bs_bs_banner
International Journal of Nursing Practice 2015; 21 (Suppl. 2), 46–57
RESEARCH PAPER
Perceived knowledge, skills, attitude and contextual factors affecting evidence-based practice among nurse educators, clinical coaches and nurse specialists Gulzar Malik PhD Candidate MN RN MACN PhD Candidate, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
Lisa McKenna PhD RN FACN Professor, Head of Campus (Clayton), Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
Virginia Plummer PhD RN FACN Associate professor Nursing Research, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Peninsula, Victoria, Australia
Accepted for publication June 2014 Malik G, McKenna L, Plummer V. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 46–57 Perceived knowledge, skills, attitude and contextual factors affecting evidence-based practice among nurse educators, clinical coaches and nurse specialists Evidence-based practice (EBP) in the clinical setting is recognized as an approach that leads to improved patient outcomes. Nurse educators (NEs), clinical coaches (CCs) and nurse specialists are in key positions to promote and facilitate EBP within clinical settings and have opportunities to advance practice. Therefore, it is important to understand their perceptions of factors promoting EBP and perceived barriers in facilitating EBP in clinical settings, before developing educational programmes. This paper reports findings from a study that aimed to explore NEs’ , CCs’ and nurse specialists’ knowledge, skills and attitudes associated with EBP. This study used a questionnaire containing quantitative and a small number of qualitative questions to capture data collected from NEs, CCs and nurse specialists working at a tertiary health-care facility in Victoria, Australia. The questionnaire was distributed to a total of 435 people, of whom 135 responded (31%). Findings revealed that the three senior nurse groups relied heavily on personal experience, organizational policies and protocols as formal sources of knowledge. Furthermore, they had positive attitudes towards EBP. However, participants demonstrated lack of knowledge and skills in appraising and utilizing evidence into practice. They indicated a desire to seek educational opportunities to upskill themselves in the process of EBP. Key words: clinical nurse specialists, evidence-based nursing, evidence-based practice, nurse educators. Correspondence: Gulzar Malik, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Building 13C, Monash University Clayton Campus, Melbourne, Vic. 3800, Australia. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12366
Evidence-based practice
INTRODUCTION Evidence-based practice (EBP) has gained momentum in a variety of disciplines (medicine, management and engineering, to name a few) and has also attracted attention in nursing. The impetus for EBP has come to health-care systems from accrediting bodies, government agencies, professional organizations and increase in malpractice legislations.1–4 Improving quality of health care requires a commitment to deliver care based on sound scientific evidence and constant innovative health-care practices and preventive approaches. Therefore, EBP has been recognized by health-care institutions as the gold standard for provision of safe and effective health care.5 The ongoing evolution of nursing as a profession requires the development of EBP outcomes and nurses’ abilities to access and evaluate professional literature. EBP empowers nurses to form innovative learning partnerships with colleagues to nourish and to strengthen critical thinking skills, and to integrate research knowledge in leading best practice.6 Literature suggests that much current practice is frequently based on experience, tradition and intuition rather than on evidence. Despite growing numbers of nurse researchers and studies designed to improve practice at staff level, many nurses lack research knowledge, skills and understanding.4–7 Brown et al.5 studied nurses’ perceptions at an academic centre in California and found a lack of knowledge in the participants related to searching and appraising research reports. Similarly, a study conducted in Africa by Barako et al.8 concluded that poor knowledge and skills of searching and retrieving research studies prevented the usage of EBP into nursing care. Majid et al.4 surveyed 1486 nurses from two public hospitals in Singapore, finding medical information provided by websites, and hospital policies and procedures were the most frequently used sources. However, nursing e-books and medical and nursing databases appeared to be referred to less often. Although reasons for introducing EBP, together with strategies for implementation and resource implications have been discussed in the literature, evidence suggests that a paradigm shift to EBP happens slowly. To explain this, researchers have focused on individual nurses’ knowledge, skills and beliefs in appraising and using research as the cornerstone for evidence-based nursing. Some models for promoting EBP emphasize the need for facilitation by external/internal agents to support the process of change.9 In the clinical setting, nurse educators (NEs), clinical coaches (CCs) and nurse specialists are
47
considered key people to promote and facilitate evidencebased nursing care. They can play a critical role in establishing a culture through various activities and programmes. However, little is known about their engagement with EBP. According to Melnyk et al.,10 there is a link between NEs’ beliefs about EBP and the extent to which they teach and practice it. Findings from their study of 79 educators supported this relationship. Similarly, Pepler et al.11 identified clinical nurse specialists (CNSs) and NEs as instrumental in disseminating evidence-based information at ward level. However, further research is needed to examine the role of specialists in promoting EBP among frontline nurses. So far, studies of evidence-based nursing have focused on clinical nurses as a collective, rather than exploring views of individuals on EBP. Therefore, it is important to understand NEs’, CCs’ and nurse specialists’ perceptions, perceived barriers and factors that motivate them to promote EBP among nurses. Studies examining NEs’ and CNSs’ perceptions are scarce, despite positioning of these nurses as trusted, knowledgeable and influential members in health-care settings. This study attempted to address the lack of previous research, seeking to uncover the perceptions of three senior nurse groups in promoting EBP, which could then guide the development of strategies to overcome barriers to implementation, and assist planning of educational programmes to foster EBP in the clinical setting. The study invited three groups comprising NEs, CCs and CNSs from the tertiary health-care setting, due to their nature of roles within practice areas. NEs are responsible for delivering clinical education programmes and promoting staff development through a variety of activities. CCs, also known as clinical support nurses, assist NEs in delivering clinical education and support new staff and graduate nurses in their clinical practice. CCs assume the responsibilities of an NE in the practice areas where no educators are allocated. Within clinical units, CNSs provide coaching and act as preceptors for graduate and student nurses, ensuring evidencebased nursing care.
METHODS The study aimed to investigate attitudes, knowledge and skills of NE, CC and CNS in fostering EBP in the clinical setting. It sought to address the questions: 1. What are NEs’, CCs’ and CNSs’ attitudes towards EBP? © 2014 Wiley Publishing Asia Pty Ltd
48
2. What is their level of knowledge and skills in regard to EBP? 3. What are the factors affecting the implementation of EBP in the clinical setting? A descriptive survey was conducted using a modified questionnaire. Questionnaire items were adapted from three validated research tools. 1. Development of Evidence-Based Practice 12 Questionnaire The original questionnaire was tested with a sample size of 1287 nurses in England. Results demonstrated that the questionnaire was drawn from well-established sources with reliability > 0.7 for each section. The Cronbach’s alpha values for the sections ranged from 0.73 to 0.913, with an overall alpha of 0.874.12 2. Attitudes to Evidence-Based Practice Questionnaire13 The original questionnaire was tested in a pilot study with 40 general practitioners across four health and social services boards in Northern Ireland and a random sample of community nurses at the University of Ulster. The pilot study sample deemed the questionnaire to have face validity, and an expert panel’s judgment provided content validity. The questionnaire has a reported reliability coefficient (internal consistency) of 0.74.13 3. Clinical Effectiveness and Evidence-Based Practice Questionnaire14 The original questionnaire was developed and psychometrically validated by Upton and Upton14. In Upton and Upton’s study, Cronbach’s alpha for practice component was 0.87, for attitude component was 0.72, 0.95 for knowledge/skills and for the entire questionnaire it was 0.94. A level of 0.94 is considered an excellent level of internal consistency.14 Permission was sought and obtained from each of the authors to use the questionnaires. The final questionnaire incorporated the three tools and consisted of 67 Likertstyle items (Appendix I). Prior to commencing data collection, ethical approval was obtained from the participating organization and relevant university ethics committee. Following approvals, questionnaires were distributed to all NE, CC and CNS working across sites of a tertiary health-care network in Victoria, Australia. To maintain confidentiality and anonymity, surveys were distributed via the internal mail system and consent was implied by the return of a completed questionnaire. A total of 435 questionnaires were distributed to 79 educators, 12 CCs and 344 CNSs. © 2014 Wiley Publishing Asia Pty Ltd
G Malik et al.
The current study tool incorporated the categories comprised of demographic details, sources of knowledge, knowledge practice gap, skills rating and attitudes to EBP. Following demographic details, participants were asked to self-rate their knowledge on EBP on a five-point Likert scale, where ‘one’ represented ‘poor’ and ‘five’ represented ‘excellent’. In regard to different sources of knowledge participants used to inform their professional practice, 10 items were rated on a five-point Likert scale, with one representing ‘never’ and five representing ‘always’ included. Participants were asked how frequently they followed a process to identify a knowledge-practice gap. This section consisted of six items and was rated on a five-point Likert scale, with one indicating ‘never’ and five indicating ‘always’. In addition, 10 items related to self-appraisal of skills associated with EBP were incorporated. Participants were provided with options to choose from beginner to expert level to rate their skills in finding, reviewing and implementing evidence in the practice setting. The scale used for the items represented one as ‘beginner’ and five as ‘expert’. In the final section, 16 items were included, exploring attitudes regarding EBP. Again, these items were rated on a five-point Likert scale, from ‘strongly disagree’ to ‘strongly agree’. In addition, general comments were invited following each section, providing opportunities for participants to further elaborate on their responses, therefore adding a qualitative dimension to the study. Data were analysed using SPSS (Statistical Packages for Social Sciences v. 17.0. Frequencies and percentages were calculated for demographic dat,a and descriptive statistics (mean, median and standard deviation) for each item were calculated. Lastly, themes were identified for the responses received in the general comments section.
RESULTS Demographic characteristics Of the 435 potential participants, 135 participated, representing a response rate of 31%. Distribution of participants was 41 NEs, 10 CCs and 84 CNSs, with response rates of 52%, 83% and 24% within each group, respectively. The majority (84%) were women, with 16% men. Thirty-eight per cent of the participants were aged between 31 and 40 years, with one aged 60 years or above. The remaining study participants were aged from 21 to 59 years. In regard to nursing experience, 35% of the participants had over 20 years, 28% had between 6 and 10 years, followed by 18% and 16% who had 11–15
Evidence-based practice
49
Table 1 Demographic characteristics (n = 135) Characteristic Gender
Frequency Percentage
Male 22 Female 113 Age (years) 21–30 22 31–40 52 41–50 41 51–60 19 60 and above 1 Position Nurse educator 41 Clinical coaches 10 Clinical nurse specialist 84 Duration of 0–5 75 38 the position 6–10 11–15 16 (years) 16–20 3 > 20 3 Educational Diploma 12 Bachelor’s degree 49 qualification Graduate certificate 39 Graduate diploma 24 Master’s degree 11 Nursing 0–5 4 38 experience 6–10 11–15 24 (years) 16–20 22 > 20 47 Teaching 0–5 76 6–10 33 experience 11–15 17 (years) 16–20 5 > 20 4
16.3 83.7 16.3 38.5 30.4 14.1 0.7 30.4 7.4 62.2 55.6 28.1 11.9 2.2 2.2 8.9 36.3 28.9 17.8 8.1 3.0 28.1 17.8 16.3 34.8 56.35 24.4 12.6 3.7 3.0
years and 16–20 years, respectively. Only 3% fell between 1 and 5 years. Thirty-six per cent of the study participants held a bachelor degree as their highest qualification earned, with 29% having a graduate certificate, 18% a graduate diploma, 9% a diploma and 8% a master’s degree. The majority (56%) of the participants were in their current positions for less than 5 years. Demographic characteristics are highlighted in Table 1.
Perceived knowledge on EBP An overall mean score of 2.98 was received in the section of self-perceived knowledge on EBP. Participants self-rated their knowledge on a five-point Likert scale where ‘one’ represented ‘poor’ and ‘five’ represented
‘excellent’. Of the 135 participants, 47% perceived they had ‘good’ knowledge, 25% ranked their knowledge as ‘fair’ and 24% rated their knowledge as ‘very good’. In addition, 2% of the NE group perceived they had ‘excellent’ knowledge. However, 2% also rated their knowledge as ‘poor’, within the CNS group. The majority of NEs and CCs rated their knowledge as ‘very good’ and ‘good’, whereas a majority of CNSs perceived their knowledge as ‘good and ‘fair’ on EBP.
Sources of knowledge Information from policies and protocols received the highest mean score of 4.35 (SD = 0.627). Fifty-one per cent of participants referred to policies and protocols on a frequent basis, and 42% always used policies as a source of knowledge (median = 4.00), indicating that most of their practice was informed by organizational policies and protocols. Furthermore, utilizing personal experience in practice was equally popular, with a median of 4.00 and mean of 4.28 (SD = .631). Results also revealed that all three groups often used information which they gained through patient care and by attending in-service education/training/conferences (mean = 4.10, median = 4.00). At the lower end of the scale, information from media ranked lowest, with a mean of 2.01 (SD = .888); however, so, too, did information from medical journals and research journals, with means of 2.74 (SD = 1.000) and 2.68 (SD = 1.020), respectively. The study was designed to capture quantitative data. However, to ensure that a breadth of data was available for analysis and interpretation, a comments section was included to capture qualitative data. Although not all participants offered additional comments, four participants offered comments related to source of knowledge use in practice, which were consistent with the abovementioned findings. One stated that: Knowledge I use is what you gather over the years of experience and new information taught by clinical teachers/doctors rounds and change made within the network. Another stated that: I always use a combination of information.
Knowledge-practice gap Overall, responses demonstrated a fairly high mean of 3.77 (median = 4.00) in sharing information with © 2014 Wiley Publishing Asia Pty Ltd
50
G Malik et al.
colleagues, followed by a mean of 3.65 (median = 4.00) towards evaluating the outcomes of practice. In the entire section of knowledge-practice gap, appraisal of literature showed the lowest results (Mean = 2.86, SD = 0.959). This finding is consistent with all three groups and can be related to a verbal comment which one participant made in relation to lack of time: Time at work doesn’t permit for this to occur due to other commitments.
reported time as a barrier to finding research reports (Mean = 3.67, median = 4.00). Furthermore, nearly half of the participants (48%) agreed that research findings were not easily transferable into their practice (Mean = 3.31, median = 4). In addition, 66% of the participants reported that it was hard for them to implement changes (Mean = 3.17, median = 4), and 53% found it difficult to keep up to date with current evidence (Mean = 3.16, median = 4).
Contextual factors affecting EBP Skills rating The entire group showed the least confidence with was critical appraisal skills, with the lowest mean of 2.67 (SD = .991). Overall, 40.7% rated themselves as ‘beginner’, 36% rated themselves as ‘quite skilled’ and 23% rated themselves as ‘competent’ towards critical appraisal skills (median = 3.00). Between the groups, 14.6% of educators reported being ‘beginner’ and 34.1% as ‘quite skilled’ in their critical appraisal skills, whereas 23.8% of CNSs had rated as ‘beginner’ and 31% as ‘novice’ their critical appraisal skills. All three groups scored low in critically appraising the literature. Findings indicated that lack of critical appraisal skills and insufficient time prevented appraising literature on a regular basis. In addition, finding research evidence, reviewing research evidence, comprehensive literature review and using research evidence to change practice also depicted fairly low results. However, participants showed confidence in finding and reviewing organizational information, and using the Internet to search for information, as one stated: Finding information is easy if you know where to look-and it is implemented as protocols of the hospital and the Network.
Attitudes to EBP The highest mean of 4.34 (SD = 0.536) demonstrated positive attitudes towards EBP. Fifty-nine per cent agreed and 37% strongly agreed that EBP was fundamental to their professional practice (median = 4.00). In addition, beliefs about implementation of EBP being of benefit to their professional development were also strong (Mean = 4.32, median = 4.00). Participants also felt there were benefits to change their practice based on research (Mean = 4.19, median = 4). Similarly, they expressed interest in accessing evidence more often than they currently did. However, 57% of the participants © 2014 Wiley Publishing Asia Pty Ltd
Of the 135, 10% of the participants outlined the facilitators and barriers to EBP in the comments section provided, following each section of the questionnaire. The key contextual factors consisted of time and staff/ organization were derived from the thematic analysis of the participants’ comments.
Time Participants reported that they had limited time for EBP during scheduled working hours and it was hard to keep up to date with current changes because of other commitments, such as meetings: Having someone to assist in supply research articles would be good as I don’t have enough time to do it all myself. No time to find and read research articles. In contrast to NEs, CNSs strongly believed they neither had sufficient time to find research reports, nor did they understand them easily, signifying that patient load might not allow them to focus on research as demonstrated by ‘No time during patient care’.’
Staff/Organization Participants described that staff in the clinical setting were resistant to change, very busy and not interested to bring about change: Staff resistant to change-go back next week it is still being done the same way. Implementation of EBP was seen to be affected by colleagues and unit managers. Participants emphasized that it needs to be actively implemented by the organization: Sometimes there is little or no evidence for some current and planned practices on network website.
Evidence-based practice
51
One participant suggested that there should be a compulsory training requirement for EBP and research which would increase the use of EBP: I find evidence-based practice a new concept to many of my colleagues. During my training a great deal of time was spent looking at research, critiquing and putting evidence into practice. However, I did not train in Australia and since qualifying, had to provide evidence of professional development. Once this becomes a training requirement, it might increase the use of EBP.
DISCUSSION This study sought to examine perceptions, attitudes, knowledge and skills of NE, CC and CNS in fostering EBP in the clinical setting. Descriptive analysis revealed that study participants who had highest qualifications, and selfrated their knowledge as excellent, were more likely to use and value best evidence for practice, supporting the findings of Koehn and Lehman15 who reported that generally diploma and bachelor-level nurses lacked knowledge and skills in EBP. Likewise, Gerrish et al.16 found nurses with masters qualifications were better prepared to implement EBP. This further supports Bonner and Sando’s17 finding that the level of university education was directly related with knowledge of research, use of research and attitudes towards research, and is not surprising. The study findings showed that NE (90%), CC (100%) and CNS (94%) used organizational policies and protocols as first-line information and sources of knowledge. This result is different from other published studies where nurses have been found to mostly rely on colleagues and experience as first sources for information.18–21 The rationale might be that in the organization where the study was conducted, participants could easily access computers to find and refer to the organizational policies and protocols. Therefore, accessibility to information technology influences sources of information nurses use to inform and change their practice, as supported by Gerrish et al.16 Gerrish and Clayton22 found reliance on experiential knowledge gained through interactions with nursing colleagues, medical staff and patients to inform practice, rather than from textbooks or journals. Participants of this study showed similar preferences with regard to sourcing information from medical and research journals.
Participants scored relatively low in the entire section on knowledge-practice gap; appraisal of the literature emerged at the bottom end. These findings could be related to unavailability of time and lack of critical appraisal skills, as highlighted by Upton and Upton,14 Bertulis,21 Majid et al.4 and Barako et al.8 Kajermo et al.23 argued that lack of knowledge and skills could be an underlying aspect of lack of time. Without proper knowledge and skills of research methods, attempts to find and evaluate research findings might be too time consuming. In addition, in a systematic review of 23 studies, Coomarasamy and Khan24 found that classroom teaching of EBP or critical appraisal courses improved knowledge of nurses, but clinically integrated teaching improved their skills, attitudes and response towards evidencebased processes. Participants of the study demonstrated positive attitudes towards benefits in changing their practice based on research, and they wanted to access evidence more often than they were. These findings correspond with Brown et al.5 and Majid et al.4 who concluded that attitudes towards EBP were more positive than their knowledge, skills and implementation. Although the present study participants were keen and wished to participate in EBP, their views were not all positive because they felt it was time consuming, research articles were not understood and research findings were often not easily transferable into their practice. Kajermo et al.23 reported that nurses in clinical practice found research articles hard to evaluate, owing to lack of knowledge and education in research methods. The key contextual factors affecting participants’ translation of EBP were identified as insufficient time and lack of support from staff/organization. These findings are supported by a significant number of studies.4,5,8,17,21,23,25–32 Therefore, organizational support to provide opportunities to NEs, CCs and CNSs in facilitating change is essential for successful implementation of EBP. These senior nurses have an obligation to seek best evidence to support their teaching and practice, promote a spirit of inquiry, critical thinking and a philosophy of life-long learning to nurses. Findings of this study need to be considered in the light of potential methodological limitations. Although the response rate was low, 31% falls within the norm.33 It is possible that those nurses who were passionate either positively or negatively were more likely to respond. Thus, findings might not be representative of © 2014 Wiley Publishing Asia Pty Ltd
52
G Malik et al.
the population. The use of self-reporting to assess knowledge, skills and attitudes might have resulted in inflated or underestimated scores in perceptions towards EBP, and is also a limitation. Finally, the study was limited to only one health-care network, so it cannot be generalized to other populations.
Recommendations For successful implementation of EBP, individual strategies need to be aimed at instilling appreciation, increasing knowledge, developing skills and changing behaviours. Strategies to overcome organizational barriers must be directed towards creating and supporting cultures where EBP can flourish. An educational programme needs to be designed, offering knowledge and developing necessary skills to promote EBP.28 Opportunities need to be provided to NEs, CCs and CNSs to attend these sessions on a regular basis. Organizational commitment needs to be demonstrated by authorization of non-patient care hours to the study participants to be able to initiate evidence-based process.8 Continued support from the organization has been identified as important for participants, as education is not effective without such support. Introducing formal systems for in-house mentoring for novices can serve as an effective strategy to support EBP.34 Research findings have indicated that EBP mentors are key in strengthening clinician’s beliefs and their ability to implement it.35 The design of mentorship programmes that create linkages between EBP mentors and educators might be an important strategy for limiting the effects of theory-practice gaps. EBP needs to be ingrained from nursing curricula and incorporated as a component of the research process. The inclusion of the core content in graduate nursing curricula is essential to establish a foundation from which knowledge and skills related to EBP can be further developed.
CONCLUSION EBP aims to provide the most effective health-care outcomes. NEs, CCs and CNSs rely on personal experiences and organizational policies and protocols as formal sources of knowledge. They showed positive attitudes towards EBP; however lack of knowledge, poor skills, limited time and lack of resources were perceived as major obstacles to implement EBP. To embrace EBP, participants need allocated time away from bedside responsibilities, autonomy over their practice, education in finding and © 2014 Wiley Publishing Asia Pty Ltd
accessing evidence, and mentorship for successful implementation. Educational initiatives informed by perceptions of NEs, CCs and CNSs will enable organizations to create EBP culture.
ACKNOWLEDGEMENTS We would like to acknowledge the participating organizations, Southern Health and Monash University, for their cooperation and support. We also convey our thanks to all the nurse educators, clinical coaches and nurse specialists for their valuable contribution towards the study.
REFERENCES 1 Hamer S, Collinson G Achieving Evidence-based Practice: A Handbook for Practitioners. Edinburgh: Bailliere Tindall Royal College of Nursing, 1999. 2 Adams D. Breaking down the barriers: Perceptions of factors that influence the use of evidence in practice. Journal of Orthopaedic Nursing 2001; 5: 170–175. 3 Zeitz K, McCutcheon H. Evidence-based practice: To be or not to be, this is the question. International Journal of Nursing Practice 2003; 9: 272–279. 4 Majid S, Foo S, Luyt B et al. Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge and barriers. Journal of the Medical Library Association 2011; 99: 229–236. 5 Brown CE, Wickline MA, Ecoff L, Glaser D. Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical centre. Journal of Advanced Nursing 2008; 65: 371–381. 6 Smith P, Trudi J. Shaping the Facts: Evidence-Based Nursing and Health Care. Edinburgh: Churchill Livingstone, 2004. 7 Penz K, Bassendowski S. Evidence based nursing in clinical practice: Implications for nurse educators. Journal of Continuing Education in Nursing 2006; 37: 250–254. 8 Barako TD, Chege M, Wakasiaka S, Omondi L. Factors influencing application of evidence-based practice among nurses. African Journal of Midwifery and Women’s Health 2011; 6: 71–77. 9 Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B. Getting evidence into practice: The role and function of facilitation. Journal of Advanced Nursing 2002; 37: 577–588. 10 Melnyk B, Fineout-Overholt E, Dadler L, GreenHernandez C. Nurse practitioner educators’ perceived knowledge, beliefs and teaching strategies regarding Evidence-based practice: Implications for accelerating the integration of evidence-based practice into graduate programs. Journal of Professional Nursing 2008; 24: 7–13. 11 Pepler C, Frisch S, Rennick J et al. Strategies to increase research-based practice interplay with unit culture. Clinical Nurse Specialist CNS 2006; 20: 23–31.
Evidence-based practice
12 Gerrish K, Ashworth P, Lacey A et al. Factors influencing the development of evidence-based practice: A research tool. Journal of Advanced Nursing 2007; 57: 328–338. 13 McKenna H, Ashton S, Keeney S. Barriers to evidencebased practice in primary care. Journal of Advanced Nursing 2004; 45: 178–189. 14 Upton D, Upton P. Nurses’ attitudes to evidence-based practice: Impact of a national policy. British Journal of Nursing 2005; 14: 284–288. 15 Koehn M, Lehman K. Nurses’ perceptions of evidencebased nursing practice. Journal of Advanced Nursing 2008; 62: 209–215. 16 Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M, Tod A. The role of advanced practice nurses in knowledge brokering as a means of promoting evidencebased practice among clinical nurses. Journal of Advanced Nursing 2011; 67: 2004–2014. 17 Bonner A, Sando J. Examining the knowledge, attitude and use of research by nurses. Journal of Nursing Management 2008; 16: 334–343. 18 Youngblut JM, Brooten D. Evidence-based nursing practice: Why is it important? AACN Clinical Issues 2001; 12: 468–476. 19 Pravikoff DS, Tanner AB, Pierce ST. Readiness of US nurses for evidence-based practice. The American Journal of Nursing 2005; 105: 40–51. 20 Thompson C, McCaughan D, Cullum N, Sheldon T, Raynoor P. Barriers to Evidence-based practice in primary care nursing: Why viewing decision-making as context is helpful. Journal of Advanced Nursing 2005; 52: 432–444. 21 Bertulis R. Barriers to accessing evidence-based information. Nursing Standard 2008; 22: 35–39. 22 Gerrish K, Clayton J. Promoting evidence-based practice: An organizational approach. Journal of Nursing Management 2004; 12: 114–123. 23 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell HA. Barriers to and facilitators of research utilization as perceived by a group of registered nurses in Sweden. Journal of Advanced Nursing 1998; 27: 798–807.
53
24 Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence-based medicine changes anything? British Medical Journal 2004; 329: 1017–1019. 25 Funk SG, Champagne MT, Wiese RA, Tornquist EM. Barriers to using research findings in practice: The clinician’s perspective. Applied Nursing Research 1991; 4: 90–95. 26 Curtin M, Jaramazovic E. Occupational therapists’ views and perceptions of evidence-based practice. British Journal of Occupational Therapy 2001; 64: 214–222. 27 Sitzia J. Barriers to research utilization: The clinical setting and nurses themselves. Intensive and Critical Care Nursing 2002; 18: 230–243. 28 Sherriff KL, Wallis M, Chaboyer W. Nurses’ attitudes to and perceptions of knowledge and skills regarding evidencebased practice. International Journal of Nursing Practice 2007; 13: 363–369. 29 Carlson CL, Plonczynski DJ. Has the BARRIERS scale changes nursing practices? An integrated review. Journal of Advanced Nursing 2008; 63: 322–333. 30 Gerrish K, Ashworth P, Lacey A, Bailey J. Developing evidence-based practice: Experiences of senior and junior clinical nurses. Journal of Advanced Nursing 2008; 62: 62–73. 31 Patter Gale BV, Schaffer MA. Organisational readiness for evidence-based practice. The Journal of Nursing Administration 2009; 39: 91–97. 32 Breimaier HE, Halfens RJG, Lohrmann C. Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing 2011; 20: 1744–1756. 33 Polit DF, Beck CT. Nursing Research: Generating and assessing evidence for nursing practice, 8th edn. New York: J. B. Lippincott, 2008. 34 Melnyk BM. The evidence-based practice mentor: A promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews on Evidence-based Nursing 2007; 4: 123–125. 35 Melnyk BM, Fineout-Overholt E. Putting research into practice. Reflections on Nursing Leadership/Sigma Theta Tau International, Honor Society of Nursing 2002; 28: 22–25.
© 2014 Wiley Publishing Asia Pty Ltd
54
G Malik et al.
APPENDIX I Evidence-Based Practice: Nurse Educators’, Clinical Coaches’ and Clinical Nurse Specialists’ Perceptions This questionnaire is designed to gather information and opinion on the use of evidence-based practice among nurse educators, clinical coaches and clinical nurse specialists. There are no right or wrong answers. We are interested in your perceptions towards evidence-based practice. This questionnaire will take about 10 to 15 min. Please answer as fully as possible. Demographic details What is your gender? What is your age?
Male 21–30 years 41–50 years 60+ years
Female 31–40 years 51–60 years
What position do you currently hold? Nurse Educator Clinical Coach Clinical Nurse Specialist How long have you held this position for? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years How many years of teaching experience do you have? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years How many years of nursing experience do you have? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years What is your highest completed educational qualification? Diploma Bachelor Degree Graduate certificate Graduate diploma Master Degree PhD Other, please specify:_______________ Do you work
full time
Which forms of evidence-based literature do yo access? (Tick all that apply) Internet Intranet
Part time Print based
How would you rate your knowledge on evidence-based practice? Please circle the best response. (Question added) Poor Fair Good V.good Excellent
© 2014 Wiley Publishing Asia Pty Ltd
None
Evidence-based practice
55
In this section, we want to explore different sources of knowledge that you use in your professional practice. Please put a tick in the box that best describes your response. The knowledge that I use in my practice is based on
Never
Seldom
Sometimes
Frequently
Always
1. Information that I learn about each patient as an individual. 2. My intuitions about what seems to be right for the patient. 3. My personal experience of caring for patients/clients over time. 4.The ways that I have always done it. 5. Information my co-workers share. 6. What doctors discuss with me. 7. Information I learnt in my training. 8. Information I get from attending in-services/training/conferences. 9. Information I get from policy and protocols. 10. Information I get from: a) Articles published in medical journal. b) Articles published in nursing journal. c) Articles published in research journals. d) Textbooks e) Internet f) Media ( magazines, TV)
Comments: ______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ Consider your practice in relation to an individual patient’s care over the past year. How often have you done the following in response to a gap in your knowledge and practice? Knowledge practice gap
Never
Seldom
Sometimes
Frequently
Always
11. Formulated a clearly answerable question as the beginning of the process 12. Tracked down the relevant evidence once formulated the question 13. Critically appraised, against set criteria, any literature I have discovered 14. Integrated the evidence I have found with my expertise 15. Evaluated the outcomes of my practice 16. Shared this information with colleagues
Comments: ______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________________________________________________________________________
© 2014 Wiley Publishing Asia Pty Ltd
56
G Malik et al.
Now, we would like you to rate your skills in finding, reviewing and implementing evidence in the practice setting. Please tick the appropriate box to indicate how you rate your current skills. Skills rating
Beginner
Novice
Quite skilled
Competent
Expert
17. Finding research evidence 18. Comprehensive literature review 19. Critical appraisal skills 20. Finding organizational information 21. Using the library to locate information 22. Using the Internet to search the information 23. Reviewing research evidence 24. Reviewing organizational information (protocols/guidelines) 25. Using research evidence to change practice 26. Using organizational information to change practice
Comments:______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________ Now, we like to ask how you feel about evidence-based practice. Please tick the appropriate box to indicate the extent to which you agree with the following statements as they apply to your current role. Attitude to EBP
27. I stick to tried and trusted methods rather than changing anything new. 28. I resent having my clinical practice questioned. 29. Much of the available research is not relevant to my professional practice. 30. I find that research articles are not easily understood. 31. I don’t have sufficient time to find research reports. 32. I believe that putting research into practice is to some extent dependent on how much it is going to cost. 33. Evidence-based practice is a waste of time. 34. I feel that there are benefits to changing my practice, based on research. 35. I find that patient compliance is a major factor in the use of evidence. 36. I find it difficult to keep up with all the changes happening in my work environment at present. 37. I find it hard to influence changes to clinical practice in my work setting. 39. I would feel more confident if there was an individual experienced in research to supply me with relevant Information. 40. I would like to access current best evidence more often than I currently do. 41. Research findings are often not easily transferable into my practice. 42. Evidence-based practice is fundamental to professional practice. 43. Implementing evidence-based practice will be of benefit to my professional development.
© 2014 Wiley Publishing Asia Pty Ltd
Strongly disagree
Disagree
Unsure
Agree
Strongly agree
Evidence-based practice
57
Comments:______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________ Thank You for completing the questionnaire. Please return the questionnaire via internal mail.
© 2014 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2015; 21 (Suppl. 2), 46–57
RESEARCH PAPER
Perceived knowledge, skills, attitude and contextual factors affecting evidence-based practice among nurse educators, clinical coaches and nurse specialists Gulzar Malik PhD Candidate MN RN MACN PhD Candidate, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
Lisa McKenna PhD RN FACN Professor, Head of Campus (Clayton), Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
Virginia Plummer PhD RN FACN Associate professor Nursing Research, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Peninsula, Victoria, Australia
Accepted for publication June 2014 Malik G, McKenna L, Plummer V. International Journal of Nursing Practice 2015; 21 (Suppl. 2): 46–57 Perceived knowledge, skills, attitude and contextual factors affecting evidence-based practice among nurse educators, clinical coaches and nurse specialists Evidence-based practice (EBP) in the clinical setting is recognized as an approach that leads to improved patient outcomes. Nurse educators (NEs), clinical coaches (CCs) and nurse specialists are in key positions to promote and facilitate EBP within clinical settings and have opportunities to advance practice. Therefore, it is important to understand their perceptions of factors promoting EBP and perceived barriers in facilitating EBP in clinical settings, before developing educational programmes. This paper reports findings from a study that aimed to explore NEs’ , CCs’ and nurse specialists’ knowledge, skills and attitudes associated with EBP. This study used a questionnaire containing quantitative and a small number of qualitative questions to capture data collected from NEs, CCs and nurse specialists working at a tertiary health-care facility in Victoria, Australia. The questionnaire was distributed to a total of 435 people, of whom 135 responded (31%). Findings revealed that the three senior nurse groups relied heavily on personal experience, organizational policies and protocols as formal sources of knowledge. Furthermore, they had positive attitudes towards EBP. However, participants demonstrated lack of knowledge and skills in appraising and utilizing evidence into practice. They indicated a desire to seek educational opportunities to upskill themselves in the process of EBP. Key words: clinical nurse specialists, evidence-based nursing, evidence-based practice, nurse educators. Correspondence: Gulzar Malik, Faculty of Medicine, Nursing and Health Sciences, School of Nursing and Midwifery, Monash University, Building 13C, Monash University Clayton Campus, Melbourne, Vic. 3800, Australia. Email: [email protected] © 2014 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12366
Evidence-based practice
INTRODUCTION Evidence-based practice (EBP) has gained momentum in a variety of disciplines (medicine, management and engineering, to name a few) and has also attracted attention in nursing. The impetus for EBP has come to health-care systems from accrediting bodies, government agencies, professional organizations and increase in malpractice legislations.1–4 Improving quality of health care requires a commitment to deliver care based on sound scientific evidence and constant innovative health-care practices and preventive approaches. Therefore, EBP has been recognized by health-care institutions as the gold standard for provision of safe and effective health care.5 The ongoing evolution of nursing as a profession requires the development of EBP outcomes and nurses’ abilities to access and evaluate professional literature. EBP empowers nurses to form innovative learning partnerships with colleagues to nourish and to strengthen critical thinking skills, and to integrate research knowledge in leading best practice.6 Literature suggests that much current practice is frequently based on experience, tradition and intuition rather than on evidence. Despite growing numbers of nurse researchers and studies designed to improve practice at staff level, many nurses lack research knowledge, skills and understanding.4–7 Brown et al.5 studied nurses’ perceptions at an academic centre in California and found a lack of knowledge in the participants related to searching and appraising research reports. Similarly, a study conducted in Africa by Barako et al.8 concluded that poor knowledge and skills of searching and retrieving research studies prevented the usage of EBP into nursing care. Majid et al.4 surveyed 1486 nurses from two public hospitals in Singapore, finding medical information provided by websites, and hospital policies and procedures were the most frequently used sources. However, nursing e-books and medical and nursing databases appeared to be referred to less often. Although reasons for introducing EBP, together with strategies for implementation and resource implications have been discussed in the literature, evidence suggests that a paradigm shift to EBP happens slowly. To explain this, researchers have focused on individual nurses’ knowledge, skills and beliefs in appraising and using research as the cornerstone for evidence-based nursing. Some models for promoting EBP emphasize the need for facilitation by external/internal agents to support the process of change.9 In the clinical setting, nurse educators (NEs), clinical coaches (CCs) and nurse specialists are
47
considered key people to promote and facilitate evidencebased nursing care. They can play a critical role in establishing a culture through various activities and programmes. However, little is known about their engagement with EBP. According to Melnyk et al.,10 there is a link between NEs’ beliefs about EBP and the extent to which they teach and practice it. Findings from their study of 79 educators supported this relationship. Similarly, Pepler et al.11 identified clinical nurse specialists (CNSs) and NEs as instrumental in disseminating evidence-based information at ward level. However, further research is needed to examine the role of specialists in promoting EBP among frontline nurses. So far, studies of evidence-based nursing have focused on clinical nurses as a collective, rather than exploring views of individuals on EBP. Therefore, it is important to understand NEs’, CCs’ and nurse specialists’ perceptions, perceived barriers and factors that motivate them to promote EBP among nurses. Studies examining NEs’ and CNSs’ perceptions are scarce, despite positioning of these nurses as trusted, knowledgeable and influential members in health-care settings. This study attempted to address the lack of previous research, seeking to uncover the perceptions of three senior nurse groups in promoting EBP, which could then guide the development of strategies to overcome barriers to implementation, and assist planning of educational programmes to foster EBP in the clinical setting. The study invited three groups comprising NEs, CCs and CNSs from the tertiary health-care setting, due to their nature of roles within practice areas. NEs are responsible for delivering clinical education programmes and promoting staff development through a variety of activities. CCs, also known as clinical support nurses, assist NEs in delivering clinical education and support new staff and graduate nurses in their clinical practice. CCs assume the responsibilities of an NE in the practice areas where no educators are allocated. Within clinical units, CNSs provide coaching and act as preceptors for graduate and student nurses, ensuring evidencebased nursing care.
METHODS The study aimed to investigate attitudes, knowledge and skills of NE, CC and CNS in fostering EBP in the clinical setting. It sought to address the questions: 1. What are NEs’, CCs’ and CNSs’ attitudes towards EBP? © 2014 Wiley Publishing Asia Pty Ltd
48
2. What is their level of knowledge and skills in regard to EBP? 3. What are the factors affecting the implementation of EBP in the clinical setting? A descriptive survey was conducted using a modified questionnaire. Questionnaire items were adapted from three validated research tools. 1. Development of Evidence-Based Practice 12 Questionnaire The original questionnaire was tested with a sample size of 1287 nurses in England. Results demonstrated that the questionnaire was drawn from well-established sources with reliability > 0.7 for each section. The Cronbach’s alpha values for the sections ranged from 0.73 to 0.913, with an overall alpha of 0.874.12 2. Attitudes to Evidence-Based Practice Questionnaire13 The original questionnaire was tested in a pilot study with 40 general practitioners across four health and social services boards in Northern Ireland and a random sample of community nurses at the University of Ulster. The pilot study sample deemed the questionnaire to have face validity, and an expert panel’s judgment provided content validity. The questionnaire has a reported reliability coefficient (internal consistency) of 0.74.13 3. Clinical Effectiveness and Evidence-Based Practice Questionnaire14 The original questionnaire was developed and psychometrically validated by Upton and Upton14. In Upton and Upton’s study, Cronbach’s alpha for practice component was 0.87, for attitude component was 0.72, 0.95 for knowledge/skills and for the entire questionnaire it was 0.94. A level of 0.94 is considered an excellent level of internal consistency.14 Permission was sought and obtained from each of the authors to use the questionnaires. The final questionnaire incorporated the three tools and consisted of 67 Likertstyle items (Appendix I). Prior to commencing data collection, ethical approval was obtained from the participating organization and relevant university ethics committee. Following approvals, questionnaires were distributed to all NE, CC and CNS working across sites of a tertiary health-care network in Victoria, Australia. To maintain confidentiality and anonymity, surveys were distributed via the internal mail system and consent was implied by the return of a completed questionnaire. A total of 435 questionnaires were distributed to 79 educators, 12 CCs and 344 CNSs. © 2014 Wiley Publishing Asia Pty Ltd
G Malik et al.
The current study tool incorporated the categories comprised of demographic details, sources of knowledge, knowledge practice gap, skills rating and attitudes to EBP. Following demographic details, participants were asked to self-rate their knowledge on EBP on a five-point Likert scale, where ‘one’ represented ‘poor’ and ‘five’ represented ‘excellent’. In regard to different sources of knowledge participants used to inform their professional practice, 10 items were rated on a five-point Likert scale, with one representing ‘never’ and five representing ‘always’ included. Participants were asked how frequently they followed a process to identify a knowledge-practice gap. This section consisted of six items and was rated on a five-point Likert scale, with one indicating ‘never’ and five indicating ‘always’. In addition, 10 items related to self-appraisal of skills associated with EBP were incorporated. Participants were provided with options to choose from beginner to expert level to rate their skills in finding, reviewing and implementing evidence in the practice setting. The scale used for the items represented one as ‘beginner’ and five as ‘expert’. In the final section, 16 items were included, exploring attitudes regarding EBP. Again, these items were rated on a five-point Likert scale, from ‘strongly disagree’ to ‘strongly agree’. In addition, general comments were invited following each section, providing opportunities for participants to further elaborate on their responses, therefore adding a qualitative dimension to the study. Data were analysed using SPSS (Statistical Packages for Social Sciences v. 17.0. Frequencies and percentages were calculated for demographic dat,a and descriptive statistics (mean, median and standard deviation) for each item were calculated. Lastly, themes were identified for the responses received in the general comments section.
RESULTS Demographic characteristics Of the 435 potential participants, 135 participated, representing a response rate of 31%. Distribution of participants was 41 NEs, 10 CCs and 84 CNSs, with response rates of 52%, 83% and 24% within each group, respectively. The majority (84%) were women, with 16% men. Thirty-eight per cent of the participants were aged between 31 and 40 years, with one aged 60 years or above. The remaining study participants were aged from 21 to 59 years. In regard to nursing experience, 35% of the participants had over 20 years, 28% had between 6 and 10 years, followed by 18% and 16% who had 11–15
Evidence-based practice
49
Table 1 Demographic characteristics (n = 135) Characteristic Gender
Frequency Percentage
Male 22 Female 113 Age (years) 21–30 22 31–40 52 41–50 41 51–60 19 60 and above 1 Position Nurse educator 41 Clinical coaches 10 Clinical nurse specialist 84 Duration of 0–5 75 38 the position 6–10 11–15 16 (years) 16–20 3 > 20 3 Educational Diploma 12 Bachelor’s degree 49 qualification Graduate certificate 39 Graduate diploma 24 Master’s degree 11 Nursing 0–5 4 38 experience 6–10 11–15 24 (years) 16–20 22 > 20 47 Teaching 0–5 76 6–10 33 experience 11–15 17 (years) 16–20 5 > 20 4
16.3 83.7 16.3 38.5 30.4 14.1 0.7 30.4 7.4 62.2 55.6 28.1 11.9 2.2 2.2 8.9 36.3 28.9 17.8 8.1 3.0 28.1 17.8 16.3 34.8 56.35 24.4 12.6 3.7 3.0
years and 16–20 years, respectively. Only 3% fell between 1 and 5 years. Thirty-six per cent of the study participants held a bachelor degree as their highest qualification earned, with 29% having a graduate certificate, 18% a graduate diploma, 9% a diploma and 8% a master’s degree. The majority (56%) of the participants were in their current positions for less than 5 years. Demographic characteristics are highlighted in Table 1.
Perceived knowledge on EBP An overall mean score of 2.98 was received in the section of self-perceived knowledge on EBP. Participants self-rated their knowledge on a five-point Likert scale where ‘one’ represented ‘poor’ and ‘five’ represented
‘excellent’. Of the 135 participants, 47% perceived they had ‘good’ knowledge, 25% ranked their knowledge as ‘fair’ and 24% rated their knowledge as ‘very good’. In addition, 2% of the NE group perceived they had ‘excellent’ knowledge. However, 2% also rated their knowledge as ‘poor’, within the CNS group. The majority of NEs and CCs rated their knowledge as ‘very good’ and ‘good’, whereas a majority of CNSs perceived their knowledge as ‘good and ‘fair’ on EBP.
Sources of knowledge Information from policies and protocols received the highest mean score of 4.35 (SD = 0.627). Fifty-one per cent of participants referred to policies and protocols on a frequent basis, and 42% always used policies as a source of knowledge (median = 4.00), indicating that most of their practice was informed by organizational policies and protocols. Furthermore, utilizing personal experience in practice was equally popular, with a median of 4.00 and mean of 4.28 (SD = .631). Results also revealed that all three groups often used information which they gained through patient care and by attending in-service education/training/conferences (mean = 4.10, median = 4.00). At the lower end of the scale, information from media ranked lowest, with a mean of 2.01 (SD = .888); however, so, too, did information from medical journals and research journals, with means of 2.74 (SD = 1.000) and 2.68 (SD = 1.020), respectively. The study was designed to capture quantitative data. However, to ensure that a breadth of data was available for analysis and interpretation, a comments section was included to capture qualitative data. Although not all participants offered additional comments, four participants offered comments related to source of knowledge use in practice, which were consistent with the abovementioned findings. One stated that: Knowledge I use is what you gather over the years of experience and new information taught by clinical teachers/doctors rounds and change made within the network. Another stated that: I always use a combination of information.
Knowledge-practice gap Overall, responses demonstrated a fairly high mean of 3.77 (median = 4.00) in sharing information with © 2014 Wiley Publishing Asia Pty Ltd
50
G Malik et al.
colleagues, followed by a mean of 3.65 (median = 4.00) towards evaluating the outcomes of practice. In the entire section of knowledge-practice gap, appraisal of literature showed the lowest results (Mean = 2.86, SD = 0.959). This finding is consistent with all three groups and can be related to a verbal comment which one participant made in relation to lack of time: Time at work doesn’t permit for this to occur due to other commitments.
reported time as a barrier to finding research reports (Mean = 3.67, median = 4.00). Furthermore, nearly half of the participants (48%) agreed that research findings were not easily transferable into their practice (Mean = 3.31, median = 4). In addition, 66% of the participants reported that it was hard for them to implement changes (Mean = 3.17, median = 4), and 53% found it difficult to keep up to date with current evidence (Mean = 3.16, median = 4).
Contextual factors affecting EBP Skills rating The entire group showed the least confidence with was critical appraisal skills, with the lowest mean of 2.67 (SD = .991). Overall, 40.7% rated themselves as ‘beginner’, 36% rated themselves as ‘quite skilled’ and 23% rated themselves as ‘competent’ towards critical appraisal skills (median = 3.00). Between the groups, 14.6% of educators reported being ‘beginner’ and 34.1% as ‘quite skilled’ in their critical appraisal skills, whereas 23.8% of CNSs had rated as ‘beginner’ and 31% as ‘novice’ their critical appraisal skills. All three groups scored low in critically appraising the literature. Findings indicated that lack of critical appraisal skills and insufficient time prevented appraising literature on a regular basis. In addition, finding research evidence, reviewing research evidence, comprehensive literature review and using research evidence to change practice also depicted fairly low results. However, participants showed confidence in finding and reviewing organizational information, and using the Internet to search for information, as one stated: Finding information is easy if you know where to look-and it is implemented as protocols of the hospital and the Network.
Attitudes to EBP The highest mean of 4.34 (SD = 0.536) demonstrated positive attitudes towards EBP. Fifty-nine per cent agreed and 37% strongly agreed that EBP was fundamental to their professional practice (median = 4.00). In addition, beliefs about implementation of EBP being of benefit to their professional development were also strong (Mean = 4.32, median = 4.00). Participants also felt there were benefits to change their practice based on research (Mean = 4.19, median = 4). Similarly, they expressed interest in accessing evidence more often than they currently did. However, 57% of the participants © 2014 Wiley Publishing Asia Pty Ltd
Of the 135, 10% of the participants outlined the facilitators and barriers to EBP in the comments section provided, following each section of the questionnaire. The key contextual factors consisted of time and staff/ organization were derived from the thematic analysis of the participants’ comments.
Time Participants reported that they had limited time for EBP during scheduled working hours and it was hard to keep up to date with current changes because of other commitments, such as meetings: Having someone to assist in supply research articles would be good as I don’t have enough time to do it all myself. No time to find and read research articles. In contrast to NEs, CNSs strongly believed they neither had sufficient time to find research reports, nor did they understand them easily, signifying that patient load might not allow them to focus on research as demonstrated by ‘No time during patient care’.’
Staff/Organization Participants described that staff in the clinical setting were resistant to change, very busy and not interested to bring about change: Staff resistant to change-go back next week it is still being done the same way. Implementation of EBP was seen to be affected by colleagues and unit managers. Participants emphasized that it needs to be actively implemented by the organization: Sometimes there is little or no evidence for some current and planned practices on network website.
Evidence-based practice
51
One participant suggested that there should be a compulsory training requirement for EBP and research which would increase the use of EBP: I find evidence-based practice a new concept to many of my colleagues. During my training a great deal of time was spent looking at research, critiquing and putting evidence into practice. However, I did not train in Australia and since qualifying, had to provide evidence of professional development. Once this becomes a training requirement, it might increase the use of EBP.
DISCUSSION This study sought to examine perceptions, attitudes, knowledge and skills of NE, CC and CNS in fostering EBP in the clinical setting. Descriptive analysis revealed that study participants who had highest qualifications, and selfrated their knowledge as excellent, were more likely to use and value best evidence for practice, supporting the findings of Koehn and Lehman15 who reported that generally diploma and bachelor-level nurses lacked knowledge and skills in EBP. Likewise, Gerrish et al.16 found nurses with masters qualifications were better prepared to implement EBP. This further supports Bonner and Sando’s17 finding that the level of university education was directly related with knowledge of research, use of research and attitudes towards research, and is not surprising. The study findings showed that NE (90%), CC (100%) and CNS (94%) used organizational policies and protocols as first-line information and sources of knowledge. This result is different from other published studies where nurses have been found to mostly rely on colleagues and experience as first sources for information.18–21 The rationale might be that in the organization where the study was conducted, participants could easily access computers to find and refer to the organizational policies and protocols. Therefore, accessibility to information technology influences sources of information nurses use to inform and change their practice, as supported by Gerrish et al.16 Gerrish and Clayton22 found reliance on experiential knowledge gained through interactions with nursing colleagues, medical staff and patients to inform practice, rather than from textbooks or journals. Participants of this study showed similar preferences with regard to sourcing information from medical and research journals.
Participants scored relatively low in the entire section on knowledge-practice gap; appraisal of the literature emerged at the bottom end. These findings could be related to unavailability of time and lack of critical appraisal skills, as highlighted by Upton and Upton,14 Bertulis,21 Majid et al.4 and Barako et al.8 Kajermo et al.23 argued that lack of knowledge and skills could be an underlying aspect of lack of time. Without proper knowledge and skills of research methods, attempts to find and evaluate research findings might be too time consuming. In addition, in a systematic review of 23 studies, Coomarasamy and Khan24 found that classroom teaching of EBP or critical appraisal courses improved knowledge of nurses, but clinically integrated teaching improved their skills, attitudes and response towards evidencebased processes. Participants of the study demonstrated positive attitudes towards benefits in changing their practice based on research, and they wanted to access evidence more often than they were. These findings correspond with Brown et al.5 and Majid et al.4 who concluded that attitudes towards EBP were more positive than their knowledge, skills and implementation. Although the present study participants were keen and wished to participate in EBP, their views were not all positive because they felt it was time consuming, research articles were not understood and research findings were often not easily transferable into their practice. Kajermo et al.23 reported that nurses in clinical practice found research articles hard to evaluate, owing to lack of knowledge and education in research methods. The key contextual factors affecting participants’ translation of EBP were identified as insufficient time and lack of support from staff/organization. These findings are supported by a significant number of studies.4,5,8,17,21,23,25–32 Therefore, organizational support to provide opportunities to NEs, CCs and CNSs in facilitating change is essential for successful implementation of EBP. These senior nurses have an obligation to seek best evidence to support their teaching and practice, promote a spirit of inquiry, critical thinking and a philosophy of life-long learning to nurses. Findings of this study need to be considered in the light of potential methodological limitations. Although the response rate was low, 31% falls within the norm.33 It is possible that those nurses who were passionate either positively or negatively were more likely to respond. Thus, findings might not be representative of © 2014 Wiley Publishing Asia Pty Ltd
52
G Malik et al.
the population. The use of self-reporting to assess knowledge, skills and attitudes might have resulted in inflated or underestimated scores in perceptions towards EBP, and is also a limitation. Finally, the study was limited to only one health-care network, so it cannot be generalized to other populations.
Recommendations For successful implementation of EBP, individual strategies need to be aimed at instilling appreciation, increasing knowledge, developing skills and changing behaviours. Strategies to overcome organizational barriers must be directed towards creating and supporting cultures where EBP can flourish. An educational programme needs to be designed, offering knowledge and developing necessary skills to promote EBP.28 Opportunities need to be provided to NEs, CCs and CNSs to attend these sessions on a regular basis. Organizational commitment needs to be demonstrated by authorization of non-patient care hours to the study participants to be able to initiate evidence-based process.8 Continued support from the organization has been identified as important for participants, as education is not effective without such support. Introducing formal systems for in-house mentoring for novices can serve as an effective strategy to support EBP.34 Research findings have indicated that EBP mentors are key in strengthening clinician’s beliefs and their ability to implement it.35 The design of mentorship programmes that create linkages between EBP mentors and educators might be an important strategy for limiting the effects of theory-practice gaps. EBP needs to be ingrained from nursing curricula and incorporated as a component of the research process. The inclusion of the core content in graduate nursing curricula is essential to establish a foundation from which knowledge and skills related to EBP can be further developed.
CONCLUSION EBP aims to provide the most effective health-care outcomes. NEs, CCs and CNSs rely on personal experiences and organizational policies and protocols as formal sources of knowledge. They showed positive attitudes towards EBP; however lack of knowledge, poor skills, limited time and lack of resources were perceived as major obstacles to implement EBP. To embrace EBP, participants need allocated time away from bedside responsibilities, autonomy over their practice, education in finding and © 2014 Wiley Publishing Asia Pty Ltd
accessing evidence, and mentorship for successful implementation. Educational initiatives informed by perceptions of NEs, CCs and CNSs will enable organizations to create EBP culture.
ACKNOWLEDGEMENTS We would like to acknowledge the participating organizations, Southern Health and Monash University, for their cooperation and support. We also convey our thanks to all the nurse educators, clinical coaches and nurse specialists for their valuable contribution towards the study.
REFERENCES 1 Hamer S, Collinson G Achieving Evidence-based Practice: A Handbook for Practitioners. Edinburgh: Bailliere Tindall Royal College of Nursing, 1999. 2 Adams D. Breaking down the barriers: Perceptions of factors that influence the use of evidence in practice. Journal of Orthopaedic Nursing 2001; 5: 170–175. 3 Zeitz K, McCutcheon H. Evidence-based practice: To be or not to be, this is the question. International Journal of Nursing Practice 2003; 9: 272–279. 4 Majid S, Foo S, Luyt B et al. Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge and barriers. Journal of the Medical Library Association 2011; 99: 229–236. 5 Brown CE, Wickline MA, Ecoff L, Glaser D. Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical centre. Journal of Advanced Nursing 2008; 65: 371–381. 6 Smith P, Trudi J. Shaping the Facts: Evidence-Based Nursing and Health Care. Edinburgh: Churchill Livingstone, 2004. 7 Penz K, Bassendowski S. Evidence based nursing in clinical practice: Implications for nurse educators. Journal of Continuing Education in Nursing 2006; 37: 250–254. 8 Barako TD, Chege M, Wakasiaka S, Omondi L. Factors influencing application of evidence-based practice among nurses. African Journal of Midwifery and Women’s Health 2011; 6: 71–77. 9 Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B. Getting evidence into practice: The role and function of facilitation. Journal of Advanced Nursing 2002; 37: 577–588. 10 Melnyk B, Fineout-Overholt E, Dadler L, GreenHernandez C. Nurse practitioner educators’ perceived knowledge, beliefs and teaching strategies regarding Evidence-based practice: Implications for accelerating the integration of evidence-based practice into graduate programs. Journal of Professional Nursing 2008; 24: 7–13. 11 Pepler C, Frisch S, Rennick J et al. Strategies to increase research-based practice interplay with unit culture. Clinical Nurse Specialist CNS 2006; 20: 23–31.
Evidence-based practice
12 Gerrish K, Ashworth P, Lacey A et al. Factors influencing the development of evidence-based practice: A research tool. Journal of Advanced Nursing 2007; 57: 328–338. 13 McKenna H, Ashton S, Keeney S. Barriers to evidencebased practice in primary care. Journal of Advanced Nursing 2004; 45: 178–189. 14 Upton D, Upton P. Nurses’ attitudes to evidence-based practice: Impact of a national policy. British Journal of Nursing 2005; 14: 284–288. 15 Koehn M, Lehman K. Nurses’ perceptions of evidencebased nursing practice. Journal of Advanced Nursing 2008; 62: 209–215. 16 Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M, Tod A. The role of advanced practice nurses in knowledge brokering as a means of promoting evidencebased practice among clinical nurses. Journal of Advanced Nursing 2011; 67: 2004–2014. 17 Bonner A, Sando J. Examining the knowledge, attitude and use of research by nurses. Journal of Nursing Management 2008; 16: 334–343. 18 Youngblut JM, Brooten D. Evidence-based nursing practice: Why is it important? AACN Clinical Issues 2001; 12: 468–476. 19 Pravikoff DS, Tanner AB, Pierce ST. Readiness of US nurses for evidence-based practice. The American Journal of Nursing 2005; 105: 40–51. 20 Thompson C, McCaughan D, Cullum N, Sheldon T, Raynoor P. Barriers to Evidence-based practice in primary care nursing: Why viewing decision-making as context is helpful. Journal of Advanced Nursing 2005; 52: 432–444. 21 Bertulis R. Barriers to accessing evidence-based information. Nursing Standard 2008; 22: 35–39. 22 Gerrish K, Clayton J. Promoting evidence-based practice: An organizational approach. Journal of Nursing Management 2004; 12: 114–123. 23 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell HA. Barriers to and facilitators of research utilization as perceived by a group of registered nurses in Sweden. Journal of Advanced Nursing 1998; 27: 798–807.
53
24 Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence-based medicine changes anything? British Medical Journal 2004; 329: 1017–1019. 25 Funk SG, Champagne MT, Wiese RA, Tornquist EM. Barriers to using research findings in practice: The clinician’s perspective. Applied Nursing Research 1991; 4: 90–95. 26 Curtin M, Jaramazovic E. Occupational therapists’ views and perceptions of evidence-based practice. British Journal of Occupational Therapy 2001; 64: 214–222. 27 Sitzia J. Barriers to research utilization: The clinical setting and nurses themselves. Intensive and Critical Care Nursing 2002; 18: 230–243. 28 Sherriff KL, Wallis M, Chaboyer W. Nurses’ attitudes to and perceptions of knowledge and skills regarding evidencebased practice. International Journal of Nursing Practice 2007; 13: 363–369. 29 Carlson CL, Plonczynski DJ. Has the BARRIERS scale changes nursing practices? An integrated review. Journal of Advanced Nursing 2008; 63: 322–333. 30 Gerrish K, Ashworth P, Lacey A, Bailey J. Developing evidence-based practice: Experiences of senior and junior clinical nurses. Journal of Advanced Nursing 2008; 62: 62–73. 31 Patter Gale BV, Schaffer MA. Organisational readiness for evidence-based practice. The Journal of Nursing Administration 2009; 39: 91–97. 32 Breimaier HE, Halfens RJG, Lohrmann C. Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing 2011; 20: 1744–1756. 33 Polit DF, Beck CT. Nursing Research: Generating and assessing evidence for nursing practice, 8th edn. New York: J. B. Lippincott, 2008. 34 Melnyk BM. The evidence-based practice mentor: A promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews on Evidence-based Nursing 2007; 4: 123–125. 35 Melnyk BM, Fineout-Overholt E. Putting research into practice. Reflections on Nursing Leadership/Sigma Theta Tau International, Honor Society of Nursing 2002; 28: 22–25.
© 2014 Wiley Publishing Asia Pty Ltd
54
G Malik et al.
APPENDIX I Evidence-Based Practice: Nurse Educators’, Clinical Coaches’ and Clinical Nurse Specialists’ Perceptions This questionnaire is designed to gather information and opinion on the use of evidence-based practice among nurse educators, clinical coaches and clinical nurse specialists. There are no right or wrong answers. We are interested in your perceptions towards evidence-based practice. This questionnaire will take about 10 to 15 min. Please answer as fully as possible. Demographic details What is your gender? What is your age?
Male 21–30 years 41–50 years 60+ years
Female 31–40 years 51–60 years
What position do you currently hold? Nurse Educator Clinical Coach Clinical Nurse Specialist How long have you held this position for? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years How many years of teaching experience do you have? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years How many years of nursing experience do you have? 0–5 years 6–10 years 11–15 years 16–20 years > 20 years What is your highest completed educational qualification? Diploma Bachelor Degree Graduate certificate Graduate diploma Master Degree PhD Other, please specify:_______________ Do you work
full time
Which forms of evidence-based literature do yo access? (Tick all that apply) Internet Intranet
Part time Print based
How would you rate your knowledge on evidence-based practice? Please circle the best response. (Question added) Poor Fair Good V.good Excellent
© 2014 Wiley Publishing Asia Pty Ltd
None
Evidence-based practice
55
In this section, we want to explore different sources of knowledge that you use in your professional practice. Please put a tick in the box that best describes your response. The knowledge that I use in my practice is based on
Never
Seldom
Sometimes
Frequently
Always
1. Information that I learn about each patient as an individual. 2. My intuitions about what seems to be right for the patient. 3. My personal experience of caring for patients/clients over time. 4.The ways that I have always done it. 5. Information my co-workers share. 6. What doctors discuss with me. 7. Information I learnt in my training. 8. Information I get from attending in-services/training/conferences. 9. Information I get from policy and protocols. 10. Information I get from: a) Articles published in medical journal. b) Articles published in nursing journal. c) Articles published in research journals. d) Textbooks e) Internet f) Media ( magazines, TV)
Comments: ______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ Consider your practice in relation to an individual patient’s care over the past year. How often have you done the following in response to a gap in your knowledge and practice? Knowledge practice gap
Never
Seldom
Sometimes
Frequently
Always
11. Formulated a clearly answerable question as the beginning of the process 12. Tracked down the relevant evidence once formulated the question 13. Critically appraised, against set criteria, any literature I have discovered 14. Integrated the evidence I have found with my expertise 15. Evaluated the outcomes of my practice 16. Shared this information with colleagues
Comments: ______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________________________________________________________________________
© 2014 Wiley Publishing Asia Pty Ltd
56
G Malik et al.
Now, we would like you to rate your skills in finding, reviewing and implementing evidence in the practice setting. Please tick the appropriate box to indicate how you rate your current skills. Skills rating
Beginner
Novice
Quite skilled
Competent
Expert
17. Finding research evidence 18. Comprehensive literature review 19. Critical appraisal skills 20. Finding organizational information 21. Using the library to locate information 22. Using the Internet to search the information 23. Reviewing research evidence 24. Reviewing organizational information (protocols/guidelines) 25. Using research evidence to change practice 26. Using organizational information to change practice
Comments:______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________ Now, we like to ask how you feel about evidence-based practice. Please tick the appropriate box to indicate the extent to which you agree with the following statements as they apply to your current role. Attitude to EBP
27. I stick to tried and trusted methods rather than changing anything new. 28. I resent having my clinical practice questioned. 29. Much of the available research is not relevant to my professional practice. 30. I find that research articles are not easily understood. 31. I don’t have sufficient time to find research reports. 32. I believe that putting research into practice is to some extent dependent on how much it is going to cost. 33. Evidence-based practice is a waste of time. 34. I feel that there are benefits to changing my practice, based on research. 35. I find that patient compliance is a major factor in the use of evidence. 36. I find it difficult to keep up with all the changes happening in my work environment at present. 37. I find it hard to influence changes to clinical practice in my work setting. 39. I would feel more confident if there was an individual experienced in research to supply me with relevant Information. 40. I would like to access current best evidence more often than I currently do. 41. Research findings are often not easily transferable into my practice. 42. Evidence-based practice is fundamental to professional practice. 43. Implementing evidence-based practice will be of benefit to my professional development.
© 2014 Wiley Publishing Asia Pty Ltd
Strongly disagree
Disagree
Unsure
Agree
Strongly agree
Evidence-based practice
57
Comments:______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _____________________ Thank You for completing the questionnaire. Please return the questionnaire via internal mail.
© 2014 Wiley Publishing Asia Pty Ltd
