Implementing evidence-based practices in an emergency department: contradictions exposed when prioritising a flow culture

BACKGROUND: An emergency department is typically a place of high activity where practitioners care for unanticipated presentations, which yields a flow culture so that actions that secure available beds are prioritised by the practitioners.OBJECTIVES: How does the flow culture in an emergency department influence nurses' use of a research-based clinical guideline and a nutrition screening routine.METHODS: Ethnographic fieldwork was carried out over three months. The first author followed nurses, medical secretaries and doctors in the emergency department. Data were also collected by means of semi-structured interviews. An activity system analysis, as described in the Cultural Historical Activity Theory, was conducted to identify various contradictions that could exist between different parts of the activity system.RESULTS: The main contradiction identified was that guidelines and screening routines provided a flow stop. Four associated contradictions were identified: insufficient time to implement guidelines; guilty conscience due to perceived nonadherence to evidence-based practices; newcomers having different priorities; and conflicting views of what constituted being a professional.CONCLUSION: We found that research-supported guidelines and screening routines were not used if they were perceived to stop the patient flow, suggesting that the practice was not fully evidence based.