Introduction

In recent years Evidence-based practice (EBP) has been advocating in nursing profession, however until now there still encounter many difficulties, conflict impact on evidence-based practice development. In this essay will be discussed the challenges and opportunities of future direction of evidence-based practice in nursing.

EBP is a decision making approach introduction in 1992. Sackett et al. (1996) state that EBP is a best evidence method of health care decision making which means to integrate sources from research findings, clinical expertise and consideration of client preferences, clinical setting and other external factors such as cost. (as cited in Hewitt-Taylor, 2002). EBP is a scientific and systematic process rather than traditional approach such as customs, rituals and authority from transmission to improve quality and efficiency of patient outcome (Shaneyfelt et al. 2006).

Challenges can be defined as barriers, difficulty during apply the evidence-based practice in nursing. Actually, there are many challenges of EBP development, in the article will try to divide into four types to discuss: Challenge of the nurse, Challenge of the clinical environment, Challenge of the research and Challenge of the organization. The part of opportunities is to analysis how to improve or diminish the gap between research evidence and clinical practice, and discuss the factors that help for the future direction of EBP in nursing.

Challenges

• 
  Challenge of the nurse,
  

Challenge of the nurse relate to the nurses’ beliefs or attitude to EBP, lack of understanding, knowledge and skills of EBP. A recent study (Oranta, Routasalo & Hupli, 2002) indicated nurses have divergence the value between research and practice; some nurses have conservative ideas that do not welcome change the nursing practice. The result reflect nurses have misunderstanding or negative attitude about evidence based care which may create wrong belief i.e. indifference or ignore the value of EBP. Nurse unawareness of research, are not familiar with EBP, and no sense improve the knowledge, not to mention to implement it in clinical care. (Hutchinson & Johnston, 2004; Wang, Jiang, Wang, Wang & Bai, 2013). Attitudes affect behavior, if nurse attitude remain unchanged, would increase degree of difficulty to carry out EBP in the future.

Lack of skills implementation of EBP also a big challenge facing by nursing (Majid et al. 2010; Hutchinson & Johnston, 2004). There are multiple components of EBP include asking suitable questions, selecting the best

pertinent

information, evaluating the evidence and integration of patient preference, research evidence etc in clinical decision making (Shaneyfelt et al. 2006). Nurse requests ability of integration and critical appraisal research skills i.e. information seeking, understand statistical terms, implementation to run through the EBP process. Provide education and training for EBP should be an important concern in the future for nurse.

• 
  Challenge of the research
  

Next challenge point related to research. Nurses always complain articles from journal are not readily available (Chau, Lopez & Thompson, 2008; Gale & Schaffer 2009; Wang et al. 2013). Actually findings from different research may not always have high level of reliability and validly, methodologies and presentation inadequacies or misconception may exist. Nurses probably feel confused and difficult to appraisal quality of findings, research reports are lengthy, include many academic, jargon terms and statistical analyses cause difficult to comprehension (Oranta, Routasalo & Hupli, 2002).

Furthermore, research finding usually not publishes fast enough and lack of guideline to implement in the clinical practice. Develop the research disseminate type to improve clinical utilization is a main direction in future, otherwise presentation of researches increase barrier to use finding in patient care, eventually obstruct EBP implementation.

• 
  Challenge of the clinical environment
  

Clinical environment seem to be a big challenge which absolute restrict nurse implementing EBP (Lee, 2003). Most studies (Hutchinson & Johnston, 2004; Gale & Schaffer 2009; Wang et al. 2013) stated that nurses have lack of time and heavy workload influences on utilization of research in practice setting. Take Hong Kong as an example, according to the survey conducted by Association of Hong Kong Nursing Staff at 2013, the average of nurse-patient ratio1:17 (normal: 1:4-6) in public hospitals, the bed occupancy rate is 92.9%. Nurses not only have daily heavy workload, also facing a serious shortage problem. Time and labour restrict and clinical safety concerns, nurse tend to use traditional practices and cannot keep frequently follow update journals during working (Hutchinson & Johnston, 2004). The working environment resistant changing tried and definitely threats EBP utilization in future.

• 
  Challenge of the organization
  

EBP is a complex and multifaceted process, cannot apply by individual, administrative support is very important. However lack of organization support is the common complaint by nurses. According to Chau et al. (2008) and Hutchinson & Johnston, (2004) the most important challenge of research utilization are lack of authority and no time to implement new ideas or involve research activity. These concerns related to the organization which include the setting barriers and limitations; e.g. time, resources, support and mentoring.

Besides, conservative attitude of organization such as lack of intention in changes or welcome new ideas must influences EBP utilization (Gale & Schaffer, 2009). It would limit the development of clinical practice to implement EBP and reduce the health care qualities.

In addition, nurse indicated that corporation with other professionals also a barrier of EBP implementation (Oranta, Routasalo & Hupli, 2002). Health care is a team working which involve many different professionals, such as physician, physiotherapist etc. during co-operation may cause differences of decision making. In traditional doctor has the most authority in clinical decision making, nurse advice may cause conflict or challenges by doctor. Therefore relationship between medical and nursing is also an organization related challenge of EBP utilization.

Although there are many challenges of EBP in clinical utilization, challenges creates opportunities, the following part would analysis how to overcome some barriers between research evidence and clinical practice, and talk about the factors that relate to the future direction of EBP in nursing.

Opportunities

Firstly, upgrading of nursing education curriculum improve nurses’ professional status and research knowledge. Nursing students learn of EBP show more potential of ability on clinical decision making (Brown et al. 2010). Although the nursing programme in universities already include research skills teaching to implement evidence-based practice, transferring finding into clinical practice still a big problem for novice nurses. The curriculum should be included how to connect the EBP to the utilization, not just focus the part of research skills training.

Besides, base on shortage of nurse, there are different kind of organizations provide nursing training such as nursing school, hospital nurse training courses, these courses more focus on clinical practice, but not include teaching EBP. At least the basic concept and skills of EBP should be educated in those courses which to improve knowledge of apply EBP into clinical practice.

Second, solidarity and cooperation is also an opportunity to future direction of EBP. No matter clusters, hospitals or ward in Hong Kong tend to working independently and lack of co-ordinate with other. To provide EBP should include cooperate and sharing. The hospitals or clusters can form some research groups from different hospitals or wards; include senior and junior nurses to conduct research-related work. This kind of workshop would improve the stuffs ability to identify the clinical issues, review researches, analysis, promote to implement research finding or conduct research etc. eventually improve the quality of nursing care.

Third relate to organization, the inferiors imitate the superiors; if the organization have positive attitude to motivate and reward EBP can raise the awareness to the staffs pay attention to EBP (Gale & Schaffer, 2009). To improve future develop of EBP, organizational should be modified the nurse ratios. Provide more time and facilities to encourage nurse for discussing and applying research finding in clinical (Lee, 2003).

Fourth, facing of decreasing birth rate, the elderly increasing inevitable, aging population already became a international problem, elderly care must pay more attention in nursing. Community services would be a big tendency and increase outreach services and day care services nursing care. Communities’ services for example community nurse and Nursing Clinic also help to relive the treatment cost, reduce stress and workload of front line nurse and bed occupancy rate. This situation closely relate to EBP because the role of nurses become more arduous and specialization, the case nurse provide professional health care services with integration, multifunction should have both evidence and knowledge to support the practice and patient outcome. The phenomenon provides opportunity to EBP to walk out the hospitals and integrate into the communities.

Fifth, in the future nurses implement EBP may not just focus on Western medicine, also include Chinese medicine. In current years, popularity of Chinese medicine increasing in Hong Kong, most elderly tend to use Chinese treatment such as acupuncture, qigong diet regimen. Chinese medicine research and the utilization on clinical should be part of concern in EBP when making decision. As favorable condition of geography and culture in Hong Kong, combine Chinese and Western medicine would be a tendency, as a nurse should have the knowledge integration and application in clinical care.

In conclude EBP utilization provide a more scientific method to the clinical decision making lead to improve and maintain health care quality, it is definitely the general direction in nursing future development. Base on the restrictive of policies and environment, working environment and organization seems to be two bigger challenges of EBP utilization. Although there are many challenges of EBP, different limitations from nursing and the external environment such as aging population, Chinese medication become more popularity etc provide some opportunities to indicate the future direction of EBP. Nursing profession need to sensitive to those factors, then appropriate to develop or improve, probably reduce the gap between clinical practice and EBP, also may provide a new direction for EBP in nursing utilization.