evidence-based management: a literature review

Evidence-based management: a literature review

SAM K. YOUNG B A ( H O N S ) , R N , P G D I P

Researcher, SOVRN Project, Doncaster & South Humber Healthcare NHS Trust, St. Catherine’s Hospital, TickhillRoad, Doncaster DN4 8QN, UK

Introduction

Evidence-based medicine and evidence-based practice

(EBP) are terms that became synonymous with clinically

effective healthcare (Lockett 1997) and became

increasingly regarded as the solution to spiralling health

costs (Hewison 1997). The incumbent government also

embraced the concepts, pledging that the �modern Ædependable� NHS would have �new evidence-based

National Service Frameworks� and �a new National

Institute for Clinical Excellence� (Department of Health

[DoH] 1997). These initiatives, among others, had the

stated aims of ensuring consistent access to services, cost-

effectiveness and quality of care. However, in order to

help fund these improvements, it was succinctly posited

that �management costs will be capped� (DoH 1997).

Hence the question emerged of whether an �evidence

base� for management decisions could also lead to

Correspondence

S. K. Young

SOVRN Research Project

School of Nursing & Midwifery

University of Sheffield

301 Glossop Road

Sheffield S10 2HL

UK

Y O U N G S. K. (2002) Journal of Nursing Management 10, 145–151Evidence-based management: a literature review

This paper presents a review of evidence-based management (EBM), exploringwhether management activities within healthcare have been, or can be, subject tothe same scientific framework as clinical practice. The evidence-based approach wasinitially examined, noting the hierarchy of evidence ranging from randomizedcontrol trials to clinical anecdote. The literature varied in its degree of criticism ofthis approach; the most common concern referring to the assumed superiority ofpositivism. However, evidence-based practice was generally accepted as the bestway forward. Stewart (1998) offered the only detailed exposition of EBM, outlininga necessary �attitude of mind� both for EBM and for the creation of a researchculture. However, the term �clinical effectiveness� emerged as a possible replacementbuzz-word for EBM (McClarey 1998). The term appears to encompass the senti-ments of the evidence-based approach, but with a concomitant concern for eco-nomic factors. In this paper the author has examined the divide between those whoviewed EBM as an activity for managers to make their own practice accountableand those who believed it to be a facilitative practice to help clinicians with evi-dence-based practice. Most papers acknowledged the limited research base formanagement activities within the health service and offered some explanation suchas government policy constraints and lack of time. Nevertheless, the overall em-phasis is that ideally there should be a management culture firmly based in evidence.

Keywords: clinical effectiveness, evidence-based management, evidence-based practice,

nursing management

Accepted for publication: 14 September 2001

Journal of Nursing Management, 2002, 10, 145–151

ª 2002 Blackwell Science Ltd 145

increased quality, effectiveness and reduced costs,

negating the need for an imposed capping of costs.

Within the author’s own practice as a preregistration

student nurse on an acute medical ward, it was also

observed that although the ward manager usually

offered a scientific rationale for clinical decisions, no

theoretical underpinnings were evident for managerial

decisions. In this scenario the manager cited his

experience of working with people and receiving

directives from his own line manager as the determi-

nants of his management practice. �Evidence-based

management� was not a term that had been knowingly

encountered.

It was therefore decided to explore this concept of

evidence-based management (EBM) with regard to

how widely it has been recognized, how it has been

perceived, and if EBM is achievable (or even desirable)

within healthcare. This review of the literature will

highlight the key issues addressed in the texts as well

as emphasizing the emergent recommendations for

practice.

Search strategy

This review of the literature focused upon the combi-

nation of the terms �evidence-based� and �management�,with the aim of encompassing articles that considered

management issues alongside evidence-based practice,

evidence-based medicine, evidence-based nursing or

indeed evidence-based management. Since evidence-

based medicine �has become increasingly fashionable�(Stewart 1998), the use of a single set of search terms

was deemed appropriate for the topic under investiga-

tion. The semantic differences between the words

�research� and �evidence� were considered significant

enough to focus purely on the latter term.

It was decided not to use the Internet to search for

articles, since the comprehensive guide to accessing

evidence-based information, Netting the Evidence

(School of Health and Related Research 1997), did not

include any sites that appeared to encompass evidence

for management decisions.

Computerized searches were undertaken using

Medline, ASSIA and CINAHL. CINAHL and Medline

were chosen to cover the health-related journals, while

ASSIA was selected to encompass publications that

were more management or policy orientated. Articles

were selected according to their relevance to manage-

ment issues, since many articles appeared to be focused

upon the �management of� particular clinical condi-

tions. It is was felt by the author that saturation point

had been reached due to the eventual repetition of

issues raised and authors cited in the particular articles

examined.

Definitions and expositions of the evidence-based approach

The majority of articles that cited examples of practice

based upon evidence began with a definition of EBP,

exemplifying the semantic difference between practice

based on evidence and practice based merely on

�research�. Lockett (1997, p. 11) offered one such defi-

nition of EBP:

�The process of systematically finding, appraising,

and using contemporaneous research findings as a

basis for clinical decisions.�White (1997) stressed that evidence-based, as opposed

to research-based practice, involved a hierarchy of evi-

dence, with randomized control trials (RCTs) being the

best form of evidence. Clinical anecdote was said to rest

at the bottom of the hierarchy. Lockett (1997) cited the

thalidomide disaster of 1961, and the subsequent

necessity to rigorously test pharmaceutical drugs, as a

major impetus for using RCTs as best evidence.

Hewison (1997) and Stewart (1998) both described

the emerging concept of EBM whereby managers use

the principles of EBP to justify their own actions as

managers. Stewart (1998) was more explicit in her

description and was the only author that detailed an

attitude of mind that is necessary for an evidence-based

culture to exist. Table 1 outlines the characteristics of

such an enquiring attitude.

In addition to the attitude described, factors were

listed that supposedly encouraged or discouraged EBM.

Discouraging factors included working conditions, poor

work habits, attitudes of the manager and peers, and

personal beliefs. Encouraging factors included a

research culture, personal beliefs, good work organ-

ization and sufficient self-discipline.

Rather than explicitly using �EBM� with regard to

nursing management practice, Morrison (1995)

favoured the utilization of �nursing management diag-

nosis�. Examples of diagnoses included �ineffective

Table 1Evidence-based management is primarily an attitude of mind(Stewart 1998):

that thinks in terms of evidence for decisions and about the nature ofthe evidence.that asks questions. What is happening? How is it happening? Why?What are the consequences?that is aware of the potential limitations of the different answers.that is interested in research to try to find the answers or at leastreduce the ignorance.

S. K. Young

146 ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 145–151

communication�, �ineffective change management�,�inadequate leadership skills� and �excessive paperwork�.However, the development process supposedly involved

was similar to that outlined by Stewart (1998):

�Once problems are identified, nurse managers can

proceed to plan change to resolve the problems.

Generating and testing of interventions for the

diagnoses will further enhance nurse manager

decision-making� (Morrison 1995).

While sounding remarkably similar to the nursing

process, it may have been reasonable to assume there-

fore that Morrison was close to adopting the type of

management practice advocated by Stewart (1998) and

Hewison (1997). Stewart’s paper was the only one that

described an actual model for EBM, and her work could

thus have arguably been regarded as being at the fore-

front of the early development of EBM as a method of

leadership within healthcare. However, it was apparent

that although the term �evidence-based� had become

well espoused generally, its specific application to the

area of �management� was only at an embryonic stage.

Criticisms of the evidence-based approach

Stewart (1998) surmised that few would argue that

management should not be evidence based, �for fear of

being seen to advocate management based on unrea-

son.� However just as EBM faced criticism, so the par-

ticulars concerning the evidence for management

decisions also came under scrutiny.

The articles were divided in their degree of support

for the evidence-based approach. Unsurprisingly, arti-

cles from the journal Evidence Based Nursing (DiCenso

et al. 1998 and Royle & Blythe 1998) were quite

defensive of this practice, whereas authors such as

White (1997) took a far more critical stance. The most

repeated criticism related to the presumed superiority of

positivism and empiricism (whereby all rational theories

can be scientifically or mathematically proven through

experimental processes) as an epistemological basis for

quantitative research methods. Booth et al. (1997)

highlighted the opinion that these reductionist methods,

�primarily concerned with the definition and control of

variables under investigation�, are presumed to result in

�unequivocal conclusions�. The authors refuted this

position by describing such unequivocal conclusions

about nursing as a theoretical impossibility. In addition:

�Positivist approaches are inappropriate for

investigating and understanding complex and

subtle nursing phenomena.�In defence of the positivist approach, DiCenso et al.

(1998) cited examples of practice that, through rand-

omized trials, were shown to be harmful. The authors

admitted, however, that �good evidence does involve

more than RCTs and systematic overviews.� They

wished to ensure that the appropriate methodology was

used for each question posed. Booth et al. (1997) also

ultimately opted for a combined approach, and reiter-

ated that neither qualitative nor quantitative methods

were capable of generating certainty, and that nursing

should be wary of committing itself exclusively to one

type of research method.

Cullum (1998) highlighted the practical problems for

nurses attempting to practice in an evidence-based

manner:

�Nurses often do not have access to libraries or the

Internet and, even if they do, relevant research

findings are often not there.�Other criticisms of the evidence-based approach were

outlined by Lockett (1997) and Hewison (1997). These

included journals only publishing positive results, not

acknowledging patient preferences, using evidence to

control costs, the desire for treatment superseding rig-

orous trial methodologies, the lack of generalizability to

general practice and general poor quality research.

Nevertheless, the criticisms levelled at the evidence-

based approach have not dampened the overall com-

mitment to the ideology (Castledine 1997, Lockett

1997, Cullum 1998). Hewison (1997) maintained that

evidence-based medicine �is probably the only way for

genuine progression in treatment and care to occur.�However, despite supportive words, perhaps a more

potent force than the philosophical drive towards evi-

dence-based approaches and hierarchies was that of

government policy. The NHS White Paper of 1997

promised new guidelines for treatment based on �the

latest scientific evidence� (DoH 1997). Since the gaining

of such scientific evidence through research often

necessitates bidding for government funding, it would

seem that an evidence-based culture, with an RCT gold

standard, has gone well past the debating stage. Yet it

was not altogether surprising that the last government

of the twentieth century and the first of the twenty-first

have made recall to the supposed universality and value

neutrality of modern science. For the past four hundred

years or so, since Francis Bacon pioneered his experi-

mental and manipulative methods, both science and

politics (Bacon became Lord Chancellor in 1618) were

dominated by this reductionist approach. These

experimental methods continued �dichotomising gender

and class relations and man�s relationship with nature’

(Shiva 1988, p. 20) into the coming centuries. Perhaps

the only possible challenges to the dominance of

reductionism would be, as Shiva suggests, through

Evidence-based management

ª 2002 Blackwell Science Ltd, Journal of Nursing Management, 10, 145–151 147

alternative, less dichotomized scientific traditions from

non-Western cultures or subjugated groups. However,

as yet such approaches have not featured noticeably

within plans for the new NHS.

Clinical effectiveness

Although the term �evidence-based management� has

been seen to be embraced by some authors, such as

Stewart (1998) and Hewison (1997), McClarey (1998)

used the term �clinical effectiveness� almost inter-

changeably with evidence-based practice when referring

to the role of nurse managers. Although clinical effect-

iveness was defined as the use of quality improvement

methods such as audit, standards, clinical guidelines,

and so on, the process sounds remarkably like that for

evidence-based practice:

• obtaining evidence;

• using evidence;

• evaluating the impact of the use of the evidence in

terms of improved patient outcome (McClarey 1998).

The Department of Health (1997) also used the term

clinical effectiveness, but always in conjunction with

�cost-effectiveness�. The pairing of these concepts was

embodied within the proposal for the National Institute

for Clinical Excellence that would �give a strong lead on

clinical and cost-effectiveness� (DoH 1997, p. 18). The

implication appeared to be, therefore, that evidence-

based practice was not enough for the �modern Ædependable� NHS, unless financial factors were also

considered. Lockett (1997) also aligned the evidence-

based approach with selective resource allocation.

Although cost-effectiveness was not alluded to by

McClarey, a local NHS Trust included �contributing to

resource management� in its exposition of evidence-

based nursing practice. The Trust also used the phrase

�doing the right thing right� with regard to evidence-

based practice, which (in a circular path of definitions)

was also used by McClarey to define clinical effective-

ness. It appeared, therefore, that there was no absolute

clarity of distinction between clinical effectiveness and

evidence-based practice, but perhaps the more �fash-

ionable� former term would become more prevalent,

having a greater emphasis on including economic con-

straints on the �evidence� obtained.

Management and EBP in the NHS

In the literature reviewed, there appeared to be a divide

between those authors who perceived EBM as managers

encouraging/facilitating evidence-based clinical nursing

practice (Caine & Kenrick 1997, Luker 1997) and those

who viewed it as a personal activity for making

accountable management decisions (Hewison 1997,

McClarey 1998, Stewart 1998).

McClarey (1998) stated categorically that managers

should not only base their own decision making on a

grounding of evidence but they should also be seen to be

doing so. Hewison (1997) realized that a �general

management science� might be far away, but that should

not deter attempts to develop this knowledge.

Caine and Kenrick (1997), however, emphasized the

enabling role of clinical directorate managers with

regard to EBP. Luker (1997) explained that this facili-

tative role was due to managers interpreting their work

as managing staff rather than clinical work itself. In this

way managers have devolved the responsibility for the

provision of evidence-based care to clinical nurses:

�Enabling them to fulfil both the responsibilities of

their job description and their professional

responsibilities outlined in the Code of Profes-

sional Conduct (UKCC 1992)� (Caine & Kenrick

1997).

Kenrick and Luker (1996) meanwhile observed that

district nursing managers often based their practice on

trial and error and questioned whether it was reason-

able for managers to expect district nurses to base their

own practice upon evidence. Kenrick therefore

appeared to be accepting both nuances of EBM. She

concluded with Luker that managers should make sure

that their own practice is evidence based as well as

ensuring that the district nurses they are responsible for

are able to provide the highest care.

Although there was a body of opinion that strongly

advocated for management decisions to be based upon

evidence, there was also the acknowledgement that

there was a limited research base for such interventions

(Morrison 1995, Hewison 1997). Caine and Kenrick

(1997) pointed out that we know little about how

managers perceive their responsibilities towards EBP in

the first place. It would seem reasonable to postulate,

however, that the paucity of references to EBM indicate

a far greater concern for obtaining evidence for clinical

practice than management activities.

Luker (1997) stated that major structural changes

within nursing were instituted due to enthusiasm, rather

than evidence, and that this practice continues regard-

less of the recognized need for evidence. Government

policy was also cited as a major determinant of the

organization of nursing rather than research. The speed

and volume of recent changes within the NHS could

only serve to confirm this view. Watt (1993) believed

that research might not be undertaken regarding man-

S. K. Young


agement questions, because a useful answer might not

be achievable within the time available and at a rea-

sonable cost. Eldridge and South (1998) supported this

view, citing time constraints as the most common rea-

son for hindering research and development work.

From the author’s own practice it was evident that the

only research activity undertaken by nurses within that

particular setting was in conjunction with academic

courses, the majority of which was secondary rather

than primary research, related to clinical activities, and

attracted no funding expenses.

Although a clear supporter of EBM, Stewart (1998)

eloquently described that there was a far weaker case

for introducing evidence-based management than evi-

dence-based medicine. This was said to be on the basis

that management was far more an art than a science

and that one �can even be a good manager without

formal training.� Obstacles in applying an evidence-

based approach to management were outlined, such as

difficulties in predicting variables and the subsequent

control of them. Nevertheless, Stewart asserted that a

research culture could and should exist for managers.

In addition to the calls for EBM by Hewison (1997)

and Stewart (1998) within the United Kingdom, there

were calls from mainland Europe for a more measur-

able approach towards healthcare management. Healy

(1998) reported a speech made at the European

Healthcare Management Association Conference in the

same year:

�Managers should stop following the latest fad,

and start approaching their jobs in a scientific

way.�The speaker, Professor Svensson, seemed to

acknowledge that little evidence existed as to what kind

of management worked in healthcare. However, he

maintained that it was only by testing and evaluating

interventions �that proven good management could be

introduced more widely� (Healy 1998). What can only

be hoped for is that Professor Svensson’s �scientific way�is a broad-based science that encompasses the more

qualitative human aspects of research and is not one

based purely around a quantitative positivist paradigm.

Implications for practice

One of the recommendations put forward by Morrison

(1995) in connection with her aforementioned nursing

management diagnoses was the need to develop and test

interventions. This view was supported by Healy (1998)

concerning healthcare managers in general and Kenrick

and Luker (1996) regarding nursing specifically.

Castledine (1997), however, emphasized the need for all

registered nurses to be able to read, critically interpret

and know where to find relevant research. Although this

opinion encompassed nurses who are managers, rather

than simply the clinicians, the stress was placed upon

reading research rather than necessarily undertaking

research oneself. It appeared, therefore, that there was a

need not only for further evidence-gathering pertaining

to management decisions but also for critical research

appreciation skills, if the evidence could not be obtained

oneself (Eldridge & South 1998).

Specifically for managers, Watt (1993) stressed the

need for readily available evidence, since decision-

making timetables were often of short duration. The

belief that �good researchers are not necessarily good

disseminators� illustrated the need for EBP to be shared

in order for it to flourish. For improvement of practice,

it was therefore necessary both to build up a body of

evidence regarding management problems and to

establish methods of publishing the evidence for those

who might wish to make use of it.

Royle and Blythe (1998) stated that �Evidence-based

practice has been realized most completely in institu-

tions that have adopted it as policy and have integrated

it at all organizational levels�. In this context there was

therefore the implication that in order for evidence-

based management to be a successful practice, there was

a requisite for clinical care to be based upon best evi-

dence. Conversely, there was also a necessity for EBM

decisions in order to encourage and stimulate evidence-

based clinical practice. McClarey (1998) supported this

view by positing that only by managers leading with

examples of their own EBP would clinicians value its

importance. Hewison (1997) stressed that if managers

and clinicians were to work collaboratively, then both

must be able to justify their actions.

If one accepted the enabling form of EBM, however,

the implication was that managers should create a

�research-friendly climate� by designating financial and

material resources (Caine & Kenrick 1997). Provision

of time to attend courses or visit the library was

advocated by Cavanagh and Tross (1996). However, if,

as the government has stated, management costs will be

capped (DoH 1997), it would be unlikely that this one-

step-removed form of EBM would be developed out of

a management budget unless economic savings could be

clearly demonstrated as a result.

Stewart (1998) also incorporated education and

initiatives, such as awaydays, within her recommenda-

tions for adopting an attitude that would embrace the

search for evidence. Strong leadership was also required

to act as a role model. Perhaps the simplest

recommendations for every nurse to implement,



however, were the �journalists� questions’ that Stewart

championed. One must ask �when, what, where, who,

how and why?�, so that the �attitude� of evidence-based

management can be developed.

Within the author’s own practice area, the lack of

EBM decisions did not appear to prevent rationales

being offered for clinical decisions. However, this did

appear to be research-based rather than evidence-based

practice, in terms of the lack of critical analysis of the

particular studies cited by the manager. The manager

did, however, seem to be sympathetic with the views of

Stewart (1998). Staff were encouraged to ask questions

about what they were doing, particularly in line with

risk assessment concerns. Perhaps what could improve

the particular area in terms of EBM practice would be

to ask the same journalistic questions of the line man-

agers who do not practice clinically. If practice is rou-

tinely inquired about at all levels, then justification will

have to be offered for the actions currently �imposed�upon clinical areas.

Conclusion

The literature concerning evidence-based management

was varied in its emphasis and scope. While authors such

as Watt (1993) and Hewison (1997) considered all

healthcare managers, Morrison (1995) and McClarey

(1998) were more specific to nursing management. For

Stewart (1998) the practice of evidence-based manage-

ment was a process for managers themselves to undertake

in order to improve their own management techniques.

Meanwhile, Kenrick and Luker (1996) also considered

evidence-based practice for managers as an enabling

process for clinicians. The term �evidence-based man-

agement� might not even be allowed to flourish for very

long, since �clinical effectiveness� appeared to be in vogue

for managers as well as clinicians (McClarey 1998).

The benefits attributed to evidence-based manage-

ment were primarily concerned with motivating clinical

staff (McClarey 1998), providing justification for

management decisions (Stewart 1998), and contributing

towards a management science (Hewison 1997).

Despite criticisms of the hierarchy of research associ-

ated with evidence-based practice (Shiva 1988, White

1997), there remained an overall commitment to ob-

taining evidence for decisions (Royle & Blythe 1998).

From the literature reviewed it was apparent that

few authors specifically stated a case for evidence-

based management, instead they incorporated man-

agement decisions within a general evidence-based

approach (Booth et al. 1997, Castledine 1997,

Department of Health 1997). Stewart (1998) and

Hewison (1997), however, made a specific case for

evidence-based management within healthcare. In

particular, Stewart’s definition, her �attitude of mind�for evidence-based management, served as a compre-

hensive guide to practising evidence-based manage-

ment within the modern NHS. Indeed, if this approach

were to be adopted by health service managers, it

would be hoped that NHS management costs would

be reduced, thus negating the need for the threat of

�management capping� that has been looming over

managers’ heads.

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