issues in research

Evidence-based nursing practice:

what US nurse executives
really think
This article by Dariene Sredl considers qualitative statements
from US nurse executives about their belief in and
implementation of evidence-based nursing practice. Their
statements suggest uncertainty about the way forward

• evidence-based nursing practice

• nurse executives
• qualitative statements
• implementation

Introduction
Health care is undergoing rapid changes, and outcomes drive processes. While
the basis for the integrated approach we now know as evidence-based practice
was established centuries ago, only since the 1990s has evidence-based medi-
cine (EBM) and evidence-based nursing practice (EBNP) emerged as a viable
framework for positive clinical outcomes built on a substantial research base
(Melnyk et a/2004, Mishel and Braden 1987).
Much of the momentum towards using evidence-based practice in the
United States comes from cost-containment efforts spurred by payer and
healthcare facility administrators eager for healthy profit margins and healthy
healthcare consumers of their services (Youngblut and Brooten 2001). The
huge growth in computerised information has enhanced the healthcare knowl-
edge base of consumers who realise that EBNP is increasingly synonymous
with the perception of high-quality patient care (Melnyk and Fineout-Overholt
2005, Youngblut and Brooten 2001). Evidence-based nursing also results in
time-saving nursing care streamlined to eliminate useless, outdated practices
and rituals, while adopting practices that result in desired outcomes (Youngblut
and Brooten 2001).

NURSERESEARCHER 2008, 1 5, 4 51
issues in research

A major responsibility of nurse executives is to provide nursing care in a

creative and cost-effective way to the institution's healthcare consumers (Perra
2000). While there is no agreement on exactly how this is to convert into prac-
tice, the EBNP philosophy allows for this creativity in an atmosphere of cost-
effectiveness if supported by top-level nursing management (Perra 2000).
Titles for these top-level nursing managers vary in different institutions and
include: director of nurses: chief nursing officer: chief nurse executive: clinical
manager: and, if in a school, dean. These titles may be similar to the respon-
sibilities of nurses working in nursing managerial positions in the UK, Australia
and Canada. For the purpose ofthis article, I will call them 'nurse executives'.

Comprehension of EBNP by nurse executives

The gap between availability of best-practice evidence and use ofthat evidence
can be traced to comprehension levels of nurse executives (Sredl 2005). If
nurse executives understand and employ the steps inherent in EBNR they may
encourage similar attempts by the nurses working with them. Although several
studies have examined comprehension levels of EBNP among staff nurses and
nurse clinicians such as advanced practice nurses, few studies have examined
the EBNP comprehension level among nurse executives (Le May et al 1998,
Sredl 2005). One study (Bostrom and Suter 1993) conducted with 1,200 prac-
tising nurses found that only 21 per cent had implemented evidence gleaned
from research into their practice within the six months prior to the study.
Practice culture differs from management culture (Le May ei al 1998). A
qualitative study with a phenomenological approach undertaken by Rodgers
(1994) found nurses working in receptive environments more amenable to the
use of EBNP in terms of individual and organisational attitudes. If a 'receptive'
environment can help nurses accept EBNR how does a 'facilitating' environ-
ment evolve? And, if an environment favourable to EBNP does evolve, who
brings about this change? Is change in one facility enough? Is change in one
state's facilities or in one nation's facilities enough?
Evidence-based nursing is a global meta-paradigm. To be effective, all
nurses, especially nurse executives, must embrace the change.
Unfortunately, while much has been published and discussed rhetori-
cally concerning EBNP there is little published evidence that nurses and nurse

52 NURSERESEARCHER 2008, 15, 4

executives can understand EBNP, much less use it (MacPhee 2002. Zeitz and
McCutcheon 2003, MacPhee and Sredl 2004, Sredl 2005). A dichotomy
exists between medicine and nursing regarding the interpretation of the term
'evidence-based' (Engebretson 1997). EBNP differs from the medical model of
evidence-based practice in many ways (Sredl 2005). The medical model uses
randomised controlled clinical trials (RCTs) as the gold standard of evidence,
greatly overextending the influence of one form of evidence over all others
(Anderson 1995, Daines 1997, Sackett et a/1996).
In contrast, the evidence-based nursing process does not try to repudiate
the medical model's reliance on RCTs. Instead it encompasses quantitative and
qualitative research; eastern, as well as western therapies; patient advocacy;
tradition; assumption; folk medicine and other holistic forms of time-honoured
remedies, clinician expertise, and patient values, preferences and beliefs
Oacobs 2001, Rush and Harr 2001, Lee et al 2002, Launer 2003).
There is a paucity of research into how well nurse executives understand
EBNP and if they comprehend the difference between the medical and the
nursing EBM models (Sredl 2005). Management innovations tend to occur
in a fluid work environment marked by rapid-paced innovative change. In a
healthcare venue concerned with efficiency and cost-containment, nurse execu-
tives may not have collectively assembled a cohesive point of view on EBNP It
is vital that they do so, however since leadership involves influencing others to
accomplish goals (Huber etal 2000).

Literature review
Healthcare costs are rising; healthcare benefits are decreasing. The shift to
EBNP is creating uncertainty in healthcare (Sredl 2005). New roles require new
competencies; new competencies require new training; new training requires
new technology; new technology requires new thought (Sredl 2005). Old pat-
terns of thought restrict nurses to mere handmaidens. Contemporary nurses are
nurse executives, clinical specialists, educators and researchers;, and they are at
the forefront of the shift. To remain at the forefront of this shift, nurses must
embrace training and technology, such as informatics, to develop competen-
cies. Conceptual competence is as important as managerial, clinical, educa-
tional or technical competence (Porter-O'Grady and Krueger Wilson 1995).

NURSERESEARCHER 2008, 15, 4 53

issues in research

An analysis
To get a better understanding of EBNP I conducted a bibliometric analysis of
the literature (Sredl 2005). Searches on CINAHL, Medline, Lancet Archive, and
Medline In-Process and non-indexed citations databases on Medline with the
keyword 'evidence-based nursing' (which became 'nursing practice, evidence-
based') yielded 2,536 citations. 'Evidence-based nursing practice' yielded 355
citations in these databases, while 'evidence-based nursing process' yielded
only seven. 'Evidence-based medicine' produced 21,695.
One key assumption of bibliometric mapping is that published research
papers represent knowledge produced by genuine scientific research, with
estimates of research productivity represented by topic count (Estabrooks etal
2003, Estabrooks et al 2004). This assumption is not always accurate (Sredl
2005). While 'nursing practice, evidence-based' resulted in 2,536 citations,
many of the citations reviewed were treatment-oriented articles addressing
a specific patient condition or disease process. Very few articles addressed
topics of executive or administrative significance in nursing. Sigma Theta Tau
International recently launched a new journal entitled Worldviews on Evidence-
Based Nursing. The Cochrane Collaboration library holds numerous titles devot-
ed to the study of EBNP but can be accessed by subscription only. Synthesised
literature reviews on EBNP are also found in the CINAHL Clinical Innovations
Database (Androwich 1999).

Theoretical framework
The theoretical underpinnings of the evidence-based nursing process flow
from five distinct postulates (Sredl 2005). The first of these is Bayes' Theorem.
Bayesian Theory starts with observed past differences accumulated into 'prior,
or posterior probabilities'. The Bayesian method requires the establishment of
prior probability, acknowledges uncertainty and bases outcomes on choosing
the conclusion that best exemplifies the expected patient benefit (Freedman
1996, Sredl 2005).
The second distinct postulate that led to the development of EBNP was
the acknowledgement of new ways of 'knowing' in scientific circles (Janesick
2000). A nineteenth century American philosopher, Charles Peirce, wrote about
four ways of knowing (Carper 1975, Marten 2002). Peirce identified tenacity,

54 NURSERESEARCHER 2008, 15, 4

or the unquestioned, traditional approach; intuition, or the common sense
approach; authority, or the expert approach; and science, or the controversial
and inquisitive approach (Marten 2002). In contrast. Carper's ways of know-
ing included empirics, aesthetics, ethics and personal (intuitive) knowledge in
nursing (Carper 1975, 1978, White 1995). While Peirce and Carper limited
themselves to only four ways of knowing, Gardner listed four to ten ways of
knowing by asserting that a human being has 'multiple intelligences' (Walters
and Gardner 1984). Gardner's theory, known as the 'multiple intelligence con-
struct', originally identified seven manifestations of human intelligence; logical-
mathematical, linguistic, musical, spatial, bodily-kinesthetic, interpersonal and
intrapersonal. His theory later evolved to include naturalist intelligence, spir-
itual intelligence and existential intelligence (Gardner 1999).
When Thomas Kuhn published his classic work The Structure of Scientific
Revolutions (Kuhn 1962), the scientific revolution, though unidentified as
such at that time, was already well under way. Kuhn's 'paradigms', or ways
in scientific communities of looking at scientific facts, is the third theoretical
construct. Although introducing the concept of paradigms was novel in itself,
Kuhn went on to proclaim an even more novel concept - that the dissolution
of an old paradigm occurs when the old paradigm can no longer answer new
pertinent questions, and when a new, more 'fitting' paradigm emerges to
replace it. According to Kuhn, these major paradigm shifts are usually pre-
ceded by periods of pronounced professional insecurity since paradigm shift
involves a disruptive change in the evolution of existing scientific thinking.
Meta-paradigms arise from the blending of a series of theories or paradigms
(Thompson 1985).
Different worldviews generate different variations on existing knowledge
bases (Mclntyre 1995). Nursing science, by virtue of the human needs it
seeks to care for, is actually a composite of theories, thereby qualifying as a
meta-paradigm (Brodie 1984, Fawcett 1984, Newman 1992). Interrelated
concepts and theories undergo metamorphosis over time to yield newer meta-
paradigms more applicable to the societal and environmental changes that
have occurred (Parse 1999).
The fourth theoretical construct is Hempel's covering law model, which
involves a 'covering' or universally accepted law (Hempel and Oppenheim

NURSERESEARCHER 2008, 15, 4 55

issues in research

1948). The law must be broad in scope, but also universally appropriate in
content. This 'covering law', or meta-paradigm as we now know it, remains in
effect until a more inclusive covering law takes effect (Klemke et al 1998).
The fifth theoretical postulate involves the embrace of change. In healthcare
and other social reforms, change occurs very slowly (Sredl 2005). Rogers'
innovation-diffusion theory examines the process of change and the adoption
and acceptance of technological innovations by a given profession (Hilz 2000,
Valente and Rogers 1995). According to this theory, change agents can help
activate the change process in the group (Hilz 2000).

Methodology
Aim
Nurse executives need to be skilled at finding and appraising research if
they are to activate change (Huber et al 2000). The profession of nursing has
committed itself to the development of a research base to support practice
(Cavanagh and Tross 1996). The contemporary healthcare market requires
effective nurse executives, leaders skilled at implementing change strategies
and improving healthcare outcomes by energising nurses to accept change,
while cognisant that the change may produce anxiety or a feeling of threat
(Buonocore 2004).
This article contains open-ended qualitative data from nurse executives'
responses to two questions (Sredl 2005). The first question was; 'Do you have
any additional comments (relative to EBNP)?' The second was; 'Do you fore-
see any problems in the global nursing implementation of EBNP? If so, please
explain.' Many of the respondents chose this opportunity to divulge their
thoughts on EBNP The resultant qualitative data greatly enhanced findings
from the quantitative part of the survey (Sredl in press).

Design
This article is concerned with qualitative questions embedded in a larger
exploratory descriptive study (Sredl 2005) that used mailed survey instru-
ments; the EBN Beliefs Scale and the EBN Implementation Scale developed
by Melnyk and Fineout-Overholt (2003). The qualitative part of the study
discussed in this article was accomplished by the subjects' invitation to com-

56 NURSERESEARCHER 2008, 15, 4

píete two open-ended qualitative questions in an effort to broaden the base
of EBNP comprehension from the nurse executive's viewpoint so that coded
keywords describing the nurse executives' viewpoint towards EBNP could be
further defined.

Research questions
The qualitative research questions that were explored included asking the
nurse executives to comment on their perceptions of EBNP and any additional
comments they might offer regarding anticipated problems with global imple-
mentation of EBNP

Sample
A stratified randomised list of nurse executives employed in key upper man-
agement positions in healthcare facilities in the 50 states of the US and the
District of Columbia was purchased from the American Organization of Nurse
Executives (AONE) and the American Hospital Association (AHA).

Procedures
The institutional review board of the sponsoring institution first gave me
"exempt status review", since I did not need access to confidential informa-
tion. This meant the project would not require quarterly review by the board.
I then obtained permission to use and slightly modify EBNP opinion surveys
developed and copyrighted by Melnyk and Fineout-Overholt. Questionnaires
were formatted to specifications designed to yield high response rates (Salant
and Dillman 1994). A covering letter and stamped, addressed return envelope
were included in the packet mailed to each participant but potential subjects
were allowed the convenience of responding by telephone, email or fax. Data
were tabulated according to indicated statistical analysis. No identifying infor-
mation was sought. A total of 951 mailings were sent for a total of 917 valid
questionnaires. The 154 responses were returned by first class mail, fax, email
and telephone; of this number, 134 were mailed back and 20 were returned
via other media routes. No 'thank you' letters with results were sent since the
data were received with no identifiers.
Human rights were protected in accordance with the guidelines devel-

NURSERESEARCHER 2008, 15, 4 57

issues in research

oped by the National Commission for the Protection of Human Subjects of

Biomédical and Behavioral Research, as established by the National Research
Act of 1974 (Burns and Grove 1993).

Confidentiality of data
Every effort was made to maintain the confidentiality of the data that these
subjects provided. Information was aggregated without identifiable tracers,
compiled then destroyed.

Risks and benefits

There were no perceived risks to this study. Study benefits included the pro-
fessional satisfaction of contributing to a broader nursing knowledge base of
EBNP among subjects who have not been studied in any great number to date.
Benefit to risk ratio is positive and strong.

Validity and reliability

The exploratory descriptive nested mixed-methodology design of the larger
study was necessary to describe and delineate a movement in nursing that
has broad consequences for the discipline. Abstract and obtuse methodologi-
cal arguments to the contrary, there are as many varieties of recognised and
accepted ways to measure validity as there are methodologies. The essence of
the meaning of validity is to assimilate the research findings so that the results
can be trusted enough to act on (Lincoln 2001).
The advent and decline of the post-modern, post-structuralism era brought
about alternative paradigms in social sciences and research methodology
that matched the alternative modes of critical analysis, such as critical theory,
participatory research modes, racial and ethnic studies, feminist and sexual
orientation models and heueristic modes of inquiry such as phenomenologi-
cal methods (Denzen and Lincoln 2000). The epistemology of what can be
known is inordinately influenced by how we come to know it, as Gardner
(1999) professed. The qualitative research methodology supports the uncov-
ering of facts as they are believed by the subjects (Lincoln 2001). General
standards regarding validity testing for qualitative studies conform, in large
part, to Bayes' Theorem (Smith eta/ 2000).

58 NURSERESEARCHER 2008, 1 5, 4
 In the Bayes' Theorem form of validity testing, the principal investigator is
challenged to ensure an appropriate fit between the research question and:
data collection procedures; appropriately analysing the dataset; remaining
cognisant of prior knowledge that has a bearing on the issue under scrutiny;
maintaining compliance with internal and external value constraints; and
assessing the comprehensiveness of the research as a whole (Smith et al 2000,
Lincoln 2001).
Mishler suggested, and Maxwell concurred, that in qualitative research
validity should ultimately reside in meaning and understanding (Mishler 1990,
Maxwell 1992). Qualitative studies are not conducive to the psychometric rig-
ours employed in quantitative study validity establishment (Sredl 2005). The
qualitative models of inquiry are alternative paradigms of research, according
to Denzen and Lincoln, and, as such, open to alternative philosophical versions
of validity (Denzen and Lincoln 2000, Lincoln 2001). This form of validity is
demonstrated in critical awareness - a mindfulness of self and others (Sredl
2005).
Elliot Eisner, the widely respected methodological theoretician, proposed
three forms of validity for qualitative research; structural corroboration, consen-
sual validation and referential adequacy (Eisner 1991). 'Structural corrobora-
tion' refers to the ways in which multiple data types are interrelated, supporting
or contradicting the interpretation of data. My larger study supports the inter-
relationship of multiple data sources including the Likert scale replies to the
quantitative questions, the heuristic unit composites of the verbatim responses
to the qualitative questions, and the graphical profiling of the data processed
in response to the profile analysis via multidimensional scaling response to data
depicted in a representational model.
'Consensual validation' refers to the composite opinions of the subjects and
the extent to which an agreement exists. The degree of agreement among
nurse executives in my study is tallied in the heueristic unit profiling. There is
a commonality among many of the responses that is apparent even without
statistical analysis.
'Referential adequacy' speaks to the enlargement of understanding that an
individual criterion prompts. Many responding nurse executives feel associate
degree nurses (ADNs), who have taken a two-year degree with no research

NURSERESEARCHER 2008, 15, 4 59

issues in research

courses, are task-oriented, are a barrier to the implementation of EBNP (Sredl

2005). The insight provided by the respondent who likened EBP to being 'part
of a toolkit for excellence' certainly provided an enlargement of understanding
of the meta-paradIgm of EBNP
Towards these ends, the two qualitative questions included in this study
meet the alternative non-psychometric paradigm of validity. They ask the nurse
executive subjects to expand, if they wish, on the topic of EBNP based on their
ways of knowing, in their own experience and expertise, and to project these
ways of knowing about EBNP onto a global schema of their creation.

Strengths
The major strength of this research is the addition of knowledge of EBNP
among nurse executives In the US, as such knowledge is used in their perceived
implementation of EBNP in their respective workplaces. Future nursing studies
replicating the methods of this study may lead to global EBNP information dis-
semination to all levels of practising nurses (Sredl 2005).

Limitations
• The relatively limited response rate of this study (n=154). Future studies
should attempt to replicate this one using a larger number of participants.
• Only nurse executives who are members of AONE and/or employed at AHA
member hospitals were sought as potential subjects for this study.
• Community outreach organisations and extended-care facility nurse execu-
tives were not included in this study.
• Not including a question about the subject's job so that statistics broken
down by executive position could be calculated.

Results
Qualitative research embodies the observations about themes and patterns that
arise from the data (Janesick 2000). These observations reveal the human ele-
ment inherent in all research. In a world not confined to quantity, quality adds
a special dimension to research (Sredl 2005). Qualitative inquiry offers rich
repositories of ideas, there for the mining. The subject of evidence-based nurs-
ing is one topic replete with understandings and misunderstandings, offering

60 NURSERESEARCHER 2008, 15, 4

guidance yet divergence, conjuring notions and representations that are not, at
present, found in any of the literature (Sredl 2005).
Eorthis reason, this study included two open-ended questions about the sub-
ject's particular understanding of EBNP The following are verbatim responses
to each of the two questions. The qualitative questions prompted the subjects
to add additional comments on any question or aspect of EBNP of special
interest to them.

Qualitative questions
Respondents who chose to answer the two qualitative questions wrote succinct
responses to one or both. The first qualitative question was an invitation to
offer additional comments regarding the respondent's opinion on EBNP. The
responses varied, with several recurrent underlying themes, such as; EBNP
[requires] 'a difficult culture change process', 'is complicated to understand'
and 'is hampered by a predominance of associate degree nurses who have
limited understanding of the process'. The second qualitative question asked
nurse executives if they could foresee any problems in the global nursing
implementation of EBNP The responses received to this were so varied that a
frequency analysis was not feasible. Individual responses are used as exemplars
throughout the remainder of text, where that particular insight helps expand
the subject under discussion.

Results exemplars
Results indicate that while most respondents thought EBNP was a good idea
whose time had come, many were unsure of how to implement it through an
EBNP initiative in their facility. An exemplar is; 'I don't think EBP is difficult
but the culture change and process of getting there maybe is.' Other answers
indicate strong personal beliefs about and in support of EBNP Exemplars
describing the beliefs of the nurse executives on these points include; 'Our
pain initiative is a perfect example of EBP Also our work with pre-op antibi-
otics - it is the way we think'; '[We are] actively involved in promoting EBP
and assessing outcomes of relationship nursing models in acute psych set-
ting'; 'Although all our policies and procedures are evidence-based, we are
still working on a level of quality nursing care to ensure EBP at the bedside';

NURSERESEARCHER 2008, 15, 4 61

issues m research

'think EBP is crucial to the profession'; and 'We have to engage in EBNP - it
is our professional responsibility'. The supporting qualitative data suggest
that contemporary nurse executives do believe in the concepts inherent to
the EBNP process.
Respondent exemplars identifying problems and perceiving difficulties in
understanding EBNR problems that can act as effective barriers to starting an
EBNP programme, include; 'I think it's more difficult for nurses to buy in'; and
'Time is unfortunately more of the issue than anything'. Other results represent
a cautious partial understanding of beliefs in EBNR with exemplars including; 'I
don't know that much about evidence-based nursing'; and 'EBNP is something
I have a vague idea about but it's not being implemented here'.
Some respondents raised the issues of using EBNP to change practice,
evaluate outcomes of a practice change and change practice based on patient
outcome data respectively. Exemplar statements on these issues include; '99
per cent of our nurses are associate degree prepared, and have little to no
exposure of EBP They are so task-oriented. To implement in our... facility will
take three years'; and 'Over 68 per cent of my staff has either a diploma in
nursing [three-year non-college affiliated] or ADN; I believe this is an added
challenge'; and 'Currently 60 per cent of staff nurses do not have bachelor's
degrees. This is a major impediment to EBNP We must insist that the entry
into practice is a bachelor's degree at the minimum, so staff nurses will have
training in how to read and use the research literature' (Sredl 2005).
The repeated contention that ADN nurses cannot function within an EBNP
dynamic was made even more poignant by such statements as; 'Over 68 per
cent of my staff has either a diploma in nursing or ADN; I believe this is an
added challenge'; and 'Difficult to implement EBNR large per cent of the staff
are AD grads, emphasis in tasks'.
These observations point to time thresholds that may not be present in
the day-to-day responsibilities of contemporary nurse executives, no matter
what their level of EBNP acceptance. Exemplar statements include; 'Time
constraints'; and 'Any related increase in expense or manpower would not be
welcomed.' Corroborating the studies cited earlier, including the original study
(Melnyk et al 2004), top administrative support is necessary for EBNP imple-
mentation since support personnel such as medical reference librarians are

62 NURSERESEARCHER 2008, 15, 4

integral to an effective evidence-based nursing regimen (Sredl 2005). Exemplar
statements related to this issue include; 'Physician buy-in = Champions'; and
'Culture barriers specific to roles of the various care givers, ie MDs'.
Budgeting for EBNP must also include access to databases and online or
hard copy information sources of best evidence. These databases, such as the
Cochrane Collaboration, are expensive and a facility subscription is necessary
for access (Sredl 2005).
Information revealed in the qualitative responses also indicates a lack of
nurses prepared at masters and doctorate level. Exemplar statements include;
'Time, resources, money, especially having master's prepared nurses'; and
'Tradition, education, availability of research data'; and 'Lack of emphasis on
EBP by academic makes this a difficult process to convince staff it adds value'.
The supporting qualitative data suggest that although contemporary nurse
executives believe in the concepts inherent in EBNP and feel confident in
their ability to effect change in their respective organisations, they are unsure
how to implement the steps involved in EBNP
The second qualitative question was; 'Do you foresee any problems in the
global nursing implementation of EBNP? If so, please explain.' This ques-
tion, like the first, elicited responses so varied that a frequency analysis was
not feasible on it either. Exemplars highlighting this point include; 'Global-
International - don't know. If using evidence-base means more cost in coun-
tries with nothing more to give, may hurt. I see bigger dichotomy between
haves and have nots'; and 'Healthcare approaches are regional in nature'.
The subjective qualitative data resulting from this research can be consid-
ered expert opinion -,one of the data sources integral to the EBNP process
(Prelec 2004). As Smith etal (2000) contend, failure to take this information
into account in making a differential diagnosis can lead to a serious misrep-
resentation of the evidence. Exemplars examining the source of this expert
opinion include; 'Depends upon compliance with standards of practice';
'Although 1 believe [the care that my nurses deliver is evidence-based] I do
not have proof. It's based on text, articles and standards of practice as we
dialogue with colleagues - other hospitals'; and 'Although all our policies
and procedures are evidence-based we are still working on a level of quality
nursing care to ensure EBP at the bedside'.

NURSERESEARCHER 2008, 15, 4 63

Implications for nursing practice
US nursing practice in the 21st century has been severely compromised by its
current nurse shortage. The nurse shortage, in turn, is severely compromised by
the shortage of nurse educators prepared at master's and doctoral levels. This
shortage, combined with the ageing of America's professional workforce, means
that nurses must do more with less and in a more efficient way (Block and Sredl
2005). Evidence-based nursing processes establish best evidence practices and
positive clinical outcomes (Sredl 2005). Using this evidence by incorporating it
into care plans can decrease costs associated with patient care by avoiding rep-
etitious, undesirable and expensive alternative outcomes (Sredl 2005).
Using evidence-based practice guidelines also eliminates stress and frustra-
tion for staff nurses attempting to reinvent the wheel in applying their basic
education to state-of-the-art patient care problems and new technology. As
one subject stated; '[We are] actively involved in promoting EBP and assessing
outcomes of relationship nursing models in acute psych setting.'

Implications for nursing education and research

Data analysis in this study reveals a nurse executive collaborative structure
hesitant and often inconsistent in proclaiming understanding of evidence-
based nursing and the steps inherent in the evidence-based nursing process.
Exemplars include; 'I am sure evidence-based guidelines can improve clinical
care for the population - not necessarily for any given individual'; and 'I con-
sult with various small hospitals and can assure you that they cannot spell EBP
and don't plan to learn'.
If EBNP is indeed to be the emphasis of nurses in a worldwide collective
effort towards practice homogeneity, nurses need to understand evidence-
based nursing and the evidence-based nursing process. EBNP courses should
be developed and taught at all levels in schools of nursing. Curricula developed
around one espoused nursing theory is too limited. Courses on how to search
for 'best evidence' and 'positive clinical outcomes', how to critique research
and how to retrieve outcome data should all be emphasised as part of an
increased emphasis on nursing informatics courses. Emphasis on curriculum
development based on EBNP should be given funding priority from the US
National Institute for Nursing Research.

64 NURSERESEARCHER 2008, 15, 4

 Future studies will determine if nurse executives move through the last
three stages of the innovation diffusion process: decision, implementation,
and confirmation (Hilz 2000). Individual attitudes and organisational climate
can greatly influence a nurse executive's propensity towards adopting a posi-
tive attitude toward EBNP. Data suggest that when EBNP is championed by
nurse executives, others in the organisation adopt positive attitudes toward
EBNP (Melnyk et al 2004, Sredl 2005).
Now that baseline data have been established, future studies can measure
nurse executives' effectiveness at implementing EBNP in healthcare organisa-
tions. Cost savings to hospitals using EBNP can include: lower nursing attrition
rates due to increased job satisfaction and performance self-efficacy; improved
patient outcomes: lower morbidity-mortality ratios: and reductions in non-
covered inpatient hospital days.

Conclusion
Nursing science has structure. This structure is in place largely due to taxonomies
such as the Cochrane database and the US's National Guidelines Clearinghouse.
While Kuhn (1962) and Hempel and Oppenheim (1948) realised the need for
this structure and the impiications that this structure would have, the qualitative
results of this study do not demonstrate such a clear understanding of the EBN
process, despite the bravado exemplified in the responses to the Beliefs Scale
(Sredl 2005). Evidence-based nursing has global implications for nursing, but
only if the nurses have been educated to understand the construct of EBNP •

Darlene Sredl PhD, RN is associate professor of nursing. University of Missouri

at St Louis, St Louis MO, US

This article has been subject to double-blind review

A n d e r s o n R (1995) Patient empowerment Block V, Sredl D (2006) Nursing eduation and

:<
and the traditional medical model. A case of professional practice: a collaborative approach
irreconcilable differences? Diabetes Care. to enhance retention. Journal for Nurses in Staff
18, 3, 4 1 2 ^ 1 5 . Development. 22, 1, 23-30.

A n d r o w i c h I M (1999) Evidence-based B o s t r o m J, Sirter W N (1993) Research

practice: harvesting the evidence. Chart. utilization: making the link to practice. Journal of
96, 2, 5. Nursing Staff Development. 9, 1, 28-34.

NURSERESEARCHER 2008, 15, 4 65

issues in research

Buonocore D (2004). Leadership in action: Fawcett J (1984) The metaparadigm of nursing:

creating a change in practice. AACN Clinical Issues. present status and future refinements. Image: The
15,2,170-181. Journal of Nursing Scholarship. 16, 3, 84-87.

Brodie J (1984). A response to Dr. J. Fawcett's Freedman L (1996) Bayesian statistical methods:
paper, "The metaparadigm of nursing: present a natural way to assess clinical evidence. British
status and future refinements"./mage.'7ihe7ouma/ Medical Journal. 313, 7057, 569-570.
of Nursing Scholarship. 16, 3, 87-89.
Gardner H (1999) Intelligence Reframed: multiple
Burns N, Grove SK (1993) The Praaice of intelligences for the 21st Century. Basic Books, New
York NY
Nursing Research: Conduct, Critique and Utilization.
Saunders, Philadelphia PA.
Hempel C Oppenheim P (1948) Studies in
Carper B (1978) Fundamental Patterns of the logic of explanation. Philosophy of Science. 15,
Knowing in Nursing. Advances in Nursing Science. 135-75.
1,1,13-23.
Hiiz LM (2000) The informatics nurse specialist as
change agent: application of innovation-diffusion
Carper BA (1975) Fundamental Patterns of
Knowing in Nursing. Columbia University Press, theory. Computers in Nursing. 18, 6, 272-281.
New York NY
Huber DL. Maas M, McCloskey J et al
(2000) Evaluating nursing administration
Cavanagh SJ, Ttoss G (1996) Utilizing
instruments. Journal of Nursing Administration. 30,
research findings in nursing: policy and practice
5,251-272.
considerations. Journal of Advanced Nursing.
24,5, 1083-1088. Jacobs BB (2001 ) Respect for human dignity:
a central phenomenon to philosophically unite
Christison MK, Kennedy D (2001) Multiple
nursing theory and practice through consilience of
intelligences: theory and practice in adult ESL. ERIC
knowledge. ANS: Advances in Nursing Science. 24,
Qgesf. www.ericdigests.org/2001-1/multiple.html
1, 17-35.
(Last accessed: June 25 2008.)
Janesick VJ (2000) The choreography
Daines B (1997) Commentary: the medical model
of qualitative research design: minuets,
is unhelpful. British Medical Journal.
improvisations, and crystallization. In Denzin
314,7083,815-816.
NK, Lincoln YS (Eds) Handbook of Qualitative
Research. Sage Publications, Thousand Oaks CA,
Denzen NK, Lincoln YS (Eds) (2000) Handbook
379-400.
of Qualitative Research. Second Edition. Sage
Publications, Thousand Oaks CA. Klemke ED, Hollinger R, Rudge DW (Eds)
(1998) Introductory Readings in the Philosophy of
Eisner E (1991) The Enlightened Eye: qualitative
Science. Prometheus Books, New York NY
inquiry and the enhancement of educational
practice. Macmillan, New York NY. Kuhn TS (1962) The Structure of Scientific
Revolutions. The University of Chicago Press,
Engebretson J (1997) A multiparadigm
Chicago IL
approach to nursing. ANS: Advances in Nursing
Sc/ence. 20, 1,21-33. Launer J (2003) Folk illness and medical models.
Qxford University Press Quarterly Journal of
Estabrooks C Floyd J, Scott-Findlay S Medicine. 96, 11,875-876.
et al (2003) Individual determinants of research
utilization: a systematic review. Journal of Advanced Lee D-J, Sirgy MJ, Larsen V et a/(2002)
Nursing. 43, 5, 506-520. Developing a subjective measure of consumer well-
being. Journa/of Macromartef/ng. 22, 2,158-169.
Estabrooks CA, Winther C Derksen L
(2004) Mapping the field: a bibliometric analysis of Le May A, Mulhall A, Alexander C (1998)
the research utilization literature in nursing. Nursing Bridging the research-practice gap: exploring the
fiesea/c/i. 53, 5, 293-303. research cultures of practitioners and managers.

66 NURSERESEARCHER 2008, 15, 4

Journal of Advanced Nursing. 28, 2,428-437. Prelec D (2004) A Bayesian truth serum for
subjective data. Sc/ence. 306, 5695,462-466.
Lincoln Y (2001) Varieties of Validity: quality
in qualitative research. In Smart JC (Ed) Higher Rodgers S (1994) An exploratory study of
Education: handbook of theory and research. research utilization by nurses in general medical
Volume XVI. Agathon Press, New York, 25-72. and surgical wards. Journal of Advanced Nursing.
20,5,904-911.
MacPhee M (2002) Evidence-based practice in
action. Journal of Pédiatrie Nursing. 17,4, 313-320. Rush SL, Harr J (2001) Evidence-based pédiatrie
nursing: does it have to hurt? A4CW Qinical Issues.
MacPhee M, Sredl D (2004) Mirror, mirror... 12,4,597-605.
Journal of Pédiatrie Nursing. 19, 6, 371-373.
Sackett DU Rosenberg WM, Gray JA et al
Marten B (2002) The Professional Scientist: (1996) Evidence-based medicine: what it is and
Experimental Design, vvvvw.theorywatch.com/ what it isn't. British Medical Journal. 312, 7023,
ist501/exper.html (Last accessed: June 25 2008.) 71-72.
Maxwell JA (1992) Understanding validity in Salant P, Dillman DA (1994). How to Conduct
qualitative research. Han/ard Educational Review. Your Own Survey. John Wiley & Sons, New York
62, 3, 279-300. NY

Mclntyre M (1995) The focus of the discipline Smith JE, Winkler RU Fryback DG (2000)
of nursing: a critique and extension. Advances in The first positive: computing positive predictive
Nursing Science. 18, 1, 27-35. value at the extremes. Annals of Internal Medicine.
132, 10,804-809.
Melnyk BM, Fineout-Overholt E (2005)
Evidence-based Practice in Nursing and Healthcare. Sredl D (2005) Evidence-based Nursing Praaice
uppincott Williams & Wilkins, Philadelphia PA. (EBNP) Meta-paradigm: a crystallized synthesis
of apperceptions, beliefs, and efforts toward
Melnyk BM, Fineout-Overholt E, Feinstein EBNP implementation among contemporary
N et al (2004) Nurses' perceived knowledge, nurse executives in the United States of America.
beliefs, skills, and needs regarding evidence-based University of Missouri at St Louis, St Louis MO.
practice: implications for accelerating the paradigm
shift. Worldviews on Evidence-Based Nursing. 1, 3,Thompson JL (1985) Practical discourse in
185-193. nursing: going beyond empiricism and historicism.
Advances in Nursing Science. 7,4, 59-71.
Mishel MH, Braden O (1987) Uncertainty.
A mediator between support and adjustment. Valente TW, Rogers EM (1995) The origins
Western Joumal of Nursing Research. 9,1,43-57. and development of the diffusion of innovations
paradigm as an example of scientific growth.
Mishler E (1990) Validation in inquiry-guided Science Communication. 16, 3, 242-273.
research: The role of exemplars in narrative studies.
Harvard Educational Review. 60,4,415-442. Walters J, Gardner H (1984) The Development
and Education of Intelligences. Chicago, Spencer
Newman MA (1992) Prevailing paradigms in Foundation.
nursing. Nursing Outlook. 40, 1, 10-13.
White J (1995) Patterns of knowing: review,
Parse RR (1999) Nursing science: the critique, and update. Advances in Nursing Science.
transformation of practice. Joumal of Advanced 17,4,73-86.
Wurang. 30, 6,1383-1387.
Youngblut JM, Brooten D (2001 ) Evidence-
Perra BM (2000) Leadership: the key to quality based nursing practice: why is it important? AACN
outcomes. Nursing Administration Quarterly. Clinical Issues. 12,4, 468^76.
24, 2, 56-61.
Zeitz K, McCutcheon H (2003) Evidence-based
Porter-O'Grady T, Krueger Wilson C (1995) practice: to be or not to be, this is the question!
The Leadership Revolution in Health Care. Aspen Internationdi Journal of Nursing Practice. 9, 5,
Publications, Gaithersburg MD. 272-279.

NURSERESEARCHER 2008, .15, 4 67