The State of the Art and Science of Evidence-Based

Regional Commentary
The State of the Art and Science of
Evidence-Based Nursing in UK and Europe
Alison Kitson, DPhil, RN, FRCN
I
want to start off this commentary by positioning developments in the UK and Europe around evidence-based
nursing within a global context. Indeed as Castells (1998)
commented in his recent study, what is happening in Europe (around integration) is “a reaction to the process of
globalization at its most advanced expression” (p. 318).
While Castells was arguing from an economic and financial
perspective, the trends that we see emerging in increasing
flows of information, networking, policy sharing, and migration attest to the reality that our private and working
lives are influenced more and more by such global external
ideologies and forces.
From this perspective we need to focus our gaze on two
propositions: namely that nursing has a major role to play
in designing and delivering effective and efficient health
care services to the world’s populations. Secondly that the
rise in the evidence-based practice (EBP) movement has to
be viewed as a global phenomenon, which will influence
the national, regional, and local decisions of hundreds and
thousands of health care workers and in that sense is no
respecter of national, geographical, or political boundaries
as such.
The EBP movement is one of several global trends
emerging on the health care landscape. A number of factors have influenced this landscape, including (1) escalating costs of health care and strategies to contain and meet
such costs that challenge every government; (2) the reality
that current health care systems and processes, particularly in terms of human resource management, are in need
of significant reform globally; (3) the awakening through
the EBP movement that a sea change was needed in the
way clinical knowledge is produced, scrutinized, implemented, and evaluated in the delivery of patient care; (4)
the refocusing on patient safety as a fundamental requirement of all health systems; and (5) the positioning of the
Alison Kitson, Executive Director for Nursing, Royal College of Nursing, 20 Cavendish
Square, London, UK.
Address correspondence to Alison Kitson, Executive Director for Nursing, Royal
College of Nursing, 20 Cavendish Square, London, UK. [email protected]
Copyright ©2004 Sigma Theta Tau International
1545-102X1/04
6
patient (rather than the system, the organization, or the
professional) at the center of the health care experience.
This has been the agenda facing policymakers and professionals in the UK and Europe for the last decade or more.
Work has been going on in parallel, with some countries
taking the lead more in some areas than others. But it must
be acknowledged that despite the overtures toward more
European integration, the political and health policy landscape in Europe is incredibly heterogeneous. What we call
the European Union (EU) currently comprises 15 countries with a further 10 countries (mostly formerly Eastern
Bloc) wishing to join. The diversity in health care delivery
systems in the 15 countries is significant not to mention the
additional challenges raised by the 10 accession countries.
So the broad picture is complex, but the stronger imperative seems to be one of integration in the face of the more
profound forces of globalization.
THE SPREAD OF EVIDENCE-BASED
PRACTICE
One cannot talk about the spread of evidence-based nursing
(EBN) without acknowledging the force of the evidencebased medicine (EBM) movement. A classic study in the
diffusion of innovations itself (Rogers 1995), EBM demonstrates all the classic hallmarks—a strong ideology, influential leaders, policy support, and investment with requisite infrastructures and product. Archie Cochrane’s (1976)
seminal text on Effectiveness and Efficiency, coupled with
the pioneering work of Sackett and his team (1997) at
McMaster University, together with the work of Iain
Chalmers and colleagues in Oxford, heralded the beginning of the movement. Now we see Cochrane Collaboration
Centres spreading across Europe (and the world) with the
accompanying policy imperatives around clinical guideline
development, research agendas focusing more on intervention studies, and whole curricula geared to problem-based
learning.
Nursing and other health-related professions have been
swept along in this tide of policy change. Rarely in on
the planning and decision making, nurses have either embraced EBP as the next inevitable health policy initiative
(Traynor 2002) and therefore something to actively pursue,
First Quarter 2004 r Worldviews on Evidence-Based Nursing
Evidence-Based Nursing in UK and Europe
or else rejected it seeing it as too overtly reductionist to be
of use to the patient-centred view of health care provision
they wish to deliver (Barker 2000, Rolfe 1999).
But mindful of the wider global context that EBP must be
considered in, it would be foolhardy for nursing not to explore how EBP can contribute toward more effective delivery of patient services. From the necessary polemic (Walker
2003) to the scholarly debates (French 1999) and empirical
research studies (Estabrooks, Floyd, Scott-Findlay, O’Leary
& Gushta 2003; Thompson, McCaughan, Cullum, Sheldon, Mulhall & Thompson 2001a, 2001b), we are beginning to see a significant move forward in nursing’s understanding of, and contribution to, the art and science of EBP.
As such, innovations and spread of new ideas do not restrict
themselves to national boundaries—the rise and spread of
EBM can be traced to a handful of individuals using their
influencing and political skills to further the cause, first
in their own locality (university or health department) and
then internationally. Similarly with EBN, the growth can
be pinpointed to a few committed enthusiasts with support who have subsequently set up the right networks and
infrastructures for sustained development.
Once the ideas have gained credence, the necessary investment must follow to sustain the initiative. In the UK,
EBN has not been funded specifically, but more and more
nurse researchers are working on intervention studies and
in collaboration with colleagues through Cochrane initiatives. Similarly, nursing involvement across Europe has
been on several levels: broad awareness raising of EBN
through European research networks such as Workgroup
of European Nurse Researchers (WENR) and WHO Collaborating Centres; research collaborations such as work
on guideline implementation in Sweden carried out by the
Swedish Nurses’ Association and the establishment of centres for EBN in UK, the Netherlands, and in other countries;
or political and policy influencing as led by the Professional
Committee on Nursing (PCN) in Brussels.
THE SCIENCE OF EVIDENCE-BASED
PRACTICE (EBP)
Following from the spread of the idea, there is a real need for
careful and rigorous exploration of the underlying concepts
and methods of EBP as they apply to and enhance nursing
practice. Two areas that are attracting significant interest
are debates around the nature of evidence and how it can
be implemented effectively.
The Nature of Evidence
DiCenso, Cullum and Ciliska (1998) define EBN as a process by which nurses make clinical decisions using the best
available research evidence, their clinical expertise, and
patient preferences in the context of available resources.
Thompson (2003) goes on to say EBN is designed as a
systematic means of combating the biases that arise from
uninformed (by research evidence) decision making. What
Rycroft-Malone et al. (in press) have argued is that just as
research evidence is derived from a very rigorous process,
so evidence from clinical experience and patients requires
a similar discipline and “reasoning trail” in order to justify
the decision. Thus bias is not necessarily invoked by lack
of one (research) type of evidence alone. Rycroft-Malone
and colleagues also go on to argue that the use of routine
information (such as quality improvement reports, audit
data, and routine evaluations) can be another important
source of evidence. How these four dimensions of EBP interact, how they can be inculcated into the practitioner, and
how evidence for each source can be painstakingly collated
and analyzed are all big questions for nursing and research
agenda.
The Nature of Implementation (of Evidence)
Another major area for research investigation is how evidence can be implemented in practice. Many European
studies have been influenced by looking at successful implementation of guidelines into practice (Grol & Grimshaw
1999; Ovretveit et al. 2002). Some of these studies have
focused on nursing interventions (Wallin, Bostrom, Wikblad & Ewald 2003). Other perspectives argue for a
more inclusive approach to improving practice suggesting that guidelines (or research evidence) are only one dimension of evidence that needs to be considered (Higgs
& Titchen 2001; Kitson 2002; Rycroft-Malone et al. in
press). Additionally, factors influencing uptake have been
identified and are numerous. But less is known about
the effective manipulation of these variables/factors to
achieve successful implementation. Two such research areas, pursued in a systematic way, could offer significant
rewards.
THE POLITICS OF EVIDENCE-BASED
NURSING
My central argument is that it is relatively unhelpful to
describe developments in EBN on a regional basis as it
belies both the global context in which we live and the
nature of the diffusion of EBP and EBN in reality.
Countries and regions will be inclined or disinclined to
engage in this topic for a host of personal, professional,
and most significantly, political reasons. What the nursing
profession can do to promote EBP in a country that has not
recognized its reforming potential is very different to another country, which has the promotion of EBP as one of its
Worldviews on Evidence-Based Nursing r First Quarter 2004 7
Evidence-Based Nursing in UK and Europe
central policy tenets. Constant questions that must occupy
the minds of nurse leaders in either of these countries are:
– How can we use EBP movement to promote improvements in patient care?
– What will EBP do to the way nurses practice in terms
of:
r clinical decision making,
r setting and use of clinical standards,
r use of protocols and care pathways,
r type of clinical information and evaluation systems,
and
r nature of the clinical encounter with patients?
– How will EBP influence the future construction and
delivery of education?
– How will EBP impact upon the future clinical nursing
research agenda?
– How will all of this impact the vision/culture and future
contribution of nursing (in UK, Europe, globally) to
improving patient care?
It is through this ongoing dialogue and reflection that alliances will be forged, possibly between like-minded individuals on an international stage and then—reinforced and
strengthened by such confirmation of vision and intent—
diffused locally, nationally, and regionally.
References
Barker P. (2000). Reflections on caring as a virtue ethic
within an evidence-based culture. International Journal
of Nursing Studies, 37(4), 329–336.
Castells M. (1998). End of millennium. The information age:
Economy, society and culture Vol II. Oxford: Blackwell
Publishers.
Cochrane A. (1976). Effectiveness and efficiency. London:
The Nuffield Trust.
DiCenso A., Cullum N. & Ciliska D. (1998). Implementing evidence-based nursing: Some misconceptions (Editorial). Evidence-Based Nursing, 1(1), 38–40.
Estabrooks C.A., Floyd J.A., Scott-Findlay S., O’Leary K.A.
& Gushta N. (2003). Individual determinants of research utilisation: A systematic review. Journal of Advanced Nursing, 43(5), 506–520.
French P. (1999). The development of evidence-based nursing. Journal of Advanced Nursing, 29(1), 72–78.
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Grol R. & Grimshaw J. (1999). Evidence-based implementation of evidence-based medicine. Joint Commission,
Journal of Quality Improvement, 25(10), 503–513.
Higgs J. & Titchen A. (2001). Practice knowledge and expertise in the health professions. Oxford: Butterworth,
Heinemann.
Kitson A. (2002). Recognising relationships: Reflections on
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Ovretveit J., Bate P., Cleary P., Cretin S., Gustafson D.,
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Rogers E. (1995). Diffusion of innovations, 4th edn. New
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