“Inside Looking In” or “Inside Looking Out”? How Leaders Shape Cultures Equipped for Evidence-Based Practice

Early studies on research translation focused on barriers from the perspectives of staff nurses, educators, and administrators. Among the 4 commonly studied barriers—innovation (research qualities), communication (research presentation), nurse (adopter), and organization (setting)—the organization has distinctly been perceived as the main impediment. Across the globe, top organizational barriers include limited (1) awareness of research, (2) time to read research and implement new ideas, (3) support from other staff, and (4) authority to change practices.1–13 In a qualitative study,14 a chief organizational barrier was the low priority given to evidence-based practice (EBP) by management. Cultural barriers included lack of clarity about roles and practice, emphasis on “routine” patient care, and little motivation to change practice.Increasing administrative support is recognized as a key facilitator of research use.2,4,5,9 The Promoting Action on Research Implementation in Health Services (PARIHS) framework15 spotlights the importance of leadership in the use of research in practice. Successful implementation of research is more likely when evidence is scientifically robust, matching professional consensus and patients’ preferences; the context is receptive to change with strong leadership and monitoring and feedback systems; and where appropriate facilitation with skilled internal or external facilitators exists. This review highlights available evidence on how leaders shape the context receptive to EBP to achieve best outcomes.The strategy involved searching CINAHL with key terms (EBP, research, leadership, culture, attitudes). All types of evidence were included.Only 6 studies were retrieved: 1 integrative review, 2 surveys, and 3 qualitative studies (Table 1). Leadership behaviors that created an EBP context included role modeling value/expectation for research use and showing clear commitment to research through strategic goals/resources, encouraging clinical inquiry, staff development opportunities, performance appraisal expectations, basing policies on research, and auditing practice to ensure adherence to evidence-based standards.Conceptually, positive leadership behaviors (transformational/transactional) were associated with encouraging staff attitudes toward EBP. Both transformational and transactional behaviors inclined staff to try innovations. Only transformational leadership (Table 2) influenced staff to find new practices appealing, adopt them, and perceive fewer gaps between current and EBPs. Nurse executives from Magnet hospitals—settings committed to clinical excellence/innovation—perceived higher transformational leadership.16 Although unit culture was a main promoter of using research, Pepler et al19 argued that leader facilitation is an integral part of this culture to embed new practices successfully.Evidence about leaders’ role in facilitating evidence-based cultures represents “level C” (qualitative/descriptive/correlational studies, integrative reviews) per the evidence-leveling hierarchy of the American Association of Critical-Care Nurses.23 Knowledge about how leaders influence contexts where EBP flourishes is in its infancy. However, beginning evidence links positive leadership—especially transformational behaviors—with research use. Undoubtedly, the enthusiasm of transformational leaders for reaching new ends encourages “outside-the-box” thinking. By inspiring a shared vision through clear roles, effective team-work/organizational structures, and providing feedback on individual/ team performance, transformational leaders enable staff to explore their professional practice.15 Indeed, in a study of more than 3000 nurses from more than 200 hospitals, the quality of unit leader-nurse exchange had a direct effect on structural empowerment, directly affecting nurses’ psychological empowerment and job commitment.24 Consequently, transformational leaders promote learning cultures, engendering commitment that brings competitive advantages for organizations as new knowledge is transferred to practice.Making a bridge to a learning culture is no easy undertaking. Not only does organizational culture shape the knowledge perceived as important, but also what activities constitute “real” work.25 Scott-Findlay and Golden-Biddle25 assert that the greater culture of health care implicitly values “doing” (busyness of accomplishing tasks) over “being” (reflecting on practice). In “doing” cultures, practical versus research knowledge is valued. By gradually integrating research activities into everyday routines of professional nurses, leaders shift the context so that applying research knowledge becomes valued as a part of the daily way of doing business.25 As leaders promote reflective practice, nurses begin to ask whether better ways exist to deliver care and thus a culture of inquiry is born. Accordingly, nurses develop deeper awareness and appreciation that research informs what constitutes best practice for clinical activities and interventions.Value for research among nursing leaders must also continue transformation for learning cultures to unfold and research findings to be reliably incorporated into practice. In a large sample of US nurse managers,26 two competencies—research-based practices and the research process—were perceived as the lowest in “need for knowledge” (No. 101 and 104, respectively) and “ability to implement” (No. 102 and 106, respectively) among 106 managerial competencies in 5 categories (technical, conceptual, human, leadership, financial). Almost a decade later, these same competencies ranked among the lowest knowledge need (No. 78 and 89, respectively) and ability to implement (No. 100 and 105, respectively) in a Canadian replication27 (albeit progress was made in need for research knowledge). The American Organization of Nurse Executives emphasizes research competencies for nurse leaders such as modeling routine use of evidence-based data in practice, interpreting and disseminating research findings, and advocating use of documented best practices.28 Indeed, staff nurses report that “fostering sound decision-making by asking for ‘best practices’ evidence” is one of the 10 universal role behaviors of supportive nurse managers.29 Developing EBP teams has also been acknowledged as a best practice to empower staff and promote autonomy over professional nursing practice.30 Despite all these data, researchers in a landmark study31 found “other organizational goal[s]” aside from research have higher priority in most organizations. Therefore, nurse executives are challenged to support nurse managers and other leaders in crafting strategies to overcome the unique barriers that exist in their organizational cultures that hinder the use of research and innovations at the bedside.Furthermore, in empowered cultures, nurses in any role serve as leaders and thus can influence the context of care. Nurses at all levels of the organization need research competencies in order for patients to benefit from evidence-based nursing care. Nurse leaders can shape the context for EBP by role modeling the value of research in their units and organizations by asking “what does the evidence show?” during clinical as well as administrative decision making.Until we as leaders agree that research evidence is a key component that influences decision quality, the cultures in our institutions may remain evidence-deprived. And if we remain evidence-deprived, who suffers? Patients. In the United States alone, it has been estimated that 30% to 40% of patients do not receive treatments of proven effectiveness, whereas 20% to 25% receive treatments that are not needed or are potentially harmful.32,33 By lobbying for resources to expand the EBP competencies of nurses, leaders will make significant strides in building capacity for evidence-based care to achieve best outcomes for patients. The choice is ours. Will we be “inside looking in” to the same old practices? Or will we become “inside looking out,’’ devoted to embedding better practices for patients?

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