What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review.

YNEDT-02833; No of Pages 8 Nurse Education Today xxx (2014) xxx–xxx

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Review

What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review Brett Williams a,⁎, Samuel Perillo a, Ted Brown b a b

Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia Department of Occupational Therapy, Monash University, Victoria, Australia

a r t i c l e

i n f o

Article history: Accepted 12 November 2014 Available online xxxx Keywords: Evidence-based practice Culture Communication barriers Evidence-based medicine Organisational culture Health care work environments

s u m m a r y Background: The responsibility to implement evidence-based practice (EBP) in a health care workplace does not fall solely on the individual health care professional. Organisational barriers relate to the workplace setting, administrational support, infrastructure, and facilities available for the retrieval, critique, summation, utilisation, and integration of research findings in health care practices and settings. Objective: Using a scoping review approach, the organisational barriers to the implementation of EBP in health care settings were sought. Method: This scoping review used the first five of the six stage methodology developed by Levac et al. (2010). The five stages used are: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The following databases were searched from January 2004 until February 2014: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL. Results: Of the 49 articles included in this study, there were 29 cross-sectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. The articles were analysed and five broad organisational barriers were identified. Conclusions: This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. Even for a health care professional who is motivated and competent in the use of EBP; all of these barriers will impact on their ability to increase and maintain their use of EBP in the workplace. © 2014 Elsevier Ltd. All rights reserved.

Introduction Continual advances in technology, drugs, treatment approaches and the understanding of the human body now mean that continual education is important in maintaining a current level of knowledge to provide the highest level of care to patients and families. Evidence based practice (EBP) as a concept was introduced by Cochrane in 1972 with the publication of “Effectiveness and Efficiency: Random Reflections on Health Services” (Cochrane, 1972). In this seminal text, Cochrane took aim at the current medical environment which was largely reliant on clinical opinion, tradition and hearsay to guide treatment. The other issue that he noted was the length of time that it took for published empirical findings that could directly impact patient care to filter down to the frontline of providing treatment. This often took 10 or more years to occur. Similarly, there were interventions that were still commonly ⁎ Corresponding author at: Department of Community Emergency Health & Paramedic Practice, Monash University, Peninsula Campus, P.O. Box 527, McMahons Road, Frankston, Victoria 3199, Australia. Tel.: +61 3 9904 4283; fax: +61 3 9904 4168. E-mail address: [email protected] (B. Williams).

being used when there was demonstrable evidence that they were no longer appropriate (such as extended bed rest for back pain). Cochrane stressed the importance of the Randomised Controlled Trials (RCTs) research methodology in furthering medical knowledge. The strength of RCTs lies in the elimination of bias, making for results less prone to the influence of external factors. An outcome was a repository for the results of these published studies into an easy to access resource for health care professionals to access (The Cochrane Collaboration, 2013). Cochrane endorsed a systematic review of corticosteroid therapy in high-risk mothers in pre-term labour (Cochrane, 1989) which then marked the way for the foundation of the Cochrane Collaboration that developed in the early 1990s. This provided a central resource whereby clinicians could access full systematic reviews of RCTs and use the information to make informed clinical decisions (Fineout-Overholt et al., 2005; The Cochrane Collaboration, 2013). Today, there are multiple databases such as the Cochrane Collaboration (The Cochrane Collaboration, 2013), BMJ Best Practice (Minhas & BMJ Publishing Group), Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus (EBSCO Publishing), Ovid MEDLINE (National Library of Medicine (U.S.)) and the Joanna Briggs Institute Evidence Based

http://dx.doi.org/10.1016/j.nedt.2014.11.012 0260-6917/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Williams, B., et al., What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-base..., Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.012

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B. Williams et al. / Nurse Education Today xxx (2014) xxx–xxx

Practice database which put the latest empirical evidence and literature within everyday reach of health care professionals. Despite increased accessibility, a gap continues to exist between the published empirical literature and the actual use and uptake of evidence in the everyday practice of health care professionals. Initially developed in 2000 by the Canadian Institutes of Health Research, the concept of Knowledge Translation (KT) describes the science that works to reduce this gap by examining the different ways by which information can be taken from its source and introduced to where it is needed (Canadian Institutes of Health Research). Through the use of various models, KT bridges the divide between those who create knowledge and those who use or apply knowledge (Sudsawad, 2007; Williams et al., 2013). Research utilisation, uptake and integration are other terms that are key in the implementation of EBP findings in health care settings as well. The successful implementation of EBP is a dynamic process dependent on a number of variables. Individual experiences, bias and attitudes alongside professional, organisational and workplace factors can act as hurdles or barriers to the translation of empirical knowledge into practice and as such this process can take many years (Brady & Lewin, 2007; Fineout-Overholt et al., 2005; Newman et al., 1998; Retsas, 2000). For individuals to effectively implement EBP, they need to be both motivated and competent (Newman et al., 1998); motivated in that they have a desire to seek out the information that best serves the needs of their patients; and competent in that they need to have the necessary skills and resources available to them to seek out, critically analyse and interpret the data they require (Kajermo et al., 2010; Leasure et al., 2008; Ploeg et al., 2007). In short, health care professionals need to be skilled and informed consumers of EBP findings. The responsibility to implement EBP in the workplace does not fall solely on the individual health care practitioner. Organisational factors relate to the workplace setting, administrational support and facilities conducive to research utilisation (Funk et al., 1991) and KT. The research itself can self-limit its own use if it is not of a sufficient quality, difficult to understand or benefits for practice are unclear, or inaccessible to those seeking to use it (Dannapfel et al., 2013; Fineout-Overholt et al., 2005; Funk et al., 1991; Kajermo et al., 2010). A health care organisation needs to provide an environment conducive to the implementation of EBP in order for its staff members to effectively provide the highest level of care (Cummings et al., 2007; Marchionni & Ritchie, 2008; Wallin et al., 2006). Using a scoping review approach, this study sought to identify organisational barriers that impact the implementation of EBP in the health care setting so that organisations can be informed, undertake further research and/or implement changes to policies and procedures to facilitate the uptake of EBP and KT. A five stage process was used to systematically identify and analyse the extent of the empirical literature describing organisational barriers; and to use the findings to comment on the major factors that act as hurdles to the implementation of EBP in health care contexts.

Methods Scoping reviews seek to identify and map the available literature on a selected topic (Davis et al., 2009; Levac et al., 2010). The goal is to define the breadth of literature available on the research area and to determine the value of venturing into a full systematic review. A scoping review was chosen for this study as it was deemed to be faster and less costly than a formal systematic review whist still being able to capture the core elements out of a diverse body literature (Davis et al., 2009). The search is inclusive of both peer-reviewed research and grey literature (i.e. non peer-reviewed material and material that lacks sufficient basic bibliographical information such as author, publishing date and publishing body), in order to obtain a broad overview and to then guide more focussed research (Davis et al., 2009). This scoping

review will use the first five out of the six stage methodology developed by Levac et al. (2010). These five stages are: 1. 2. 3. 4. 5. 6.

Identify the research question Identify relevant studies Study selection Charting the data Collating, summarising and reporting the results Consultation (stage 6 is not included in this study).

The methodology for scoping reviews advocated by Levac et al. (2010) was originally devised by Arksey and O'Malley in 2005. Arksey and O'Malley suggested that the sixth stage consultation was optional to provide opportunities for the community and stakeholders to suggest additional insights and references (Arksey & O'Malley, 2005), however, Levac et al. (2010) recommended that this sixth stage be mandatory. Unfortunately due to resources and the scope of this study, the authors have made a decision to not include this sixth stage in this paper. Identify the Research Question The research question guiding this scoping review was: What are the factors of the organisational culture in a health care setting that act as barriers to the implementation of evidence-based practice? This question was formulated as it was considered broad enough to allow for a wide selection of papers from all health care disciplines to be included, but also was focused enough for targeted search strategy to be developed (Levac et al., 2010). Identify Relevant Studies A search of multiple databases was conducted using the strategy outlined in Table 1. The search strategy was undertaken through the following databases: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL. The Monash University Research Repository, British thesis library (EThOS) and grey literature sites (Grey Literature Report: http://www.greylit.org/ and GreyNet International: http://www.greynet.org/greysourceindex.html) were also searched to identify non-peer reviewed papers. The dates the databases were searched from were January 2004 until February 2014. The initial search resulted in 221 articles. Hand searching of relevant journals yielded a further 15 articles. A title and abstract review left 68 articles. Full text analysis resulted in 49 articles selected for inclusion in the scoping review. The reporting of the search strategy can be seen in Fig. 1. Study Selection The inclusion criteria were: 1. Article published between January 2004 and February 2014 (a ten year period due to time and cost considerations, and to ensure the literature was relevant and current) 2. Organisational factors were a major outcome of interest or topic of discussion 3. Article including any health care profession 4. Evidence-based practice as a major theme.

Table 1 Search strategy. 1. (Evidence-based medicine or EBM).mp. 2. (Evidence-based practice or EBP).mp. 3. 1 or 2 4. Organizational culture.mp. or organizational culture 5. Organisational Culture/or organisational culture.mp. 6. 4 or 5 7. Barrier*.mp. 8. 3 and 6 and 7



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Fig. 1. Flow diagram for study selection.

Studies were excluded if they were not written in English. The database search and title/abstract review were conducted by one author (SP). The three authors convened to review the 68 articles selected for full text review. Five articles were unanimously excluded as they did not address organisational factors. A further 14 were excluded following discussion surrounding the inclusion criteria. Charting the Data Charting the data is a ‘narrative review’ or ‘descriptive analytical’ method that is used to extract the data from each study (Arksey & O'Malley, 2005). Table 2 provides an overview of the 49 articles selected for inclusion in the scoping review. The articles were reviewed and five broad organisational barriers were identified: 1. 2. 3. 4. 5.

Workload Other staff/management not supportive of EBP Lack of resources Lack of authority to change practice Workplace culture resistant to change.

These barriers were identified as being recurring themes throughout the results and discussion sections of the selected articles following the full text analysis. Collating, Summarising and Reporting the Results Of the 49 articles included in this review, there were 29 crosssectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. While the majority of the studies focused on the nursing profession there were also studies that involved occupational therapists, physiotherapists, physicians, social workers and emergency medical services; as well as comparisons of junior and senior staff and management. The majority of studies were undertaken in the United States (U.S.) (Atkinson et al., 2008) with studies also conducted in the United Kingdom (U.K.) (National Library of Medicine (U.S.)), Europe (Minhas & BMJ Publishing Group), Canada

(Fineout-Overholt et al., 2005), Australia (Minhas & BMJ Publishing Group) and Asia (Cochrane, 1989). Table 3 shows a ranking of the five barrier themes according to the number of times they were identified. This method of tabulating and charting the data is the same as that used by Gray et al. (2013) as it provides a good, clear overview of the major themes sought by this study. These themes were formulated following the full text review and were identified within the studies as being major barriers to the use of EBP in health care practice. Discussion Organisational barriers to EBP are significant as they are often beyond the control of the individual. This scoping review found 49 articles that analysed barriers to EBP, with five organisational barrier themes identified as being major hindrances to the implementation of EBP within health care environments. Without removing or minimising these factors, it is difficult to create an organisational culture which is conducive to EBP, research utilisation and KT. Each of these five organisational barriers will now be discussed. Workload Workload is a barrier that has been extensively reported on, and was the most frequently identified barrier. The health care environment is one which is heavily reliant on time. Health care resources are under pressure from increased demands, which translates to staff being asked to deal with more acutely ill patients in less time. As a barrier to EBP, workload is a problem as patient-based tasks (medication dispensing, assessments, goal setting, responding to patient needs, discharge planning, debriefing with family members, etc.) need to come first and foremost (Brown et al., 2009; Chau et al., 2008; Kenny et al., 2010; Leonard et al., 2012; Plath, 2013; Profetto-McGrath et al., 2007; Turner, 2009). This leaves health care staff with little or no protected time in their typical working day to sit down, find, evaluate and integrate EBP findings (Gray et al., 2013). Positive attitudes towards EBP were reported, however, participants reported that there was no time for them to


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Table 2 Studies selected for inclusion. Author/year

Country

Research topic/focus

Study type

Barriers identified

Atkinson et al. (2008) Bartelt et al. (2011) Bennetts et al. (2012) Bonner and Sando (2008) Bostrom et al. (2008) Breimaier et al. (2011) Brown et al. (2009) Chan et al. (2011)

U.S.

Perceived barriers to research utilisation by nurses working in a community hospital

Cross-sectional survey

1, 2

U.S.


2, 4

Australia

Evaluating the effectiveness of an EBP education series on health care professionals' EBP perceptions, skills and activities; and identifying perceived barriers to applying EBP in practice Identify enablers and barriers for best-practice pain management

2, 3, 4, 5

Australia

To determine the knowledge, attitudes and use of research by nurses working in a regional area

Qualitative (focus groups and interviews) Cross-sectional survey Cross-sectional survey

1, 2, 3, 4


2, 3, 4


2, 3, 5


1, 2, 3


1, 2, 3


1, 2, 3, 4

Narrative review

2, 3, 4

Qualitative (focus groups) Cross-sectional survey

2, 3, 4, 5


1, 2, 3

Sweden

To describe perceived barriers and facilitators to research utilisation by registered nurses and examine validity of the BARRIERS scale Austria To identify and describe nurses' wishes, needs, knowledge and attitudes to nursing research, as well as perceived barriers to and facilitators of research utilisation in nursing practice in Austria. U.S. To describe nurses' practices, knowledge, and attitudes related to evidence-based nursing, and the relation of perceived barriers to and facilitators of evidence-based practice. U.S. To understand levels of education in research, the extent of experience, and needs and barriers to research at the individual and organisational levels in emergency nursing. Chang et al. Taiwan Investigation of attitudes towards EBP as well as perceived barriers and facilitators amongst Taiwanese (2010) registered nurses working in nursing homes Chau et al. (2008) Hong Kong To determine perceived barriers to, and facilitators of, research utilisation amongst nurses in Hong Kong and also to find the associations between barriers and individual and organisational factors Chummun and U.K. To determine the extent to which clinical nursing practice has adopted research evidence. To identify barriers Tiran (2008) to the application of research findings in practice and to propose ways of overcoming these barriers. Dannapfel et al. Sweden Explores the conditions at different system levels that physiotherapists in Sweden perceive to be (2013) supportive of their use of research in clinical practice. Döpp et al. Netherlands Explores how the evidenced-based practice (EBP) is perceived by Dutch occupational therapists (OTs), (2012) what sources of research data are used to make clinical decisions, and what barriers are identified in implementing EBP. Fink et al. (2005) U.S. To identify changes in nurse attitudes towards research utilisation and the organisation's research environment pre-implementation and post-implementation of a multifaceted intervention to promote the use of research in practice. U.K. To assess the effectiveness of organisational infrastructures in promoting evidence-based nursing. Flodgren et al. (2012) Gale and Schaffer U.S. Explores factors that affect the adoption or rejection of evidence-based practice (EBP) changes and (2009) differences in nurse manager and staff nurse perceptions about those factors Gerrish and U.K. To identify a range of factors which influence evidence-based practice within a hospital Clayton (2004) U.K. Report of a study to compare factors influencing the development of evidence-based practice identified Gerrish et al. (2008) by junior and senior nurses. Geyer (2004) U.S. Reviewing the literature around evidence-based nursing Gifford et al. Canada To describe leadership activities of nurse managers that influence nurses' use of research evidence; and (2007) to identify interventions aimed at supporting nurse managers to influence research use in clinical nursing practice. Golenko et al. Australia Describes and analyses perspectives of senior managers in allied health on how organisational factors (2012) influence research capacity building Grant et al. U.S. To present recommendations to overcome barriers to research utilisation so that staff development (2012) educators can promote research utilisation and evidence-based practice. Gray et al. (2013) Australia A review of the literature to determine barriers and facilitators to EBP implementation in human services Green and Ruff U.S. A study to explore medical residents' experiences in answering their own clinical questions (2005) Hockenberry U.S. Describes essential concepts for developing an environment which supports EBP and its et al. implementation and demonstrates this through implementation of an initiative to reduce procedure (2007) related pain in paediatric hospital Karin et al. Belgium Exploration of perceived obstacles to the use of EBP amongst Belgian physiotherapists (2009) Karkos and Peters U.S. Identifies barriers to research utilisation for nurses in a community hospital (2006) Kenny et al. U.S. Describes the processes of a collaborative project to train nurses in EBP and to share resources in (2010) developing and implementing evidence-based clinical nursing guidelines in two large military medical centres Leasure et al. U.S. To identify the presence or absence of provider and organisational variables associated with the use of (2008) evidence-based best practices amongst nurses Leonard et al. U.S. To explore the barriers and motivators to emergency medical services participating in prehospital (2012) research at the agency and provider levels and to solicit suggestions for improving the success of prehospital research projects. McKenna et al. U.K. Identifies perceived barriers to implementing EBP amongst general practitioners (2004a, 2004b) McKenna et al. U.K. Analyses the literature surrounding the use of research in primary care (2004a, 2004b) Melnyk and U.S. Assesses the perceptions towards EBP amongst nurses Fineout-Overholt (2012) Ogiehor-Enoma U.S. Describes the steps taken to change the use of research in practice at a hospital et al. (2010)

2, 3, 4

4

Systematic review Cross-sectional survey

2, 4


1, 2, 3, 4


1, 2, 4, 5

Narrative review Literature review

3, 4 1, 3

Qualitative (interviews) Literature review

2, 3 3

Literature review Qualitative (focus groups) Description of intervention

2, 3, 4, 5 2, 3, 4, 5

Qualitative (focus groups) Cross-sectional survey

1, 3, 4, 5

Description of intervention

2, 3


3, 4

Qualitative (focus groups and interviews)

2, 3, 4, 5


2, 3, 4

Literature review

2, 4


2, 3, 4, 5

Description of intervention

2, 3, 5

1, 2, 3



5

Table 2 (continued) Author/year

Country

Research topic/focus

Study type

Barriers identified

Osterling and Austin (2008) Plath (2013)

U.S.

Describes factors related to dissemination and utilisation of research within human service agency settings

Literature review

1, 2, 3

Australia

Case study used to illustrate the implementation of EBP

1, 2

Profetto-McGrath et al. (2007) Reavy and Tavernier (2008) Rycroft-Malone (2004) Salbach et al. (2007) Sams et al. (2004)

Canada U.S.

Pilot study to assess the sources, nature and application of evidence used by clinical nurse specialists in practice Describes a new model and process to implement evidence-based practice

Qualitative (focus groups and interviews) Qualitative (interviews) Description of intervention

U.K.

Assesses the PARIHS framework as a guideline for implementing EBP

Canada

U.S. U.S.

Identifies practitioner barriers and organisational barriers to physical therapists' implementation of EBP for people with stroke Describes an innovative collaborative project for establishing evidence-based practice in managing pain in paediatric oncology patients Describes barriers to nurses' learning Identifies barriers to research utilisation for nurses in a community hospital

Description of intervention Literature review Cross-sectional survey

1, 2, 3, 4 1, 2

Canada

Examines the role of nursing unit culture in research utilisation

Ethnographic study

1, 3, 5

U.S.

Describes a method of evaluating organisational readiness for the implementation of EBP

Narrative review

1, 2, 3, 4

U.S.

Examines barriers and facilitators to EBP using an existing framework

Literature review

1, 2, 4, 5

U.S.

Assesses perceptions of research utilisation in clinical nurse educators


1, 2, 3

Asia

Explores the barriers to developing evidence-based guidelines in eleven hospitals in Australia, Indonesia, Malaysia, the Philippines and Thailand Describes a conceptual model for EBP that addresses how to overcome barriers to implementation

Qualitative (interviews) Narrative review

2, 4

Santos (2012) Schoonover (2009) Scott and Pollock (2008) Smith and Donze (2010) Solomons and Spross (2011) Strickland and O'Leary-Kelley (2009) Turner (2009) Vratny and Shriver (2007)

U.S.

U.S.

Description of intervention Cross-sectional survey

1, 2, 3, 5 2, 3

3, 4, 5 2, 3 1, 3, 4

1, 2, 3, 4

Identified barriers: 1. Lack of authority to change practice. 2. Workload. 3. Other staff/management not supportive. 4. Lack of resources. 5. Workplace culture resistant to change.

properly engage in EBP activities; particularly if they wished to maintain a healthy work–life balance (Bonner & Sando, 2008). Time pressures will always be an issue in health care. Patients are heavily time consuming if they are to be assessed, treated and managed appropriately. While measures are being taken to try and mitigate high patient loads on health resources, this is not a factor which can be easily reduced to make way for EBP at the frontline staff level. Research is generally regarded as an activity which is to be conducted on top of a normal workload (Gray et al., 2013) and needs to be taken into consideration in how to best facilitate EBP initiatives. The provision of regular, scheduled opportunities for staff to come together and discuss research and evidence is important in an environment where time is a limited resource (Dannapfel et al., 2013; Gerrish & Clayton, 2004; Ogiehor-Enoma et al., 2010; Osterling & Austin, 2008). Time management is an important skill for the individual worker, nonetheless support from administration and health care funders is required to manage workload for each staff member and provide opportunities to invest their time in EBP. Activities such as a weekly journal club, a staff member identified

Table 3 Organisational barriers to EBP. Barrier

No. of times identified

Workload Other staff/management not supportive of research Lack of resources Lack of authority to change practice Workplace/professional culture resistant to change

38 37 28 22 14

as an EBP champion, funded back-fill time or brief EBP information bytes have all been successful in providing opportunities for staff to stay current with EBP developments while maintaining quality patient care. Other Staff/Management Not Supportive of EBP Health care staff have identified their colleagues as being one of the most important sources of information (Bostrom et al., 2008; Dannapfel et al., 2013; Geyer, 2004; Solomons & Spross, 2011). Testament to this is that this barrier was identified just as frequently as workload. If health care professionals do not feel that EBP is valued by their colleagues and managers, they are less likely to try to implement new ideas whereas a staff member whose colleagues use, implement and discuss EBP on a regular basis is more likely to be motivated to seek out and use information in order to feel that they can contribute to the workplace (Bonner & Sando, 2008; Bostrom et al., 2008; Gerrish et al., 2008; Osterling & Austin, 2008). A collaborative workplace where open exchange of ideas is encouraged is more conducive to EBP use and implementation than a hierarchical workplace culture since it provides more open channels for information to flow between individual staff members and workplace groups (Green & Ruff, 2005; Plath, 2013; Rycroft-Malone, 2004; Scott & Pollock, 2008). Managing this barrier is a top-down approach. Management and senior staff need to lead from the front and by example with the integration of organisational support, mentorship, education, multidisciplinary cooperation and, where possible, incentives and rewards to elicit positive behaviour changes towards EBP (Chan et al., 2011; Gifford et al., 2007; Melnyk & Fineout-Overholt, 2012).


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Lack of Resources The emphasis here was on fast, easy access to information. While health care staff demonstrated increasingly positive attitudes towards EBP, they also reported difficulties in accessing the information they required (Breimaier et al., 2011; Plath, 2013; Santos, 2012; Schoonover, 2009). To an extent this can be attributed to the research itself and the way in which it is collated and communicated, nevertheless it is vital that time-poor employees can quickly and easily call on the resources they need. For example, a hospital may have a fully resourced library open to staff, but the nurse has to leave the ward and thus her/his patients to access the information. This is where the timely accessibility to the evidence becomes important. Empirical literature needs to be available, if not at the point of care, then at the very least in a easily accessible designated area within each department (Brown et al., 2009; Chau et al., 2008; Chummun & Tiran, 2008; Gale & Schaffer, 2009; Green & Ruff, 2005; Leasure et al., 2008; McKenna et al., 2004b; Sams et al., 2004). For the resources to be properly utilised, staff need to know how to access them and interpret them. An increase in tertiary level education for many health care professions has led to increased awareness of how and where to access empirical evidence, as well as its importance (Bonner & Sando, 2008). This does not mean that further training and skills maintenance are not required. Staff need to be given opportunities to hone and increase their research skills and knowledge, in order to effectively utilise pointof-care resources. Lack of Authority to Change Practice This barrier links into the need for a supportive employment culture and to break down hierarchical work place structures. An employee needs to feel that their inputs and ideas are valued and that they feel they have some level of power to enact change within the organisation. In health care this translates to staff members feeling that they have the power to make changes to their practice that will positively influence patient outcomes (Fink et al., 2005; Karin et al., 2009; Reavy & Tavernier, 2008). A domain in which this is was identified as being prevalent in health care was between doctors and nurses. Several studies reported that nurses felt that they had a very low level of autonomy and power and that their opinions and thoughts on patient care were not valued by doctors (Brown et al., 2009; Chang et al., 2010; Profetto-McGrath et al., 2007; Sams et al., 2004; Scott & Pollock, 2008). This led to negative perceptions towards the value of EBP if they were not going to be listened to by other health care providers who were higher-up in the professional hierarchy. Staff need to feel that they can contribute to organisational goals. In health care this is usually defined through positive patient outcomes. If employees have the knowledge that they can improve patient outcomes through changes in their clinical practices developed by themselves or their colleague, it is more likely to motivate them to use EBP (Fink et al., 2005; Reavy & Tavernier, 2008). The use of EBP needs to become a recognised core skill in health care (Golenko et al., 2012; Leasure et al., 2008), with staff given the opportunity to be involved in activities which directly influence tangible workplace and patient outcomes (Kenny et al., 2010). If staff feel empowered to apply EBP principles, this will facilitate KT. Workplace Culture Resistant to Change The attitude of “this is how it's always been done” is a significant barrier towards EBP. Similar to a lack of support from other colleagues, working in a culture bogged down in rigid, outdated protocols does not facilitate nor encourage the flow of new ideas. Organisations should be wary of creating a ‘blame culture’ whereby staff who attempt to work flexibly within protocols are reprimanded, since this activity inhibits the formation of new approaches to existing practices (Gray et al.,

2013; Scott & Pollock, 2008). There also needs to be a step away from the notion that one working group has all the knowledge and recognising the expertise and input from staff from a variety of working groups (Brown et al., 2009; Karin et al., 2009; Sams et al., 2004). Another factor is the misalignment between the professional goals of the staff, and the organisational goals which were driven more by political and financial agendas (Bartelt et al., 2011; Golenko et al., 2012; Green & Ruff, 2005; Karin et al., 2009; Kenny et al., 2010; RycroftMalone, 2004). Heath care professionals should feel that they have some autonomy to exercise some degree of flexibility within the recognised protocols and guidelines, without fear of reprisal. Again it is the senior staff and organisational policies leading from the front and the top that can help create a working environment open to innovation, revitalisation and positive change (Gerrish & Clayton, 2004; Plath, 2013). Workplace guidelines and protocols should be based on up-to-date, best evidence, with the background literature available to staff (Gerrish & Clayton, 2004; Leasure et al., 2008). Policies should also have input from staff working groups and be reflective of each working group's needs and ideas, which may help align professional and organisational goals (Gifford et al., 2007; Ogiehor-Enoma et al., 2010; Santos, 2012; Smith & Donze, 2010). Limitations and Future Research Scoping reviews are a recent addition to the set of accepted methodological approaches in EBP, systematic reviews of literature and health care research. As such, there is still room for improvement in the framework and methodology that are best for health settings (Levac et al., 2010). Scoping reviews seek to define the breadth of literature available on a selected topic as opposed to assessing the quality and depth of literature as occurs in a systematic review (Davis et al., 2009; Levac et al., 2010). The quality of the studies selected for this scoping review was not assessed, thus no comment can be made on the rigour and validity on the findings of each study. Another limitation is the difficulty of searching the grey literature. While databases do exist, they are limited in the ability to be systematically searched with MeSH terms and Boolean operators. This means that there may have been some grey literature missed by this review. Finally, while the selected articles had their reference lists hand searched, there was no subsequent review of the reference lists of the hand selected articles. The use of EBP in health care is a sizeable topic. This study focused on organisational barriers in health care settings in order to maintain the balance between an appropriate breadth of search and feasibility of result analysis. Many of the studies (both included and excluded) gave a broad overview of barriers to the use of EBP. More focused study on specific factors where barriers have been identified (i.e. individual factors, accessibility factors) would provide useful information into how these barriers are linked in with each other and how they can be better managed. Conclusions The use of EBP in health care is vital in providing the highest level of patient care. In the face of rapid advancements in best treatment practices for patients, it is essential that health care providers are able to keep their knowledge and practices current and relevant. This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. There were five major organisational barriers which emerged from the selected studies: 1) workload, 2) other staff/management not supportive of EBP, 3) a lack of resources, 4) the lack of authority to change practice, and 5) a workplace culture resistant to change. Even for an individual who is motivated and competent in the use of EBP, all of these barriers will impact their ability to increase and maintain their use of EBP in the



workplace. The authors recommend that health services review their policies and procedures particularly in the areas surrounding the aforementioned barriers to assist in the uptake of EBP.

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