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Re-moo-ving the sacred cows of nursing

How evidence-based practice can update long-held beliefs

  • Illlustrations by Dennis Murphy
  • Story by Pam Roe
  • Published: Sept. 1, 2008
Cow illustration

The patient was so thin that the nursing student was convinced a 90-degree-angle subcutaneous injection of enoxaparin would hit a bone or an organ. Unfortunately, her instructor had told her the angle was the proper one for this type of injection.

Her instinct told her to use a drastically different angle, so nursing instructor Gretchen Gregory put the “sacred cow” up for examination. “I told her she needed to bring me the evidence to support a change,” Gregory says. “Not only did this student find the evidence that you can give this medication effectively at a 45-degree angle, but it is actually recommended for extremely thin individuals.”

Instructors tend to teach nursing students strict procedures. “If you were taught a skill and taught it the ‘right way,’ then you should do it that way forever,” Gregory says. “That is our current practice; that’s where the sacred cows in nursing come from.”

Evidence-based practice is practical and calls for questioning the rules. “In the past, nurses would have thought about the problem and stopped because it wasn’t ‘hospital protocol’ or ‘how I was taught,’” she says. “Now nurses are thinking about whether their question makes sense and whether maybe someone else had thought about it too.”

In the mid 1970s, the school gained recognition as a leader for developing theory-based nursing with the adoption of Dorothy Orem’s Self-Care Nursing Theory. In 2004, the school once again pushed the educational envelope by integrating evidence-based practice (EBP) into the curriculum. Louise Miller, a faculty member who teaches EBP in the graduate program, introduced the concept to the curriculum committee after attending a week-long workshop at Canada’s McMaster University, a leader in evidence-based medicine (EBM).

“I was concerned that we were sending new graduates into the work force without EBP knowledge,” Miller exclaims. “Although physicians have incorporated EBM into physician education over the past few years, EBP is a newer concept in nursing education.”

Instructors have spread EBP throughout the curriculum so students can learn it incrementally and build a strong base of knowledge. Different levels of evidence are accessible through databases and the Internet. As a general guideline, a research pyramid is employed to demonstrate each of these levels and the type of support it gives the evidence.

“It used to be that we had to read these very in-depth research articles and it was tedious work,” Gregory says. “Now we are okay with different types of evidence, so now students don’t have to read the hard-core articles — even though we introduce them to the top levels of the research pyramid.”

Students learn that critical thinking is most important; employers search out Mizzou grads because they are trained in critical-thinking skills.

“I want students to think,” says. “It is their job to put quality patient care at the forefront of their nursing practice. That’s why most of us become nurses in the first place, and that’s why it is crucial students are introduced to evidence-based practice as soon as they get into the nursing program.”

Gregory believes it will take five to 10 years to get everyone thinking in terms of evidence-based practice. “But I think we need to build the next generation to think about the questions,” she says. “Why am I doing this? Does it make sense? That’s the key to getting rid of our profession’s sacred cows.”

So what happened in the case of the student’s wafer-thin patient? “She thought I was going to be mad because she was questioning my teaching style,” Gregory says. “Matter of fact, I told her that she just went to the top of the class. I wanted her to ask the questions, bring in the evidence and let it change my practice. We don’t have to hurt these patients if there is evidence to show us how to do a procedure differently.”