Editorial: Cleaning out the Closet: Getting Ready for Evidence-Based Practice
Although the weather in some parts of the country is still warm, this is the time of year when the closet doors are opened and items begin to be sorted and either discarded or stored. The stimulus for such activity may be something as major as deciding what to take to a college dorm or as minor as just being tired of looking at the same clothes hanging in the same place after several months. As I was beginning to do my seasonal shifting and sorting of summer and fall items, it dawned on me that getting staff ready for evidence-based practice is similar to cleaning out a closet. For example, when eyeing the closet, we ask questions such as, “What is old and worn out and should be discarded?” “What is still worth keeping?” “What will I need for the future?”
What Is Old and Worn Out?
Creating a climate of inquiry in which staff are comfortable challenging practices and policies that are “worn out” and do not seem to “fit” any more is a challenge. It is like being empowered to dig into the closet and daring to throw out the old pair of shoes that are so comfortable that they are now just shreds of leather or to finally discard the clothes that have been kept “just in case” those 20 pounds creep back again (even though those pounds have been gone for more than 10 years). Once so empowered, it can be a very freeing feeling to “finally” discard some of the interventions that just do not seem to work any more on a patient population that has, perhaps, become older or more “consumer savvy” or more chronically ill than in previous years. Or perhaps discard the policy that is so outdated that some of the committees or positions listed who are responsible for its application no longer exist. Changes in healthcare are moving at lightning speed, and once-treasured interventions and dynamic tasks forces may “wear out” in the process. A culture of inquiry allows staff to sift through the closet freely, question the traditional, and shine a light into the darkest “we've always done it that way” shelf of the closet.
What Is Still Worth Keeping?
Although there are some who would want to immediately discard everything in the closet and eagerly go on a buying spree, a legitimate question to ask is whether anything in the closet is worth keeping. As the closet is opened and clinical questions arise, staff needs to understand that after finding the latest and most valid evidence, parts or all of a present clinical practice may indeed still be valid. In some cases, it may be that the intervention itself is based on the best evidence, but the process by which the intervention is rendered needs a “fashion upgrade.” The little black dress in the closet still “works” for an evening out, but it now needs different accessories to make it “pop.” For example, perhaps the morbidity rate in stroke patients after being admitted through the emergency department is not where it should be. However, after searching the latest evidence, if it is found that tPA given within 3 hours of first stroke symptoms can decrease permanent sequelae, then perhaps the problem is not with the dress (i.e, the tPA), but rather with the same old flat shoes and out-of-date belt (i.e, the community who, as a whole, does not recognize the signs of stroke or the importance of going to the nearest emergency room in a timely manner). The obvious thing to do in this case is to keep the dress, but update the shoes and belt (in this case, perform massive community educational outreach).
What Will I Need for the Future?
Once old items in the closet have been thoughtfully discarded, then there is room for new ones. However, whatever is bought still needs to blend fashionably with the older items still hanging there. A culture of inquiry fosters staff's willingness to develop new guidelines or to find and adopt existing ones; however, it also includes keeping in mind the resources and the culture of the institution and the patients who are served. Once these factors are considered, guidelines will more easily be implemented, and the “evidence-based closet” will be complete for another season—or at least until the next clinical issue is identified.