Community nurses are a large and diverse group within the nursing workforce, and their role includes preventive, therapeutic, supportive and end-of-life care. The evidence base they draw from to inform their practice includes a broad range of academic disciplines and knowledge. Although a commitment to ensuring that practice is evidence based is now firmly established, the challenges of implementing this in reality are well recognised and documented (Thompson et al, 2005; Orton et al, 2011; Nursing and Midwifery Council, 2018; Mathieson et al, 2018).
Evidence-based practice (EBP) evolved from evidence-based medicine and is defined by Sackett et al (1996:71) as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients'. Rycroft-Malone et al (2004) go on to define evidence as a combination of research, clinical experience, patient experience and information from the local context. EBP demands that clinicians assume a questioning approach to practice and have skills in the analysis and synthesis of all forms of evidence. Clinicians then ‘match’ this to the individual needs, preferences and values of patients using their professional expertise (Greenhalgh et al, 2014). This is at the heart of the ‘realistic’ approach to care advocated by NHS England and Scotland's Chief Medical Officer, ensuring that the values and preferences of patients are central to care delivery (NHS England, 2013; Scottish Government, 2018).
Community nurses work with people, patients, families and communities, so the transactional nature of the role and the need to respect individual preferences and choices add to the complexity of ensuring that practice is based on evidence (Pereira et al, 2018). It is, therefore, important that community nurses can access information to support their practice and can discern the utility of that evidence to inform their interactions with the groups with which they work.
This paper reports findings from a qualitative study conducted in Scotland with community nurses. The overall aim was to explore community nurse participants' experiences of EBP. The specific questions were to (1) explore participants' experiences of making a change in their practice; (2) establish what resources or information they required to achieve change; (3) identify related ‘hot topics’; and (4) to establish what assistance they may require to implement recent evidence and experience into practice.
Methods
This qualitative study used semi-structured interviews (n=9) and focus groups (n=2), involving 17 community nurses. The indicative topic guide was piloted and developed from feedback gathered using world café methods from practitioners and academics at the Queen's Nursing Institute Scotland Annual Conference in 2018. As mentioned above, the questions aimed to explore participants' experiences of making a change in their practice; establish which resources or information they drew on, determine what assistance they may require and identify ‘hot topics’, for example, variation in practice and evidence gaps in their area of work. All interviews and focus groups were recorded and transcribed. Data were analysed using framework analysis (Gale et al, 2013). The coding frame was developed inductively from the interviews, applied and refined across all data. Codes exploring barriers to and enablers of how to introduce EBP, accessing recent evidence and what can be done to support community nurses informed the identification of three themes (referred to here as ‘pathways’).
Participants
Participants were community nurses based in one health board and/or associated with a school of nursing and midwifery in Scotland. The participants had a variety of specialisations, including district nursing (n=6), health visiting (n=2), community mental health nursing (n=1), community midwifery (n=1), occupational health nursing (n=2) and care home nursing (n=5). They worked in both the private and public sectors, and some were team leaders (n=7). The approach to sampling was purposive, and participants received an invitation letter to contact the researcher if they wished to participate.
Ethics statement
The School of Nursing and Midwifery Ethics Review Panel at Robert Gordon University approved this study. Oral or written consent was obtained from all participants.
Findings
Three pathways to introduce change in practice were identified by the participants: bottom-up, top-down and collaborative pathways. These are based on the nature of the proposed change, the available evidence, ‘buy in’ from colleagues and issues around implementation. These pathways are not mutually exclusive, and one service change/improvement may use more than one pathway. Change using the bottom-up pathway was grounded in the choices and decisions of those initiating it. In contrast, the top-down pathway was generally policy and/or management driven. Both these pathways could be combined. For example, a policy- or management-led change may require discretionary decision-making to facilitate implementation, and similarly, a bottom-up change could require more formal support, guidance and approval to initiate.
The participants recognised that many evidence-based resources are available. However, the volume of evidence available alongside time constraints meant that evidence was not always used to shape services. This could result in community nurses being reactive rather than proactive in determining and enacting changes to their practice.
‘It actually gets very difficult when you're on that treadmill, to be able to identify what would be better to make it easier and what changes are needed’.
Bottom-up pathway
Participants reported that they initiated some practice changes through reading academic papers, conducting audits, responding to service-user feedback, following training and on the basis of information on social media. Through this pathway, small but important changes were introduced. For example:
‘I've implemented that community nurses have access to the orange waste bags, which seems really insignificant but, it was a big problem’.
These changes required managerial support. Participants felt the need to build their case on evidence relevant to the proposed change and the UK context and on cost neutrality or a result of savings. This justification process was time consuming, and participants recognised that they needed to bring others on board to implement and sustain changes.
You can suggest something, yes, and it might take a wee while before that changes but, you can't change practice yourself’.
Responding to feedback from patients, service users, clients or their families gathered through surveys, complaints or through expressions of gratitude was reported, but the limitations of this form of feedback were recognised.
‘[Patients] tend to provide, like, maybe letters or cards and how they felt during the time we're looking after them but, it's not a questionnaire, it's not a named review, nothing like that. It's that kind of feedback’.
Participants recognised that collecting feedback from older people, those with dementia or those at the end of life was challenging and that the feedback could have had a positive bias, due to patients' concerns around ongoing care should they provide negative responses. Some participants felt that senior management could control patient surveys, which they considered, could shape the content and limit opportunities to engage. Participants noted that collecting information from patient feedback that did not shape services was problematic.
‘I don't know what actually happens to the data when it goes in … we have changed the data we collect because we felt we were collecting far too much data and there was never anything happening as a result so, we, the team leaders and manager collectively decided that we would reduce the data because health visitors were spending far too long sitting putting, you know, counting up all these numbers for it to disappear into the ether’.
Local patient groups could identify issues or challenges, and the following example demonstrates how nurses worked with them to find a workable solution.
‘They wanted a GP practice but, it's quite a rural village and it's quite small … it wasn't possible to have a GP out there. So, the community formed a steering group and, along with the Scottish Government, I think they got involved at that point, just to see what they could do, and that's when I was approached, when I was a district nurse up there, to ask if we could do some nurse-led clinics up there … we had the facilities already. They had this little three-roomed consulting area, which was never used’.
Participants reported using social media to stay up to date with recent evidence. Facebook was the most popular platform, as well as Twitter. There are a number of closed Facebook groups for community nurses specific to one speciality, for example, district nursing and occupational health nursing, or to a clinical issue, for example, infection control and infant feeding. Facebook was seen as a good platform to share information and experiences or to ask a question of colleagues.
‘It's (Facebook) really active as well so you can put your viewpoint across and other people can put points across as well’.
Participants recognised that this evidence may not be peer-reviewed and lacks references, so has limitations.
‘It's anecdotal evidence, so how good is it? Just ‘cause someone says to do it, it's not evidence-based’.
Participants pointed out that it was extremely difficult to set up any Facebook group in the NHS due to the paperwork required.
‘Setting up anything is a logistical nightmare (…) If you want to set up a Facebook page you've to fill out something like a 30-page document to, erm, to justify what you're doing’.
Volunteers run these groups in their own time, and nurses may use their own phones or computers to participate. Access to a smartphone was also identified as a barrier to using the many applications to support EBP available for mobile and tablet devices. The nurses spoke about a lack of confidentiality on social media and the need to ensure privacy around patient-specific issues. Moderators ask if a new member is a registered nurse, but they have no opportunity to check this. Twitter allows nurses to follow organisations and specialists relevant to their clinical practice.
‘The Faculty of Occupational Medicine, they tend to put new research papers or research evidence into medical guidelines that we follow (…) there might be changes in medical guidelines for sickness to do specific roles (…) I find that Twitter's the best place to actually find these, you know, find the links and it's very fast and up to date’.
Participants spoke about attending training or local fora as a place to hear new ideas. However, even when the training was free, nurses may not have been released to attend because of staff shortages. They suggested the need to develop interactive, online and practical training opportunities, as well as a practice-development role.
Some nurses had to study in their free time. Thus, some participants proposed the introduction of a study day.
‘Nurses should have a free study day that, you know, it doesn't mean that they won't be paid for it, they come to (the) home and study, you know (…) at the moment, we're doing our own studies in our own time’.
The majority of participants read professional journals, and some had personal subscriptions. Paper and online copies were equally popular. Online versions were generally accessed through a university (when the participant was also a postgraduate student) or public libraries. However, only one participant mentioned the Knowledge Network, which is available to all NHS Scotland staff. Organisational websites, for example, that of the Care Inspectorate, were mentioned as a rich source of information for care home nurses.
Participants reported various ways of identifying new evidence. This included using a mix of sources depending on their personal preferences and the time and resources available. Taking the initiative to change practice is something participants in this study reported doing, and they gleaned information from various sources to underpin this as well. There was a recognition that some of the information accessed was anecdotal rather than evidence based.
Top-down pathway
Legislation and policy guidance have implications for nursing practice. Many participants saw this as ‘it was done to us and not with us’ (Health Visitor 1), and others found some legislation and policy guidance to be out of date and prescriptive. Occupational health and health visiting were areas where legislation was described as influential.
‘There was a change in blood pressure for group two driving so, medical guidelines changed the blood pressure readings so, again, we had to change our policies, you know, this is the level of blood pressure now, it wasn't what it was before, because it's a government guideline so, it can be as simple’.
Keeping up to date with new guidance and policies was accomplished through similar ways as in the bottom-up pathway. Participants may have prioritised internal messages over other sources of information.
Management, in response to incidents, can introduce changes to working policies without consulting frontline staff. For example, one participant spoke of new requirements to support lone working. This had elicited both positive and negative responses among their team members. Similarly, the introduction of a new referral system in one NHS area brought mixed responses, with some participants questioning the basis of the changes. Sometimes, changes introduced by senior management were viewed as poorly justified or as ‘cost saving’ without an adequately strong basis (District nurses' focus group).
The top-down pathway saw community nurses responding to directions to change, although in many cases, there remained scope to manage the implementation and evaluation at a local level.
Collaborative pathway
Key to sustaining change was working together in collaboration and as a team, and this was the same for both bottom-up and top-down changes.
‘It's not just I decide to change something and then everybody else gets on board, the three of us actually discuss it before we implement any changes’.
Raising ideas for change may happen during a team meeting, and unless consensus can be achieved, the change may not last.
‘It's incredibly challenging. It's not so much the actual change, it's more the buy in, the longevity of it, so people may do it for a short time and then they'll go back to their old ways again’.
Participants viewed the collaborative pathway as an efficient way to deal with time constraints, by allowing individual staff members opportunities to share experiences. One example given was a journal club.
‘Four times a year we will have a journal club. So, what we'll do is we'll present. Three of us will present something that we have found, or that we have looked at, an article or a piece of research, or something interesting that informs our practice and we'll bring that, and we'll have a discussion around it’
Sustaining these groups also brought challenges, particularly with staff shortages. Some suggested that they relied on students to keep them going.
‘Tends to be the trainees that do it because we are so short staffed, it's a vicious circle’.
Participants suggested that moving from a top-down to a collaborative pathway may be possible through using a practice-development approach, allowing team members to prioritise and agree local aims. An example was given of feedback received through an anonymous staff questionnaire, which enabled the team to reach consensus on the way forward and helped team members to feel empowered and not just consulted.
Discussion
The pathways presented in this study offer a way of thinking about approaches to identifying and implementing change in practice with a strong evidence base. These pathways are not hierarchical or mutually exclusive, and their elements overlap. An advantage of conceptualising approaches to change in this way, as opposed to the identification of facilitators and barriers to EBP, is the recognition that the nature of the change differs from the nature of the drivers for it. The evidence accessed by participants in this study was variable in terms of its potential rigour and trustworthiness. Participants in this study perceived lack of time as a major obstacle to identifying new evidence, as was also reported by Thompson et al (2005). The challenges of heavy workloads and increasing expectations mean that participants required easily accessible, high-quality information, although they did recognise that this information may be anecdotal and, thus, not necessarily of high quality. This time pressure is all the more significant in light of the findings from a systematic review that calls for reflection as a core component of EBP (Mantzoukas, 2008). Reflection and initiating a cycle of change require protected time. Where the change is ‘top down’, this is likely to be underpinned by policy or legislation, but still requires team working, reflection and consideration of how best to introduce and sustain the change.
There exist potential tensions between changes imposed through policy and legislation and those that practitioners initiate in response to service-user feedback and community initiatives. Evidence of direct dialogue with people, patients, families and communities to identify ‘bottom-up’ priorities did not emerge strongly in this study. In the case of the bottom-up and collaborative pathways, these were, in the main, nurse or manager driven: nurses identified the need for change, built a case, obtained managerial support and delivered on a proposal.
Findings from this study show the need to support community nurses to implement EBP. Sufficient time, organisational support and further education are key facilitators of EBP (Mallion and Brooke, 2016). Resources need to be maximised to empower nurses to engage with best evidence, both at the clinical decision-making level in partnership with patients and in the local implementation of system-wide changes. Digital access to materials and the support from nursing leaders emerged as important needs of the participants in this study. Practical advice around challenges and enablers, and signposting to appropriate resources were viewed as lacking, and support for nurses, especially those who had not recently undertaken formal study, was viewed as essential (Sadoughi et al, 2017). Participants in this study saw the creation of a practice-development role, which could assist with EBP and introduction of improvements, as important.
The findings suggest that new resources should be accessible, available online and be concise. E-learning courses have been growing in popularity among nurses (Atack, 2003), and online club journals have recently started to emerge (Roberts et al, 2015; Ferguson et al, 2017). Videos summarising research or demonstrating practical skills were highlighted as a helpful resource. The need for interactive materials alongside access to a facilitator to address questions were other suggestions. Online materials should also be available as open access in order to enhance opportunities for reflection and thinking time. Participants identified that facilitators should understand and have experienced the realities of clinical practice. They also reported that they were often unaware of practice innovations being led by others or key topics relevant to them. Therefore, more sharing of information between and across various groups of community nurses and other health professionals will help ensure that resources are used to best effect.
Participants were unable to readily access digital resources for work, and they reported having to use personal phones or computers during their personal time. Where participants had access to NHS IT, they found materials blocked because of restrictions.
Participants identified that more funding was needed to support facilitated online groups, such as those on Facebook, for community nurses. Several organisations, for example, the Royal College of Nursing, We Communities and NHS Education for Scotland, are already supporting groups that offer a safe discussion forum for community nurses. In addition, there are inter-professional fora, for example, the Primary Care Communities of Practice (Kislov et al, 2012). There is scope to further develop social media to continue to build clinical academic communities around EBP.
Limitations
This study was relatively small and conducted within the Scottish context, which could limit the transferability of its findings. Further, community nurses are not a single homogeneous group, and although participants represented a variety of nursing roles, all roles falling within community nursing were not represented.
Implications for practice
The findings from this study illuminate some of the issues surrounding the complex process of changing practice on the basis of evidence. They demonstrate that community nurses are involved in the change process and experience some challenges in synthesising the range of evidence to make the case for change. Although three pathways have been suggested on the basis of the findings, it is important to recognise that these are not mutually exclusive, and there exists considerable overlap among them.
The findings suggest that practitioners would benefit from support to navigate the complex process of change. Support for practitioners could be provided through access to a facilitator to help them and through the provision of accessible online resources. Strategies for developing team working should be considered to help facilitate both bottom-up and top-down approaches to change.
Conclusion
Navigating change in practice is a complex process, and practitioners understand its importance. Change required through the introduction of new legislation, guidance or policy requires a team approach to implementation. Where change is responsive to service-user feedback or practitioner expert opinion, securing support from managers is essential, yet challenging. Regardless of the drivers for change, easy access to support was recognised as essential. The challenges of working across complex systems were identified. Clear understanding of roles, a shared vision and service-user involvement are necessary components of the change process alongside the use of best-available evidence.