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Evidence-Based Practice Competence: A Concept Analysis Natasha Laibhen-Parkes, RN, MSN, CPN, PhD-c Natasha Laibhen-Parkes, RN, MSN, CPN, PhD-c, is a Staff Nurse Leader, Children’s Healthcare of Atlanta, Atlanta, Georgia, and a PhD student in Nursing, Georgia Baptist College of Nursing of Mercer University, Atlanta, Georgia.

Search terms: Competence, concept analysis, evidence-based practice, evidence-based practice competence, nursing Author contact: [email protected], with a copy to the Editor: [email protected] Jonas Scholar Recipient 2012–2014 Conflicts of interest: No conflict of interest has been declared by the author. Funding: This paper did not receive any extramural funding or commercial financial support. However, the writing of the manuscript occurred while the primary author was in doctoral study at the Georgia Baptist College of Nursing of Mercer University, and doctoral study was supported by the Jonas Scholars Leadership Scholarship.

PURPOSE: To report an analysis of the concept of evidence-based practice competence for nurses using Walker and Avant’s (2011) eight-step, iterative concept analysis process as a guide. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature, PubMed, OVID, PsycINFO, and Sociological Abstracts were searched. DATA SYNTHESIS: References were read and analyzed according to associated meanings, usages, attributes, antecedents, consequences, and empirical referents. CONCLUSION: An operational definition for the concept was developed. IMPLICATIONS FOR NURSING PRACTICE: A clear and operational definition of evidence-based practice competence will help guide nurses at all levels of experience to use the best available evidence for improving the quality of care and maximizing patient outcomes.

Introduction Emphasis on evidence-based practice (EBP) in healthcare delivery has increased the expectation that nurses utilize research findings to make informed clinical decisions and guide their nursing actions and interactions with clients in a constantly changing and increasingly complex healthcare environment. Increasing demands for patient safety and quality health care require translation of best possible evidence into practice to ensure improved patient outcomes. Within this social context, EBP is seen as the key to quality improvement in health care. The use of EBP, particularly in nursing, requires clinicians to have specific competencies in (a) asking and formulating clinical questions generated from practice, (b) searching various sources of evidence to clinical questions, (c) appraising the evidence, © 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 25, No. 3, October 2014

(d) applying the evidence to practice, and (e) assessing the impact of evidence. EBP competence must be clearly defined to properly prepare the professional nurse to practice in the twentyfirst century and provide optimal nursing care. Society’s growing expectations for evidence-based quality improvement require nurses to possess clearly defined EBP competencies to function with confidence in their healthcare roles. To date, inadequate assessments and measurements of EBP competence have been employed within nursing because EBP competence has not fully been understood, and ambiguity exists in its definition, attributes, and characteristics (i.e., Gerrish et al., 2007; Melnyk et al., 2004; Thiel & Ghosh, 2008; Upton & Upton, 2006). Consequently, this paper reports a concept analysis of EBP competence. 173

Evidence-Based Practice Competence: A Concept Analysis Background Descriptions of EBP vary slightly among healthcare disciplines. However, there is consistency among healthcare disciplines on the significance of EBP use by clinicians. Consequently, it is imperative that clinicians possess specific EBP competencies to use EBP. As such, clinicians who lack competence in EBP have limited knowledge and skills to use research evidence to make the best practice decisions. In the current societal and healthcare climate, healthcare professionals and consumers have viewed EBP as a means to improve patient care and safety, and reduce healthcare costs (Health Research Institute, 2007). Consequently, all major health professions endorse the policy of EBP (Brownson, Gurney, & Land, 1999; Dysart & Tomlin, 2002; Etminan, Wright, & Carleton, 1998; Gambrill, 1999; Ismail & Bader, 2004; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000; Stetler, 2001). In addition, influential organizations throughout the world have emphasized the significance of EBP in education, practice, and research (Institute of Medicine [IOM], 2001, 2003; Joint Commission, 2007; World Health Organization, 2007). The concept analysis process was begun by reviewing the literature to determine the meanings and uses of the terms EBP and competence separately. The author explored the meanings and uses of EBP competence in the literature to arrive at an operational definition of the concept. Walker and Avant’s (2011) eight-step, iterative concept analysis process was used to guide the concept analysis. Thus, in this concept analysis, (a) existing definitions and descriptions of EBP competence will be examined, (b) cases demonstrating model, borderline, related, and contrary attributes of EBP competence will be explored, (c) an operational definition for EBP competence will be proposed, and (d) recommendations for development of a research instrument that accurately reflects the defining attributes of EBP competence in nursing will be explicated. Purpose The purpose of this critical analysis of EBP competence was to examine its essence, and how it has been interpreted, studied, and applied in the nursing profession, as well as in other related and non-related professions. It was necessary to define and analyze the current perspective on EBP competence in nursing because conceptual meanings change over time. Data Sources In keeping with Walker and Avant’s (2011) concept analysis process, multiple uses of the terms EBP, competence, and EBP competence were examined. In addition to nursing literature, literature connected with medicine, psychology, education, law and criminal justice, business, and sociology were used as reference sources. A review was undertaken 174

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using a systematic English-language literature search to electronically scan articles, dating from the years 1970 to 2013, from the Cumulative Index to Nursing and Allied Health Literature, PubMed, OVID, PsycINFO, and Sociological Abstracts databases, searching the terms competence, competency, EBP, EBP competence, and EBP competency. A hand search was also employed to peruse reference literature not available in electronic format. Complementary searches included Google Scholar, dictionary sources, e-journals, and e-books. Furthermore, the referenced articles listed in each of the selected publications were examined to locate possible relevant material. At this point, the search was then refined by adding the terms nurse, education, professional, healthcare, clinical practice, evaluation, and assessment. All literature that did not link EBP competence to nursing or healthcare professionals was excluded from the review. Table 1 summarizes the process of the literature search. Data Synthesis Definitions and Uses of EBP Concerning the definitions and uses of EBP, the emerging themes identified EBP as a concept, process, and/or outcome. Melnyk and Fineout-Overholt (2005) defined EBP as “a problem-solving approach to clinical practice that integrates (a) a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question, (b) one’s own clinical expertise, and (c) patient preferences and values” (p. 6). Also describing EBP as a process, Newhouse, Dearholt, Poe, Pugh, and White (2007) defined EBP as “a problem-solving approach to clinical decision making within a health-care organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence” (p. 3). In nursing, some of the confusion about EBP stems from the fact it is often considered synonymous with research utilization (Foster, 2004; Goode, 2003; McKenna, Cutcliffe, & McKenna, 1999). The adoption of EBP was initially overshadowed by this approach in the 1970s (Horsley, Crane, & Bingle, 1978). Similar to EBP, research utilization focused on translating research findings into practice and critically appraising research. However, unlike EBP, it failed to incorporate the patient’s preferences or clinical judgment (Estabrooks, Winther, & Derksen, 2004). In the broader healthcare context, EBP has generally been referred to as the use of scientific evidence to enhance individual patient care and improve accountability (Sox & Woolf, 1993). The prevailing model of EBP adopted by the medical and healthcare communities was proposed by Sackett et al. (2000), and adapted by the IOM in 2001 as the following: “evidence-based practice is the integration of the best research evidence with clinical expertise and patient values” (p. 147). In psychology, EBP is referred to as EBP in psychology (EBPP) and defined as “the integration of

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Evidence-Based Practice Competence: A Concept Analysis

Table 1. Data Sources and Search Strategy for EBP Competence Data sources

Search terms

Inclusion criteria

Number of hits

CINAHL

Initial: ■ Competence, competency, EBP, EBP competence, EBP competency Refined: ■ EBP competence and nurse

Initial: ■ Publication year: 1970–2013 ■ English language Refined: ■ Limiters—full text; references and abstracts available ■ Advanced search; subject major headings (clinical practice, assessment, evaluation) Initial: ■ Publication year: 1970–2013 ■ English language Refined: ■ Advance search builder Initial: ■ Publication year: 1970–2013 ■ English language Refined: ■ Advanced search; full text; academic journals Initial: ■ Publication year: 1970–2013 ■ English language Refined: ■ Articles with abstracts; full text available; article reviews ■ Publication year: 1970–2013 ■ Articles

Initial: (n = 19,643)

PubMed

PsycINFO

OVID

Google Scholar

Initial: ■ Competence, competency, EBP, EBP competence, EBP competency Refined: ■ EBP competence and nurse Initial: ■ Competence, competency, EBP, EBP competence, EBP competency Refined: ■ EBP competence and nurse Initial: ■ Competence, competency, EBP, EBP competence, EBP competency Refined: ■ EBP competence and nurse

Initial: ■ Competence, competency, EBP, EBP competence, EBP competency Refined: ■ EBP competence and nurse

Refined: (n = 48)

Initial: (n = 10) Refined: (n = 51) Initial: (n = 9,994) Refined: (n = 50) Initial: (n = 259) Refined: (n = 14)

Initial: (n = 16,400)a Refined: (n = 16,600)a

Note: Additionally, reference lists, e-journals, e-books, and dictionary sources were reviewed. a Few articles reviewed for relevance from this data source and included in analysis as applicable; actual number reviewed not tracked. CINAHL, Cumulative Index to Nursing and Allied Health Literature; EBP, evidence-based practice.

the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (American Psychological Association [APA] Presidential Task Force on EBP, 2006, p. 273). The discipline of psychology builds on the IOM’s definition by deepening the examination of clinical expertise and broadening the consideration of patient characteristics. The goal of EBPP is to “promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention” (APA Presidential Task Force on EBP, 2006, p. 273). In professions and industries outside of health care, EBP is referred to as evidence-based management (Dyba, Kitchenham, & Jorgensen, 2005; Pfeffer & Sutton, 2006a, 2006b; Sherman, Farrington, Welsh, & MacKenzie, 2002; Sloan & Boyles, 2003). Evidence-based management is an emerging movement to explicitly use the current best evidence in management decision making. It is defined as a process that enhances the overall quality of organizational decisions and practices through deliberative use of relevant and best available scientific evidence (Evidence-Based Management Collaborative, n.d., para. 1). Additionally, it

combines this evidence with individual expertise, ethics; valid, reliable business and organizational facts; and consideration of impact on stakeholders (Evidence-Based Management Collaborative, n.d., para. 1). Unlike the fields of medicine, education, and nursing, evidence-based management is viewed as a hypothetical process because contemporary managers are making limited use of scientific evidence relevant to effective management practice (Pfeffer & Sutton, 2006a; Rousseau, 2005, 2006; Walshe & Rundall, 2001).

Definitions and Uses of Competence There are various definitions of the term competence. The Merriam-Webster Dictionary Online defines competence as the quality or ability to perform a task or function, to be proper or rightly pertinent, to have requisite or adequate ability, or to be legally qualified or adequate (MerriamWebster’s online dictionary, n.d.). Dictionary Online defines competence as “possession of required skill, knowledge, qualification, or capacity” (Dictionary Online, n.d.). The terms competency and competence are frequently used 175

Evidence-Based Practice Competence: A Concept Analysis interchangeably within the literature. However, there are important distinctions between the terms. In behavioral sciences, such as psychology and sociology, competence is referred to as individuals’ mental capacity to perform ordinary contractual tasks, such as selling a house, signing into the hospital, or making decisions about their own medical care, among a host of other functions (Crowley, n.d.). In law, competence is referred to as the measure of both capacity to perform and performance itself. The lawyer must be able to carry out lawyering functions with a requisite degree of knowledge and skill, and he or she must also be willing to perform such functions honestly, completely, and on time. Competent representation requires the legal knowledge, skill, thoroughness, and preparation reasonably necessary for the representation (New York State Bar Association, 2013). As it relates to the medical profession, Epstein and Hundert (2002) defined competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (p. 226). Earlier, Schon (1983) argued that professional competence was more than factual knowledge and the ability to solve problems with clear-cut solutions, but it was defined by the ability to manage ambiguous problems, tolerate uncertainty, and make decisions with limited information. Along the same trajectory, competence depends on using expert scientific, clinical, and humanistic judgments to engage in clinical reasoning (Downie, Macnaughton, & Randall, 2000; Feinstein, 1994; Friedman, Connell, Olthoff, Sinacore, & Bordage, 1998; Mandin, Jones, Woloschuk, & Harasym, 1997). Competence has also been viewed as context-dependent. Korthagen (2004) defined competence as “the capability to choose and use an integrated combination of knowledge, skills and attitudes with the intention to develop a task in a certain context” (p. 78). Klass (2000) explained this view of competence as “a statement of relationship between ability, a task, and the ecology of the health systems and clinical contexts in which those tasks occur” (p. 484). Sternberg (1990) asserted that “competence and incompetence involve, at a minimum, an interaction among person, tasks, and situation” (p. 117). This view is in contrast to the attributes of knowledge, skills, and attitudes that are pervasively assumed to serve physicians well in all the situations that they may encounter in their practice. Epstein and Hundert (2002) also asserted that “competence is developmental” (p. 228). Miller (1990) expanded on this attribute of competence with his framework for clinical assessment that illustrates a progression from “knows” (knowledge), to “knows how” (competence), then “shows how” (performance), and finally “does” (action). Competence has varied definitions within nursing as well. Benner (1982a) defined competence as “the ability to perform the task with desirable outcomes under the varied circumstances of the real world” (p. 304). In 1995, Nagelsmith defined competence as “a combination of knowl176

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edge, skills, attitudes, and values” (p. 246). Meretoja, Leino-Kilpi, and Kaira (2004) defined competence as functional adequacy, and the capacity to integrate knowledge, skills, attitudes, and values in specific contextual situations of practice. Competence has also been defined in terms of expertise, as the ability to draw rapid and accurate conclusions relative to the patient’s clinical condition (Reischman & Yarandi, 2002). According to the American Nurses Association (ANA, 2004), competence is situational, dynamic, and is both an outcome and an ongoing process. The attribute of competence as a process has also been manifested in Benner’s (1982b) work. Benner’s novice to expert model is commonly cited when describing the attributes of effective nurses. Benner characterized competence as the third of five stages in practice. During the competent level of development, nurses are viewed as having what it takes to function capably with an increased capacity to view situations holistically, but still lacking the expertise to handle a wide range of situations proficiently. In this sense, competence inferred that there was something more for qualified nurses to achieve. Accordingly, Benner (1982b) affirmed: The competent nurse lacks the speed and flexibility of the nurse who has reached the proficient level, but the competency stage is characterized by a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing. The competent nurse’s conscious, deliberate planning helps achieve a level of efficiency and organization. (p. 405) In some healthcare organizations, competent nursing practice has been delineated through clinical ladder systems. Clinical ladders offer a system to recognize, reward, recruit, and retain bedside nurses (Buchan, 1999; Snyder, 1997). The clinical ladder systems provide a grading structure that facilitates career advancements and differentiation of competencies by defining different levels of clinical and professional practice within nursing. Progression up the clinical ladder is dependent on the individual nurse meeting defined criteria of clinical excellence (Buchan, 1999). This conception of competence is contextual because it is concerned with an elemental approach where competence is a number of discreet elements against which practice can be judged as a whole. In 2007, the ANA Congress on Nursing Practice and Economics Competency Workgroup created a report to identify definitions of competence and competency that can be incorporated within current and future professional activities. They addressed such initiatives as the development of the scope and standards of nursing practice, creation of educational curricula, formulation of a research agenda, and revision of the model nurse practice act and other regulatory language (ANA, 2007). Competency was defined as “an expected level of purposeful performance that results from an integration of knowledge, skills, abilities and judgment” (ANA, 2007, p. 2). Likewise, competence was

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Evidence-Based Practice Competence: A Concept Analysis

defined as what an individual demonstrates to perform successfully at an expected level (ANA, 2007, p. 2). The ANA (2007) further explicated that the ability of a nurse to demonstrate the expected level of purposeful performance requires an iterative process of continual lifelong learning. Building on Benner’s (1982b) model, the ANA affirmed that the successful evolution from novice to expert relies on such an iterative process (ANA, 2007). The National Council of State Boards of Nursing (NCSBN) defined competence as “the application of knowledge and the interpersonal, decision-making and psychomotor skills expected for the practice role, within the context of public health, safety and welfare” (NCSBN, 1996, p. 5). In 2007, the Joint Commission required hospitals to assess the competency of employees when hired and then regularly throughout employment. According to the Joint Commission (2007), Competence assessment is systematic and allows for a measurable assessment of the person’s ability to perform required activities. Information used as part of competence assessment may include data from performance evaluations, performance improvement, and aggregate data on competence, as well as the assessment of learning needs. (p. 346) In 2003, McMullen and colleagues distinguished between competence and competency, affirming that competence was focused on the description of the action or behavior, while competency was focused on the individual’s behavior that reinforces the competent performance. A decade earlier, Woodruffe (1993) also made the distinction between competence and competency, conceding competence as the aspect of a job an individual could perform, while competency was the behavior underpinning such performance.

few guides to direct curriculum reform in nursing (Stevens, 2009). In 1994, the ANA issued a position statement that specified that basic level nurses (associate and baccalaureate degree) use research findings in clinical practice and implement nursing research findings. A decade later in 2004, the ANA published the professional standards for nursing that emphasized that nursing practices should be based on the best available evidence. Evolving from the ANA professional standards, the quest for Magnet accreditation, particularly in the acute care setting, has been a major catalyst for EBP in nursing (Gasda, 2002; Mueller, 2002; Schlag, Sengin, & Shendell-Falik, 1998; Steltzer, 2002). The American Nurses Credentialing Center (ANCC) designates an organization Magnet status if it can validate a provision of evidence-based nursing care and favorable work environments (ANCC, 2007). Additionally, the AACN has included competencies in EBP to prepare nurses for professional practice at the baccalaureate, master’s, and doctoral level (AACN, 2008). To date, the most comprehensive report available to nurses on EBP competencies has been developed by the Academic Center for Evidence-Based Practice (ACE). The report represents a “national consensus on essential competencies for EBP that would guide inclusion of EBP skills and content in nursing education programs and provide a basis for professional competencies in clinical practice” (Stevens, 2009, p. 1). However, despite all the effort in establishing these essential EBP competencies, ACE failed to provide an explicit definition for EBP competence and/or competencies. Nonetheless, the report has been very valuable in illustrating the EBP competencies that a nurse should be performing based on their degree (associate, baccalaureate, master’s, and doctoral) in nursing. Measuring EBP Competence

Definitions and Uses of EBP Competence The IOM has set a goal that by 2020, 90% of all healthcare decisions are evidence-based in the United States (IOM, 2001), but research suggests that nurses may not be consistently implementing EBP in their clinical settings (Bartelt et al., 2011; Beke-Harrigan, Hess, & Weinland, 2008; Brown, Wickline, Ecoff, & Glaser, 2009; Cadmus et al., 2008; Gale & Schaffer, 2009; Pravikoff, Tanner, & Pierce, 2005; Thiel & Ghosh, 2008). The fact that many nurses are still not incorporating EBP into their practice, despite long-standing recommendations for EBP (American Association of Colleges of Nursing [AACN], 1995, 1996; ANA, 1994; IOM, 2001, 2003), suggests that the structure and function of EBP competence need to be clarified. Additionally, nurses’ achievement of EBP competencies requires curriculum revision in nursing education so that new nurses are prepared early in their careers to use EBP in their practice environment. However, there is lack of common terminology, no universal agreement on EBP functions to be performed, and

Validated tools to assess EBP competence are scarce. The assessment tools in existence have assessed EBP competence primarily among medical students and physicians (Hatala & Guyatt, 2002; Johnston, Leung, Fielding, Tin, & Ho, 2003; Landry, Pangaro, Kroenke, Lucey, & Herbers, 1994). The majority of these tools have been self-report and learner satisfaction questionnaires, both of which present threats to the validity and reliability of these instruments (Green, 1999; Norman & Shannon, 1998; Taylor, Reeves, & Ewings, 2000). Shaneyfelt et al. (2006) conducted a systematic review of instruments that evaluated EBP teaching, and concluded that the Fresno (Ramos, Schafer, & Tracz, 2003) and Berlin (Fritsche, Greenhalgh, Falck-Ytter, Neumayer, & Kunz, 2002) assessment tools, both used to evaluate EBP in medicine, were the only instruments to evaluate all the steps in the EBP process. Within nursing, the tools used to assess EBP have been self-report instruments that focus more on the attitudes and beliefs toward EBP implementation (Gerrish et al., 2007; Melnyk et al., 2004; Ruzafa-Martinez, Lopez-Iborra, & Madrigal-Torres, 177

Evidence-Based Practice Competence: A Concept Analysis 2011; Ruzafa-Martinez, Lopez-Iborra, Moreno-Casbas, & Madrigal-Torres, 2013; Thiel & Ghosh, 2008; Upton & Upton, 2006). To date, no validated tools have been published that measure EBP competence within nursing. Defining Attributes of EBP Competence The defining attributes associated with EBP competence are explicated in this analysis using examples from the discipline of medicine and nursing. Incorporating Miller’s pyramid of competence within the field of medicine, health professionals can demonstrate their EBP competency via a four-step process, namely (a) knowledge (e.g., formulating a structured answerable question), (b) competence (e.g., searching medical databases), (c) performance (e.g., critical appraisal), and (d) behavior (e.g., applying the outcomes in practice) (Miller, 1990). In this case, each step of the EBP process requires a more advanced level of competency. Similar attributes of EBP competence have been defined by disciplines other than medicine, such as nursing, in which a five-step process is used that comprises (a) asking questions, (b) acquiring the evidence, (c) appraising the evidence, (d) applying the evidence by engaging in collaborative health decision making with the affected individual(s) and/or group(s), and (e) analyzing and assessing the intervention or practice change (APA Presidential Task Force on EBP, 2006; Gambrill, 1999; Melnyk & Fineout-Overholt, 2005). Commonality is demonstrated in the first four steps of the EBP process between both professions. However, nursing includes an additional step in the EBP process to demonstrate the attribute of evaluating the impact of the evidence applied, which is an essential component in practice change. Model Case of EBP Competence A model case provides an example of the use of the concept that demonstrates all the defining attributes of the concept, or a paradigmatic example (Walker & Avant, 2011). The following example illustrates a model case for EBP competence in a pediatric acute care setting. Working with adolescent Cystic Fibrosis (CF) patients for a number of years, Dawn, a pediatric nurse, notes a large proportion of these patients have become non-adherent with their diet and respiratory treatments when hospitalized. As a result, they are hospitalized more frequently, are much sicker when they return, and stay hospitalized for longer periods. Dawn searches the literature as well as consults child life experts and other children’s hospitals to answer the following clinical question, “Are there any evidence-based interventions that can increase adherence in CF adolescent patients?” Her search revealed successful “token programs” being used in other children’s hospitals for issues with 178

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non-adherence. A critical appraisal of the evidence concludes a similar token program could be successful with her CF population. This evidence is shared with her nurse manager and medical director as well as with her colleagues. The token programs are voluntary and the CF patients would have to sign a contract agreeing to adhere with different aspects of their hospitalization. With each activity they adhere to, they would receive a token. Tokens can then be exchanged for prize items at the end of their hospitalization. The token program is implemented and after 6 months of data collection, Dawn’s findings indicated an increase in adherence with diet and treatments. This model case represents a paradigmatic example of EBP competence. Additionally, all the defining attributes of EBP competence are present. The first and second steps of EBP competence were demonstrated when the clinically relevant question was asked and the answer for that question was searched using multiple knowledge sources. The third step of EBP competence was demonstrated when the information or evidence found was critically appraised for validity and applicability to the patient population of interest. The case also demonstrated the fourth and fifth step of EBP competence when the token program was implemented and then evaluated for its effectiveness after 6 months. Borderline Case of EBP Competence A borderline case is an example of a case that contains most of the defining attributes of the concept but not all of them (Walker & Avant, 2011). For a borderline case of EBP competence in the pediatric emergency department (ED) setting, consider the following example: A 36-month-old child presents to the ED with an acute asthma episode. In the course of 3 months, this child has been seen frequently in the ED and received nebulizer treatments via a t-piece device. The child was either sent home or admitted on these prior visits depending on the severity of the asthma exacerbation. The child has been diagnosed with reactive airway disease (RAD) and has a history of moderate, persistent wheezing. In this visit, he is cared for by Tyler, an ED nurse. During the assessment, Tyler notes a pulse oximetry of 90% and wheezing. The new attending ordered a multi-dose inhaler (MDI) with spacer to deliver albuterol. At the end of Tyler’s shift, he wonders if there is evidence to support the request over using the standard t-piece nebulizer and decides to search the literature. Prior to searching the literature, he formulates the following question, “In a 36-month-old child with asthma, is administering albuterol through an MDI/ spacer more effective than administering albuterol through a t-piece nebulizer for diminishing an asthma attack?”

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Evidence-Based Practice Competence: A Concept Analysis

This borderline case represents EBP competence where some of the defining attributes of the concept are present. The nurse in this case is able to formulate a clinically relevant question and begin a search of the literature for evidence concerning this practice. However, steps three to five, which focus on appraising the evidence, applying the evidence to practice, and assessing the impact of the practice change, are not evident in this case. Related Case of EBP Competence A related case is an example of a case that contains concepts related to the concept being studied but do not contain all the defining attributes (Walker & Avant, 2011). The following case is an example of a related case of EBP competence: Joan, a registered nurse, must demonstrate competencies annually at her hospital. The competencies are set up as simulation stations. At the first simulation station, Joan must recognize the deteriorating status of a baby and manage the situation based on evidence provided by the facilitator and the simulator. Joan begins by performing an assessment of the simulator baby and asking the facilitator specific questions concerning her assessment. As the simulator baby begins to deteriorate, Joan utilizes all her resources and makes decisions to manage the situation. As the simulation progresses, she continues to reassess her interventions and rescues the simulator baby from deterioration accordingly. In this related case, the nurse used all her knowledge sources as evidence for making decisions to impact patient outcomes. She performed an assessment of the clinical situation and based her decisions from that initial assessment. This example contains concepts related to EBP competence but does not have all the defining attributes. Additionally, the nurse does ask clinically relevant questions, uses evidence to base her decisions on, and evaluates her interventions. However, the context and remaining attributes of EBP competence are not illustrated in this example (i.e., asking a searchable question based on a clinical problem, searching various sources of knowledge, including the literature, for the best evidence to a clinical problem, and critically appraising the evidence for its applicability to the clinical problem). Contrary Case of EBP Competence A contrary case is one in which none of the defining attributes are met, or a case that is “not the concept” (Walker & Avant, 2011). For a contrary case of EBP competence, consider the following constructed example: Ann is a new nurse caring for a 6-month-old infant admitted with respiratory syncytial virus (RSV) bronchiolitis.

The mother questions Ann about why respiratory treatments have not been ordered on her child. The mother continues by informing Ann that her older child who has RAD always receives respiratory treatments when he is admitted. Ann asks her preceptor, “Why are respiratory treatments not given to RSV patients and given to RAD patients?” Her preceptor replies, “I don’t know but it has always been ordered this way.” In this case, none of the defining attributes of EBP competence are present. In particular, the new nurse and her preceptor failed to recognize the opportunity to apply evidence to this situation. The clinical question is asked but without the intent to base patient care decisions on. Thus, they do not continue the EBP process of (a) acquiring the evidence, (b) appraising the evidence, (c) applying the evidence, and (d) analyzing and assessing the impact of the evidence. Instead, the preceptor in this example accepts the status quo and relays this conception to the new nurse. Antecedents and Consequences Antecedents are events that must occur prior to the occurrence of the concept, and consequences are the events that occur as a result of the occurrence of the concept (Walker & Avant, 2011). Formulating a clinical question is considered the first step toward providing evidence-based care to patients (Sackett et al., 2000). Therefore, an antecedent of EBP competence can be recognizing the clinical problem. EBP involves making clinical decisions based on the most relevant and valid body of evidence available (Sackett et al., 2000). Therefore, another antecedent of EBP competence concerns the availability of evidence within the setting. Yet still another antecedent for EBP competence can be role models and/or mentors for EBP. Del Mar, Glasziou, and Mayer (2004) affirmed that if individuals see EBP being used by their supervisors or mentors in practice, they are more likely to value it as clinically important and be motivated to acquire the relevant skills and knowledge. Additional antecedents for EBP competence can be knowledge of and skill sets necessary to engage in the five steps of EBP. The current literature implies that consequences of EBP competence in practice are improved patient outcomes, high-quality care, patient-centered care, informed clinical decisions, empowerment, self-worth, satisfaction, and decreased healthcare costs (ANA, 2004; Dawes, 1996; IOM, 2001, 2003; Titler, Cullen, & Ardery, 2002). However, studies are limited that empirically demonstrate the consequence of EBP. Empirical Referents Empirical referents are processes by which the concept of EBP competence can be measured (Walker & Avant, 2011). As Walker and Avant (2011) noted, empirical referents may be identical to the defining attributes of the concept. 179

Evidence-Based Practice Competence: A Concept Analysis This was the case with EBP competence as the empirical referents are the same as the five steps of EBP in nursing described earlier.

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in Nursing of the Georgia Baptist College of Nursing of Mercer University, Atlanta, USA, for their honest feedback, insightful comments, and guidance in the preparation of this manuscript.

Discussion References

In this concept analysis, the essence of EBP competence was explored by examining its associated meanings, usages, attributes, antecedents, consequences, and empirical referents. The concept of EBP competence has been discussed much in the literature with implications for education, practice, and research. However, no formal definition of EBP competence has been published. Based on this analysis, it is proposed that EBP competence be defined as “the ability to ask clinically relevant questions for the purposes of acquiring, appraising, applying, and assessing multiple sources of knowledge within the context of caring for a particular patient, group, or community.” Walker and Avant (2011) affirmed the “tentativeness of concepts” (p. 158). Therefore, the proposed definition is a working definition and an attempt to capture the critical elements of EBP competence within the current social context. Conclusion In this analysis, it was demonstrated that EBP competence has specific attributes and antecedents. The consequences of EBP competence, especially in nursing, need further study. For EBP competence to progress in nursing, several issues must be addressed. First, a clear and consistent definition of EBP competence is necessary. Second, EBP is characteristically transformative with the progression of time. Therefore, initial competency measurement in EBP is critical as novice nurses transition into practice and guidelines for assuring ongoing or continued EBP competence need to be developed. Finally, determination of what point to measure competence in EBP relative to nursing degree and expertise needs to be established and explored further. High-quality research on EBP competence with these specific foci will make significant contributions toward a highly relevant concept within the current social healthcare climate. Implications for Nursing Practice Having a clear and operational definition of EBP competence will assist in the sustainment of a healthcare delivery system that effectively employs EBP. Ultimately, this will help nurses demonstrate competence in EBP to maximize their patients’ outcomes and improve the quality of care they provide. Acknowledgments. The author would like to thank Dr. Susan S. Gunby, Professor at the Georgia Baptist College of Nursing of Mercer University, Atlanta, USA, and Dr. Laura P. Kimble, Professor and Piedmont Healthcare Endowed Chair 180

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