Particularly from a systems perspective, use of evidence in health care is no longer an option (Porter-O’Grady & Malloch, 2008). It must become the habit of leaders and clini- cians. If use of evidence, or empirical research data, is truly to make a difference, it must be embraced at all levels, from point of contact to the broadest systems perspective.
Furthermore, evidence must be implemented and evaluated from the perspective of all aspects of leader, clinician, and patient experiences. The effects or outcomes of evidence cannot be evaluated from any sole viewpoint. Evidence must be integrated and synthe- sized into the practice experience, into the patient response, into the entire caregiving or healing event. “Evidence of making a difference is . . . evidence of collaboration, inte- gration, and systemization of all the related contribution” (Porter-O’Grady & Malloch, 2007, p. 54).
According to Melnyk and Fineout-Overholt:
Evidence-based practice is the conscientious use of current best evidence in making decisions about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). It is the problem- solving approach to clinical practice that integrates:
· A systematic search for and critical appraisal of the most relevant evidence to answer a burn- ing clinical question
· One’s own clinical expertise
· Patient preferences and values (2005, p. 6)
The current sweeping movement toward evidence-based practice has been largely pro- moted by academics and targeted to clinicians in direct patient care. Nurse leaders have long been accustomed to the challenges of promoting research utilization within health- care organizations. Current care settings are often laden with practices of habit, tradi- tion, and routine. Nevertheless, Porter-O’Grady and Malloch (2008, pp. 185–186) warned against joining “the evidence-based practice fad,” that the current surge toward use of evidence should “not exclude other nonquantitative sources of evidence,” and cautioned not to oversimplify clinical nursing knowledge. It is important as we embrace evidence- based practice that we not lose, but rather empirically document, other significant ways of knowing and practice such as clinical intuition, attention to individual differences, the art of practice based on clinical expertise, and professional autonomy (Tracy, Dantas, &
Upshur, 2003). Indeed, Råholm (2009, p. 168) “challenged the wisdom of basing the prac- tice of leadership on a narrow, reductionistic understanding” of evidence and defended the meaning of context in the definition of evidence.
Although the development, discovery, and use of evidence for clinical practice con- tinue to mount, there is a continuing need to close the gap between evidence and practice (Hay et al., 2008). In most clinical settings, truly integrated evidence-based practice is still not second nature. Indeed, Shirey (2006a) cited data that suggest that 85% of current practice is not based on scientific evidence. Thus, only about 15% of nurses consistently practice within an evidence utilization paradigm, while we have other data showing that patient outcomes are improved by 28% when evidence-based practice is in place (Melnyk, 2005; Shirey, 2006a).
There is a movement underfoot to emphasize the role of the nurse manager and leader in executing the appropriate use of evidence into practice. Unfortunately, we have lit- tle evidence on how this is best accomplished. Gifford, Davies, Edwards, Griffin, and Lybanon (2007) reviewed the literature on what may constitute effective nursing leader- ship in leading the charge toward evidence-based practice. They found the following leadership activities that influenced nurses’ use of research: managerial support, policy revisions, and auditing. They also found that, often, organizational practice structures impose barriers to both leaders and nurses to access, promotion, and ultimate use of evidence. They concluded that “both facilitative and regulatory” measures for leaders are necessary and proposed research that links leadership to promote evidence-based practice and relates it to patient outcomes. DeSmedt, Buyl, and Nyssen (2006) found that implementation of evidence-based practice is best facilitated by clear communica- tion, provision of summaries of evidence, easily understood protocols, and Web-based databases accessible within the work environment in addition to leaders themselves who practice more with evidence and less from sheer personal experience. It is the role of the
leader to remove barriers and provide resources for clinicians to access the best research evidence. Such practice often represents a change of culture and total integration of use of evidence in clinical communications (Hannes et al., 2005).
It continues to be largely the responsibility of the leader to break the path, to facilitate the culture for evidence-based practice to be comprehensive throughout all systems.
Use of evidence must simply become a way of doing and being in clinical practice.
Indeed, leadership and operational structures must align to “place clinical practice at the center of the organization’s purpose and build the structures and processes neces- sary to support it” (Goad, 2002; Porter-O’Grady & Malloch, 2008, p. 177). The entire organizational culture, especially its leadership, must support the ongoing practice of evidence-based decision making, actions, and evaluation of outcomes. Holloway, Nes- bit, Bordley, and Noyes (2004) and Quinlan (2006) pointed out that although the litera- ture may offer methods to teach evidence-based practice, traditional teaching methods for integrating evidence-based practice do not lead to sustained, integrated change. This can be done only by setting standards, clearly outlining role expectations, and support- ing practices that use and promote the wise use of evidence. Leaders must incorporate the language and concepts of evidence-based practice into the organizational mission and strategic plans, establish clear performance expectations related to the use of evi- dence, integrate the work of evidence-based practice into the governance structures of the system, and recognize and reward performance and outcomes based on the use of evidence (Titler, Cullen, & Ardery, 2002). The transformational leader coaches and pro- motes collaboration among clinicians, patients, and researchers to create a “professional culture and transformed environment of care in which decisions are made on the basis of best evidence, patient preferences and needs, and expert clinical judgment” (Worral, 2006, p. 339).
Thus, it is well established that evidence-based practice will not thrive without leader- ship support (Berwick, 2003; Carr & Schott, 2002; Everett & Titler, 2006; Shirey, 2006a;
Stetler, 2003). Leaders must provide access to evidence, authority to change practice, an environment of collaboration, and policies that support evidence-based practice (Everett
& Titler, 2006; Thomson O’Brien et al., 2002; Titler, 2004).
With all of our attention to the trend of the past decade toward evidence-based prac- tice, although we have become more careful to seek and use research for aspects of patient care, we have largely neglected the need to generate and use evidence spe- cifically related to leadership practices. We have a growing body of clinical guidelines used internationally (Hutchinson, McIntosh, Anderson, Gilbert, & Field, 2003; Mäkelä
& Kunnamo, 2001), but we do not have an empirically tested database for best prac- tices in leadership. Vance and Larson (2002) reviewed nearly 20 years of research on leadership outcomes in health care. Of 6,628 articles, only 4% was data based, and 41%
was purely descriptive of the demographic characteristics or traits of leaders. Thus, we know little about either what actually works for leaders or what or how to teach effective leadership (Welton, 2004). We are just beginning to document and promote models for evidence-based decision making in leadership (Nicklin & Stipich, 2005). Porter-O’Grady and Malloch (2008, p. 182) warned, “There is not a long-term, time-tested script upon which leaders can depend. They are writing a new script as they travel, which is always the conditional circumstance of a new reality. Leaders must now be inventive, stretching the limits of experience with the efforts of knowledge creation, generation, application, and evaluation.” The next generation of transformational leaders must pick up the task of discovering and utilizing best evidence for successful leadership.