Leaning into Evidence-Based Practice

Carol Pehotsky:

Evidence-Based practice, evidence-based nursing, terms that we've heard throughout our careers, but what that's meant over that time, whether you've been a nurse for a year or 40 years, continues to evolve, and the speed at which evidence is coming out, whether that's in healthcare in general or about nursing, is nonstop and is much faster these days than it certainly was back when I was first talking about evidence-based practice. But how does a nurse evaluate that evidence? How does a nurse know what quality evidence is, what we should be considering, how to identify where there's a gap, and how do we make sure we close that? I'm joined today by Dr. Nancy Albert to talk more about evidence-based practice in nursing and where nurses can lean in.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care, to advancing your career, to navigating tough on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing. Welcome back, everyone. Evidence-Based practice, evidence-based nursing practice. We've been talking about it really since I became a nurse many, many years ago. And while it was important then, of course, when we think about it, I became a nurse in 2004, the amount of evidence available to us in the nursing research was vast, but perhaps manageable. Accelerate 22 years, and thankfully, there's no shortage of evidence coming out, research and quality improvement, and all this data coming into us as nurses. But how do we sort through all of that, determine what are good sources, what is true evidence-based practice, and more importantly, how do we make sure that we are implementing it and living it?

Dr. Nancy Albert:

Thanks for having me. Happy to be here.

Carol Pehotsky:

Oh, I'm so glad to have you here. In previous episodes, we did ask you to tell us a little bit about your nursing journey, so we'll spare you that <laugh> this time. But listeners, you can check out Nancy in two other episodes prior to this one. She's got great stories to tell, so definitely check those out. Today, we're going to talk about evidence-based practice. So, to get us all on the same page, or perhaps there's some listeners unfamiliar with the term, can you just start us out with, how do you define evidence-based practice in nursing?

Dr. Nancy Albert:

That's a really good question, because it is a term that was recoined in the mid - 80s, and it really involves three factors. The first one is using or guiding your practice based on high-quality research articles. The second component is clinical expertise, and not everybody is a clinical expert. And then the third component, it's an interesting one, is the patient or the client perspective. So, involving patients and family in the evidence and what you're planning to do is really important.

Carol Pehotsky:

Wow, there's a lot to unpack there. One step at a time. I love the part about the perspective of the patient as well. So, when we think about why that's so important, what's your response to that question?

Dr. Nancy Albert:

It is important because think about it, you're a patient in a hospital bed and somebody says they want to conduct surgery or do a special treatment, and you don't really understand. You want to be the one making your own decisions for your health, and we rely on people to give us the best evidence or evidence-based practice. And so, some people just inherently trust their provider. Other people want details and want to be able to understand and make their own decisions. And to do that, we as nurses have to be educated enough and knowledgeable enough to understand what that evidence is and what it all means. And it's not as easy as we think.

Carol Pehotsky:

I know. And so, lingering on the guiding practice of high-quality research. That could probably also be its own episode, but in the myriads of information out there, what are some key signs that something is high quality?

Dr. Nancy Albert:

That's a great question, and it's really an important one because many nurses don't understand the difference between quality of evidence and strength of evidence. What we really want to focus on for high quality. You could go to the journals that we know only publish the best of the best, you know, the Journal of American Medical Association or Lancet or some of these very high-quality journals. But the bottom line is we're looking for research that's a randomized controlled trial. So, some patients are in a control group, others are in a treatment group, and we're comparing differences versus just having a single group who something happened to them. And then you're not sure, what if the other group would've had the same things happen?

Carol Pehotsky:

Right.

Dr. Nancy Albert:

So, then you're just guessing what the evidence is. We're looking for randomized control trials whenever possible. And then we look to see how well they're conducted, what are the methods, what's the design, what's the length of time? And that helps us understand what that evidence really means. The Food and Drug Administration, as an example, uses that kind of evidence to approve new drugs, therapies, or device therapies.

Carol Pehotsky:

Which we want them to.

Dr. Nancy Albert:

But without that evidence or strong evidence, they may not. And so, we've got some control when it comes to medications, but think of all the other things we as nurses do, and we may not be following evidence-based practice. And it could be detrimental to our patients' outcomes in the end.

Carol Pehotsky:

And so that other component you talked about in your definition about clinical experts, nursing has always relied on clinical judgment and experience. Bringing our full selves and our full experience and our full training to the role, but also that evidence-based, clinical expert-based practice complement, how do we complement all together?

Dr. Nancy Albert:

That's also really important because evidence is ever-changing. What's important today may not be important tomorrow if a new research study comes out and tells us we need to do things differently. So, for nurses to have clinical expertise, they really need to keep up with the literature, which could be difficult. Where to go, which literature? Do I trust what I'm reading? How do I understand what I'm reading? There are many ways that nurses can do it. They can go to education sessions that are led by experts, whether they're providers or other clinicians. They can join organizations who make a point to keep up with the literature and put on podcasts and seminars that help nurses to stay current, because it's so easy to fall behind. And we may be doing things that we did 15 years ago that 10 years ago were considered obsolete, but we're still doing them.

So again, that's not evidence-based practice anymore. Trying to keep that clinical expertise can be daunting. We're just a fast-paced environment and the research literature is moving at a fast pace right now.

Carol Pehotsky:

In the last 20 plus years, the organizations that I belong to that publish guidelines or standards are really doubling down and making sure that their recommendations have evidence, so that some of that work is done for the nurse if they're going back to their organization's guidelines as well.

Dr. Nancy Albert:

Right. And even for us in our own setting, when we develop policies, we actually put the strength of evidence next to the policy so people can't see the big picture fully, but they see enough of the picture to understand is this high quality? Is this low quality? Is this really low quality? So, they can figure out what really to trust and how much evidence we have on what we're doing.

Carol Pehotsky:

We've come a long way. So, the nurse says, yes, I want to make sure I'm doing the best evidence-based practice. I'm a member of my organization. I read the guidelines and I'm up to date on my Cleveland Clinic policies or wherever I work and I can see that my policies are evidence-based. In addition to that, I'm out there living practice. How might we be able to identify when it might be time to look at a current practice or workflow to determine whether we are really still doing the best evidence-based care?

Dr. Nancy Albert:

That is a common theme that we ought to be doing day in and day out. Whenever somebody gets that sixth sense or feels like something doesn't seem right anymore, why am I doing this? What's the evidence on it? If you're asking questions in your head, then that means you need to think about looking up the literature and seeing if it's real. I'll give you a simple example. Years ago, at one of our hospitals, nurses in the cancer field felt odd putting patients on neutropenic diets because it's the healthy food. It's all the fruits and vegetables, the things that maybe if they're not cleaned properly can cause problems. And so, we did a literature review and we found out that being on a neutropenic diet is no longer warranted.

But then we found out our policy still showed that patients needed to be on a neutropenic diet. So, we went to the oncology specialists, found out who the policy owners were, talked about the policy, and they agreed to change it for everybody except transplants immediately after transplant, like the first month. We changed policy based on somebody asking a question, "How come we're still doing this? That doesn't seem right. We're supposed to be teaching them to eat healthy and yet you can't do it if everything is boxed and bagged and frozen and junk food."

Carol Pehotsky:

Goosebumps. What a fantastic example. And so that nurse has that question and is interested in it, but it can be intimidating. What can that nurse's leaders or the organization do to really help draw out that question, but then help that nurse take the next step?

Dr. Nancy Albert:

Evidence-based practice is a process. It's not one and done. And there are many steps along the way. What we've done here, and I think other people have as well, is create a center of excellence for evidence-based practice. On ours, it's all web-based. It's all electronic. It's on our intranet. And we have a bunch of diagrams and algorithms for our nurses, and it takes them step by step. You know, the first part is what is your question? What is your issue? What's your need? Then reviewing the evidence, then determining if we need to change practice. And then if we need to change practice, then you get into an evidence-based practice implementation project. And that could be daunting all in and of itself. But at least we could see the steps to get to the end game, and the end game is, am I practicing the highest quality evidence-based way?

So, it is a process. It takes many steps along the way. They may not all be easy steps. You need the support of your leader, your boss, possibly. And support from your institution. Is somebody offering, for example, a fellowship or a grant or a program to allow you to spend time to create a project, implement something, and then evaluate it? The evaluation alone could take a lot of time and effort. So, it's not a quick process usually, unless you review the literature, you find out your policy matches the literature exactly, there's no new literature, and then you know you're good to go.

Carol Pehotsky:

That's probably not a very likely scenario though. <Laugh>

Dr. Nancy Albert:

It is and it isn't. It just really depends. There are some areas of clinical practice where there is no evidence other than expert opinion.

Carol Pehotsky:

Sure.

Dr. Nancy Albert:

When it's expert opinion, I've actually sat at the table for some organizations when they're developing their guidelines. People need to understand it's not usually one expert. It's a whole committee. There's maybe 20 of us sitting at the table arguing with each other and determining what that expert opinion ought to be to make sure that we're putting out the best evidence.

Carol Pehotsky:

So that first step probably has a lot to do with, I have this idea in my head, how do I formulate the question? We're so fortunate to have you and your team helping nurses do that. What advice do you have for that nurse that has sort of this vague, how do I formulate my question, so when I start looking at the research, it matches what I'm really looking for?

Dr. Nancy Albert:

What we usually say to people is there's a background and a foreground to a research question or even any question about practice. The background is all the fluff and stuff around the topic so it may not be your topic specifically. In my world of heart failure, maybe I have a question about heart failure, but before I even get to that question, I need to understand the background. So, if a nurse isn't really well connected with the background of the problem, they need to go there first so that they understand the diagnosis, the issue, the theme, and what’s going on. And then they jump into the foreground, which is actually the question itself to see how it fits in with everything else. That's probably the best way to get started. Again, it takes a literature review. And again, literature reviews are not always easy for people who haven't done them.

But once you've completed a literature review and you understand the steps, it can be very manageable and it can be fun, especially if you're somebody with an inquiring mind, you're curious and you really want to get to the bottom of the problem.

Carol Pehotsky:

And we're so very fortunate. I've shouted out this team on previous podcasts, but our Cleveland Clinic librarians are an amazing, untapped resource. And if you, listeners, are not part of Cleveland Clinic, you still probably have a library. It might not be physical anymore but connect with your librarians. They are so eager to help and they're so skilled at, here's what I'm looking for. They can take some of those ideas and really help get you that evidence you're looking for.

Dr. Nancy Albert:

I agree completely. And in addition to librarians, look for people that you work with. It could be a clinical nurse specialist. It could be somebody who just finished college and went back for a DNP and had to take some courses on evidence-based practice. It could be a research scientist. It could be a provider, a physician, an APP who really is steeped in the literature and can help weigh through some of the issues so that you really get to the question that's important to you.

Carol Pehotsky:

So, the nurse has worked with your team, refined their question, worked with librarians, worked with others. They've come up with the literature, they've looked at the evidence, and they've identified there's a gap. Again, daunting. Step number, what are we on? 15 here? But so, what advice do you have for nurses there? They know they want to do something with it. Where do they go next?

Dr. Nancy Albert:

I would say the next step for them is to seek support because if you have an important question, you don't want to waste time flailing around trying to figure out what to do. And it takes a village. So take advantage of the village. At Cleveland Clinic, we're very fortunate here. We have a team of research scientists. These are nurse scientists who all understand the steps of evidence-based practice because it's the first step of conducting research as well. But not all evidence-based practice projects need to be researched. So, for people who are afraid of research, it doesn't always need to be research. It can be an implementation project that uses quality improvement or program evaluation. It doesn't need to be research. But I think if you connect with the right people, you'll save time and steps and you'll get to the nuts and bolts of what you need to do much quicker without the headache of feeling like you're running around in circles and chasing your tail.

Carol Pehotsky:

So often we identify a problem and there's a fix it now.

Dr. Nancy Albert:

Mm-Hmm.

Carol Pehotsky:

And sometimes that fix is temporary and can't be sustained. Sometimes the fix ends up being the right long-term thing. But often we aren't taking the time to do a little bit of baseline and move forward. How can nurses work with their leaders to really set up a structured plan so that we can say this implemented and made a change?

Dr. Nancy Albert:

Right. You bring up what happens day in and day out. People want a quick fix. They come up with a solution. They of course think it's theirs, so it's got to be great. And then they implement whatever it is. The problem is, is they don't evaluate the outcomes. And it could be that we're wasting time, energy, possibly cost -

Carol Pehotsky:

Yes.

Dr. Nancy Albert:

In implementing something that really doesn't work. Now you have to try it to see if it's going to work. But part of the problem we have in our society today, not just here at Cleveland Clinic, but it would apply anywhere, is that we've got this bell curve of adopting change. And on the far-left side are the early adopters and the very early adopters, the innovators. And they account for only 15%. When you finally get up to the top of the curve, that's when people really start buying in and doing what needs to happen. So even during that implementation phase, you need to have people who are willing to jump in early and be an early adopter.

Follow along with the new plan, do it every day, all the time, whenever you're supposed to, because we know what happens. Somebody introduces something new. We start doing it because the boss is watching over us. And then we stop as soon as no one's watching us because it's easier to go back to what's comfortable, which is the old habit. Making change happen can be difficult. And you can't get to the evaluation phase until you've fully implemented the intervention to really assess if it's worthy. If 90% of the time people aren't doing it, the only people doing it are those early adopters, two or three people once a week, then it's difficult to find out if it ever works. And when people say it didn't work, it's because they really never implemented it.

Carol Pehotsky:

Then you think about how much time and effort you're spending on the other half of the curve that are actively fighting innovation. Why are you doing this too?

Dr. Nancy Albert:

You’ve got the slow adopters, the people that will finally give in when they see the benefit or they're forced to. And sometimes it's easy if it comes from your CEO or the CNE and people are saying, "You must do this because we've got strong evidence and we all are forced to jump in." That's almost the easiest scenario because now you've got the early adopters and the very late adopters jumping in together because they know they must. But most evidence-based practice projects are not quite that strict, and that's where we get into trouble.

Carol Pehotsky:

So, we've already talked about some barriers in terms of comfort level with evidence-based and having some resources there and sometimes the eagerness to just implement. What are some other barriers that nurses face and how can nurse leaders, nurse colleagues, and organizations help mitigate those barriers?

Dr. Nancy Albert:

Some other barriers are cost. Sometimes there's a cost to implementing something. You may have to purchase something. You may have to buy equipment, buy time to make it happen, nurses time so that they can plan things out. That's one really important barrier that we need to overcome. There is also the know-how and knowledge. Many nurses may not know how to implement change. And so having people understand the steps of change, you know, making sure everybody's educated, making sure that you spend time not just jumping in and two weeks later saying, "Oh, it didn't work." It may be that at the end of two weeks, only 10 people out of 80 know what you really want them to do. You've got to follow those natural steps of implementation processes, have that time where people can ask questions. You're giving in-services, training, teaching and the leader has to allow for that time.

This is when huddles could be important reminders so that everybody's on the same page. And then the quality monitoring is really important because oftentimes, again, it's easy to fall back to what you're used to, especially if you're having a bad day; it's a busy day, it's just quicker to do what I know versus trying to figure out what I don't know. So, I think it's really about education, nurses' knowledge, nurses knowing why they're making a change. Oftentimes, the people who know the answer to why are people who did all that background work, but they may not be the one implementing the change, especially if it was started on another unit, now it's coming to your unit. So, somebody behind the scenes needs to have talking points, all the right information so people could get that why and understand that value add. And then we also know that we're never queens and kings in our own kingdom or queendom.

<Laugh> So sometimes if you're the person leading it and they know you as the boss or know you in a different role, they may not trust your knowledge and evidence because you're just one of the team.

Sometimes, you have to bring somebody in. It could be somebody from outside, somebody from a department that really understands, can answer questions, allow people to vent and think about all the issues so that you could maybe even overcome problems before you get started.

Carol Pehotsky:

Let's say it all works. Congratulations. The nurse has worked with their leaders. Their unit is very successful. It's time to share it with the world.

Dr. Nancy Albert:

Yes, that's really important. We can't have evidence-based practice if the evidence is not disseminated, right? So, dissemination is truly important. There are many ways of disseminating. The easiest one is to create a poster and show it at a national meeting because you just stand by the poster. All the words are in front of you. You don't have to pull things out of your head. You could also do an oral presentation. But the most important, and of course the only durable method of dissemination is to publish. At Cleveland Clinic, we really push our nurses to publish not just research, but also evidence-based practice projects, QI projects, continuous improvement projects that all show benefits and change because other people out there are in the same boat and want to learn from what's in the literature. Writing for publication though can be difficult for somebody who really has not taken an English class for 40 years…

Since maybe high school or whatever. And so, it always helps to have people who understand the writing process, know what journals want, because it's a formula, it's an academic type of writing. And having people behind the scenes to help can really save time and effort. But it does take time and leaders need to understand that they need to give their nurses time, even if it's small segments so that they can do the work.

Carol Pehotsky:

Another great example of reaching out for help, somebody who's finished their DNP or PhD or if you don't have a formal office, reaching out to people who have been there to help you with that journey.

Dr. Nancy Albert:

So true. And, we're very fortunate in today's nursing world, not just here, but in many hospitals, especially those that have magnet designation because they usually have people, they have at least one resource, if not a team, who could help them with writing, help them with even if the evaluation process. Oftentimes, we get statistics back and the nurse looks at it and says, Nancy, you have to teach me. I don't even know what I'm reading. Of course, I want them to be able to talk the talk in their own voice, and in order to do that, we have to teach them how to do that.

Carol Pehotsky:

So as a nurse leader, there's a lot on them too, right? They have to help manage this change. They have to be in support of this. What can nurse leaders do to really help welcome that work and the change?

Dr. Nancy Albert:

Leaders can do a lot because they’re the ones who help foster evidence-based practice. I think the first thing is leaders need to understand continuous improvement, the processes, the steps, the visual management, the whole package so that they can use continuous improvement to enhance evidence-based practice. The other thing I think leaders need to do is to have an inquiring mind. When you have an inquiring mind, instead of saying, "Oh, I don't have time for this right now," or, "I'll get to it later," you start to change your mantra to, "That's a really important question. Let me write it down. Let me take those next steps." And maybe it's the leader who calls the librarian to get the information to start sharing with their teams. I think it's really important for people to think about critical thinking and how they can help their nurses to have those critical thinking skills.

One of the simplest ways to do it is to post good articles on a board in the lounge. There's always somebody sitting around who's going to want to read an article, and especially if it's important to that unit, that team, in terms of patient care. Brief in-services by experts are always welcome. Now, if you can't afford to bring a company rep in or we don't want to have company reps come in because of potential bias, then find a provider, find somebody who's an expert who can really talk the talk. I think staff welcome it. And it helps them to think of themselves as being professionals versus just coming in, doing my job every day and going home, because the leader is actually spending time to bring people in to help them with their own growth and development. I think that's really important. And then I think it's important for leaders when they meet with individuals or even at staff meetings to please say, "What are we missing in our work every day? What should be doing differently? Can we do things differently? How can we simplify work? How can we make it more important or get things done in a timely manner?" And it could be that those are the facilitators of getting EBP started.

Carol Pehotsky:

It sets that culture for an appreciative inquiry.

Dr. Nancy Albert:

Right. And if because of the appreciative inquiry, people will come back to the nurse saying, "Can we do this? How can we not do that?" And then the nurse leader, although they may be thinking, "Oh my God, what did I get started here?" <laugh> What they really should be thinking of is, Who do I call? Who do I know? Who are the right people I could contact so those people can help my nurse bring things to life? And we're very fortunate here at Cleveland Clinic, especially on main campus, the nurse leaders call me all the time saying, "I have a nurse who wants something." I don't even know the name of the nurse half the time. I say, "Send them over to me." It's just knowing who to call, when to contact people so that you're not feeling the burden as a leader, but you're helping to develop professionalism and a growth mindset for the team.

Carol Pehotsky:

So, before we call it a day, I'd like to flip to some fun questions. What's the best place you've traveled to?

Dr. Nancy Albert:

When I think about the best place I've traveled to, I always like to go to places that are unique. And one of them was a work trip, but it was really quite unique. I went to China, to Beijing to give a talk at a heart conference. And before I left, the physician who invited me literally sent me an email saying, "What do you want to do when you're here?" And I looked up the top seven things to do when you're in Beijing, China, including the Great Wall, Tiananmen Square, just all the different things. And they took me everywhere. They did everything on my bucket list for China. I think the Great Wall was a hugely fascinating experience. I'm so grateful that they invited me to speak and allowed me to go there and gave me some escorts so I could get there. It was a wonderful day and I'll never forget it. That's one of the really unique places I've been.

Carol Pehotsky:

That's amazing. And finally, as you know, we've revised our organization's values this year. So now our three values are serve with heart, succeed as one team, and shape the future. I've asked all of our other guests this year, I'm going to ask you the same question. Which of those three resonates with you the most and why?

Dr. Nancy Albert:

I think all three resonate, but the one that I love the most would be shape the future because I'm a research scientist and somebody who's always looking at how we can give the best care possible, how we can make changes to do that. And with AI and all the other implementing factors we have going on right now, it's going to be an interesting time. And I think nurses can shape their future. We just need to be able to jump in and get started.

Carol Pehotsky:

Wonderful. Thank you so much for joining me today.

Dr. Nancy Albert:

Thanks so much for having me, Carol.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing. Until next time, take care of yourselves and take care of each other. The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.