Overcoming Barriers to ImplementingEvidence-Based PracticeA Collaboration Between Academics and Practice

Pamela Rickbeil, MS, RN, ACNS-BC ƒ Joyce Simones, MS, EdD, RN

This article describes twocollaborative paired studentYpreceptor

efforts. One project resulted in the implementation of a

hospital-wide oral care protocol, and the second enhanced

the admission assessment process for adult patients at risk

for respiratory compromise after sedation and/or receipt of

narcotic analgesia. Recommendations for staff development

are addressed

The benefits of implementing evidence-basedpractice (EBP) are numerous. Increases in pa-tient safety, reduction in variations of care, and

increases in positive patient outcomes have all been re-ported as positive outcomes of EBP (Fink, Thompson, &Bonnes, 2005; Leasure, Stirlen, & Thompson, 2008; Nay,2003). The literature reveals that implementing EBP hasproven to decrease the length of time between discoveryof effective interventions through clinical research andthe application of these discoveries at the bedside (Cor-rigan, Greiner, & Erickson, 2003). The excitement thataccompanies both sound decision making and confi-dence gained by applying ‘‘best practice’’ by nursingcolleagues has strengthened the level of professionalnursing practice (Gennaro, Hodnett, & Kearney, 2001).The literature also shows that implementation of EBP ishard work and requires more than desire and excite-ment. Successful implementation of EBP requirescommitment by practitioners and support from adminis-trators and nurse educators.

Evidence-based practice has been described as ‘‘the in-tegration of best evidence with clinical experience andpatient values’’ (Sackett, Strauss, Richardson, Rosenberg,

& Haynes, 2001, p. 1). Best evidence is not limited to clini-cal and experimental research studies but also includesexpert opinion and clinical expertise. Each patient bringsa different perspective and value system, which mustbe included in the healthcare decision-making pro-cess (Pape, 2003). The literature demonstrates thatdespite best intentions, successful implementation of EBPis doomed to fail unless the organizational culture is pre-pared to change through strengthening facilitators andreducing barriers.

Facilitators are identified as factors that support andencourage the development and implementation ofEBP (Parahoo & McCaughan, 2001). Significant facilita-tors have been identified as manager support, time,guidance, and institutional support of nurse educators.Barriers are identified as obstacles that discourage thedevelopment and implementation of EBP. Barriers tosuccessful implementation of EBP (Parahoo, 2000) mostcommonly cited by nurses include lack of time, lack ofinterest of nursing staff, lack of knowledge of the EBPprocess and change theory, and lack of support fromothers. Many nurses indicate that they do not understandthe research process and are incapable of evaluating thequality of research and statistical analyses. Nurses believethat they lack the necessary skills and authority to changepatient care procedures within the institution. Another bar-rier is the perception that the work culture is unwelcomingto new ideas and suggestions (Pravikoff, Tanner, & Pierce,2005).

Research has provided recommendations to enhancefacilitators and diminish barriers. Recent recommenda-tions that enhance EBP efforts include enhancing staffnurse skill in critically analyzing research studies, buildingpractice policies and procedures that cite EBP references,and developing staff nurse expertise in using computers,databases, and search engines. These are all responsi-bilities and talents of the staff development specialist(Gerrish & Clayton, 2004; Krugman, 2003).

The staff development specialist is often identified toinitiate and lead EBP and research utilization projectswithin a hospital setting; this role is instrumental to thesuccess of dissemination of EBP throughout the organi-zation. Omery and Williams (1999) reported ‘‘unless

Pamela Rickbeil, MS, RN, ACNS-BC, is Clinical Nurse Specialist, De-partment of Education and Professional Development, Saint CloudHospital, Minnesota.

Joyce Simones, MS, EdD, RN, is Professor, Department of NursingScience, Saint Cloud State University, Minnesota.

The authors have disclosed that they have no significant relationship with,or financial interest in, any commercial companies pertaining to this article.

ADDRESS FOR CORRESPONDENCE: Pamela Rickbeil, MS, RN,ACNS-BC, Saint Cloud Hospital, 1406 6th Ave. N., Saint Cloud, MN56303 (e-mail: rickbeilp@centracare.com).

DOI: 10.1097/NND.0b013e31824b4141

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nursing leadership believes in research utilization andpromotes a culture that supports its activities, research uti-lization fails to become a lived value’’ (p. 55). Paramonczyk(2005) argued that ‘‘the responsibility to develop strategiesdesigned to encourage and facilitate nurses’ participationin research-related activities rested with the organization’’(p. 12). The staff development specialist needs to be the‘‘champion’’ in the organization.

Research studies have shown that the most frequentbarrier of EBP implementation has been lack of organiza-tional support and that organizations have the respon-sibility to develop strategies to promote EBP (Funk,Champagne, Wiese, & Tornquist, 1991a, 1991b). Funket al. (1991b) recommended strategies to confront thesebarriers, which include empowering role models and es-tablishing collegial relationships (formal or informal) withuniversity faculty. Specific responsibilities of the staff de-velopment specialist would include (a) coordination ofadministrative details such as arranging meetings andproviding copies of materials, (b) identifying practiceconcerns, (c) providing access to resources such as theCochrane Library, (d) collaborating with research expertsin the agency, and (e) motivating staff to participate in thisrelationship (Quinlan, 2006).

Stone and Rowles (2007) reported that when nursingstudents provided education to staff nurses on researchpertinent to frequently occurring patient concerns, staffnurses became engaged in that research and related top-ics. A benefit frequently cited by staff nurse preceptorswas the positive educational impact the students had onthem. This collaboration resulted in policies and pro-cedure changes to reflect current evidence-based findings.Students in this study also gained valuable experience inreal-life patient care and unit challenges.

Schoenfleder (2007) stated that when students in agerontologic nursing experience were paired with regis-tered nurse preceptors, both nurses and nursing studentsbenefited. The students were required to create ‘‘tipsheets’’ based on the current evidence of identified patientcare problems. These tip sheets were then distributedto areas where the students worked with preceptors.Frequently, students used evidence-based protocolsdeveloped by the University of Iowa Gerontologic Nurs-ing Interventions Research Center in their tip sheets. Byciting the recommended practice change with the sourceof the EBP guidelines, staff nurses grew in their awarenessof EBP and increased their familiarity with EBP toolssuch as the Gerontologic Nursing Interventions ResearchCenter guidelines.

Leasure, Stirlen, and Thompson (2008) reported en-couraging outcomes as a result of collaborative effortsbetween students and staff nurses in the area of expand-ing EBP efforts to staff nurses. As a final assignment,students bridge research to clinical practice in their re-

view of agency clinical procedures or protocols. Thestudents used research or EBP to either support or refuteselected current agency practices. Students then reportthe findings of their assignment to the staff nurse. It ap-pears that such assignments develop important skills offormulating questions, obtaining evidence, critiquingevidence, and summarizing evidence to make recom-mendations for practice.

Although this work provides promising evidence ofthe benefits of studentYnurse collaboration, no articleshave looked at the effectiveness of large group studentprojects conducted with staff nurses. Therefore, this arti-cle reports the outcomes of two collaborative evidence-based projects by groups of nursing students and groupsof staff nurses under the facilitation and guidance of thestaff development specialist.

A collaborative EBP project was formed with two aca-demic nursing programs and a hospital. The director ofthe intensive care unit (ICU) reported a safety alert relatedto oral care in the critically ill population (American Asso-ciation of Critical-Care Nurses, 2007). The practice alertrecommended development and implementation of acomprehensive oral hygiene program for patients in criticalcare and acute care settings. The practice alert advised thatan ICU program include specifics on the developmentof an oral care protocol.

It was hypothesized that perhaps other patient popu-lations would also benefit by implementation of a similaroral care protocol. Members of the research committee,which included nursing directors, staff development spe-cialists, and faculty from two baccalaureate nursingprograms, suggested conducting a literature review andbeginning an EBP project to provide a rich leadershipexperience for senior nursing students. It was proposedthat nursing students from the two schools work togetherto complete the project, including researching current bestpractices regarding oral care, collecting information regard-ing the current practice of oral care from nursing person-nel, and then providing education on best practices of oralcare to nursing personnel throughout the hospital.

The director of the ICU was established as the pointperson for the technical aspects of this project. Nursingfaculty from the research committee were the contactsfor the two nursing programs. The staff developmentspecialist coordinated the administrative details becauseshe had previous experience as the liaison between thehospital and the nursing programs. Meetings wereplanned throughout the semester for all 20 student par-ticipants. Students from both nursing programs weredivided into subcommittees, which included literaturereview (both for pediatric and adult populations), surveyconstruction, development of education resources in-cluding PowerPoint and posters, and hospital policydevelopment.

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Students found specific evidence-based literature re-lated to benefits of oral care for both adults and pediatricpatients in nearly all patient care areas of the hospital. Asurvey was constructed based on the specific needs ofthe hospital (e.g., which level of staff provided oral hygienemost frequently, use of hospital supplies, and current oralcare practices). A random sample of eight registerednurses, eight licensed practical nurses, and eight nursingassistants completed the survey. Staff development specia-lists assisted in the distribution and collection of thesurveys. The completed surveys revealed that althougheffective oral care was completed consistently throughoutthe hospital, there was need for new products (e.g., softertoothbrushes). Students who were involved in the de-velopment of educational resources worked with theinformation technologists and unit staff development spe-cialists in the hospital to develop educational tools.Information was integrated into a new oral care protocolthat followed the hospital format. Twice, students pre-sented their findings to the hospital clinical nurse practicecommittee. At the first meeting, staff nurses provided con-structive feedback, and the students then incorporated thisinformation into the next draft of the protocol. At the sec-ond meeting, the protocol was approved and added to thehospital’s policy and proceduremanuals. The product spe-cialist for the hospital took the lead on refinement of theoral care protocol. Students taught staff nurses and nursingpersonnel about the new oral care protocol as well as theevidence that supported this practice. New supplies suchas denture tablets, denture brushes, and softer tooth-brushes were purchased and supplied for patients on thenursing units. Students also developed a computer-basedtraining module on this topic that staff viewed as a compo-nent of their annual education.

The next semester, a group of four postbaccalaureatenursing students initiated another project. A patientsafety alert regarding patients with sleep apnea who re-ceived narcotics and sedation had recently been released(American Society of Anesthesia, 2005). Improving iden-tification of this vulnerable population and reducingpotential adverse events for patients with diagnosedsleep apnea were chosen as the EBP project. The staffdevelopment specialist was designated as the hospitalpoint person for this EBP project.

The second EBP project began with an investigationof best practices with sleep apnea patients receiving nar-cotics and/or analgesia. Nursing staff were surveyed abouttheir knowledge of sleep apnea, continuous positive air-way pressure, and patient response to sedation andanalgesia. Respiratory care staff and staff development spe-cialists were consulted on current practice, asked theiropinion on staff nurses’ competence with continuous pos-itive airway pressure, and asked their suggestions forprocess improvement. After gathering all the evidence, a

draft of a policy was developed. Students presented tothe Nursing Research Committee the evidence collected,a draft of a potential new policy, and personal experienceswith patients they witnessed experiencing breathing dif-ficulties after sedation and analgesia. In addition to Re-search Committee members, student preceptors from thevarious units and the infection control nurse attended thestudent presentation. The policy draft and supplementalevidence-based data were then forwarded to hospitalnurse leaders from units with this population. This projectresulted in additional questions being added to the PatientAdmission Assessment forms. Upon admission, patients arenow routinely asked if they use a ‘‘breathing machine’’ athome, which, when answered positively, results in a respira-tory care consultation to further assess the patient’s knowl-edge and skill in managing the equipment. The studentsprovided staff education to both unit staff and those who at-tended the research committee meeting. Lastly, a poster wascreated for Nurses Week to highlight this vulnerable popu-lation and impart the evidence used to improve patient care.

Many lessons were learned by both clinical and aca-demic staff on these two projects:

n Identify one lead person from both the student groupand from the hospital staff to assist in communicationand to coordinate efforts. A staff development specia-list is in an ideal position to serve in such a role.

n Flexibility is required in expectations from both aca-demics and practice. A poster at the completion of thesleep apnea project was one such expectation. Be-cause the changes had not fully been implemented,development of a poster at the original assigned timewould have been premature. Instead, a poster wasdeveloped at a later time after implementation ofthe practice changes.

n As with any joint project, all participants from boththe hospital and academic programs must be ac-tively involved.

n The project focus should be realistic for the size ofthe group of students and time requirements. Fa-culty need to determine if the scope of the projectis appropriate to be completed during the allottedtime. The project must also meet the student learn-ing outcomes of the course.

n If more than one school is collaborating on a project,the students from both schools should have the sameguidelines and expectations. An example is jointcompletion dates for all components of the project.

n Networking and collaborative work takes time. Stu-dents from both programs did not know each otherbefore the project began; it took time for joint com-mittees to form effective work groups.

n An interdisciplinary group that included physicians,therapists, nurses, and students in this project mayhave been beneficial.

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n More detailed statistical analysis than collected onsurveys would provide stronger evidence to sup-port practice changes.

This article supports the earlier literature that collabora-tion between academics and practice can successfullyovercome barriers to successful implementation of EBP.Student nurses provided expertise in searching the litera-ture and offering an unbiased view of research findings.Hospital staff nurses identified significant problems andknew hospital processes. Staff development specialistsprovided guidance and institutional support to maintainthese changes in practice.

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