8
Maura MacPhee
Evidence-based practice can only occur if leaders plan for and provide the organizational structures and processes. Success lies in making these structures and processes “transparent” and part of normal daily business for clinicians.
—R. P. Newhouse (2007, p. 21)
Introduction
This chapter will demonstrate how leaders influence those around them to make evidence-informed decisions and deliver evidence-informed care. Evidence-informed care is associated with positive outcomes for patients, such as lower rates of injury and mortality, and less burnout and turnover for nurses. Within health care settings, leaders influence organizational culture by promoting the use of evidence and critical thinking. Their quest for evidence-informed excellence is often challenged by competing concerns, such as finances, which can put patients and nurses at risk. Brave leaders are those who seek out evidence and use the best available evidence to guide them.
Learning Objectives
- Justify the importance of evidence-informed practice to nursing.
- Explain how evidence-informed leaders contribute to quality, safe patient care delivery.
- Identify barriers to use of evidence within health care organizations.
8.1 Evidence-Informed Leadership
Let’s begin with a review of evidence-informed practice, also known as evidence-based practice. Whether you are a student, a practicing nurse, or a nurse leader with formal authority within a health care setting, you are expected to use evidence to inform your decisions and your actions.
Essential Learning Activity 8.1.1
Read the Canadian Nurses Association’s Position Statement titled “Evidence-Informed Decision-Making and Nursing Practice,” then answer the following question:
- What types of evidence should nurses and nurse leaders use when making decisions?
The CNA Position Statement indicates that it’s important to evaluate the quality of evidence. Nurses and nurse leaders need to know where to locate different types of evidence; they need to determine whether or not it is trustworthy evidence (i.e., valid, reliable); and they need to know how to use it in their practice—whether caring for patients or leading within a health care setting. Schools of nursing, in their undergraduate and graduate programs, include critical thinking and assessment and use of evidence as important learner competencies.
8.2 Innovation, Leadership, and Clusters of Influence
Essential Learning Activity 8.2.1
Watch the following YouTube videos:
- “What is Evidence-Based Practice?” with Ann Dabrow Woods (3:27)
- “Evidence-Informed Practice” by the Ontario Centre of Excellence for Child and Youth Mental Health (4:14)
In the first video, Dabrow states that the Joanna Briggs Institute is a great source for health care evidence. Look at the Institute’s website. Resources like this are vital to evidence-informed nurse leaders. The speaker in the first video describes how McMaster University in Canada actually coined the term evidence-based practice.
The second video reinforces the importance of using best available evidence in service provision.
After watching both videos, answer the following questions: What should organizational leaders do to promote evidence-informed practice? What should individual nurses do to optimize use of evidence in their practice?
Regardless of whether you are a student nurse or are a leader in a formal role (e.g., unit manager, facility director, chief nursing officer), your decisions need to be informed by evidence. And yet, as emphasized in the first video, only a small proportion (20 per cent) of the decisions made in health care are based on evidence. Furthermore, Dabrow Woods states, “It takes 15 to 20 years to get evidence into practice.” What is going on?
Essential Learning Activity 8.2.2
Read Dr. Donald Berwick’s 2003 paper titled “Disseminating Innovations in Health Care.” This classic paper discusses why innovation, or positive change, is difficult to integrate within health care settings.
According to innovation experts such as Dr. Donald Berwick, “failure to use available science is costly and harmful; it leads to overuse of unhelpful care, underuse of effective care, and errors in execution” (2003, p. 1969). For nurses and doctors, our errors can cost injury and even loss of life. Dr. Berwick asks the following set of questions:
Why is the gap between knowledge and practice so large?
Why do clinical care systems not incorporate the findings of clinical science or copy “best known” practices reliably, quickly, and even gratefully into their daily work simply as a matter of course? (p. 1969)
For successful innovation uptake and use, there are three basic clusters of influence that need to be addressed by leaders at all levels of a health care organization: perceptions of the innovation, composition of staff, and contextual information.
Perceptions of the Innovation
The first cluster is perceptions of the innovation. Leaders need to thoughtfully consider how to introduce a new policy or protocol or a new piece of technology or medicine: first impressions count. Leaders need to consider five characteristics of an innovation by asking the following questions before introducing that innovation to their staff:
- Will staff perceive the innovation as a benefit to them?
- Does the innovation fit with staff’s current needs? (e.g., Will the innovation enhance care delivery?)
- Is the innovation easy to understand? Is it simple to do? Complexity (e.g., multiple parts, steps) slows down innovation. Simplicity promotes “spread.”
- Is it possible to do a small-scale pilot? Trialability improves the rate of innovation.
- Is it possible for staff to observe the innovation in progress, to learn about it and answer any questions or concerns they may have? Observability and trialability often work well together.
Leaders, therefore, need to plan in advance for how they will influence staff’s first impressions of an innovation. Change is frightening to people; we typically resist proposed changes because change often involves extra effort, resources, and time. With the busyness in our lives, we need to know, from leaders, that they are making evidence-informed decisions about proposed changes. Why should we change the status quo?
Composition of Staff
The second cluster of influence that leaders need to think about is the composition of their staff. Leaders cannot impose innovation on their own; they need the right staff helping them out. Without the right complement of helpers, their attempts at innovation will fail. Take a look at Figure 2 in the Berwick paper (2003, p. 1972). For innovation to succeed, you need: innovators, early adopters, and an early majority.
Innovators are the source of proposed positive changes. They are those individuals within an organization that read scientific journals, attend conferences, and keep informed about best practices. They are well connected with sources of evidence outside the organization, and they bring ideas back to the organization.
Early adopters are well connected within the organization. They are the leaders who have influence and authority. They can make things happen, given their formal power within the organization. These leaders believe in the value of innovation, and they support their innovators. As one example, an early adopter leader provides release time and financial support for a nurse educator to attend a conference on medical-surgical practice innovations. The nurse educator brings back great ideas and presents them to the leadership and staff.
Once an early adopter leader recognizes the potential of an innovation, the leader gets to work, planning for how to present the innovation to staff (i.e., how to make the first impression). The leader proposes a pilot and asks for staff volunteers to help. Those staff who step forward to trial the innovation make up the early majority. In many instances, the early majority consists of new graduate nurses who are eager to try something new.
If the pilot has been successful, the rest of the staff—who have observed the positive outcomes from the pilot—will readily adopt the innovation. These staff comprise the late majority. And lastly, there are some staff, the laggards, who remain resistant to change. Leaders should listen to their concerns, but ultimately, if some staff members are uncomfortable with the change, it may be time for them to look for another unit or place of employment. The laggards typically represent only a small number of staff (16 per cent), and yet leaders often get sidetracked trying to convince them to change. The fact is that they may never change.
Leaders, therefore, should focus their energies on the initial 20 per cent of staff at the beginning of the innovation curve (i.e., innovators, early adopters, early majority) who need leadership support: they are the critical mass for positive change.
Contextual Information
The third cluster of influence consists of contextual factors that facilitate or impede innovation within the organization. The leadership and the organizational culture both have major influence over innovation spread. You need evidence-informed leaders (i.e., early adopters) throughout the organization who: (1) promote staff interactions, discussions, and networking across the organization (remember observability?); (2) trust and enable their staff to adapt new ideas to their needs; (3) invest essential resources, supports, and time in innovation; and (4) “walk the talk” or champion the innovations themselves. As Dr. Berwick (2003) wrote about Captain James Cook, an early explorer and innovator and early adopter: “James Cook had to eat his own sauerkraut, and health care leaders who want to spread change must change themselves first” (p. 1974).
Essential Learning Activity 8.2.3
Answer the following questions:
- What kind of leaders would you like to work with? Why?
- What kind of organization would you like to work in? Why?
From the Field
Let’s take a look at what happens when you do not have evidence-informed leadership.
In England, there is a single payer system, the National Health Service (NHS), which is very similar to our health care system in Canada. The NHS is made up of health regions known as trusts. Over a period of several years, evidence around safe staffing was ignored by the leadership within one NHS trust, the Mid Staffordshire Trust. To balance their budget, the trust’s leadership began replacing nurses with unlicensed care aides. After a public outcry by the loved ones of patients who were harmed or died due to negligent care, an independent inquiry was conducted by the NHS to find out what was going on in the Mid Staffordshire Trust. The inquiry revealed appalling care conditions due to nurse understaffing. The NHS was “shamed” by this inquiry and vowed to enforce policies and procedures in place throughout all trusts to restore quality, safe public health care delivery.
The Mid Staffordshire Trust leadership chose to ignore over two decades of safe staffing research evidence. For example, the numbers (patient to nurse ratios) and the types of nurses (skill mix) are directly linked to rates of patient morbidity (e.g., hospital acquired infections, preventable falls, and pressure ulcers), patient mortality, and failure to rescue. Heavy nurse workloads, characterized by high patient to nurse ratios (e.g., 10 patients per nurse) results in adverse patient events and nurses’ inability to detect changes or deterioration in patients’ status (Berry & Curry, 2012). Richer skill mix, with proportionally more RNs among direct care staff, is associated with better patient outcomes (Needleman, 2016).
The NHS was puzzled: what went wrong? Why didn’t the Mid Staffordshire leadership use the evidence to inform their staffing decisions? Dr. Berwick, who wrote a 2003 paper on innovation, is considered an internationally renowned expert on quality and safety. Dr. Berwick was asked by the NHS to review the inquiry report and to recommend quality and safety policy changes. Dr. Berwick’s recommendations are set out in a document titled “A Promise to Learn—A Commitment to Act.” What he recognized, right away, was that the Mid Staffordshire Trust had a culture of secrecy and oppression, as well as a significant lack of leadership throughout the organization. In fact, doctors and nurses were afraid to speak up. There was evidence of leaders bullying and threatening doctors and nurses who complained about unsafe work conditions.
Based on information from “Valuing Patient Safety: Responsible Workforce Design” (MacPhee, 2014).
One of Dr. Berwick’s key recommendations to the NHS (discussed in the From the Field textbox) was about leadership. Leaders are essential for creating an open, transparent culture of learning, where everyone is expected to use the evidence to ensure best practice and best possible delivery of care to patients. Leaders are essential for modelling the way for others and providing the necessary information, resources, and supports so that all nurses and other staff have the means to provide quality, safe care to patients. Leaders are essential for promoting a culture of continuous learning, openness, and transparency toward sharing and using evidence to make a difference—what is known as a learning organization.
Take a look at the following table, from Dr. Berwick’s “Promise to Learn.” Under his recommendations on leadership, he identifies the overarching responsibility of all staff and leaders.
| Who | What |
|
All staff and leaders of NHS-funded organisations |
Every person working in NHS-funded care has a duty to identify and help to reduce risks to the safety of patients, and to acquire the skills necessary to do so in relation to their own job, team, and adjacent teams. Leaders of health care provider organisations, managers, clinical leaders . . . have a duty to provide the environment, resources, and time to enable staff to acquire these skills. |
All members of an organization, staff and leaders alike, are expected to contribute to a learning organization culture.
Essential Learning Activity 8.2.4
Watch the following three videos on learning organizations, then answer the questions that follow:
“What is a Learning Organization?” (4:56) by the Ontario Centre of Excellence for Child and Youth Mental Health
“Introduction to Organizational Learning” (3:13) by Peter Senge
“Learning Organisation” (2:01)
- Imagine you are a nurse within a learning organization, such as the Ontario Centre of Excellence for Child and Youth Mental Health. Describe how you will contribute to the culture of continuous learning.
- The Ontario Centre of Excellence for Child and Youth Mental Health adopted core values associated with learning organizations and continuous learning. Why do you think they chose these core values?
8.3 Research Supports a Healthy Organization
Research on organizations from all different sectors (including industry, business, and health care) has shown that organizations that promote practices associated with learning organizations have significantly better outcomes, such as improved quality, efficiency, and effectiveness. Organizations and their leadership, therefore, are making wise investments when they support cultures that promote continuous learning (Robbins, Garman, Song, & McAlearney, 2012).
As you may have surmised by watching the video by Peter Senge, organizations do better when they expect everyone within the organization to “make a deep commitment to learning.” In his presentation, “high leverage” refers to the ability to make positive changes, to be innovative. When we get stuck in one way of thinking and one way of doing things (habit), we miss opportunities to improve and enhance the way we work together. Senge urges us to break out of our old “mental models” and to “triangulate” or bring our knowledge and ideas together with others—to gain multiple perspectives. He also emphasizes that it takes time to “develop, adapt and apply.” Evidence-informed leaders need to “walk the talk.” Leaders have to constantly challenge the status quo and invite diverse perspectives from their staff, from patients and families, and from their colleagues to explore better ways for delivering quality, safe care within their organizations.
Let’s return to the Mid Staffordshire Trust. Within the trust, leaders ignored evaluation data that reported adverse events, and they ignored patient complaints and staff complaints. They focused almost exclusively on financial targets set by the government to produce balanced budgets. The NHS finally commissioned a public inquiry of Mid Staffordshire Trust after a whistle-blower group of families went to the media with stories of terrible injury to their loved ones. Julie Bailey, one of the organizers of the movement, lost her mother. The public and the media were responsible for government action.
Essential Learning Activity 8.3.1
Watch this Channel 4 News video titled “Mid Staffs: Julie Bailey and Jeremy Hunt” (7:51). The reporter interviews Julie Bailey, one of the organizers of the public movement (who lost her mother), and Jeremy Hunt, the Minister of Health. The video is dated February 6, 2013, shortly after the release of the Francis report on the Mid Staffordshire Trust.
In the video, Ms. Bailey concludes that “we need a leader” to make the changes necessary to ensure quality, safe care delivery. Ms. Bailey also asserts that change will not happen without new leadership. The reporter, however, challenges whether or not the resignation of the current leader will take care of the problem. What do you think?
Essential Learning Activity 8.3.2
Read the 2017 “Position Statement on Harm Reduction” from the British Columbia Nurses’ Union (BCNU). The background of the position statement highlights how evidence-informed harm reduction approaches represent nursing principles. Identify those concepts of harm reduction that are associated with nursing professional standards and codes of ethics.
For more information on injectable drugs and risks that influence evidence-informed nursing, see the World Health Organization’s web page on HIV/AIDS.
8.4 Evidence-Informed Nursing: Leading the Way
In British Columbia, illicit drug overdose deaths topped 914 in 2016, and in Alberta, there were 343 deaths in 2016 from fentanyl overdoses (Canadian Press, 2017). This opioid crisis in Canada and the US has spurred policy-makers and health care providers to seek guidance from research on mental health and addictions treatment.
Position statements are typically evidence-based documents that can be found on websites of professional organizations, regulatory colleges, unions, and the government. Although these documents are often referenced and fact-checked, they may also include guiding principles that reflect their organization’s mission, vision, and values. It’s important for nurses, therefore, to seek guidance from organizations that reflect professional nursing standards and codes of ethics. For students, these documents are great resources, which also provide an introduction to the professional principles that define who we are as nurses.
The BCNU position statement referenced in the Essential Learning Activity above begins with bulleted principles, including “The BC Nurses’ Union believes that harm reduction policies and programs can provide support for people coping with the effects of substance use” (BCNU, 2017). Note the references and the use of research evidence to describe key evidence-based harm reduction strategies. A number of recent research studies are included in this position statement. You’ll see that the references include qualitative, quantitative, and economics (cost-effectiveness) research.
What does this mean from a leadership perspective? As nurses, we need to lead the way with respect to knowing the research evidence on topics that affect our patients, and more broadly, Canadian public health and well-being. Harm reduction is significant to nurses at local, provincial, and national levels—even globally. If you are interested in doing further exploration on harm reduction, see the World Health Organization’s global perspective on reducing harm for anyone who uses injectable drugs here.
Research Note
The Study to Assess Long-Term Opioid Medication Effectiveness (SALOME) was a clinical research trial in Vancouver to determine whether a legally prescribed opioid, hydromorphone, could be an effective substitute for illicit injectable heroin. Another component of the study compared the efficacy of injectable heroin and hydromorphone to oral versions of these two opioids.
An interdisciplinary team of physicians, nurses, social workers, and counselors were involved in this study. This study demonstrated that injectable heroin could be substituted with injectable hydromorphone, an opioid with less social stigma than heroin. Oral versions of both medications were not effective in curbing illicit drug use. Supervised injection sites, managed by care teams with nurses, now have a variety of evidence-based treatment options (e.g., methadone, suboxone, hydromorphone) to offer individuals with chronic addictions—legal options that reduce potential harm, even death to some of our society’s most vulnerable members.
An overview of harm reduction research can be found at SALOME Clinical Trial Questions and Answers.
Summary
Return to the quote at the beginning of this chapter, rethinking it in terms of everything you have just read.
Evidence-based practice can only occur if leaders plan for and provide the organizational structures and processes. Success lies in making these structures and processes “transparent” and part of normal daily business for clinicians.
—R. P. Newhouse (2007, p. 21)
Evidence-informed leaders are early adopters who seek out the best available evidence and promote evidence-informed practices among their staff. These leaders provide the structures and the processes necessary to spread the use of evidence and innovation throughout their organizations. Evidence-informed leaders do not only seek out the best available evidence, but they use it to drive their decisions—that is to say, they “walk the talk.” Moreover, evidence-informed leaders promote learning organization cultures of transparency and continuous learning.
Leaders who ignore the evidence are often the greatest barriers to quality, safe care delivery. As illustrated in the Mid Staffordshire Trust tragedy, there’s more to evidence-informed leadership than having access to evidence or even use of evidence. Sir David Nicholson, the head of the NHS at that time, had access to lots of evidence, but he chose to focus on financial evidence, and the leaders under him focused almost exclusively on financial targets. Leaders influence how others interpret and share evidence, depending on other leadership attributes they possess. As discussed throughout this book, it takes other leadership attributes, such as authenticity, moral integrity, and effective use of power, to make a great leader.
After completing this chapter, you should now be able to:
- Defend the importance of evidence-informed practice to nursing.
- Explain how evidence-informed leaders contribute to quality, safe patient care delivery.
- Identify barriers to use of evidence within health care organizations.
Exercises
Debate the following question with your classmates: When a leader ignores available evidence and allows serious quality or safety breaches to happen under his or her leadership, should he or she be given another chance to lead the organization?
References
Berry, L., & Curry, P. (2012). Nursing workload and patient care. Ottawa: Canadian Federation of Nurses Unions.
Berwick, D. (2003). Disseminating innovations in health care. Journal of the American Medical Association, 289(15), 1969–1975.
Berwick, D. (2013). A promise to learn—a commitment to act. Improving the safety of patients in England. National Advisory Group on the Safety of Patients in England. Retrieved from https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf
British Columbia Nurses Union. (2017). Harm reduction position statement. Retrieved from https://www.bcnu.org/AboutBcnu/Documents/PS_HarmReduction.pdf
Canadian Press (2017). Severity of opioid crisis in Canada, U.S. prompted inclusion in joint statement: Goodale. Toronto Star, Feb. 14. Retrieved from https://www.thestar.com/news/canada/2017/02/14/severity-of-opioid-crisis-in-canada-us-prompted-inclusion-in-joint-statement-goodale.html
MacPhee, M. (2014). Valuing patient safety: Responsible workforce design. Ottawa: Canadian Federation of Nurses Unions. Retrieved from https://nursesunions.ca/wp-content/uploads/2017/05/Valuing-Patient-Safety-PRINT-May-2014.pdf
Needleman, J. (2016). The economic case for fundamental nursing care. Nursing Leadership, 29(1), 26–36.
Newhouse, R. P. (2007). Creating infrastructure supportive of evidence-based nursing practice: Leadership strategies. Worldviews on Evidence-based Nursing, First Quarter, 21–29.
Robbins, J., Garman, A. N., Song, P. H., & McAlearney, A. S. (2012). How high-performance work systems drive health care value: an examination of leading process improvement strategies. Quality Management in Healthcare, 21(3), 188–202.