules. http://www.nhc.gov.cn/yzygj/s3585/202212/e3e6f4819a094ab5835b7fe1315c7733.shtml Accessed 13 May 2024.

Di Z, Shan D, Juqing K, Ping H, Yan C, Lin Y, et al. Current Situation and influencing factors of emergency nurses’ DisasterNursing ability in Jiangsu Province. Chin Health Qual Manage. 2023;30(09):50–3. https://doi.org/10.13912/j.cnki.chqm.2023.30.9.11 .

Guo J, Liu J, Liu C, Wang Y, Xu X, Chen Y. Nursing informatics competency and its associated factors among palliative care nurses: an online survey in mainland China. BMC Nurs. 2024;23(1):157. https://doi.org/10.1186/s12912-024-01803-5 .

Zhan Yf, Ma S, Jian Xd C, Yj, Zhan Xq. The current Situation and influencing factors of job stress among Frontline nurses assisting in Wuhan in fighting COVID-19. Front Public Health. 2020;8. https://doi.org/10.3389/fpubh.2020.579866 .

Kim-Godwin YS, Lee MH, Logan JG, Liu X. Factors influencing Sleep Quality among female staff nurses during the early COVID-19 pandemic in the United States. Int J Environ Res Public Health. 2021;18(9). https://doi.org/10.3390/ijerph18094827 .

Labrague LJ, de los Santos JAA, Fronda DC. Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic. J Nurs Adm Manag. 2022;30(1):62–70. https://doi.org/10.1111/jonm.13483 .

Gumussoy S, Kiratli D. Burnout status, occupational satisfaction, and intention to leave the profession of nurses during the COVID-19 pandemic period; the case of Turkey. Health Care for Women International. https://doi.org/10.1080/07399332.2022.2134392

Zelauskas B, Howes DG. The effects of implementing a professional practice model. J Nurs Adm. 1992;22(7–8):18–23. https://doi.org/10.1097/00005110-199207000-00006 .

Liu S, Wang C, Jiang Y, Ren H, Yu T, Cun W, et al. Nurse scheduling in COVID-19-designated hospitals in China: a nationwide cross-sectional survey. J Nurs Adm Manag. 2022;30(8):4024–33. https://doi.org/10.1111/jonm.13832 .

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Acknowledgements

We would like to sincerely thank all nurses who participated in this study.

This work was supported by the key R&D projects of the Science and Technology Department of Hunan Province(2024JK2133) and the Teaching Reform Project for Ordinary Higher Education Institutions in Hunan Province (2023JGB043).

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Z.Y.*: Conceptualization and design. LXT: Writing-Original draft preparation. GYB&ZY: Investigation, Methodology. All authors read and approved the final manuscript.

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Liu, X., Guo, Y., Zhou, Y. et al. The present situation of the nursing practice environment and its influence on nursing quality in a post-epidemic era: a cross-sectional study. BMC Nurs 23 , 543 (2024). https://doi.org/10.1186/s12912-024-02202-6

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Nurses’ roles in changing practice through implementing best practices: A systematic review

Wilma ten ham-baloyi.

1 Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa

Associated Data

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Nurses play an important role in the implementation of best practices. However, the role of nurses in changing practice by implementing best practices requires further exploration. No systematic review was found that summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. This study summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. A systematic review was used to search for studies in the English language, where a best practice was implemented in a clinical context and which included findings regarding the roles of nurses when implementing best practices. Scopus, EBSCOhost (Academic Search Ultimate, APA PsycInfo, CINAHL with Full Text, ERIC, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete), PUBMED, and ScienceDirect databases were searched from January 2013 to June 2021. The search generated 1343 citations. After removing duplicates and applying eligibility criteria, 27 studies were included. Five definite roles were identified as follows: leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. These roles are interrelated, but equally crucial in order to implement best practices. This study found five interrelated but equally crucial nurse roles in changing practice through the implementation of best practices.

Contribution

The study’s findings and gaps identified can be used for further nursing research, improving practice change and health outcomes through the implementation of best practices and the role nurses can play in this process.

Introduction

Globally, in the last decades, there have been rapid changes in healthcare and nursing practice, based on the best available evidence, to improve patient, nursing and organisational outcomes whilst, at the same time, using resources efficiently (Cullen & Donahue 2016 ; Salmond & Echevarria 2017 ). A sustained change in practice through the implementation of best practices is required to improve health and patient outcomes such as length and costs of hospital stay (Leviton & Melichar 2016 ).

Research findings based on rigorous methods that have been identified as best evidence and evidence-based products such as evidence-based innovations, interventions, strategies, practice improvements, guidelines, initiatives, programmes or recommendations (in this study referred to as ‘best practices’) assist in changing health and nursing practice (International Council of Nurses 2012 ). However, implementation of best practices remains problematic (Greenhalgh, Howick & Maskrey 2014 ). Innovative ways are required to firstly translate best evidence, which is the application of knowledge (Graham et al. 2018 ) and thereafter implement the best practice. This is especially relevant for a healthcare and nursing environment that is increasingly competitive and has to operate in a cost-effective way (Salmond & Echevarria 2017 ).

Furthermore, there are various stakeholders who influence implementation of best practices or change in practice and these stakeholders are also affected by change in practice (Agency for Healthcare Research and Quality [AHRQ] 2016 ). Thus, there is a strong drive for stakeholders to be actively engaged in and to make committed decisions about changing practice (Norris et al. 2017 ). To do so, the roles of the various stakeholders in changing practice – which includes patients and their families, the nurses and other healthcare practitioners and the managers at micro, meso and macro levels of the health system – need to be understood. Understanding the roles of these stakeholders in changing practice will assist in a more effective and efficient implementation and uptake of innovative best practices and, ultimately, will improve healthcare outcomes (Leviton & Melichar 2016 ).

Nurses, as one of the stakeholders, play an important role in the implementation of best practices. However, the role of nurses in changing practice by implementing best practices is not always well understood (Kristensen, Nymann & Konradsen 2016 ). No systematic review was found that summarised the best available evidence on the roles of nurses in changing practice through the implementation of best practices. This review therefore aimed to summarise the best available evidence on the roles of nurses in changing practice through the implementation of best practices.

A systematic review was conducted to collect data, identify high-quality relevant studies and to synthesise the findings in a rigorous and comprehensive way so that a comprehensive picture of current best available evidence could be provided. In this case, the best available evidence on the roles of nurses in changing practice through the implementation of best practices as a preliminary search did not yield any systematic reviews. The systematic review was conducted according to the Systematic Review guidelines of the Joanna Briggs Institute (JBI). The following review question was formulated: ‘What is/are the role(s) of nurses in changing practice when implementing best practices’?

Search methods

Sources of evidence.

The following databases were searched: Scopus, EBSCOhost (Academic Search Ultimate, APA PsycInfo, CINAHL with Full Text, ERIC, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE Complete), Pubmed and ScienceDirect.

A broad combination of keywords was used to search the literature on the topic. A set of keywords per database was selected to yield the most relevant studies. The following keywords were used: role OR function AND nurse OR nurses OR nursing AND implement* AND best practice OR best practices.

Inclusion criteria and exclusion criteria

Studies of the following levels of evidence, according to JBI ( 2016 ), were included: Level I Experimental studies: (c) randomised controlled trials (RCT), (d) pseudo-RCTs; Level II Quasi-experimental studies: (c) quasi-experimental prospectively controlled study, (d) pre-test, post-test/retrospective control group; Level III Observational Analytical studies: (c) cohort study with control group, (d) case controlled study, (e) observational study without a control group; Level IV Observational Descriptive studies: (b) cross-sectional study, (c) case series, (d) case studies. Only those studies published in English from January 2013 to June 2021 were eligible for selection.

Studies were included where a best practice was implemented in a healthcare or clinical context (inside or outside a hospital setting where nursing care is rendered, e.g. old age setting), published in English, which included findings regarding the roles of nurses when implementing best practices. Systematic types of reviews and non-research studies were excluded as well as studies that were not implementing best practices (e.g. studies where no intervention was implemented or not described, studies regarding the views on the role of nurses implementing best practices in general or general perceived facilitators and barriers).

The entire search strategy, including the choice of keywords and electronic databases was conducted with the assistance of an experienced librarian from the Nelson Mandela University. Similar assistance was provided in obtaining studies, some via Inter-Library Loan services.

Search outcome

For this study, the following steps for selection were followed:

• The researcher read titles and abstracts (whereby irrelevant studies were excluded according to the pre-determined inclusion and/or exclusion criteria).
• Possible relevant literature was selected in order to obtain full-text. The researcher read the full text of potentially relevant studies and selections for inclusion were made according to pre-determined inclusion and/or exclusion criteria.
• When no full text could be obtained to determine inclusion and/or exclusion of an article, Inter-Library Loan services was used and authors were contacted.

EndNote X9 was used for data management, obtaining full-texts and for deduplication. The search and selection process is outlined in Figure 1 .

Search and selection process.

As a result of the literature search, 1343 initial hits were imported from electronic databases. After removing 456 duplicates, 887 titles and abstracts were read. A total of 823 were excluded as they did not meet inclusion criteria. From the remaining titles, total of 59 full-texts were obtained as five articles could not be located. Reading of the 59 articles led to exclusion of a further 29 articles, based on the study criteria.

Critical appraisal

A total of 30 studies fulfilled the review criteria and were included for critical appraisal. Appraisal was done using various tools, according to the different research designs or levels of evidence of the literature, including the various 64 JBI (Pearson, Jordan & Munn 2012 ) tools, including: checklist for analytical cross-sectional studies ( n = 2), checklist for cohort studies ( n = 1), checklist for qualitative research ( n = 7); checklist for quasi-experimental studies ( n = 2) (JBI 2021 ).

The following critical appraisal tools were found most suitable but were not available through JBI: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies (Von Elm et al. 2007 ) ( n = 16), Mixed Methods Appraisal Tool (MMAT) (Hong et al. 2018 ) ( n = 1) and the Effective Practice and Organization of Care Risk of Bias (EPOC RoB) tool for retrospective observational studies such as audits, developed by Cochrane (eds. Higgins et al. 2019 ) ( n = 1).

To reduce bias in review selection and to ensure that the appraisal was performed in a rigorous way, whilst allowing for appropriate consensus, the appraisal was conducted by two reviewers independently using the same critical appraisal tools. The outcome of the critical appraisals was shared amongst the researcher and independent reviewer during a meeting and consensus was achieved in terms of inclusion or exclusion of literature. Out of the total of 30 articles that were included for critical appraisal, three observational studies using audits were excluded because of weak rigour (see Figure 1 ).

Data extraction

Data extraction from the sample was done by recording relevant elements of studies regarding the topic in a tabular format. Headings in the table included: study reference, design, level of evidence, sample and setting, best practice and change strategy and findings relevant to the topic.

Data synthesis

For this review because of the heterogeneous nature of the study designs included thematic analysis, which was done to synthesise the extracted findings of each study, followed by a classification of findings and a summary of findings under thematic headings (as formulated in Academy of Nutrition and Dietetics [ 2012 ]).

Ethical considerations

This study obtained ethical approval from the University’s Faculty Postgraduate Studies Committee (ethics number: H19-HEA-NUR-008). The author adhered to the principles of honesty and transparency in reporting the data. In line with recommendations of Vergnes et al. ( 2010 ), participant consent was not obtained because this study had no participants.

Quality of evidence

The majority of studies ( n = 17) were observational analytical studies: Level III(e) evidence and Level IV evidence ( n = 7, of which n = 4 IV(b) and n = 3 IV(d)). Two other studies ( n = 2) included Level II(d) evidence. One ( n = 1) mixed method study included both Level III(e) and Level IV(b) evidence (JBI 2016 ).

Healthcare or clinical context

Studies were from a variety of healthcare or clinical contexts, with the majority ( n = 20) from a hospital setting. Of these, n = 14 were conducted in specialised hospital-based settings, including: medical and surgical wards ( n = 2) (Siegel 2020 ; Travers et al. 2018 ), paediatric settings ( n = 2) (Rosenberg et al. 2016 ; Yu et al. 2017 ), postnatal ward ( n = 1) (Anderson & Kynoch 2017 ), neonatal intensive care unit ( n = 1) (Ceballos et al. 2013 ), surgical ward ( n = 1) (Hu et al. 2019 ), haemodialysis centre ( n = 1) (Jia et al. 2016 ), haematology–oncology ( n = 1) (Naseer et al. 2017 ), orthopaedic ward ( n = 1) (Ong et al. 2017 ), medical ward ( n = 1) (Ullrich, McCutcheon & Parker 2015 ), intensive care unit ( n = 1) (Chiwaula et al. 2021 ), in-patient rehabilitation ( n = 1) (Mullins 2021 ) and a neurology department (Sheng et al. 2020 ).

A total of five ( n = 5) studies were from outside hospital settings, including long-term care ( n = 2) (Kilpatrick et al. 2020 , Mitchell 2017 ), homecare centres ( n = 1) (Bayly et al. 2018 ), acute ambulatory settings ( n = 1) (Chong et al. 2013 ) and a general practitioner (GP) practice ( n = 1) (Williams et al. 2020 ).

Two ( n = 2) studies were conducted inside and outside hospital settings. One of these studies was conducted in both a residential age-care facility and hospital setting (Ullrich, McCutcheon & Parker 2014 ) and the other study was conducted in a hospital setting (inpatient, acute care medical or surgical, intensive care units) and in a long-term care setting (progressive care/stepdown, community home, long-term care, rehabilitation, palliative/hospice care and spinal cord injury) (Becker et al. 2020 ).

Studies were conducted in a variety of countries, including Australia ( n = 6), United States of America ( n = 6), Canada ( n = 4), China ( n = 4), Singapore ( n = 3), United Kingdom ( n = 2), Malawi ( n = 1) and Thailand ( n = 1).

Best practices and implementation strategies for change

In total, seven ( n = 7) best practices and 11 ( n = 11) implementation strategies for change were identified from the included studies. The best practices included: best practice, intervention, strategy, guideline, initiative, programme and recommendation. The implementation strategies included: educational sessions or workshops, (development of) educational material, champion or knowledge broker, discussions, evaluation and feedback, development of an evidence-based practice (EBP) product, employing team or specialists, meetings, observations, equipment, assessments or examinations. Table 1 outlines the best practice and implementation strategies for change, per included study.

Best practices and implementation strategies for change ( n = 27).

EBP, evidence-based practice.

As outlined in Table 1 , included studies indicated a variety of implemented best practices, with best practice or intervention being mostly identified as best practice. Various implementation strategies for change were used, but most studies used more than one strategy, up to six strategies and had an element of education and leadership.

Roles of nurses

Eleven ( n = 11) of the included studies were nurse-led quality improvement projects, in which a team was formed in the clinical setting with nurses who took the lead and facilitated change through the implementation of the best practice in this setting (Anderson & Kynoch 2017 ; Bayly et al. 2018 ; Ceballos et al. 2013 ; Chong et al. 2013 ; Hu et al. 2019 ; Jia et al. 2016 ; Monkong et al. 2020 ; Naseer et al. 2017 ; Ong et al. 2017 ; Travers et al. 2018 ; Yu et al. 2017 ).

Five definite roles were identified: leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. These roles are further described in the following subsections.

Leadership played a role in almost all studies ( n = 21). This could be individuals, for example, a clinical champion (Allen et al. 2018 ; Becker et al. 2020 ), a (clinical) team leader (Anderson & Kynoch 2017 ; Chong et al. 2013 ), a project leader (Hu et al. 2019 ; Mullins 2021 ; Yu et al. 2017 ) or nurse leader (Ceballos et al. 2013 ), a nurse clinician (Nazeer et al. 2017; Ong et al. 2017 ), a knowledge broker (Bayly et al. 2018 ), a practice facilitator (Shade et al. 2020 ), Facilitator CogChamps (Travers et al. 2018 ), a programme or project coordinator (Fleiszer et al. 2015 , 2016 ; Monkong et al. 2020 ) or an audit team leader (Jia et al. 2016 ). In some studies, the leader was the researcher (Mitchell 2017 ) or part of the research team (Kilpatrick et al. 2020 ; Rosenberg et al. 2016 ; Williams et al. 2019 ).

Roles of leaders included:

• recruitment of participants (Becker et al. 2020 )
• facilitating the implementation of the best practice (Anderson & Kynoch 2017 )
• creating educational material (e.g. a computer-based educational module, completion of a comprehensive literature review to inform the educational intervention) (Ceballos et al. 2013 ; Yu et al. 2017 ).
• communication (e.g. sending staff electronic communication with information about the best practice and why practice changes were necessary [Ceballos et al. 2013 ]; explain roles and responsibilities to every team member in fortnightly meetings [Chong et al. 2013 ]; introduce the project to the members and project timelines [Becker et al. 2020 ; Naseer et al. 2017 ])
• data analysis, interpretation of data and report writing (Ceballos et al. 2013 ; Chong et al. 2013 ; Yu et al. 2017 )
• managing the project, process control and promotion and keeping timelines (Monkong et al. 2020 ; Mullins 2021 ; Yu et al. 2017 )
• role modelling in terms of enthusiasm (Chong et al. 2013 ; Yu et al. 2017 ; Williams et al. 2019 ), commitment (Chong et al. 2013 ; Williams et al. 2019 ), approachability, sound clinical knowledge and legitimacy (Williams et al. 2019 ), ability to communicate clearly, being tenacious (keep on going when some nurses showed disinterest) and being able to think creatively about patients and patient care (Travers et al. 2018 )

Education and training

Education and training were found to play a big role in nurses implementing best practices in the majority of the studies ( n = 21). Education and training were sometimes provided by the nurse leader (Shade et al. 2020 ; Travers et al. 2018 ; Yu et al. 2017 ).

Education focused mainly on nursing/healthcare staff in terms of educational sessions (Mitchell 2017 ; Monkong et al. 2020 ; Naseer et al. 2017 ), such as ward-based in-service training (Anderson & Kynoch 2017 ; Chong et al. 2013 ; Hu et al. 2019 ), (1-day) training/workshop (Chiwaula et al. 2021 ; Fleiszer et al. 2015 ; Shade et al. 2020 ; Travers et al. 2018 ), two half-day training sessions including formal presentations, video demonstration of the delivery of the best practice, participative learning and practice sessions (Williams et al. 2020 ), an educational programme (Yu et al. 2017 ), a lecture (Siegel 2020 ), a multimedia educational framework (Rosenberg et al. 2016 ; Sheng et al. 2020 ), online educational videos (Siegel 2020 ), online modules or courses (Bayly et al. 2018 ; Ceballos et al. 2013 ; Williams et al. 2019 ), along with educational tools such as notebooks containing hard copies of online training (Ceballos et al. 2013 ).

Other educational tools and strategies included: user guide (Kilpatrick et al. 2020 ), demonstration of sample scripts (Ong et al. 2017 ), scripts to educate patients (Siegel 2020 ) and documents and ‘informants’ with knowledge (Fleiszer et al. 2015 ). Training of the stakeholders (e.g. volunteer practice change advocates) in the implementation of best practices (Fleiszer et al. 2015 ) and daily practice under supervision (Chong et al. 2013 ) was also done.

As part of the implementation, nurses also used patient education through the development and use of educational tools such as hand-outs (Anderson & Kynoch 2017 ), a patient education leaflet (Hu et al. 2019 ), an educational booklet (Bayly et al. 2018 ) and pamphlets, posters or slides using an iPad (Jia et al. 2016 ).

The impact of education and training as part of the implementation of best practices for nurses was that it imparted knowledge, increased nurses’ empathetic and adaptable problem-solving skills, raised awareness and compliance with best practices amongst nurses and made nurses more confident in their roles (Allen et al. 2018 ; Naseer et al. 2017 ; Shade et al. 2020 ; Travers et al. 2018 ; Williams et al. 2019 ; Yu et al. 2017 ).

Collaboration

Changing practice was often performed through a collaborative effort, as found in most studies ( n = 20). For example, the nurse often led and formed a team with other nurses (Chiwaula et al. 2021 ; Chong et al. 2013 ; Fleiszer et al. 2016 ; Jia et al. 2016 ; Mitchell 2017 ; Naseer et al. 2017 ; Ong et al. 2017 ; Ullrich et al. 2015 ; Yu et al. 2017 ). Alternatively, a nurse led and collaborated with multiple health professionals besides nurses (specialists and managers) in a team in order to implement the best practice (Allan et al. 2018). Such teams including mainly medical staff/directors (Ceballos et al. 2013 ; Hu et al. 2019 ; Kilpatrick et al. 2020 ; Monkong et al. 2020 ; Rosenberg et al. 2016 ; Shade et al. 2020 ), as well as other professions such as a lactation consultant (Anderson & Kynoch 2017 ), a researcher (Bayly et al. 2018 ), a clinical pharmacist (Rosenberg et al. 2016 ), a respiratory specialist (Ceballos et al. 2013 ) and a dietician (Mullins 2021 ). One study also collaborated with a patient’s family as part of the interventions (Mullins 2021 ).

The various team members or stakeholders served as support (Anderson & Kynoch 2017 ; Chong et al. 2013 ; Kilpatrick et al. 2020 ; Naseer et al. 2017 ; Travers et al. 2018 ). Collaboration overcame challenges (Chong et al. 2013 ), enhanced care policies based on best evidence (Rosenberg et al. 2016 ), enhanced accountability (Fleiszer et al. 2016 ), raised collective awareness and expectations for practice, leading to a change in culture, empowerment, mutual respect and communication (Ceballos et al. 2013 ).

Communication and feedback

Besides education, communication and feedback by nurses played an important role in the implementation of the best practice and often facilitated the implementation and uptake of the best practice, as found by more than half ( n = 16) of the studies. Pre-implementation of the best practice, communication was done through meetings or brain storming sessions with ward stakeholders to discuss current practices (Monkong et al. 2020 ) or outlining the project audit (data collection) and timelines (Anderson & Kynoch 2017 ; Hu et al. 2019 ).

During the implementation, discussions or (feedback) meetings were held to present baseline audits and to gather feedback about the project (Anderson & Kynoch 2017 ; Becker et al. 2020 ; Chong et al. 2013 ; Fleiszer et al. 2015 ; Hu et al. 2019 ; Mullins 2021 ; Naseer et al. 2017 ; Shade et al. 2020 ), to discuss barriers to the implementation of the best practice (Jia et al. 2016 ; Mullins 2021 ; Naseer et al. 2017 ; Ong et al. 2017 ; Shade et al. 2020 ; Ullrich et al. 2014 , 2015 ; Yu et al. 2017 ) and how to overcome the barriers (Mullins 2021 ; Shade et al. 2020 ; Ullrich et al. 2014 , 2015 ; Yu et al. 2017 ), to develop and further improve strategies for implementation (Ceballos et al. 2013 ; Naseer et al. 2017 ; Ong et al. 2017 ) and to discuss progress (Rosenberg et al. 2016 ).

Post-implementation communication was used to brief stakeholders regarding the evaluation of the intervention (Chong et al. 2013 ; Fleiszer et al. 2015 ; Ong et al. 2017 ; Ullrich et al. 2015 ), to discuss how to overcome future barriers (Ong et al. 2017 ; Shade et al. 2020 ) or to celebrate success (Shade et al. 2020 ). Communication was also done online regarding the intervention (Becker et al. 2020 ; Ceballos et al. 2013 ), using emails (Naseer et al. 2017 ; Rosenberg et al. 2016 ) and text messages (Naseer et al. 2017 ).

Ongoing communication and feedback assisted in facilitating the implementation of best practices as it led to the creation of a supportive rapport, which increased engagement (Anderson & Kynoch 2017 ), compliance (Hu et al. 2019 ) and both technical and personal support for the project (Anderson & Kynoch 2017 ; Hu et al. 2019 ). It further helped to keep the knowledge translation strategies on track (Bayly et al. 2018 ; Shade et al. 2020 ), enhance the collaborative processes, enhance the ability to learn from peers’ professional experiences and share and use new information learned (Bayly et al. 2018 ). Finally, ongoing communication helped to identify barriers (Ceballos et al. 2013 ; Hu et al. 2019 ) and enhanced sustainability of the change (Becker et al. 2020 ).

Development and tailoring of the best practice

Nurses play a role in the development and tailoring of the best practice, including the development of intervention materials as part of the implementation, as found in more than half ( n = 16) of the included studies. The roles of nurses mainly involved developing an action plan (knowledge translation) or strategies, which was often done through informal discussions with nursing/midwifery staff and identifying barriers and facilitators of planned practice change (Anderson & Kynoch 2017 ; Bayly et al. 2018 ; Becker et al. 2020 ; Chong et al. 2013 ; Hu et al. 2019 ; Jia et al. 2016 ; Monkong et al. 2020 ; Naseer et al. 2018; Ong et al. 2017 ). Development of the best practice activities were also done (Sheng et al. 2020 ; Ullrich et al. 2015 ).

Other roles included developing educational material based on best evidence as part of the best practice, such as educational content, posters and hand-outs (Anderson & Kynoch 2017 ; Travers et al. 2018 ), videos and slides and a nursing newsletter (Becker et al. 2020 ), a computer-based educational module (Ceballos et al. 2013 ) and notebooks containing hardcopies of the online training information or information/resource booklet (Bayly et al. 2018 ; Ceballos et al. 2013 ).

Checklists to assist nurses to care for patients (Travers et al. 2018 ), a structured tool based on communication skills, workflows and reminder cards (Yu et al. 2017 ) and audit tools to evaluate the best practices were developed by nurses to be implemented as part of the best practice (Becker et al. 2020 ; Chong et al. 2013 ). In one study regarding improving the quality of care for hospitalised patients with cognitive impairment (Travers et al. 2018 ), nurses developed resources (e.g. card games, camouflage aprons/fiddle blankets) for patients to use whilst in hospital as part of the implemented best practice.

This review highlighted five definite roles nurses play in the implementation of best practices: leadership, collaboration, education and training, communication and feedback and development and tailoring of the best practice. The importance of the leadership role nurses play in this regard was also discussed elsewhere (Bianchi et al. 2018 ; Vogel et al. 2021 ). In this review, multiple sub-roles in the nurses’ leadership role in the implementation of best evidence were identified, including recruitment, developing the educational intervention and data analysis. However, it seems from this study that behaviour such as role-modelling, plays a big role in the success of practice change, as found elsewhere (Whitby 2018 ). Furthermore, for nurses to be equipped for this leadership role, they need to have the necessary educational and managerial support and resources required for implementation of best practices (Bianchi et al. 2018 ).

Education and training were found to be one of the major roles, with multiple benefits, that the nurse can play in changing practice. These findings confirmed those of Davis and D’Lima ( 2020 ), who found that teaching and training initiatives can build capacity in dissemination and implementation of best practices. However, the authors also found a need to increase the number of training opportunities to enhance the number of researchers and practitioners who implement best practices.

Changing practice was often carried out through a collaborative effort with other (specialist) nurses and stakeholders, as part of an interdisciplinary team. The concept of the (interdisciplinary) team approach is widely accepted as the ‘gold standard’ of care delivery globally, influencing patient, nursing and organisational outcomes and policy development which, taken together, are aspired for achievement of high-quality care (Ansell, Sørensen & Torfing 2017 ; Soukup et al. 2018 ). Collaboration in changing practice should be fostered through engagement and involvement (Holmes et al. 2019 ), preferably early in implementation as, from the studies included, collaboration showed multiple benefits. Furthermore, evidence-based practice also includes the patient and families as part of clinical decision-making. However, the nurses’ collaboration with the patient during the implementation of best practices was not highlighted in most included studies. Therefore, the collaborative roles of nurses with patients and families when implementing best practices should be further explored.

The nurse also had a role in ongoing communication and feedback when implementing best practices. Doing so could improve care for an increased number of patients and enhance cost-effectiveness (Brown et al. 2019 ). Leaders also have a role in enhancing the facilitation of communication. It is important that they are trained in using various platforms for communication in order to facilitate the implementation of the best practice.

Nurses also had a role in development and tailoring of the best practice. As the included studies were conducted in different clinical contexts, with different resources, using a variety of implementation strategies, a needs assessment and intervention mapping – which refers to planning the implementation of best practices based on using theory and evidence – could assist in systematically tailoring a best practice for both nurses and patients and their families (Van Belle et al. 2018 ).

These identified five roles are interrelated but equally crucial in order to implement best practices. For example, the leadership role will not be fully executed without education and training or collaboration. Communication was found to enhance teamwork (Bayly et al. 2018 ).

This review found several best practices and implementation strategies. However, studies were found from predominantly middle- and high-income countries. More nurse-led intervention studies describing the role of nurses in the implementation of best practices could therefore be conducted in lower- and middle-income countries where resources are often limited and where the role of nurses is inclined to be more innovative and cost-effective in order to implement these best practices (WHO 2020 ). Finally, there is a need for nurse-led quality improvement studies to be conducted to produce Level I (e.g. randomised controlled trials) as no such studies were identified.

Conclusions

The role of nurses in changing practice by implementing best practices is not always well understood. This study found five interrelated, but equally crucial nurse roles in changing practice through the implementation of best practices, namely leadership, education and training, collaboration, communication and feedback and development and tailoring of the best practice. Further exploration on the roles of nurses in changing practices, using randomised controlled trials, including low- and middle-income settings, is required. The study’s findings and identified gaps can be used for further nursing research and education to improve the implementation of best practices and enhance the role nurses can play in this process, thus enhancing patient, nursing and organisational outcomes.

Acknowledgements

The author would like to thank Vicki Igglesden for editing the article.

Competing interests

The author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article.

Author’s contributions

W.T.H.B. is the sole author of this review article.

Funding information

This work is based on the research supported in part by the National Research Foundation of South Africa in partnership with FUNDISA for the PLUME grant (unique reference: FUNDISA/NRF 2019/009). Any opinion, finding and conclusion or recommendation expressed in this material is that of the author. The NRF and FUNDISA do not accept any liability in this regard.

Data availability

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Ten Ham-Baloyi, W., 2022, ‘Nurses’ roles in changing practice through implementing best practices: A systematic review’, Health SA Gesondheid 27(0), a1776. https://doi.org/10.4102/hsag.v27i0.1776

• Academy of Nutrition and Dietetics , 2012, Evidence analysis manual: Steps in the Academy of Nutrition and Dietetics evidence analysis process , Scientific Affairs and Research, Academy of Nutrition and Dietetics, Chicago, IL. [ Google Scholar ]
• Agency for Healthcare Research and Quality (AHRQ) , 2016, How do we implement best practices in our organization? , viewed 01 August 2019, from https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool4a.html .
• Allen, E., Williams, A., Jennings, D., Stomski, N., Goucke, R., Toye, C. et al., 2018, ‘ Revisiting the pain resource nurse role in sustaining evidence-based practice changes for pain assessment and management ’, Worldviews on Evidence-Based Nursing 15 ( 5 ), 368–376. 10.1111/wvn.12318 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Anderson, L. & Kynoch, K., 2017, ‘ Implementation of an education package on breast engorgement aimed at lactation consultants and midwives to prevent conflicting information for postnatal mothers ’, International Journal of Evidence-Based Healthcare 15 ( 1 ), 13–21. 10.1097/XEB.0000000000000090 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ansell, C., Sørensen, E. & Torfing, J., 2017, ‘ Improving policy implementation through collaborative policymaking ’, Policy & Politics 45 ( 3 ), 467–486. 10.1332/030557317X14972799760260 [ CrossRef ] [ Google Scholar ]
• Bayly, M., Forbes, D., Blake, C., Peacock, S. & Morgan, D., 2018, ‘ Development and implementation of dementia-related integrated knowledge translation strategies in rural home care ’, Online Journal of Rural Nursing & Health Care 18 ( 2 ), 29–64. 10.14574/ojrnhc.v18i2.509 [ CrossRef ] [ Google Scholar ]
• Becker, S., Hagle, M., Amrhein, A., Bispo, J., Hopkins, S., Kogelmann, M. et al., 2020, ‘ Implementing and sustaining bedside shift report for quality patient-centered care ’, Journal of Nursing Care Quality 36 ( 2 ), 125–131. 10.1097/NCQ.0000000000000509 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bianchi, M., Bagnasco, A., Bressan, V., Barisone, M., Timmins, F., Rossi, S. et al., 2018, ‘ A review of the role of nurse leadership in promoting and sustaining evidence-based practice ’, Journal of Nursing Management 26 ( 8 ), 918–932. 10.1111/jonm.12638 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Brown, B., Gude, W.T., Blakeman, T., Van der Veer, S.N., Ivers, N., Francis, J.J. et al., 2019, ‘ Clinical performance feedback intervention theory (CP-FIT): A new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research ’, Implementation Science 14 ( 1 ), 1–25. 10.1186/s13012-019-0883-5 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ceballos, K., Waterman, K., Hulett, T. & Makic, M.B.F., 2013, ‘ Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU ’, Advances in Neonatal Care 13 ( 3 ), 154–163. 10.1097/ANC.0b013e318285fe70 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chiwaula, C.H., Kanjakaya, P., Chipeta, D., Chikatipwa, A., Kalimbuka, T., Zyambo, L. et al., 2021, ‘ Introducing evidence-based practice in nursing care delivery, utilizing the Iowa model in intensive care unit at Kamuzu Central Hospital, Malawi ’, International Journal of Africa Nursing Sciences 14 ( 2021 ), 100272. 10.1016/j.ijans.2020.100272 [ CrossRef ] [ Google Scholar ]
• Chong, L.M., Chow, Y.L., Kong, S.S.C. & Ang, E., 2013, ‘ Maintenance of patency of central venous access devices by registered nurses in an acute ambulatory setting: An evidence utilisation project ’, International Journal of Evidence-Based Healthcare 11 ( 1 ), 20–25. 10.1111/j.1744-1609.2012.00303.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cullen, M. & Donahue, M., 2016, ‘ Partnership negotiations: Innovation for nurse contract negotiations during turbulent times ’, Nursing Administration Quarterly 40 ( 1 ), 33–38. 10.1097/NAQ.0000000000000140 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Davis, R. & D’Lima, D., 2020, ‘ Building capacity in dissemination and implementation science: A systematic review of the academic literature on teaching and training initiatives ’, Implementation Science 15 ( 1 ), 1–26. 10.1186/s13012-020-01051-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fleiszer, A.R., Semenic, S.E., Ritchie, J.A., Richer, M.C. & Denis, J.L., 2015, ‘ An organizational perspective on the long-term sustainability of a nursing best practice guidelines program: A case study ’, BMC Health Services Research 15 ( 1 ), 1–16. 10.1186/s12913-015-1192-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Fleiszer, A.R., Semenic, S.E., Ritchie, J.A., Richer, M.C. & Denis, J.L., 2016, ‘ A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study ’, International Journal of Nursing Studies 53 , 204–218. 10.1016/j.ijnurstu.2015.09.004 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Graham, I.D., Kothari, A., McCutcheon, C., Angus, D., Banner, D. & Bucknall, T. [On behalf of The Integrated Knowledge Translation Research Network Project], 2018, ‘ Moving knowledge into action for more effective practice, programmes and policy: Protocol for a research programme on integrated knowledge translation ’, Implementation Science 13 ( 1 ), 22. 10.1186/s13012-017-0700-y [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Greenhalgh, T., Howick, J. & Maskrey, N., 2014, ‘ Evidence-based medicine: A movement in crisis? ’, British Medical Journal 348 , g3725. 10.1136/bmj.g3725 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Higgins, J.P., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J. & et al.. (eds.), 2019, Cochrane Handbook for Systematic Reviews of Interventions , John Wiley & Sons, London. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Holmes, L., Cresswell, K., Williams, S., Parsons, S., Keane, A., Wilson, C. et al., 2019, ‘ Innovating public engagement and patient involvement through strategic collaboration and practice ’, Research Involvement and Engagement 5 ( 1 ), 1–12. 10.1186/s40900-019-0160-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hong, Q.N., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P. et al., 2018, ‘ The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers ’, Education for Information 34 ( 4 ), 285–291. 10.3233/EFI-180221 [ CrossRef ] [ Google Scholar ]
• Hu, Y., McArthur, A. & Yu, Z., 2019, ‘ Early postoperative mobilization in patients undergoing abdominal surgery: A best practice implementation project ’, Joanna Briggs Institute Evidence Synthesis 17 ( 12 ), 2591–2611. 10.11124/JBISRIR-D-19-00063 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• International Council of Nurses , 2012, Policy statements , viewed 01 August 2019, from https://www.icn.ch/nursing-policy/position-statements .
• Jia, S., Huang, B., Chu, Y., Lu, Y. & McArthur, A., 2016, ‘ Management of non-adherence to fluid intake restrictions in hemodialysis patients in a tertiary hospital: A best practice implementation project ’, Joanna Briggs Institute Evidence Synthesis 14 ( 8 ), 309–322. 10.11124/JBISRIR-2016-003046 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Joanna Briggs Institute (JBI) , 2016, The JBI approach , viewed 30 April 2021, from http://joannabriggs.org/jbi-approach.html#tabbed-nav=Levels-of-Evidence .
• Joanna Briggs Institute (JBI) , 2021, Critical appraisal tools , viewed 30 April 2021, from https://jbi.global/critical-appraisal-tools .
• Kilpatrick, K., Tchouaket, É., Jabbour, M. & Hains, S., 2020, ‘ A mixed methods quality improvement study to implement nurse practitioner roles and improve care for residents in long-term care facilities ’, BioMed Central Nursing 19 ( 1 ), 1–14. 10.1186/s12912-019-0395-2 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kristensen, N., Nymann, C. & Konradsen, H., 2016, ‘ Implementing research results in clinical practice – The experiences of healthcare professionals ’, BMC Health Services Research 16 , 48. 10.1186/s12913-016-1292-y [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Leviton, L.C. & Melichar, L., 2016, ‘ Balancing stakeholder needs in the evaluation of healthcare quality improvement ’, BMJ Quality & Safety 25 ( 10 ), 803–807. 10.1136/bmjqs-2015-004814 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mitchell, R., 2017, ‘ Hourly rounding: A fall prevention strategy in long-term care ’, Masters dissertation, Walden University, viewed 20 April 2021, from https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=4811&context=dissertations&httpsredir=1&referer= . [ Google Scholar ]
• Monkong, S., Krairit, O., Ngamkala, T., Chonburi, J.S.N., Pussawiro, W. & Ratchasan, P., 2020, ‘ Transitional care for older people from hospital to home: A best practice implementation project ’, Joanna Briggs Institute Evidence Synthesis 18 ( 2 ), 357–367. 10.11124/JBISRIR-D-19-00180 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mullins, N., 2021, ‘ Nutrition and hydration management among stroke patients in inpatient rehabilitation: A best practice implementation project ’, Joanna Briggs Institute Evidence Implementation 19 ( 1 ), 56–67. 10.1097/XEB.0000000000000244 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Naseer, B., Tan, S.S., Ramli, S.S. & Ang, E., 2017, ‘ Protected mealtimes for adults with cancer in a hematology-oncology setting: An evidence-based implementation project ’, Joanna Briggs Institute Evidence Synthesis 15 ( 4 ), 1209–1219. 10.11124/JBISRIR-2016-003038 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Norris, J.M., White, D.E., Nowell, L., Mrklas, K. & Stelfox, H.T., 2017, ‘ How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study ’, Implementation Science 12 ( 1 ), 98. 10.1186/s13012-017-0625-5 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ong, A.Y.J., Tan, J., Yeo, H.L. & Goh, M.L., 2017, ‘ Patient-centred hand hygiene information in orthopaedics units: An evidence-based implementation project ’, International Journal of Evidence-based Healthcare 15 ( 1 ), 22–29. 10.1097/XEB.0000000000000094 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Page, M.J., McKenzie, J., Bossuyt, P., Boutron, I., Hoffmann, T. & Mulrow, C.D., 2020, ‘ The PRISMA 2020 statement: An updated guideline for reporting systematic reviews ’, British Medical Journal 2021 ( 372 ), n71. 10.1136/bmj.n71 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Pearson, A., Jordan, Z. & Munn, Z., 2012, ‘ Translational science and evidence-based healthcare: A clarification and reconceptualization of how knowledge is generated and used in healthcare ’, Nursing Research and Practice 2012 , 792519. 10.1155/2012/792519 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rosenberg, R.E., Klejmont, L., Gallen, M., Fuller, J., Dugan, C., Budin, W. et al., 2016, ‘ Making comfort count: Using quality improvement to promote pediatric procedural pain management ’, Hospital Pediatrics 6 ( 6 ), 359–368. 10.1542/hpeds.2015-0240 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Salmond, S.W. & Echevarria, M., 2017, ‘ Healthcare transformation and changing roles for nursing ’, Orthopedic Nursing 36 ( 1 ), 12–25. 10.1097/NOR.0000000000000308 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shade, L., Reeves, K., Rees, J., Hendrickson, L., Halladay, J., Dolor, R.J. et al., 2020, ‘ Research nurses as practice facilitators to disseminate an asthma shared decision-making intervention ’, BioMed Central Nursing 19 ( 2020 ), 40. 10.1186/s12912-020-00414-0 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sheng, L., Yin, L., Peng, D. & Zhao, L., 2020, ‘ From best evidence to best practice: Enteral nutrition from continuous nasal feeding in stroke patients ’, International Journal of General Medicine 2020 ( 13 ), 927. 10.2147/IJGM.S269393 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Siegel, V., 2020, ‘ Best practice implementation of skin cancer guidelines on the EMR to educate patients ’, Medsurg Nursing 29 ( 6 ), 407–410. [ Google Scholar ]
• Soukup, T., Lamb, B.W., Arora, S., Darzi, A., Sevdalis, N. & Green, J.S., 2018, ‘ Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: An overview and synthesis of the available literature ’, Journal of Multidisciplinary Healthcare 19 ( 11 ), 49–61. 10.2147/JMDH.S117945 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Travers, C., Henderson, A., Graham, F. & Beattie, E., 2018, ‘ CogChamps: Impact of a project to educate nurses about delirium and improve the quality of care for hospitalized patients with cognitive impairment ’, BioMed Central Health Services Research 18 ( 1 ), 1–13. 10.1186/s12913-018-3286-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ullrich, S., McCutcheon, H. & Parker, B., 2014, ‘ Nursing practice in nutritional care: A comparison between a residential aged care setting and a hospital setting ’, Journal of Advanced Nursing 70 ( 8 ), 1845–1855. 10.1111/jan.12345 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ullrich, S., McCutcheon, H. & Parker, B., 2015, ‘ Undernutrition in older people in Australia ’, British Journal of Nursing 24 ( 7 ), 364–370. 10.12968/bjon.2015.24.7.364 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Van Belle, E., Zwakhalen, S.M., Caris, J., Van Hecke, A., Huisman-de Waal, G. & Heinen, M., 2018, ‘ Tailoring of the tell-us card communication tool for nurses to increase patient participation using intervention mapping ’, Journal of Clinical Nursing 27 ( 3–4 ), 621–630. 10.1111/jocn.13968 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vergnes, J.N., Marchal-Sixou, C., Nabet, C., Maret, D. & Hamel, O., 2010, ‘ Ethics in systematic reviews ’, Journal of Medical Ethics 36 ( 12 ), 771–774. 10.1136/jme.2010.039941 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vogel, R., Bours, G., Erkens, P., Metzelthin, S., Zwakhalen, S. & Van Rossum, E., 2021, ‘ The content of the nurses in the lead programme for empowering community nurse leadership in implementing evidence ’, Leadership in Health Services 34 ( 2 ), 69–83. 10.1108/lhs-08-2020-0063 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gøtzsche, P.C. & Vandenbroucke, J.P., 2007, ‘ The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies ’, Annals of Internal Medicine 147 ( 8 ), 573–577. 10.1371/journal.pmed.0040296 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Whitby, P., 2018, ‘ Role of front-line nurse leadership in improving care ’, Nursing Standard 33 ( 8 ), 30–34. 10.7748/ns.2018.e11018 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Williams, L., Cooper, T., Bradford, L., Cooledge, B., Elner, F., Fisher, D. et al., 2019, ‘ An evaluation of an infection prevention link nurse programme in community hospitals and development of an implementation model ’, Journal of Infection Prevention 20 ( 1 ), 37–45. 10.1177/1757177418789480 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Williams, S.L., McSharry, J., Taylor, C., Dale, J., Michie, S. & French, D.P., 2020, ‘ Translating a walking intervention for health professional delivery within primary care: A mixed-methods treatment fidelity assessment ’, British Journal of Health Psychology 25 ( 1 ), 17–38. 10.1186/ISRCTN95932902 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization (WHO) , 2020, Seven approaches to investing in implementation research in low- and middle income countries , viewed 29 May 2021, from https://www.who.int/tdr/publications/ESSENCE_Seven_Approaches_to_Investing_web.pdf .
• Yu, Z., Zhang, Y., Gu, Y., Xu, X. & McArthur, A., 2017, ‘ Pediatric clinical handover: A best practice implementation project ’, Joanna Briggs Institute Evidence Synthesis 15 ( 10 ), 2585–2596. 10.11124/JBISRIR-2016-003296 [ PubMed ] [ CrossRef ] [ Google Scholar ]