Mind the Research-Practice Gap!

Mind the Gap! That’s a sign you’ll see in the London underground (AKA subway). The point is to watch where you are walking and not misstep into the gap between the train and platform. If you mind the gap, you’ll have a good outcome and get on the train safely.

Although there is no obvious visible warning, like a physical gap, for healthcare providers, there is [still] a gap between the use of research and evidence and practice – it’s called the research-practice gap. Basically, that means that there are healthcare providers who do not use the latest guidelines or other evidence-based practices (EBP) to guide their clinical or professional practice decisions.

The healthcare providers who eschew EBP as “cookbook medicine” or worse, will perhaps suffer on a performance review for not using best practices; however, it’s the patients that will potentially suffer the most by falling through the cracks or “into the gap” because of outdated knowledge and practices. In this post, I’ll compare research utilization, research-based practice, and evidence-based practice and shed some light on the existence of the research-practice gap.

What’s the Difference Between Research Utilization, Research-Based Practice, and Evidence-Based Practice?
The nursing profession has been promoting research utilization and research-based practice (RBP) for over 50 years!

Research utilization is an umbrella term that is defined as both a process (how to “do” research utilization) and a product (i.e., the research findings, themselves) (Stetler, 2001; Thompson, 1997). Since I just wrote a series of posts on concept analysis, I’ll share that I settled on this definition after I did a concept analysis of this phenomenon!

The definition of research-based nursing practice is pretty straightforward: nursing practice interventions that are based on valid and reliable scientific research findings (note that we are not talking evidence), instead of tradition and authority. Research-based practice provides the rationale underlying nursing practice interventions. Using research in practice makes visible the answer to the question: “how is scientific knowledge USED in clinical practice?” It’s the technical “why” for why nurses do the things they do.

Evidence-based practice is a logical, systematic method of clinical decision-making that incorporates the best evidence available (for the clinical or patient question of interest), clinical expertise and experience (of the clinician), and patient preferences (of the patient being treated). According to Sackett et al. (1997), EBP as a process of lifelong, self-directed learning by the clinician for the purpose of providing the best care for patients.

Evidence-based practice evolved from evidence-based medicine (EBM), which was “birthed” in the 1980s by Dr. Archie Cochrane and grew in popularity in the 1990s. EBM was considered a major paradigm shift in medicine because traditional medicine had been largely based on an authority-model of teaching and emphasizing the use of clinical intuition and clinical experience (EBM Working Group, 1992). Sound familiar? Many nursing practices were also based on authority and passed-down information!

Evidence-based practice denotes a more healthcare team-inclusive, clinically-oriented practice with a specific set of rules and a systematic process from which to make decisions for patient care.

Why Did Nursing Leaders Change From RBP to EBP?
So if nursing was already going down the path of using research to guide practice, why did we change to new terminology? I wondered this myself at first! Most basic nursing research textbooks have at least one chapter on research utilization, which discusses the history of the research utilization movement and its evolution into EBP.

It’s not too hard to see the connection between these terms. And, in fact, evidence-based nursing practice, AKA evidence-based nursing, is frequently understood to be research utilization or research-based practice (Scott & McSherry, 2009). Indeed, the ultimate goal is the same – to provide excellent care for the purpose of improving and promoting patient outcomes.

Though the nursing profession has been encouraging nursing practice to be research-based for a very long time — we adopted the terminology of EBP and the discipline-specific idea of evidence-based nursing (EBN) to label nursing practice that is based on evidence, clinician experience, and patient preferences; that is, on more than just research findings.

My personal opinion is that to work well with our interdisciplinary team members we need to speak the same language – not that RU or RBP were unfamiliar terms to our medical or allied health colleagues. But the terminology and concepts of EBP have clearly been embraced by the global community; so using the same language makes communication clear and puts us all on the same page. In my opinion, I don’t believe that using the term EBP dilutes or negates our nursing history of research utilization and our pursuit of research-based practice, one bit!
In response to changes in healthcare priorities and the promotion of EBP, some early research utilization models and frameworks have been transformed into evidence-based practice models. For example, the Stetler Model of research utilization was revised to reflect the changing times and terminology (Stetler, 2001). The popular Iowa Model has also undergone multiple revisions from its inception as The Iowa Model of Research-Based Practice to Promote Quality Care. Revisions (with rationales) were made to change the model to the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001) and recently the model was revised again, validated, and retitled the Iowa Model-Revised: Evidence-Based Practice to Promote Excellence in Health Care (Buckwalter et al., 2017).

Are the Terms Research Utilization, Research-Based Practice, and Evidence-Based Practice Synonymous?
Is there really a difference between these three concepts? Are these terms synonymous?

Well no, not really. RU and RBP are predicated on the use of RESEARCH findings in practice, ONLY. EBP also relies on scientific research findings as the preferred evidence source for practice interventions; however, recognizes that other forms of data and evidence, including expert opinion, have a place in clinical decision making, too. EBP acknowledges the roles that the clinician’s experience and the patient’s beliefs and preferences play in informing clinical practice decisions. These essential components are not spelled out in most RU or RBP frameworks.

The Research-Practice Gap
The Research-Practice Gap
Continued Challenges: The Research-Practice Gap Photo by Tim Bogdanov on Unsplash

The push by nursing leaders for nursing practice to be research-based spawned a multitude of research utilization projects and research utilization models and frameworks in the 1970s and 1980s. These initiatives increased the amount of nursing research being conducted and the promoted the acceptance of research as a base for nursing practice. In addition, nurses became more aware of their role in changing practice to promote positive patient outcomes. However, without national initiatives and demonstration projects to push the issue, nor research mentors to guide the staff, research-based practice did not “catch fire” nor become the standard of nursing care in many institutions.

The realization by nurse researchers that nurses were not aware of research findings to guide practice led to the coining of the phrase, “Research-Practice Gap.” With this understanding came a renewed call for all nursing practice to be research- and evidence-based. But despite the promotion of EBP as a healthcare expectation, a gap between the availability of research and the translation of those findings into practice is still evident today.

The research-practice gap is clearly identified when there is an inconsistency between available and valid research findings and the use of these findings in clinical or professional practice. A similar idea is used in other situations in nursing: you may have heard of the theory-practice gap, which relates to the fact that many nurses do not consciously use theory to guide their clinical, professional, or teaching practice.

The research-practice gap isn’t only a problem for healthcare disciplines, by the way. In a recent Google search, I found the term research-practice gap attributed to architecture design, management practice, human resources, knowledge development, librarianship, education, clinical psychology, and social work, to name a few. In nursing, and apparently in all of the named professions above, the term is recognized and lamented, but still persists (Bansal, Bertels, Ewart, MacConnachie, & O’Brien, 2012; Ferguson, 2005; Geelan & Hirschkorn, 2008; Graham & Kormanik, 2004; Parrish, 2015/2014; Stirman, 2016; Thompson, 1997). Everyone is looking for solutions!

The ultimate purpose of research utilization, research-based practice, and evidence-based practice is to promote positive patient outcomes by transferring or translating research knowledge into bedside practice. These positive patient outcomes can’t occur if healthcare providers don’t use evidence to guide their practice decisions. I’ll discuss some common reasons for the research-practice gap in nursing next week.