Evidence-Based Practice: The Need for Leadership

Parfitt CLINICAL / EDITORIAL NURSING RESEARCH / February 2002 ♦ Editorial Evidence-Based Practice: The Need for Leadership Imagine a remote mountainous country where since the collapse of the Soviet Union 10 years ago or more, nurses have had no improvement in their conditions of work, no new equipment to work with, few drugs, and little or no access to any form of professional development. A recent study (Parfitt, 2001) carried out in Tajikistan as part of a baseline evaluation prior to the introduction of family health nursing showed that things have not stood still since the collapse of the Soviet Union; rather, they have gone backwards. Nurses once proud of their standards now despair over the little they can do to deliver good care. They acknowledge their lack of current levels of knowledge with shame and regret; they believe that the only way they can improve care apart from increased resources is to apply current clinical research findings to their practice. They are hampered by the attitudes of the traditional physicians, and they recognize that a culture where nurses are powerless, scholarly and leadership skills are not seen as necessary, and nursing research is not understood has influenced them. What the nurses themselves recognize is that without the skills of leadership and a culture of scholarship, the nursing profession will not have the capacity to bring about the changes in practice proposed in the Health Reform Program (Dovlo, 1999). To promote the development of high-powered notions of clinical research, scholarly thinking, and leadership into such a situation might seem an insult. Yet in discussions on the way forward, the promotion of concepts of leadership and the development of a culture of research and scholarly activity were the issues identified as most relevant. Nurses who are highly competent technically but who feel powerless to bring about change recognize the force that evidence has and the signifiCLINICAL NURSING RESEARCH, Vol. 11 No. 1, February 2002 5-9 © 2002 Sage Publications 5 6 CLINICAL NURSING RESEARCH / February 2002 cance of clinical research. They also recognize that they do not have the leadership skills to promote change and sustain it. They have been nurtured in a culture of obedience, acting at all times as assistants to the medical staff, who in turn see nurses as there to assist them, not to act independently. There is little or no expectation that they will make decisions or lead their profession. The Health Reform Program led by the minister of health challenges these attitudes and indicates clearly that if the health of the nation of Tajikistan is to improve, the role of nurses must change. Similar to the Tajikistan government, many governments are seeking to introduce major health reforms to combat the increasing threat of ill health. Morbidity and mortality rates fail to improve and in many cases have deteriorated. In response, new methods of delivering health care are being introduced. These focus on the serious development of primary health care services and a greater utilization of the expertise of nurses. The expansion of the roles and the skills of nurses are central to the ability of a country to successfully meet the health needs of its population. There is at last recognition that nurses impact directly on the ability of a country to introduce and sustain an effective health service. Nurses have the responsibility to lead in this change and capitalize on the new opportunities. Nursing research can change practice, but to do so, it requires nurses with both scholarship and leadership skills to promote the necessary change and innovation. Clinical research and leadership are not immediately linked together or seen as interdependent activities. Clinical research is part of the wider competence of scholarship, whereas leadership and scholarship are key attributes that are identified as fundamental to the development of nursing worldwide. The assumption that the existence of new knowledge generated through research will lead to a change in practice cannot often be supported. Many practices remain unchanged as the research reaches no further than the conference paper or the report lodged in the library. There are many reasons for this but not least because nurses have often felt powerless to change the traditions and cultures of the working environment. They have not been able to influence the traditional approaches to care that are the result of years of experience, little of which has been tested for its clinical effectiveness. Those who are armed Parfitt / EDITORIAL 7 with findings from sound research, who value scholarship in nursing, and who are prepared to promote change are necessary for the long-term improvement of care. For many years the nursing profession has believed in an inverse relationship between intelligence and the ability to care. We need leaders who can refute this and demonstrate that the way forward must be evidenced based and that nursing research is necessary to support development. Nurses in Scotland have recently had the opportunity to contribute to the recently published Caring for Scotland, the Strategy for Nursing and Midwifery (National Health Service Scotland, 2001). The new strategy emphasizes the need for leadership skills. It highlights the necessity for nurses to not only understand research methods and be able to interpret findings but also the need for them to take a leadership role in practice. The new agenda for health in Scotland (Scottish Office Department of Health, 1999) outlines an agenda for change that will require nurses to be proactive in changing their role. For the government to achieve its health agenda, it is critical that nurses take this leadership role. The development of a clear research strategy to support the nursing and midwifery strategy is also underway, and the focus on integrated leadership with scholarly thinking and research utilization to meet the health agenda is paramount. Within Glasgow, Scotland, there is a major initiative led by the four Trusts to target the development of leadership skills among nurses at the senior ward-sister/charge-nurse level. Glasgow Caledonian University is also participating in this initiative. Ward sisters and charge nurses are in a critical position to be able to introduce change and develop nursing practice through the application of clinical research findings. In Tajikistan, the challenge is enormous, but the government has committed itself to a program of nursing development. In a country where nurses have rarely taken a leadership role, they will now be required to participate at the highest level in the development of health services and in the delivery of care. This is to be done in partnership with their medical colleagues. Two ways in which this development is being carried out is through the establishment of a Nursing Center at the Institute for Postgraduate Studies and secondly through the development of the role of the family health nurse. The Nursing 8 CLINICAL NURSING RESEARCH / February 2002 Center will be responsible for the development of a nursing strategy and for the setting of standards for education and practice. At present there are no nurse teachers, nurse researchers, or nurse leaders. Physicians have previously taken on these leadership roles. The new family health curriculum introduces research skills within the context of scholarship and leadership not as a separate subject. Family health nurses will be decision makers, and using the findings from research to inform their practice will be critical. A key competency that is being assessed as part of the evaluation of the family health nursing role is this ability to integrate leadership and scholarly approaches using research as a tool for effective practice. The World Health Organization has set up three pilot sites for this evaluation, and the first nurses who enter the program will be included in the evaluation. Supporting and developing the personal confidence and self-esteem of nurses in the program, increasing their knowledge of the scientific base for nursing practice, and providing an infrastructure that allows them to develop a new culture for nursing will be the challenge. A recent visit that I carried out to South Africa has highlighted for me the need for leadership and decision-making skills among nurse educators in that country. The Constitution of South Africa indicates that nursing education is to move into the higher education sector. Nurse educators have remained largely within a traditional nurse education environment where research, scholarly activity, and leadership have not been stressed. There is now a recognition that capacity building must focus on the development of these skills if nurses are to take their place in higher education and if the next generation of nurses are to have such skills incorporated into their curriculum. Unlike Tajikistan, there is strong leadership in nursing from both the Black and the White representatives of nursing, with a Black nurse holding a senior position in the government as the chief director of human resources and having a major influence on the development of nursing. Even in such a positive climate, however, there is recognition that many nurses are not prepared for a leadership role or encouraged to develop a personal scholarly and research profile. The debate around the move of nursing into higher education is primarily a political one, with manpower and funding Parfitt / EDITORIAL 9 considerations the chief concern. Capacity building is central to the government’s human resource strategy and the recognition that for nurses to learn and thrive within such a culture, its teachers and educators must themselves develop their own expertise to share with others. Moving into higher education for many nurse educators is seen, understandably, as an excuse for governments to rationalize manpower requirements and so threaten jobs rather than an opportunity to develop a culture of leadership and scholarly and research activity within the higher education environment. The central issue in each of these global examples is the need for the development of leadership and scholarship skills for nurses. There is a universal recognition that nurses must change their culture if they are to be effective contributors to health reform. Clinical research is increasingly necessary within nursing to support the decision-making process of nurses who directly deliver care. For this research to be utilized, not only must nurses know and understand the research process and be able to apply it to practice, but they also need a scholarly environment where research knowledge is valued, and most of all, they require leadership skills to empower their colleagues and themselves to implement change. —Barbara A. Parfitt REFERENCES Dovlo, D. (1999). Human resources—Master plan for Tajikistan. Unpublished consultancy report, Tajikistan. National Health Service Scotland. (2001). Caring for Scotland, the strategy for nursing and midwifery in Scotland. Edinburgh, Scotland: The Stationery Office. Parfitt, B. A. (2001, June). An evaluation of family health nursing. Paper presented at the International Council of Nursing, Denmark. Scottish Office Department of Health. (1999). Toward a healthier Scotland: A white paper on health. Edinburgh, Scotland: The Stationery Office.