Editorial

Implementing Evidence-Based Practice in theReality of Clinical Practice

More often than not, evidence-based practice projectsresult in more questions than conclusive answers.

Most papers published in Worldviews on Evidence-BasedNursing result in a number of implications for futureresearch, and often highlight the challenges of improv-ing practice and patient care. My own experience reflectsthis—particularly at the end of research studies that havebeen implementing and evaluating implementation inter-ventions. These challenges are perhaps partly a result ofconducting research and evidence-based practice projectsin the real world of clinical practice—described by Schoen(1984) as the swampy lowlands of practice. In this issueof Worldviews, a number of articles report on projects thatwere conducted in the reality of practice, and with peopleworking at the front line of care. These articles highlightsome of the challenges of this messy work, but also someways to overcome them.

Individual practitioners, such as advanced practicenurses, play a potentially critical role in promotingevidence-based practice. As Gerrish et al. (2011) found intheir study of factors influencing advanced practice nurses’role in evidence-based practice, their ability to functionin this role is not only determined by personal attributessuch as their clinical credibility and leadership style, butalso by factors related to organisational context, such asculture, responsibility, workload, and resources. There-fore to be effective in promoting evidence-based practiceon the ground, advanced practice nurses need support toaddress the person, interpersonal, and organisational fac-tors that mediate their ability to realise the full potential.In a very different project, Chaboyer et al. (2011) reporton a quality improvement study to evaluate the impact ofa redesigned intensive care unit discharge process. Theyachieved positive outcomes in this study by significantlyreducing average patient discharge delay. Whilst report-ing some of the challenges in implementing the interven-tions, such as lack of staff awareness and interruptionsin communication, they also highlight what they thoughthad made the project successful. In this study, the plan-ning of the change process was undertaken collaboratively,with ward staff indentifying that they needed to improvedischarge processes—this co-design approach engaged theend-users, i.e., frontline staff, in the whole change process.Not only did this result in changes to some outcomes, but

Copyright ©2012 Sigma Theta Tau Internationaldoi: 10.1111/j.1741-6787.2011.00240.x

also to teamworking and joint problem-solving. Tuckeret al. (2011) also report on an implementation project setin the real world of clinical practice in which they evalu-ated the feasibility and translation of a falls intervention.Whilst the implementation of the intervention resulted ina downward trend in numbers of falls, they experiencedmultiple challenges in undertaking this translational re-search. One of the critical issues concerned the fidelity ofthe intervention—once put into practice, other issues maymean it gets adapted, or in the worst case, not implementedat all. This is just one of the challenges of conducting prag-matic studies that as far as possible mimic the reality ofpractice—you cannot control what happens.

If we want to improve practice and patients’ experiences,much of our work will be conducted within the reality ofvery complex environments. Working with the multipleinteractions that arise in particular contexts will likely de-termine the success or failure of evidence-based practiceefforts, which means we need to draw on a wide range ofpractical and methodological approaches and skills. How-ever, perhaps more importantly, we should be develop-ing strong collaborative partnerships with clinicians andservices—in this way the practice environment becomespart of the process, not a backdrop to a project.

Jo Rycroft-Malone, PhD, MSc, BSc(Hons), RN, Editorj.rycroft-malone@bangor.ac.uk

ReferencesChaboyer W., Lin F., Foster M., Retallick L., Panuwat-

wanich K. & Richards B. (2011). Redesigning theICU nursing discharge process: A quality improvementstudy. Worldviews on Evidence-Based Nursing, 9(1), DOI:10.1111/j.1741-6787.2011.00234.x.

Gerrish K., Nolan M., McDonnell A., Tod A., KirshbaumM. & Guillaume L. (2011). Factors influencing ad-vanced practice nurses’ ability to promote evidence-based practice among frontline nurses. Worldviewson Evidence-Based Nursing, 9(1), DOI: 10.1111/j.1741-6787.2011.00230.x.

Schoen D. (1984). The reflective practitioner. New York:Basic Books.

Tucker S., Bieber P.L., Attlesey-Pries J.M., Olson M.E.& Dierkhising R.A. (2011). Outcomes and challengesin implementing hourly rounds to reduce falls in or-thopaedic units. Worldviews on Evidence-Based Nursing,9(1), DOI: 10.1111/j.1741-6787.2011.00227.x.

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