“Knowledge must be at the patient’s bedside” is one of the sentences that has marked the first experience in Nursing Advanced Practice at the Health Service of the Balearic Islands (Illes Balears), Spain. I had the privilege of preparing my doctoral thesis as part of this project, and I have been offered the opportunity to share some of its conclusions in this editorial. The objective of the research was to improve the implementation of Evidence-Based Practice (EBP) by clinical nurses working at hospitalization units, by incorporating the role of Advanced Practice Nurse (APN) as enabler element. In this article, I want to focus on the usefulness of boosting the competence of expert nurses in order to improve those clinical health indicators that depend directly on nursing care.

My interest on EBP implementation in the work of nurses arises from my amazement at its persistent lack of implementation in clinical practice, regardless of its proven value. The barriers that nurses find in order to conduct it have remained for decades (1). Particularly at hospitalization units, the high number of nurses involved in the decision making process regarding patient care, as well as a high rotation of professionals, represent some of the barriers for the application of EBP. Besides, there is still an important variability in clinical practice which, paradoxically, increases with the emergence of new evidence. Therefore, transforming EBP in an authentic paradigm at hospitalization units is a challenge that must be pursued.

Alongside this reality, it seems more than proven that nurses are increasingly more qualified to provide evidence-based care, which allows them to adapt to an ageing population, with an increase in chronic conditions. On the other hand, nursing research has increased in quantity, quality and acknowledgement. Thus, nurses are present in a wide range of social settings, leading projects for innovation and development in health, with an increasingly higher level of competence. This evolution has resulted in the emergence of roles with extended competences, such as the APN, which go beyond the role of the general nurse. Numerous studies support the incorporation of APNs to the health system, highlighting their contribution to an improvement in patient care (2). However, its implementation and acceptance are still creating controversy due to the different roles played, according to their practice setting, which makes it difficult to understand their specific contribution.

Regardless of all these undoubted advances of nurses, the health system relegates them to roles mostly of care, without acknowledging or motivating those who make an effort to keep updated in terms of knowledge, or boosting their valuable contribution. Anyway, nurses continue their training in an autonomous way and in their free time; attendance to congresses is only funded (and this is usually not easy to obtain) if any communication is presented, typically prepared outside working hours. This lack of stimulus by the system can lead nurses to reduce their involvement in scientific or training activities additional to their daily practice, in order to focus on offering care based on their previous experience.

On the other hand, in order to consider that a nurse is working according to the EBP construct, they are required to follow a series of steps: to reflect on clinical practice, to cultivate a research spirit, to prepare a structured clinical question, to search for and collect the best evidence, to evaluate it critically, to integrate it with clinical experience and patient preferences and values, to evaluate the results of the decision or the change of practice and, finally, to spread the results. Within the context stated in the previous paragraph, it is not only difficult but also unrealistic to demand that all nurses have all the attitudes, skills and knowledge to conduct each of these steps. For this reason, a coherent and effective option for EBP application is to use a team-based approach (3). And for this, it is favourable to have roles that drive the application of EBP as part of the hospitalization teams, and the APN has the skills necessary for this.

At the time of conducting the research, there were no recognized advanced practice nurses at the Balearic Islands, which led to the search for nurses to undertake this role. Specifically, there was a selection of those nurses expert in care for patients admitted to the hospitalization units that participated in the study, who had a master or doctorate training, and who were acknowledged by their team as informal leaders (4). These nurses were offered training, follow-up and mentorship, so when research was completed, and within just one year. they had reached a competence level in advanced practice that could be equated with that by APNs already recognised in other settings. One of their functions was the implementation of two clinical practice guidelines on care and treatment for pressure ulcers, and care for vascular access.

In order to evaluate the level of adherence of the Nursing team to evidence-based recommendations, there was a measurement, before and after the incorporation of APNs, of the process and outcome indicators, among other variables (5). The use of different strategies for EBP implementation, such as collection-based feedback and analysis and interpretation of indicators, had a significant impact by improving aspects as important as the rate of adverse events associated with the vascular catheter or the prevalence of pressure ulcers, which are indicators directly associated with hospital morbimortality rates (6).

The measurement of clinical indicators is essential for an adequate hospital management, because they provide a panoramic view of the care received by patients, and allow to identify areas for improvement, the need for implementing new protocols, and to ensure excellence in care offered. Traditionally, only professionals with management roles have been interested in these indicators; however, it was achieved by these expert nurses that they also became useful for clinical nurses.

In this sense, APNs in hospitalization units played a key role. They became real leaders, and achieved an improvement in team dynamics, normalized self-evaluation as a feedback mechanism for continuous improvement, and encouraged critical thought among clinical nurses. In this way, the achievement of an authentic EBP was established as a team, involving all professionals in those stages of the process where they could collaborate, and boosting the acquisition of individual skills.

The challenge accepted by nurses who performed the APN role in our study (5,6), as well as the outcomes they obtained, are an example of the potential of nurses when they are trained, motivated, and supported by their organization. To boost the competences of nurses is associated with substantial improvements in the health status of the population; therefore, it is imperative to encourage the progression of advanced practice in the Spanish setting.