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Research into Clinical Practice
Perception of Spanish primary healthcare nurses about evidence-based clinical practice: a qualitative study J. Pericas-Beltran1 RN, PhD, S. Gonzalez-Torrente2 RN, MSc, J. De Pedro-Gomez1 RN, PhD, J.M. Morales-Asencio3 RN, PhD & M. Bennasar-Veny1 RN, PhD 1 Full Professor, Nursing Department, Evidence, Lifestyles and Health Research Group Members, Universitat de les Illes Balears, 2 PhD Candidate, Nursing, Primary Health Care, Balearic Islands Health Service, Palma, 3 Full Professor, Faculty of Nursing, Physiotherapy, Podology and Occupational Therapy, University of Malaga, Malaga, Spain
PERICAS-BELTRAN J., GONZALEZ-TORRENTE S., DE PEDRO-GOMEZ J., MORALES-ASENCIO J. M. and BENNASAR-VENY M. (2014) Perception of Spanish primary healthcare nurses about evidence-based clinical practice: a qualitative study. International Nursing Review 61, 90–98 Background: Although evidence-based clinical practice constitutes a priority for healthcare services in many countries within the last few years, there is a general lack of implementation of evidence-based clinical practice in nursing care, especially in primary health care. Few qualitative studies concerning the influencing factors on evidence-based clinical practice for community nurses have been carried out. Aim: This study examined the perception of nurses in Spanish primary health care with regard to the knowledge, advantages and barriers within the application process with evidence-based clinical practice. Methods: We used a descriptive qualitative study with focus groups to collect data. Forty-six primary care nurses took part in this study and they were distributed into five focus groups. Results: Five main topics arose from the results achieved: knowledge and development of evidence-based clinical practice, evidence searching, evidence dissemination, advantages of use of evidence-based clinical practice, and barriers for its application and implementation. Participants had a positive attitude towards evidence-based practice, although they used this infrequently because of lack of competence and organizational support for its application. Conclusion: Our participants are increasingly determined to take into account evidence within the decision-making processes in their usual clinical practice. We consider it advisable to develop specialized training strategies as well as provide necessary resources for the implementation of evidence-based clinical practice duly adapted to the field of primary health care.
Correspondence address: Miquel Bennasar-Veny, Nursing Department, Evidence, Lifestyles and Health Research Group Members, Universitat de les Illes Balears, Ctra. Valldemosa km 7.5, 07122 Palma, Islas Baleares, Spain; Tel: +34-971-172367; Fax: +34-971-173190; E-mail: [email protected].
Funding statement This article forms part of a project entitled ‘Determining Factors in Evidence-Based Clinical Practice among Hospital and Primary Care Nursing Staff in the Balearics. A Facilitation Proposal Based on the PARIHS Model’, financed by the Health Research Fund (PI 09/90512, Health Ministry) following a rigorous peer-reviewed funding process. Conflict of interest No conflict of interest.
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Implications for nursing and health policy: This study highlights the existing gap in translating knowledge to practice and its potential implications in the effectiveness of nursing interventions and decision making in primary health care, and thus its implications for education policy. Keywords: Evidence-Based Practice, Focus Groups, Nursing, Primary Health Care, Qualitative Research
Introduction The contribution of primary health care (PHC) to the improvement of results in a population’s health is firmly supported by research. A differential impact has been demonstrated in those countries providing solid PHC in premature mortality, low birth weight newborns, cardiovascular diseases, reduction of the effects of inequality in health as well as the improvement in the perception of health among other benefits (Starfield et al. 2005). Current challenges for health care demand more sustainable and efficient systems, and PHC plays a key role in this aim. Health promotion and proactive management of chronic diseases are critical components of this reorientation, with community nurses placed in an outstanding position for making a difference through effective interventions to the community and, in particular, to those more vulnerable groups (Birch & Thabane 2012). Nevertheless, these outcomes depend largely on how the PHC policy is implemented: in care coverage, equity in the resource distribution, comprehensive health services and access to such services. The right combination of such elements produces a good PHC in which gatekeeping, longitudinal and person-centred care, as well as the coordination of the assistance must be the common denominator to guarantee its effectiveness (Starfield 2012). Emphasis on prevention, early attention to health problems, guarantee of free access to health care as well as high quality of health care offered (Starfield 2012) are indispensable for its effectiveness. In this respect, one of the most important pillars is the use of the most reliable knowledge within the decisionmaking process, developing an evidence-based practice (EBP) (McCrae 2012). EBP concept has evolutioned through the last decades and, currently, the Sicily statement proposes a more comprehensive definition. Thus, EBP requires that decisions about health care be based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources (Dawes et al. 2005). One of the pillars that is currently being encouraged in many health services worldwide is to empower highly qualified com-
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munity nurses within healthcare teams, who base their services on health determinants according to the best evidence available (Birch & Thabane 2012). EBP leads to higher quality of care, improved patient outcomes, reduced costs and greater nurse satisfaction. Nonetheless, there still remain problems with regard to the transferability of the evidence in general terms (Calderon et al. 2011) and more specifically within the nursing field (Holmes et al. 2006). Among these difficulties are the reservations of certain organization leaders, the lack of support by managers as well as the unsuitable training of nurses to carry out EBP (Grant et al. 2012; Melnyk et al. 2012). Besides, there is a lack of quality research that would lead to knowing the most suitable strategies in terms of organization in order to encourage EBP (Flodgren et al. 2012).
Background Few studies have researched the factors that influence the application of the EBP in PHC and examine where nurses base their daily practice. In England, Thompson et al. (2007) carried out a study among PHC nurses with the aim of identifying the barriers they might perceive when applying EBP. Lack of available scientific information, limited time for the decision-making process and distance between the theoretical and practical knowledge were pointed out as the main barriers to applying EBP. Other studies that examined the nature of the decisions taken by PHC nurses observed that most of them were based on their personal experience or on the advice provided by their colleagues (McCaughan et al. 2005). In Canada, Profetto-McGrath et al. (2007) researched the information sources on which those nurses with a higher level of qualification (doctorate or master’s degree) based their daily clinical practice, and they concluded that it was mainly grounded on enquiries to other health professionals, their personal experience or education, and selected literature. In a recent qualitative study carried out with focus groups of PHC nurses in Norway, Berland et al. (2012) found that most nurses apply in their daily clinical practice what they have learned during their pre-graduate nursing training, colleagues’ knowledge and nursing literature.
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In Australia, Mills et al. (2011) detected with the EvidenceBased Practice Questionnaire (EBPQ) that the transfer of evidence by PHC nurses depended on their abilities to find and check the evidence, the knowledge of published sources, and the existence of barriers and facilitating factors. Although nurses generally have a positive attitude towards the use of evidence, reliable tools are needed to assess the implementation of EBP. In Iceland, Thorsteinsson (2012) validated the instruments ‘Information Literacy for Evidence-Based Nursing Practice Questionnaire’ and the ‘Evidence-Based Practice Beliefs Scale’. In Spain, our research group has already carried out studies using quantitative methods in order to identify the factors that might influence the EBP in PHC nurses by using EBPQ and Practice Environment Scale-Nursing Work Index (PES-NWI). We observed a greater knowledge and abilities on EBP among nurses with shorter professional experience, as well as a more positive attitude in management nurses, when compared with the clinical nurses (Gonzalez-Torrente et al. 2012). However, given that most of the studies have been carried out by quantitative methodologies, we consider that an approach by qualitative methods would improve the knowledge about the perceptions, beliefs and attitudes of the professional health staff with regard to the EBP in PHC (Calderon et al. 2011). There are different qualitative studies based on physician’s perception about EBP (Calderon et al. 2011; Sánchez et al. 2010); however, there are no studies focused on nurses.
Aim This study examined the perceptions of a group of Spanish PHC nurses about the knowledge, advantages and barriers of the EBP.
Methods Design
For the purpose of this qualitative study, the focus group technique was used in order to identify the origin, causes, beliefs and opinions about the problems found in previous quantitative studies (Gonzalez-Torrente et al. 2012) with regard to the factors affecting the application of the EBP on their daily clinical practice. Sample and participants
The recruitment of the participants took place between March and September 2010 among 619 nurses distributed in 57 different PHC centres (PHCC) in the Balearic Islands Health Service (Spain). The selection criteria of the focus groups were both with professional experience in PHC and the area of practice
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(clinical or management). A first selection criterion was to work in PHC at least during the last 6 months. If this criterion was achieved, nurses were divided into the following groups: 1 management nurses, 2 clinical nurses: additionally, these nurses were subdivided into four groups: 2.1 less than 10 years of experience in PHC (regardless the healthcare centre), 2.2 between 10 and 20 years of experience in PHC, 2.3 more than 20 years of experience in PHC, 2.4 more than 20 years of experience, regardless the clinical context. The selection criteria of the focus groups were years of professional experience in any healthcare centre, years of professional experience in PHC and practicing nurses vs. management nurses. Participants’ enrolment was carried out by purposive sampling. Accordingly, five focus groups were configured so that homogeneity in experience and focus of practice were guaranteed, as well as representativity from most of the 57 PHCC. The focus group G MAN included nurses with management responsibilities. Group G PHC0–10 were nurses with less than 10 years of professional experience in PHC. They were nurses without a permanent contract in any of the PHCC and were thus subject to frequent jobs changes, and therefore might provide a wider perspective on the organization. Group G PHC10–20 included nurses with professional experience ranging from 10 to 20 years. They were registered nurses with more stable jobs but they had a higher prevalence of family responsibilities, which made their work–family balance more difficult. Group G PHC > 20 included nurses with more than 20 years of professional experience in PHC. The contribution of this group of nurses was very valuable given that many of them had taken part in the beginnings of the PHC in Spain and they had had management responsibilities at some time. Finally, group G HC > 20 included nurses with more than 20 years of professional experience, most of them in hospital care (HC), however, with a short professional experience in PHC (around 2 years). The composition of groups G PHC > 20 and G HC > 20 would enable us to contrast two groups of similar segmentation with regard to the number of years of professional experience, but with a different point of view given their training and professional background. The results of studies prior to our research detected significant differences because of professional experience (Gonzalez-Torrente et al. 2012). Thus, in the group of nurses with a professional experience ranging from 0 to 10 years, a better attitude towards the EBP was seen when comparing it with the group of nurses with 10–20 years of professional experience. The positive attitude increased again in those nurses
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Table 1 Focus group acronyms and their characteristics Group acronym
G MAN G PHC0–10 G PHC10–20 G PHC > 20 G HC > 20
Characteristics
PHC coordinators 0–10 years working in PHC 10–20 years working in PHC More than 20 years working in PHC More than 20 years working in HC before PHC
Number of nurses
8 8 11 9 10
Gender
Age (years)
Worked years
Men
Women
Mean (range)
Mean (range)
2 2 1 2 1
6 6 10 7 9
44 (34–47) 32 (27–41) 38 (34–44) 49 (42–60) 54 (51–58)
20 (12–22) 6 (1–10) 17 (12–20) 26 (21–32) 32 (29–34)
HC, hospital care; PHC, primary health care.
with more than 20 years of professional experience. Table 1 describes the detailed composition of each group, which ranged from 8 to 11 nurses. During the sampling process, participants were informed about duration and audio recording of discussions. During the initial enrolment process, some participants considered it an institutional evaluation and stated they were not prepared enough for this experience. Besides, some of them did not understand properly their role or expressed certain concerns about confidentiality. Therefore, it was necessary to clarify the independent nature of the study and point out that our aim was not at any time, nor at any stage, to assess the knowledge of participants on EBP. Because of this, the enrolment process was laborious, although once finished, almost all participants stated their satisfaction and their willingness to repeat these groups because of the possibility of expressing their opinion on this subject, which led them to feel more relieved.
Data collection
Focus groups were conducted by a specialized sociologist, assisted by an observer who took notes on the attitudes, nonverbal communication and the interaction among the participants. Both experts contrasted and checked the notes after every session. Permission was granted by management to hold the sessions during working hours at the Universitat de les Illes Balears, which has no direct relationship with the PHC, to decrease the potential participants’ inhibition because of the institutional environment. The maximum length of the focus group sessions was 2 h. For the purpose of this study, semi-structured guides were used to lead the interviews. These guides were drafted based on the review of two internationally known tools to identify barriers and supporting factors for EBP. The EBPQ aimed at identi-
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fying nursing professionals’ knowledge, use and attitude towards the EBP (Upton & Upton 2006), and the PES-NWI, which is designed to measure the nurse practice environment in hospitals (Lake 2002). These tools had been previously validated within the Spanish context and the PHC environment (De Pedro-Gomez et al. 2012). The list of potential topics identified were discussed and agreed to by the research team (Table 2). The same person who conducted the groups transcribed the interviews and the observer’s field notes were incorporated to enrich the transcriptions with the attitudes and atmosphere in the group. Data analysis
A thematic analysis was carried out through an inductive coding process. Three researchers performed separately the coding procedure to assure the rigour and credibility of the analysis. By this triangulation process, researchers identified emerging topics and patterns in a first reading of the data, and they drafted a list with possible topics that were subsequently used to set-up the codes. Data reduction was carried out by matching codes and setting relationships and analogies (Milne & Oberle 2005). In order to identify code patterns sharing common characteristics, one researcher grouped the codes into categories and subcategories (Elo & Kyngäs 2008) that were subjected to discussion with the other two researchers, until a final coding structure was obtained. Afterwards, the researchers itemized the codes obtained in order to determine a unique final code for each discussion group (Hsieh & Shannon 2005). Thus, each discussion group was coded four times, three times by three researchers independently and a fourth time resulting from the joint coding session for obtaining the researchers’ consensus. The qualitative data analysis was assisted by software ATLAS.ti 6.0 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).
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Table 2 Topics discussed in the focus groups Primary health care nurses – How do you solve clinical problems in your daily nurse practice? – If you have uncertainty for decision making in the process of care, where do you try to find information? – In which moment of your working time? – Which research activities are you involved in? – Have you heard about evidence-based practice (EBP), evidence-based nursing or evidence-based medicine? – How would you define EBP? – What’s your opinion about EBP? Which importance do you attribute to EBP for your daily practice? – Which barriers or difficulties do you face to practise EBP? – If you practise normally EBP, which resources do you use? – How do you value EBP for quality improvement? – Which importance do you attribute to knowledge and skills to practise EBP? – How do you share evidence with your colleagues? – Which factors, in your opinion, inhibit or promote the applicability of EBP in your work environment? – How do you think that primary health care organizations facilitate EBP? – Which attitude do you usually have for the promotion of EBP implementation? Additional topics for primary health care nurses with management responsibilities – What’s your opinion about the capability of nurses to generate evidence-based knowledge? – How can EBP contribute to professional development? – How accountable are health care organizations to EBP implementation? – Who should be the main responsible/s for EBP implementation? – How do you think about the nurses’ cooperation with the rest of the team for implementing EBP? – Which mechanisms could activate managers and executives in primary health care to promote EBP? – Which perception do you have concerning to the potential feedback between clinicians and managers for the implementation of EBP?
Ethical considerations
Evidence searching
The Balearic Clinical Research Ethical Committee (CEIC-IB) granted ethical approval for the study. All nurses participating in the study were informed that they could quit the project at any time. Confidentiality was guaranteed and a statement of informed consent was obtained from all participants. All the names of participants and work institutions were anonymized.
Concerning the evidence sources that the participants used the most to solve the doubts arising within their professional practice, some explained that when facing a problem they could not solve, they initially try to search in their own experience for any similar situation that they may have faced before. . . . depending on the kind of problem, the first step is usually to analyse the previous experience you had with this kind of problem and the results you may expect. (G MAN) (F2)
Rigor and trustworthiness
The strategy chosen to ensure the rigour and quality of this qualitative study was the standards established by Guba and Lincoln’s (1985). As mentioned previously, the groups were conducted by a specialized sociologist who had no relation with the participants. Triangulation process applied in the coding process guaranteed the credibility of the results.
Results Four main themes arose from data analysis: (1) evidence searching, (2) dissemination of evidence, (3) advantages of the application of EBP, and (4) barriers for the implementation and use of EBP.
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The most usual step participants followed when facing a problem in their daily professional practice was to ask a colleague they are working with. Usually, the quickest thing is to ask your colleagues. (G PHC10–20) (F1) Likewise, participant nurses usually searched for the solution to their clinical doubts by Internet using Google, e-journals, databases, Fisterra (Spanish website for clinical enquiries) or some institutional websites, for example: If you need it quickly it will be Fisterra and if I have more time, I will look for it in the Joanna Briggs, for example, . . .
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Although we have some guides and protocols here, I had to use the clinical practice guidelines of the Andalusian Health Service. (G HC > 20) (F2) Dissemination of evidence
With regard to the way in which the knowledge of new evidence is shared, all groups agreed that they have formal time at work in which they received educational sessions taught by specialist experts unrelated to the PHCC as well as sessions taught by the PHCC nurses, the latter being preferred by participants: We try to share it in the sessions. For instance, one of our colleagues conducted a workshop on stitches because he knows about this. (G HC > 20) (F8) Because, if you say I don’t know anything about this, and somebody comes and does it for you, it means you are not interested in what you are doing, it is something passive. (G PHC > 20) (F5) Sometimes, EBP was promoted in contexts and situations not intended specifically to share scientific information. In many occasions it is in the coffee break when we usually say: do you remember what we were discussing few days ago? I have found a scientific paper that. . . . (G PHC > 20) (F4) Participants also mentioned differences among PHCCs concerning the quality and quantity of the clinical sessions and other methods for EBP dissemination. This code emerged in all focus groups except in the group with management nurses. I have been working in several health centres, the difference is so huge. (G PHC > 20) (F7) Advantages on the application of EBP
This theme included what participants considered a positive contribution when basing their work and clinical practice on evidence, and that EBP reduces the variability of the clinical practice. I believe that, when we all work in the same way we provide the best health care. (G MAN) (F10) They also believed that evidence-based health care provided patients a higher quality of care and that they made the most of resources and time: I think that if you base yourself on the evidence you will provide people with more suitable care. You can achieve better results with fewer resources. (G MAN) (F9)
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Participants asserted that the clinical practice with a scientific basis improves professional image and gives legal backing. I believe that it makes the profession more valuable and reinforces it. Then, it is a back-up when you say . . . well, we work based on a scientific method. . . . (G MAN) (F1) They expressed that the EBP is encouraging and becomes both a challenge and a motivation. Yes, I also think so, when you see people doing things, you feel like doing things too. When you go to a different place where people are settled, who do not care about anything and they just go to comply with their work schedule. . . . (G PHC0–10) (F7) I would love to base all my work on the evidence. I would be happy if I could investigate at work. . . . (G PHC10–20) (F11) EBP lead to awareness of what being a nurse means and what their professional responsibilities were. Furthermore, EBP confers a professional commitment to the patient. But, where are our limits? We must know them clearly as well as knowing when we do our work properly. (G PHC > 20) (F1) Then, I have to do research, I have to give an answer to this person who is coming and tells me something about Avian Influenza. . . . (G MAN) (F5)
Barriers for the implementation and application of EBP
Barriers for the implementation of EBP emerged more frequently than advantages from its application. Participant mentioned the lack of incentives to encourage and recognize EBP and highlighted the importance of institutional support and motivation: In a certain way, I believe that the managing board should be responsible for motivating, encouraging and generating enthusiasm in people and I don’t know how . . . I believe that training must come first, and after encouragement. (G PHC > 20) (F6) Nurses do not believe that when protocols or clinical practice guidelines (CPGs) are developed, factors such as resources, the type of patient or professional characteristics are taken into account: Are the needs of each population group with whom we work taken into account in order to start-up the protocol process? It doesn’t seem so, because when applying or taking them into account. . . . (G PHC > 20) (F2)
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Participants considered that there are contradictions about clinical practice among different health professionals. They reported the pressure put on them by the hospital specialists, the patients, their colleagues as well as the lack of written scientific documentation: It is the patients who push you, they tell you that the previous day another nurse healed them and they did it in a different way, and it’s they who oblige you. . . . (G HC > 20) (F7) Participants also expressed tiredness and disappointment concerning institutional support when they have tried to introduce well-founded changes in their health centres and they felt that eventually, former clinical practice still prevails: We attended a congress recently, didn’t we? We learned obvious things, didn’t we? Then you give a session and tell them, look, here it is explained that this is not evidencebased. It doesn’t matter, the next day you find out again that they keep doing it in the same way. . . . (G PHC > 20) (F4) With reference to the barriers, the most common difficulties mentioned were the scepticism regarding new evidence and resistance to change. Weak arguments arose in all groups as excuses for not applying EBP, such as its complexity, and the lack of relevant studies in many clinical areas. Now that we are trying to apply EBP, yes, it is very complicated to be wondering all the time if you are doing it correctly. (G MAN) (F11) Sometimes participants were sceptical regarding the fact that evidence might be applicable to clinical practice: Then, that I believe that, the scientific method is quite good, which gives value to the profession and whatever, but I think that we don’t have to become robots just because someone has proven something. (G MAN) (F1) Participants admitted that it is very difficult for them to change standards already set, even when there is a scientific base supporting the new practice. This section was extensively discussed in all groups, except in the group of the least experienced nurses: The first problem you face is that it is difficult to change. People tell you: No, I have always done it this way, it works well this way. (G MAN) (F5) They also reported the lack of knowledge about EBP methodology: The first difficulty we face is the change, then, to get trained to be able to do it and later, it is the fear, what if I do something wrong? What if I am unable to do it? (G MAN) (F5)
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Discussion This study examined the perceptions of a group of Spanish PHC nurses about the knowledge, advantages and barriers of the EBP. Concerning the usual evidence resources to solve doubts within their professional practice, the main resource used in all groups was to ask colleagues with whom they worked. This result matches different studies carried out among those nurses working in PHC (Berland et al. 2012; Bostrom et al. 2009) and those working in hospitals (Aitken et al. 2010; Gerrish et al. 2008; Spenceley et al. 2008). Other common resources were CPGs and clinical protocols, although they reported that many of the latter are frequently obsolete. All groups mentioned the need to establish a periodic updating system that would be a useful tool for the EBP (Gallagher-Ford et al. 2011; Goldman et al. 2010). Likewise, different available resources on Internet were mentioned; however, issues such as technology misuse and the lack of an advanced level of English were cited as barriers. In different studies based on nurses, a lack of familiarity has also been found towards the evidence resources available (Berland et al. 2012; Thompson et al. 2007). With regard to the way in which the knowledge of a new evidence is shared, all groups agreed that they had formal working time to attend educational sessions intended to share and update their knowledge, although they admit there was a substantial difference among the different health centres in terms of the quality and quantity of such sessions. Clinical session carried out at the workplace is one of the factors positively related to the use of searching and investigation (Fineout-Overholt et al. 2011; Squires et al. 2011). In all groups, it was likewise admitted that knowledge transfer takes place in non-formal periods within working hours, which might indicate nurses’ interest for good clinical practice (Berland et al. 2012). In the framework ‘Promoting Action on Research Implementation in Health Services’, three factors contribute to successful implementation of evidence into practice in healthcare settings: (1) the level and nature of the evidence, (2) the context or environment into which the evidence is to be placed, and (3) the method or way in which the process is facilitated (Kitson et al. 1998). Concerning the context, our participants had a pessimistic discourse concerning their institutional support and the facilitating forces existing in their clinical settings. This pessimistic atmosphere may be related to the financial situation and the restrictions that the Spanish population is coping with because of the austerity plan implemented since 2010 because of the economic crisis. In any case, our participants agreed that they would also feel encouraged with non-financial resources such as training within their working hours or the improvement
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of their general working conditions. Respecting this, they also agreed they would accept better the changes and even the budget cuts if those were properly founded and backed up (Birch & Thabane 2012). Participants were sceptical regarding EBP, as it is necessary to adapt findings to the context, the patient, the community, the available resources and the characteristics of the professional staff carrying out the work (Calderon et al. 2011; Ozdemir & Akdemir 2009). They considered EBP as theoretical, far from reality, and therefore, they even preferred sessions prepared by themselves, rather than those sessions provided by an expert who is unrelated to their PHCC. It seems that the most suitable situation to provide quality of health care would be to complement the clinical judgment of nurses together with their prior experiences and the most accurate evidence available (Calderon et al. 2011; McCaughan et al. 2005; Olsen & Bradbury-Jones 2013). Consequently, there is a need to determine which facilitating strategies are more effective at an institutional level to assist translating knowledge into practice (Dijkstra et al. 2006; Rycroft-Malone et al. 2004). The need to improve communication between the PHC and the HC has been reported in many occasions, so that, according to nurses’ criticisms, the patient is the most adversely affected person as a result of this lack of coordination (Flink et al. 2012). In this study, nurses with managerial roles listed a higher number of advantages and placed great importance on the fact that EBP provided them with legal support, and this has been reported in other studies (Berland et al. 2012). Our participants felt they need scientific support to grant strength and social recognition to their profession, so that EBP might contribute easily to this aim. They also stated that appropriate EBP may improve motivation and may encourage the staff to be creative, but the work environment is considered as an essential aspect for EBP, as other authors had stated (Melnyk et al. 2010; Squires et al. 2011).
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findings thus have relevance to inform policies on the implementation of EBP into health care and nursing.
Conclusion This study has enabled us to examine the attitudes of the PHC nurses as well as the difficulties and advantages perceived by them concerning the EBP. According to the literature reviewed, we consider our findings relevant to informing professional practice in PHC worldwide and encourage similar research in other countries. In general, we can say that our participants had a clear concept of what the evidence is and they have a positive attitude towards its application, but they experienced difficulties in the application of EBP, mostly because of the lack of methodological knowledge and resources for its application. We consider it would be advisable to develop training strategies and make EBP implementation easier by adapting the environment in PHC.
Acknowledgements The authors would like to thank the Spanish Ministry of Health for funding this project, the Balearic Health Service for its involvement and collaboration, and all the nursing professionals who took part in this study.
Author contributions JP-B: Study conception and design, data collection and analysis, drafting of manuscript. SG-T: Data collection and analysis, drafting of manuscript. MB-V: Study conception and design, critical revisions for important intellectual content, drafting of manuscript, supervision. JDP-G: Data collection and analysis, drafting of manuscript. JMM-A: Substantial contributions to analysis and interpretation of data, critical revisions for important intellectual content, and final approval of the version to be published.
Limitations
References
Because there were only a limited number of participants in this study, and we used a convenience sample, it is not possible to widely generalize the findings elsewhere. Moreover, useful comparisons of our findings can only be made between countries that have a similar PHC system to Spain. However, our rich findings add important knowledge to the topic for EBP within nursing practice.
Aitken, L.M., et al. (2010) The impact of Nursing Rounds on the practice environment and nurse satisfaction in intensive care: pre-test post-test comparative study. International Journal of Nursing Studies, 48 (8), 918– 925. Berland, A., Gundersen, D. & Bentsen, S.B. (2012) Evidence-based practice in primary care: an explorative study of nurse practitioners in Norway. Nurse Education Practice, 12 (6), 361–365. Birch, S. & Thabane, L. (2012) Better care: an analysis of nursing and healthcare system outcomes. Ottawa, Ontario, Canadian Health Services Research Foundation (CHSRF). Bostrom, A.M., Ehrenberg, A., Gustavsson, J.P. & Wallin, L. (2009) Registered nurses’ application of evidence-based practice: a national survey. Journal of Evaluation in Clinical Practice, 15 (6), 1159–1163.
Implications for nursing and health policy This study highlights the existing gap in translating knowledge into practice and its potential implications in the effectiveness of nursing interventions and decision making in PHC. Our
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Calderon, C., et al. (2011) EBM in primary care: a qualitative multicenter study in Spain. BMC Family Practice, 12, 84. Dawes, M., et al. Second International Conference of Evidence-Based Health Care, T. & Developers (2005) Sicily statement on evidence-based practice. BMC Medical Education, 5 (1), 1. De Pedro-Gomez, J., et al. (2012) Psychometric testing of the Spanish version of the practice environment scale of the nursing work index in a primary healthcare context. Journal of Advanced Nursing, 68 (1), 212– 221. Dijkstra, R., et al. (2006) The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis. BMC Health Services Research, 6, 53. Elo, S. & Kyngäs, H. (2008) The qualitative content analysis process. Journal of Advanced Nursing, 62 (1), 107–115. Fineout-Overholt, E., et al. (2011) Following the evidence: planning for sustainable change. The American Journal of Nursing, 111 (1), 54–60. Flink, M., et al. (2012) Beliefs and experiences can influence patient participation in handover between primary and secondary care-a qualitative study of patient perspectives. BMJ Quality & Safety, 21 (Suppl 1), i76– i83. Flodgren, G., Rojas-Reyes, M.X., Cole, N. & Foxcroft, D.R. (2012) Effectiveness of organisational infrastructures to promote evidence-based nursing practice. Cochrane Database of Systematic Reviews, (2), CD002212. Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B.M. & Stillwell, S.B. (2011) Evidence-based practice, step by step: implementing an evidencebased practice change. The American Journal of Nursing, 111 (3), 54–60. Gerrish, K., Ashworth, P., Lacey, A. & Bailey, J. (2008) Developing evidence-based practice: experiences of senior and junior clinical nurses. Journal of Advanced Nursing, 62 (1), 62–73. Goldman, J., et al. (2010) Interprofessional primary care protocols: a strategy to promote an evidence-based approach to teamwork and the delivery of care. Journal of Interprofessional Care, 24 (6), 653–665. Gonzalez-Torrente, S., et al. (2012) Perception of evidence-based practice and the professional environment of primary health care nurses in the Spanish context: a cross-sectional study. BMC Health Services Research, 12, 227. Grant, H.S., Stuhlmacher, A. & Bonte-Eley, S. (2012) Overcoming barriers to research utilization and evidence-based practice among staff nurses. Journal for Nurses in Staff Development, 28 (4), 163–165. Guba, E.G. & Lincoln, Y.S. (1985) Naturalistic Inquiry. Sage Publications, Incorporated, London, UK. Holmes, D., Murray, S.J., Perron, A. & Rail, G. (2006) Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. International Journal Evidence-Based Healthcare, 4 (3), 180–186. Hsieh, H.F. & Shannon, S.E. (2005) Three approaches to qualitative content analysis. Qualitative Health Research, 15 (9), 1277–1288. Kitson, A., Harvey, G. & McCormack, B. (1998) Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7 (3), 149–158. Lake, E.T. (2002) Development of the practice environment scale of the Nursing Work Index. Research in Nursing and Health, 25 (3), 176–188.
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McCaughan, D., et al. (2005) Nurse practitioner and practice nurses’ use of research information in clinical decision making: findings from an exploratory study. Family Practice, 22 (5), 490–497. McCrae, N. (2012) Evidence-based practice: for better or worse. International Journal of Nursing Studies, 49 (9), 1051–1053. Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L. & Kaplan, L. (2012) The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. The Journal of Nursing Administration, 42 (9), 410–417. Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B. & Williamson, K.M. (2010) Evidence-based practice: step by step: the seven steps of evidencebased practice. The American Journal of Nursing, 110 (1), 51. Mills, J., Field, J. & Cant, R. (2011) Factors affecting evidence translation for general practice nurses. International Journal of Nursing Practice, 17 (5), 455–463. Milne, J. & Oberle, K. (2005) Enhancing rigor in qualitative description. Journal of Wound Ostomy & Continence Nursing, 32 (6), 413–420. Olsen, P.R. & Bradbury-Jones, C. (2013) Using a knowledge utilization framework to explore how findings from one study can be applied to other nursing contexts. International Nursing Review, 60, 381–388. Ozdemir, L. & Akdemir, N. (2009) Turkish nurses’ utilization of research evidence in clinical practice and influencing factors. International Nursing Review, 56 (3), 319–325. Profetto-McGrath, J., et al. (2007) Clinical nurse specialists’ use of evidence in practice: a pilot study. Worldviews on Evidence-Based Nursing, 4 (2), 86–96. Rycroft-Malone, J., et al. (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13 (8), 913–924. Sánchez, L.M.C., et al. (2010) [What do general practitioners think about evidenced-based medicine? A study with focus groups]. Atencion Primaria, 42 (10), 507–513. Spenceley, S.M., et al. (2008) Sources of information used by nurses to inform practice: an integrative review. International Journal of Nursing Studies, 45 (6), 954–970. Squires, J., Estabrooks, C., Gustavsson, P. & Wallin, L. (2011) Individual determinants of research utilization by nurses: a systematic review update. Implementation Science, 6 (1), 1. Starfield, B. (2012) Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gaceta Sanitaria, 26 (Suppl 1), 20–26. Starfield, B., Shi, L. & Macinko, J. (2005) Contribution of primary care to health systems and health. The Milbank Quarterly, 83 (3), 457–502. Thompson, D.S., et al. (2007) Interventions aimed at increasing research use in nursing: a systematic review. Implementation Science, 2 (1), 15. Thorsteinsson, H.S. (2012) Translation and validation of two evidencebased nursing practice instruments. International Nursing Review, 59 (2), 259–265. Upton, D. & Upton, P. (2006) Development of an evidence-based practice questionnaire for nurses. Journal of Advanced Nursing, 53 (4), 454–458.
Research into Clinical Practice
Perception of Spanish primary healthcare nurses about evidence-based clinical practice: a qualitative study J. Pericas-Beltran1 RN, PhD, S. Gonzalez-Torrente2 RN, MSc, J. De Pedro-Gomez1 RN, PhD, J.M. Morales-Asencio3 RN, PhD & M. Bennasar-Veny1 RN, PhD 1 Full Professor, Nursing Department, Evidence, Lifestyles and Health Research Group Members, Universitat de les Illes Balears, 2 PhD Candidate, Nursing, Primary Health Care, Balearic Islands Health Service, Palma, 3 Full Professor, Faculty of Nursing, Physiotherapy, Podology and Occupational Therapy, University of Malaga, Malaga, Spain
PERICAS-BELTRAN J., GONZALEZ-TORRENTE S., DE PEDRO-GOMEZ J., MORALES-ASENCIO J. M. and BENNASAR-VENY M. (2014) Perception of Spanish primary healthcare nurses about evidence-based clinical practice: a qualitative study. International Nursing Review 61, 90–98 Background: Although evidence-based clinical practice constitutes a priority for healthcare services in many countries within the last few years, there is a general lack of implementation of evidence-based clinical practice in nursing care, especially in primary health care. Few qualitative studies concerning the influencing factors on evidence-based clinical practice for community nurses have been carried out. Aim: This study examined the perception of nurses in Spanish primary health care with regard to the knowledge, advantages and barriers within the application process with evidence-based clinical practice. Methods: We used a descriptive qualitative study with focus groups to collect data. Forty-six primary care nurses took part in this study and they were distributed into five focus groups. Results: Five main topics arose from the results achieved: knowledge and development of evidence-based clinical practice, evidence searching, evidence dissemination, advantages of use of evidence-based clinical practice, and barriers for its application and implementation. Participants had a positive attitude towards evidence-based practice, although they used this infrequently because of lack of competence and organizational support for its application. Conclusion: Our participants are increasingly determined to take into account evidence within the decision-making processes in their usual clinical practice. We consider it advisable to develop specialized training strategies as well as provide necessary resources for the implementation of evidence-based clinical practice duly adapted to the field of primary health care.
Correspondence address: Miquel Bennasar-Veny, Nursing Department, Evidence, Lifestyles and Health Research Group Members, Universitat de les Illes Balears, Ctra. Valldemosa km 7.5, 07122 Palma, Islas Baleares, Spain; Tel: +34-971-172367; Fax: +34-971-173190; E-mail: [email protected].
Funding statement This article forms part of a project entitled ‘Determining Factors in Evidence-Based Clinical Practice among Hospital and Primary Care Nursing Staff in the Balearics. A Facilitation Proposal Based on the PARIHS Model’, financed by the Health Research Fund (PI 09/90512, Health Ministry) following a rigorous peer-reviewed funding process. Conflict of interest No conflict of interest.
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Implications for nursing and health policy: This study highlights the existing gap in translating knowledge to practice and its potential implications in the effectiveness of nursing interventions and decision making in primary health care, and thus its implications for education policy. Keywords: Evidence-Based Practice, Focus Groups, Nursing, Primary Health Care, Qualitative Research
Introduction The contribution of primary health care (PHC) to the improvement of results in a population’s health is firmly supported by research. A differential impact has been demonstrated in those countries providing solid PHC in premature mortality, low birth weight newborns, cardiovascular diseases, reduction of the effects of inequality in health as well as the improvement in the perception of health among other benefits (Starfield et al. 2005). Current challenges for health care demand more sustainable and efficient systems, and PHC plays a key role in this aim. Health promotion and proactive management of chronic diseases are critical components of this reorientation, with community nurses placed in an outstanding position for making a difference through effective interventions to the community and, in particular, to those more vulnerable groups (Birch & Thabane 2012). Nevertheless, these outcomes depend largely on how the PHC policy is implemented: in care coverage, equity in the resource distribution, comprehensive health services and access to such services. The right combination of such elements produces a good PHC in which gatekeeping, longitudinal and person-centred care, as well as the coordination of the assistance must be the common denominator to guarantee its effectiveness (Starfield 2012). Emphasis on prevention, early attention to health problems, guarantee of free access to health care as well as high quality of health care offered (Starfield 2012) are indispensable for its effectiveness. In this respect, one of the most important pillars is the use of the most reliable knowledge within the decisionmaking process, developing an evidence-based practice (EBP) (McCrae 2012). EBP concept has evolutioned through the last decades and, currently, the Sicily statement proposes a more comprehensive definition. Thus, EBP requires that decisions about health care be based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources (Dawes et al. 2005). One of the pillars that is currently being encouraged in many health services worldwide is to empower highly qualified com-
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munity nurses within healthcare teams, who base their services on health determinants according to the best evidence available (Birch & Thabane 2012). EBP leads to higher quality of care, improved patient outcomes, reduced costs and greater nurse satisfaction. Nonetheless, there still remain problems with regard to the transferability of the evidence in general terms (Calderon et al. 2011) and more specifically within the nursing field (Holmes et al. 2006). Among these difficulties are the reservations of certain organization leaders, the lack of support by managers as well as the unsuitable training of nurses to carry out EBP (Grant et al. 2012; Melnyk et al. 2012). Besides, there is a lack of quality research that would lead to knowing the most suitable strategies in terms of organization in order to encourage EBP (Flodgren et al. 2012).
Background Few studies have researched the factors that influence the application of the EBP in PHC and examine where nurses base their daily practice. In England, Thompson et al. (2007) carried out a study among PHC nurses with the aim of identifying the barriers they might perceive when applying EBP. Lack of available scientific information, limited time for the decision-making process and distance between the theoretical and practical knowledge were pointed out as the main barriers to applying EBP. Other studies that examined the nature of the decisions taken by PHC nurses observed that most of them were based on their personal experience or on the advice provided by their colleagues (McCaughan et al. 2005). In Canada, Profetto-McGrath et al. (2007) researched the information sources on which those nurses with a higher level of qualification (doctorate or master’s degree) based their daily clinical practice, and they concluded that it was mainly grounded on enquiries to other health professionals, their personal experience or education, and selected literature. In a recent qualitative study carried out with focus groups of PHC nurses in Norway, Berland et al. (2012) found that most nurses apply in their daily clinical practice what they have learned during their pre-graduate nursing training, colleagues’ knowledge and nursing literature.
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In Australia, Mills et al. (2011) detected with the EvidenceBased Practice Questionnaire (EBPQ) that the transfer of evidence by PHC nurses depended on their abilities to find and check the evidence, the knowledge of published sources, and the existence of barriers and facilitating factors. Although nurses generally have a positive attitude towards the use of evidence, reliable tools are needed to assess the implementation of EBP. In Iceland, Thorsteinsson (2012) validated the instruments ‘Information Literacy for Evidence-Based Nursing Practice Questionnaire’ and the ‘Evidence-Based Practice Beliefs Scale’. In Spain, our research group has already carried out studies using quantitative methods in order to identify the factors that might influence the EBP in PHC nurses by using EBPQ and Practice Environment Scale-Nursing Work Index (PES-NWI). We observed a greater knowledge and abilities on EBP among nurses with shorter professional experience, as well as a more positive attitude in management nurses, when compared with the clinical nurses (Gonzalez-Torrente et al. 2012). However, given that most of the studies have been carried out by quantitative methodologies, we consider that an approach by qualitative methods would improve the knowledge about the perceptions, beliefs and attitudes of the professional health staff with regard to the EBP in PHC (Calderon et al. 2011). There are different qualitative studies based on physician’s perception about EBP (Calderon et al. 2011; Sánchez et al. 2010); however, there are no studies focused on nurses.
Aim This study examined the perceptions of a group of Spanish PHC nurses about the knowledge, advantages and barriers of the EBP.
Methods Design
For the purpose of this qualitative study, the focus group technique was used in order to identify the origin, causes, beliefs and opinions about the problems found in previous quantitative studies (Gonzalez-Torrente et al. 2012) with regard to the factors affecting the application of the EBP on their daily clinical practice. Sample and participants
The recruitment of the participants took place between March and September 2010 among 619 nurses distributed in 57 different PHC centres (PHCC) in the Balearic Islands Health Service (Spain). The selection criteria of the focus groups were both with professional experience in PHC and the area of practice
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(clinical or management). A first selection criterion was to work in PHC at least during the last 6 months. If this criterion was achieved, nurses were divided into the following groups: 1 management nurses, 2 clinical nurses: additionally, these nurses were subdivided into four groups: 2.1 less than 10 years of experience in PHC (regardless the healthcare centre), 2.2 between 10 and 20 years of experience in PHC, 2.3 more than 20 years of experience in PHC, 2.4 more than 20 years of experience, regardless the clinical context. The selection criteria of the focus groups were years of professional experience in any healthcare centre, years of professional experience in PHC and practicing nurses vs. management nurses. Participants’ enrolment was carried out by purposive sampling. Accordingly, five focus groups were configured so that homogeneity in experience and focus of practice were guaranteed, as well as representativity from most of the 57 PHCC. The focus group G MAN included nurses with management responsibilities. Group G PHC0–10 were nurses with less than 10 years of professional experience in PHC. They were nurses without a permanent contract in any of the PHCC and were thus subject to frequent jobs changes, and therefore might provide a wider perspective on the organization. Group G PHC10–20 included nurses with professional experience ranging from 10 to 20 years. They were registered nurses with more stable jobs but they had a higher prevalence of family responsibilities, which made their work–family balance more difficult. Group G PHC > 20 included nurses with more than 20 years of professional experience in PHC. The contribution of this group of nurses was very valuable given that many of them had taken part in the beginnings of the PHC in Spain and they had had management responsibilities at some time. Finally, group G HC > 20 included nurses with more than 20 years of professional experience, most of them in hospital care (HC), however, with a short professional experience in PHC (around 2 years). The composition of groups G PHC > 20 and G HC > 20 would enable us to contrast two groups of similar segmentation with regard to the number of years of professional experience, but with a different point of view given their training and professional background. The results of studies prior to our research detected significant differences because of professional experience (Gonzalez-Torrente et al. 2012). Thus, in the group of nurses with a professional experience ranging from 0 to 10 years, a better attitude towards the EBP was seen when comparing it with the group of nurses with 10–20 years of professional experience. The positive attitude increased again in those nurses
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Table 1 Focus group acronyms and their characteristics Group acronym
G MAN G PHC0–10 G PHC10–20 G PHC > 20 G HC > 20
Characteristics
PHC coordinators 0–10 years working in PHC 10–20 years working in PHC More than 20 years working in PHC More than 20 years working in HC before PHC
Number of nurses
8 8 11 9 10
Gender
Age (years)
Worked years
Men
Women
Mean (range)
Mean (range)
2 2 1 2 1
6 6 10 7 9
44 (34–47) 32 (27–41) 38 (34–44) 49 (42–60) 54 (51–58)
20 (12–22) 6 (1–10) 17 (12–20) 26 (21–32) 32 (29–34)
HC, hospital care; PHC, primary health care.
with more than 20 years of professional experience. Table 1 describes the detailed composition of each group, which ranged from 8 to 11 nurses. During the sampling process, participants were informed about duration and audio recording of discussions. During the initial enrolment process, some participants considered it an institutional evaluation and stated they were not prepared enough for this experience. Besides, some of them did not understand properly their role or expressed certain concerns about confidentiality. Therefore, it was necessary to clarify the independent nature of the study and point out that our aim was not at any time, nor at any stage, to assess the knowledge of participants on EBP. Because of this, the enrolment process was laborious, although once finished, almost all participants stated their satisfaction and their willingness to repeat these groups because of the possibility of expressing their opinion on this subject, which led them to feel more relieved.
Data collection
Focus groups were conducted by a specialized sociologist, assisted by an observer who took notes on the attitudes, nonverbal communication and the interaction among the participants. Both experts contrasted and checked the notes after every session. Permission was granted by management to hold the sessions during working hours at the Universitat de les Illes Balears, which has no direct relationship with the PHC, to decrease the potential participants’ inhibition because of the institutional environment. The maximum length of the focus group sessions was 2 h. For the purpose of this study, semi-structured guides were used to lead the interviews. These guides were drafted based on the review of two internationally known tools to identify barriers and supporting factors for EBP. The EBPQ aimed at identi-
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fying nursing professionals’ knowledge, use and attitude towards the EBP (Upton & Upton 2006), and the PES-NWI, which is designed to measure the nurse practice environment in hospitals (Lake 2002). These tools had been previously validated within the Spanish context and the PHC environment (De Pedro-Gomez et al. 2012). The list of potential topics identified were discussed and agreed to by the research team (Table 2). The same person who conducted the groups transcribed the interviews and the observer’s field notes were incorporated to enrich the transcriptions with the attitudes and atmosphere in the group. Data analysis
A thematic analysis was carried out through an inductive coding process. Three researchers performed separately the coding procedure to assure the rigour and credibility of the analysis. By this triangulation process, researchers identified emerging topics and patterns in a first reading of the data, and they drafted a list with possible topics that were subsequently used to set-up the codes. Data reduction was carried out by matching codes and setting relationships and analogies (Milne & Oberle 2005). In order to identify code patterns sharing common characteristics, one researcher grouped the codes into categories and subcategories (Elo & Kyngäs 2008) that were subjected to discussion with the other two researchers, until a final coding structure was obtained. Afterwards, the researchers itemized the codes obtained in order to determine a unique final code for each discussion group (Hsieh & Shannon 2005). Thus, each discussion group was coded four times, three times by three researchers independently and a fourth time resulting from the joint coding session for obtaining the researchers’ consensus. The qualitative data analysis was assisted by software ATLAS.ti 6.0 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).
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Table 2 Topics discussed in the focus groups Primary health care nurses – How do you solve clinical problems in your daily nurse practice? – If you have uncertainty for decision making in the process of care, where do you try to find information? – In which moment of your working time? – Which research activities are you involved in? – Have you heard about evidence-based practice (EBP), evidence-based nursing or evidence-based medicine? – How would you define EBP? – What’s your opinion about EBP? Which importance do you attribute to EBP for your daily practice? – Which barriers or difficulties do you face to practise EBP? – If you practise normally EBP, which resources do you use? – How do you value EBP for quality improvement? – Which importance do you attribute to knowledge and skills to practise EBP? – How do you share evidence with your colleagues? – Which factors, in your opinion, inhibit or promote the applicability of EBP in your work environment? – How do you think that primary health care organizations facilitate EBP? – Which attitude do you usually have for the promotion of EBP implementation? Additional topics for primary health care nurses with management responsibilities – What’s your opinion about the capability of nurses to generate evidence-based knowledge? – How can EBP contribute to professional development? – How accountable are health care organizations to EBP implementation? – Who should be the main responsible/s for EBP implementation? – How do you think about the nurses’ cooperation with the rest of the team for implementing EBP? – Which mechanisms could activate managers and executives in primary health care to promote EBP? – Which perception do you have concerning to the potential feedback between clinicians and managers for the implementation of EBP?
Ethical considerations
Evidence searching
The Balearic Clinical Research Ethical Committee (CEIC-IB) granted ethical approval for the study. All nurses participating in the study were informed that they could quit the project at any time. Confidentiality was guaranteed and a statement of informed consent was obtained from all participants. All the names of participants and work institutions were anonymized.
Concerning the evidence sources that the participants used the most to solve the doubts arising within their professional practice, some explained that when facing a problem they could not solve, they initially try to search in their own experience for any similar situation that they may have faced before. . . . depending on the kind of problem, the first step is usually to analyse the previous experience you had with this kind of problem and the results you may expect. (G MAN) (F2)
Rigor and trustworthiness
The strategy chosen to ensure the rigour and quality of this qualitative study was the standards established by Guba and Lincoln’s (1985). As mentioned previously, the groups were conducted by a specialized sociologist who had no relation with the participants. Triangulation process applied in the coding process guaranteed the credibility of the results.
Results Four main themes arose from data analysis: (1) evidence searching, (2) dissemination of evidence, (3) advantages of the application of EBP, and (4) barriers for the implementation and use of EBP.
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The most usual step participants followed when facing a problem in their daily professional practice was to ask a colleague they are working with. Usually, the quickest thing is to ask your colleagues. (G PHC10–20) (F1) Likewise, participant nurses usually searched for the solution to their clinical doubts by Internet using Google, e-journals, databases, Fisterra (Spanish website for clinical enquiries) or some institutional websites, for example: If you need it quickly it will be Fisterra and if I have more time, I will look for it in the Joanna Briggs, for example, . . .
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Although we have some guides and protocols here, I had to use the clinical practice guidelines of the Andalusian Health Service. (G HC > 20) (F2) Dissemination of evidence
With regard to the way in which the knowledge of new evidence is shared, all groups agreed that they have formal time at work in which they received educational sessions taught by specialist experts unrelated to the PHCC as well as sessions taught by the PHCC nurses, the latter being preferred by participants: We try to share it in the sessions. For instance, one of our colleagues conducted a workshop on stitches because he knows about this. (G HC > 20) (F8) Because, if you say I don’t know anything about this, and somebody comes and does it for you, it means you are not interested in what you are doing, it is something passive. (G PHC > 20) (F5) Sometimes, EBP was promoted in contexts and situations not intended specifically to share scientific information. In many occasions it is in the coffee break when we usually say: do you remember what we were discussing few days ago? I have found a scientific paper that. . . . (G PHC > 20) (F4) Participants also mentioned differences among PHCCs concerning the quality and quantity of the clinical sessions and other methods for EBP dissemination. This code emerged in all focus groups except in the group with management nurses. I have been working in several health centres, the difference is so huge. (G PHC > 20) (F7) Advantages on the application of EBP
This theme included what participants considered a positive contribution when basing their work and clinical practice on evidence, and that EBP reduces the variability of the clinical practice. I believe that, when we all work in the same way we provide the best health care. (G MAN) (F10) They also believed that evidence-based health care provided patients a higher quality of care and that they made the most of resources and time: I think that if you base yourself on the evidence you will provide people with more suitable care. You can achieve better results with fewer resources. (G MAN) (F9)
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Participants asserted that the clinical practice with a scientific basis improves professional image and gives legal backing. I believe that it makes the profession more valuable and reinforces it. Then, it is a back-up when you say . . . well, we work based on a scientific method. . . . (G MAN) (F1) They expressed that the EBP is encouraging and becomes both a challenge and a motivation. Yes, I also think so, when you see people doing things, you feel like doing things too. When you go to a different place where people are settled, who do not care about anything and they just go to comply with their work schedule. . . . (G PHC0–10) (F7) I would love to base all my work on the evidence. I would be happy if I could investigate at work. . . . (G PHC10–20) (F11) EBP lead to awareness of what being a nurse means and what their professional responsibilities were. Furthermore, EBP confers a professional commitment to the patient. But, where are our limits? We must know them clearly as well as knowing when we do our work properly. (G PHC > 20) (F1) Then, I have to do research, I have to give an answer to this person who is coming and tells me something about Avian Influenza. . . . (G MAN) (F5)
Barriers for the implementation and application of EBP
Barriers for the implementation of EBP emerged more frequently than advantages from its application. Participant mentioned the lack of incentives to encourage and recognize EBP and highlighted the importance of institutional support and motivation: In a certain way, I believe that the managing board should be responsible for motivating, encouraging and generating enthusiasm in people and I don’t know how . . . I believe that training must come first, and after encouragement. (G PHC > 20) (F6) Nurses do not believe that when protocols or clinical practice guidelines (CPGs) are developed, factors such as resources, the type of patient or professional characteristics are taken into account: Are the needs of each population group with whom we work taken into account in order to start-up the protocol process? It doesn’t seem so, because when applying or taking them into account. . . . (G PHC > 20) (F2)
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Participants considered that there are contradictions about clinical practice among different health professionals. They reported the pressure put on them by the hospital specialists, the patients, their colleagues as well as the lack of written scientific documentation: It is the patients who push you, they tell you that the previous day another nurse healed them and they did it in a different way, and it’s they who oblige you. . . . (G HC > 20) (F7) Participants also expressed tiredness and disappointment concerning institutional support when they have tried to introduce well-founded changes in their health centres and they felt that eventually, former clinical practice still prevails: We attended a congress recently, didn’t we? We learned obvious things, didn’t we? Then you give a session and tell them, look, here it is explained that this is not evidencebased. It doesn’t matter, the next day you find out again that they keep doing it in the same way. . . . (G PHC > 20) (F4) With reference to the barriers, the most common difficulties mentioned were the scepticism regarding new evidence and resistance to change. Weak arguments arose in all groups as excuses for not applying EBP, such as its complexity, and the lack of relevant studies in many clinical areas. Now that we are trying to apply EBP, yes, it is very complicated to be wondering all the time if you are doing it correctly. (G MAN) (F11) Sometimes participants were sceptical regarding the fact that evidence might be applicable to clinical practice: Then, that I believe that, the scientific method is quite good, which gives value to the profession and whatever, but I think that we don’t have to become robots just because someone has proven something. (G MAN) (F1) Participants admitted that it is very difficult for them to change standards already set, even when there is a scientific base supporting the new practice. This section was extensively discussed in all groups, except in the group of the least experienced nurses: The first problem you face is that it is difficult to change. People tell you: No, I have always done it this way, it works well this way. (G MAN) (F5) They also reported the lack of knowledge about EBP methodology: The first difficulty we face is the change, then, to get trained to be able to do it and later, it is the fear, what if I do something wrong? What if I am unable to do it? (G MAN) (F5)
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Discussion This study examined the perceptions of a group of Spanish PHC nurses about the knowledge, advantages and barriers of the EBP. Concerning the usual evidence resources to solve doubts within their professional practice, the main resource used in all groups was to ask colleagues with whom they worked. This result matches different studies carried out among those nurses working in PHC (Berland et al. 2012; Bostrom et al. 2009) and those working in hospitals (Aitken et al. 2010; Gerrish et al. 2008; Spenceley et al. 2008). Other common resources were CPGs and clinical protocols, although they reported that many of the latter are frequently obsolete. All groups mentioned the need to establish a periodic updating system that would be a useful tool for the EBP (Gallagher-Ford et al. 2011; Goldman et al. 2010). Likewise, different available resources on Internet were mentioned; however, issues such as technology misuse and the lack of an advanced level of English were cited as barriers. In different studies based on nurses, a lack of familiarity has also been found towards the evidence resources available (Berland et al. 2012; Thompson et al. 2007). With regard to the way in which the knowledge of a new evidence is shared, all groups agreed that they had formal working time to attend educational sessions intended to share and update their knowledge, although they admit there was a substantial difference among the different health centres in terms of the quality and quantity of such sessions. Clinical session carried out at the workplace is one of the factors positively related to the use of searching and investigation (Fineout-Overholt et al. 2011; Squires et al. 2011). In all groups, it was likewise admitted that knowledge transfer takes place in non-formal periods within working hours, which might indicate nurses’ interest for good clinical practice (Berland et al. 2012). In the framework ‘Promoting Action on Research Implementation in Health Services’, three factors contribute to successful implementation of evidence into practice in healthcare settings: (1) the level and nature of the evidence, (2) the context or environment into which the evidence is to be placed, and (3) the method or way in which the process is facilitated (Kitson et al. 1998). Concerning the context, our participants had a pessimistic discourse concerning their institutional support and the facilitating forces existing in their clinical settings. This pessimistic atmosphere may be related to the financial situation and the restrictions that the Spanish population is coping with because of the austerity plan implemented since 2010 because of the economic crisis. In any case, our participants agreed that they would also feel encouraged with non-financial resources such as training within their working hours or the improvement
EBCP in primary care
of their general working conditions. Respecting this, they also agreed they would accept better the changes and even the budget cuts if those were properly founded and backed up (Birch & Thabane 2012). Participants were sceptical regarding EBP, as it is necessary to adapt findings to the context, the patient, the community, the available resources and the characteristics of the professional staff carrying out the work (Calderon et al. 2011; Ozdemir & Akdemir 2009). They considered EBP as theoretical, far from reality, and therefore, they even preferred sessions prepared by themselves, rather than those sessions provided by an expert who is unrelated to their PHCC. It seems that the most suitable situation to provide quality of health care would be to complement the clinical judgment of nurses together with their prior experiences and the most accurate evidence available (Calderon et al. 2011; McCaughan et al. 2005; Olsen & Bradbury-Jones 2013). Consequently, there is a need to determine which facilitating strategies are more effective at an institutional level to assist translating knowledge into practice (Dijkstra et al. 2006; Rycroft-Malone et al. 2004). The need to improve communication between the PHC and the HC has been reported in many occasions, so that, according to nurses’ criticisms, the patient is the most adversely affected person as a result of this lack of coordination (Flink et al. 2012). In this study, nurses with managerial roles listed a higher number of advantages and placed great importance on the fact that EBP provided them with legal support, and this has been reported in other studies (Berland et al. 2012). Our participants felt they need scientific support to grant strength and social recognition to their profession, so that EBP might contribute easily to this aim. They also stated that appropriate EBP may improve motivation and may encourage the staff to be creative, but the work environment is considered as an essential aspect for EBP, as other authors had stated (Melnyk et al. 2010; Squires et al. 2011).
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findings thus have relevance to inform policies on the implementation of EBP into health care and nursing.
Conclusion This study has enabled us to examine the attitudes of the PHC nurses as well as the difficulties and advantages perceived by them concerning the EBP. According to the literature reviewed, we consider our findings relevant to informing professional practice in PHC worldwide and encourage similar research in other countries. In general, we can say that our participants had a clear concept of what the evidence is and they have a positive attitude towards its application, but they experienced difficulties in the application of EBP, mostly because of the lack of methodological knowledge and resources for its application. We consider it would be advisable to develop training strategies and make EBP implementation easier by adapting the environment in PHC.
Acknowledgements The authors would like to thank the Spanish Ministry of Health for funding this project, the Balearic Health Service for its involvement and collaboration, and all the nursing professionals who took part in this study.
Author contributions JP-B: Study conception and design, data collection and analysis, drafting of manuscript. SG-T: Data collection and analysis, drafting of manuscript. MB-V: Study conception and design, critical revisions for important intellectual content, drafting of manuscript, supervision. JDP-G: Data collection and analysis, drafting of manuscript. JMM-A: Substantial contributions to analysis and interpretation of data, critical revisions for important intellectual content, and final approval of the version to be published.
Limitations
References
Because there were only a limited number of participants in this study, and we used a convenience sample, it is not possible to widely generalize the findings elsewhere. Moreover, useful comparisons of our findings can only be made between countries that have a similar PHC system to Spain. However, our rich findings add important knowledge to the topic for EBP within nursing practice.
Aitken, L.M., et al. (2010) The impact of Nursing Rounds on the practice environment and nurse satisfaction in intensive care: pre-test post-test comparative study. International Journal of Nursing Studies, 48 (8), 918– 925. Berland, A., Gundersen, D. & Bentsen, S.B. (2012) Evidence-based practice in primary care: an explorative study of nurse practitioners in Norway. Nurse Education Practice, 12 (6), 361–365. Birch, S. & Thabane, L. (2012) Better care: an analysis of nursing and healthcare system outcomes. Ottawa, Ontario, Canadian Health Services Research Foundation (CHSRF). Bostrom, A.M., Ehrenberg, A., Gustavsson, J.P. & Wallin, L. (2009) Registered nurses’ application of evidence-based practice: a national survey. Journal of Evaluation in Clinical Practice, 15 (6), 1159–1163.
Implications for nursing and health policy This study highlights the existing gap in translating knowledge into practice and its potential implications in the effectiveness of nursing interventions and decision making in PHC. Our
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J. Pericas-Beltran et al.
Calderon, C., et al. (2011) EBM in primary care: a qualitative multicenter study in Spain. BMC Family Practice, 12, 84. Dawes, M., et al. Second International Conference of Evidence-Based Health Care, T. & Developers (2005) Sicily statement on evidence-based practice. BMC Medical Education, 5 (1), 1. De Pedro-Gomez, J., et al. (2012) Psychometric testing of the Spanish version of the practice environment scale of the nursing work index in a primary healthcare context. Journal of Advanced Nursing, 68 (1), 212– 221. Dijkstra, R., et al. (2006) The relationship between organisational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis. BMC Health Services Research, 6, 53. Elo, S. & Kyngäs, H. (2008) The qualitative content analysis process. Journal of Advanced Nursing, 62 (1), 107–115. Fineout-Overholt, E., et al. (2011) Following the evidence: planning for sustainable change. The American Journal of Nursing, 111 (1), 54–60. Flink, M., et al. (2012) Beliefs and experiences can influence patient participation in handover between primary and secondary care-a qualitative study of patient perspectives. BMJ Quality & Safety, 21 (Suppl 1), i76– i83. Flodgren, G., Rojas-Reyes, M.X., Cole, N. & Foxcroft, D.R. (2012) Effectiveness of organisational infrastructures to promote evidence-based nursing practice. Cochrane Database of Systematic Reviews, (2), CD002212. Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B.M. & Stillwell, S.B. (2011) Evidence-based practice, step by step: implementing an evidencebased practice change. The American Journal of Nursing, 111 (3), 54–60. Gerrish, K., Ashworth, P., Lacey, A. & Bailey, J. (2008) Developing evidence-based practice: experiences of senior and junior clinical nurses. Journal of Advanced Nursing, 62 (1), 62–73. Goldman, J., et al. (2010) Interprofessional primary care protocols: a strategy to promote an evidence-based approach to teamwork and the delivery of care. Journal of Interprofessional Care, 24 (6), 653–665. Gonzalez-Torrente, S., et al. (2012) Perception of evidence-based practice and the professional environment of primary health care nurses in the Spanish context: a cross-sectional study. BMC Health Services Research, 12, 227. Grant, H.S., Stuhlmacher, A. & Bonte-Eley, S. (2012) Overcoming barriers to research utilization and evidence-based practice among staff nurses. Journal for Nurses in Staff Development, 28 (4), 163–165. Guba, E.G. & Lincoln, Y.S. (1985) Naturalistic Inquiry. Sage Publications, Incorporated, London, UK. Holmes, D., Murray, S.J., Perron, A. & Rail, G. (2006) Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. International Journal Evidence-Based Healthcare, 4 (3), 180–186. Hsieh, H.F. & Shannon, S.E. (2005) Three approaches to qualitative content analysis. Qualitative Health Research, 15 (9), 1277–1288. Kitson, A., Harvey, G. & McCormack, B. (1998) Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7 (3), 149–158. Lake, E.T. (2002) Development of the practice environment scale of the Nursing Work Index. Research in Nursing and Health, 25 (3), 176–188.
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McCaughan, D., et al. (2005) Nurse practitioner and practice nurses’ use of research information in clinical decision making: findings from an exploratory study. Family Practice, 22 (5), 490–497. McCrae, N. (2012) Evidence-based practice: for better or worse. International Journal of Nursing Studies, 49 (9), 1051–1053. Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L. & Kaplan, L. (2012) The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. The Journal of Nursing Administration, 42 (9), 410–417. Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B. & Williamson, K.M. (2010) Evidence-based practice: step by step: the seven steps of evidencebased practice. The American Journal of Nursing, 110 (1), 51. Mills, J., Field, J. & Cant, R. (2011) Factors affecting evidence translation for general practice nurses. International Journal of Nursing Practice, 17 (5), 455–463. Milne, J. & Oberle, K. (2005) Enhancing rigor in qualitative description. Journal of Wound Ostomy & Continence Nursing, 32 (6), 413–420. Olsen, P.R. & Bradbury-Jones, C. (2013) Using a knowledge utilization framework to explore how findings from one study can be applied to other nursing contexts. International Nursing Review, 60, 381–388. Ozdemir, L. & Akdemir, N. (2009) Turkish nurses’ utilization of research evidence in clinical practice and influencing factors. International Nursing Review, 56 (3), 319–325. Profetto-McGrath, J., et al. (2007) Clinical nurse specialists’ use of evidence in practice: a pilot study. Worldviews on Evidence-Based Nursing, 4 (2), 86–96. Rycroft-Malone, J., et al. (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13 (8), 913–924. Sánchez, L.M.C., et al. (2010) [What do general practitioners think about evidenced-based medicine? A study with focus groups]. Atencion Primaria, 42 (10), 507–513. Spenceley, S.M., et al. (2008) Sources of information used by nurses to inform practice: an integrative review. International Journal of Nursing Studies, 45 (6), 954–970. Squires, J., Estabrooks, C., Gustavsson, P. & Wallin, L. (2011) Individual determinants of research utilization by nurses: a systematic review update. Implementation Science, 6 (1), 1. Starfield, B. (2012) Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gaceta Sanitaria, 26 (Suppl 1), 20–26. Starfield, B., Shi, L. & Macinko, J. (2005) Contribution of primary care to health systems and health. The Milbank Quarterly, 83 (3), 457–502. Thompson, D.S., et al. (2007) Interventions aimed at increasing research use in nursing: a systematic review. Implementation Science, 2 (1), 15. Thorsteinsson, H.S. (2012) Translation and validation of two evidencebased nursing practice instruments. International Nursing Review, 59 (2), 259–265. Upton, D. & Upton, P. (2006) Development of an evidence-based practice questionnaire for nurses. Journal of Advanced Nursing, 53 (4), 454–458.
