Evidence-Based Practice in Pediatric Critical Care Nursing

In the mid-1900s, British epidemiologist Dr Archie Cochrane noticed that thousands of premature infants were dying despite the availability of a proven treatment. Multiple randomized controlled trials supported the use of corticosteroid therapy during premature labor in high-risk patients, but this therapy was not routinely given to those high-risk patients. Dr Cochrane conducted a systematic review of the literature, concluding that corticosteroid therapy reduced the rate of premature infant death from 50% to 30%.1 He shared these findings and encouraged clinicians to align their practice with this evidence. Dr Cochrane worked across multiple clinical areas to encourage the practice of medicine based on evidence, and he is widely regarded as the founder of evidence-based practice (EBP).1The benefits of EBP appear obvious when studying objective findings, as in Dr Cochrane’s story, but understanding the benefits is only part of implementing EBP. There is a notable dearth of EBP in nursing, especially in pediatric critical care settings, with many nurses lacking an understanding of what EBP looks like in practice.2 A term used frequently in theory across nursing education, EBP is a complicated, human-driven, and multifaceted process of applying research findings to direct patient care.1,2 Rigorous research generates a collection of facts; these facts are then classified as evidence. Evidence can be used to inform nursing actions through guidelines, policies, and procedures.Use of EBP leads to safer care, improves patient outcomes and satisfaction, and reduces health care costs.1,2 When clinicians use EBP, it empowers them to make decisions, giving them confidence, independence, and improved job satisfaction.1 Given the obvious benefits, why is EBP not used consistently for all clinical decisions?It takes an average of 15 to 17 years for evidence to reach clinical practice.1,3–5 Research must go through multiple steps to translate into clinically useful material, including publication and guideline development. Each step in the process required for clinical research to reach clinicians can take years, and by the time evidence reaches clinical practice it is likely to be out of date.3In pediatric critical care, quality evidence is especially difficult to obtain. Randomized trials with child participants present unique ethical and legal issues; how does a researcher or consenting parent justify potential risks to a child?4 Large randomized controlled trials (RCTs) are the criterion standard for determining the safety and efficacy of a treatment, but only about 0.5% of pediatric clinical trials are large RCTs.6 Other types of studies may provide value but are less likely to statistically conclude a clinical difference and thus less likely to generate usable evidence.6Pediatric participants are more difficult to recruit and enroll in research studies than adults.7 Children require parental consent to participate, and researchers often meet resistance from parents when trying to enroll child participants. Parental perception of the child’s illness can impact enrollment; for example, a parent may feel that their child is too sick to engage in study procedures, even if treating clinicians approve the activities.7 Parents may also decline participation if they feel the study will not benefit their child, even if the study has minimal risk of harm.7 Other common barriers to pediatric enrollment include parental concerns about risks to the child, potential negative impacts on medical care, and logistical issues.7Even when quality evidence for pediatric critical care exists, nurses face multiple barriers to implementing EBP. Nurses cite lack of time, lack of education about EBP, and lack of access to information as the most common barriers to using EBP.2 One study from a 10-hospital health care system found that 71% of nurses used Google when making clinical decisions, and most nurses using Google did not use any other resources.2 This study also showed that nurses relied on information from personal experience, hospital policy, and colleagues when making clinical decisions, rather than scientific evidence.2Sustainable, broad application of new evidence in clinical settings does not happen automatically. Adoption of new evidence requires system-wide changes, in addition to addressing nurses’ knowledge of EBP and access to resources. Despite these challenges, nurses can take actionable steps to use EBP at the bedside. Nurses can (1) use implementation science methodologies to apply research to practice; (2) promote a safe, trusting, and collaborative environment; and (3) use evidence-based tools at the point of care.Implementation science (IS) is a relatively new methodology that addresses the gap from research to practice; how does the research go from evidence to real-world patient care?4,8 Implementation science evaluates how best practices are adopted within a given system and why that process may succeed or fail.5 It is the science of behavioral change in health care at the individual, team, and institutional level.Implementation science researchers note that, in the critical care setting, it is important to address and identify team-based dynamics that affect evidence implementation. Intensive care unit (ICU) culture and team dynamics are common reasons why EBP initiatives fail.4,5 To begin applying new evidence to practice, nurses must feel comfortable asking questions and challenging the status quo. In a unit where nurses feel threatened or otherwise psychologically unsafe, new EBP initiatives are likely to fail.5Proponents of IS encourage units to use established implementation theories, models, and frameworks to support EBP initiatives. Although most theories, models, and frameworks have not been used in pediatric critical care nursing, recent studies have evaluated their potential for use in this setting.4,5,9 Researchers and clinicians can use IS tools to ask and answer questions about “feasibility, acceptability, and adoptability of proposed interventions.”4(p949) Even if a specific tool is not validated for use in pediatric critical care, clinicians and researchers can still explore clinical questions through the lens of the IS perspective.4 Implementation science methodology can guide those interested in bridging the gap between research and practice.Nursing culture and team dynamics can determine the success or failure of EBP in a clinical setting. In ICUs especially, culture can be a significant barrier to implementing EBP.4 Trust and positive working relationships are crucial for the sustained implementation of EBP, and this culture is often determined by nursing leadership.10,11 An environment that supports collaboration encourages nurses to share information and learn together, which in turn supports EBP.11Kitson et al10 examined the ways in which nurse leaders promote EBP at the point of care across multiple care areas, including critical care. They found that “policies and procedures were seen as the formal manifestation of EBP, but it was the engagement, conversations, teamwork and trust between colleagues that made the process come alive.”10(p2450) Specifically, these nurse leaders relied on developing and sustaining positive working relationships through role modeling and informal connections.10There is an important human component to EBP that goes beyond the data. Nurse leaders can publish guidelines and policies, but this is usually insufficient to enact change in a clinical setting. Further engagement and conversation are required to develop trust and successfully implement EBP. Nurses need to feel safe, supported, and empowered to use EBP, especially when EBP supports changes to current practice.10–12Nurse leaders can model EBP behaviors and mentor staff to educate their teams and promote an evidence-based culture. Leader-driven processes that successfully promote EBP include clinical rounds, huddles, spot checks, and education sessions.10 Leaders can further encourage nurses to participate in EBP activities away from the bedside, such as journal clubs, professional conferences, workshops, and nursing grand rounds.13Lack of access to information is one of the most common nurse-reported barriers to EBP.2 With the availability of computers, smartphones, and tablets at the bedside, nurses increasingly have access to information. As previously stated, 71% of nurses use Google to make clinical decisions.2 However, what nurses lack is access to the right kind of information: current and reliable research. Nurses must not only have access to this research but also feel confident in their ability to access and use it in clinical situations.2Evidence-based point-of-care tools can meet the demand for access to evidence. Multiple tools exist across different platforms, typically provided at the bedside through facility-based subscriptions. Some point-of-care tools are written for nurses, whereas others focus on providers who diagnose and prescribe. Regardless of the specific tool, nurses should be educated on how to find relevant information within the tool. Nurses should feel empowered to apply that information to clinical decision-making.Another common nurse-reported barrier to EBP is lack of education about how to find and implement evidence. Ongoing education of nurses is key to implementing and sustaining EBP in the clinical setting.12 This education includes anything related to EBP, such as where to find evidence, how to evaluate evidence, and general knowledge of diseases and treatments. Evidence-based point-of-care tools can provide information about diseases, treatments, skills, and procedures. Some tools provide study plans to be used individually or with educators, and some tools even award continuing education units to nurses and other health care providers.Nurses can take action to use EBP individually in clinical practice, as well as support initiatives that promote EBP across the unit. Nursing ownership of EBP is especially important in pediatric critical care medicine, where evidence is lacking and unit cultures tend to resist change. Nursing leadership must create positive cultures that will in turn give nurses the confidence and support to ask questions and take initiative when making clinical decisions, recognizing that historically ICU culture has inhibited EBP progress. Nurses can encourage the movement of research to practice through implementation science frameworks. Nurse leaders and educators can teach nurses how to access evidence-based material, and health care facilities can provide high-quality resources for nurses to use.