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Worldviews on Evidence-Based Nursing

Volume 14, Issue 6, Virtual Issue

Published December 2017

Barriers to and Best Practices in Advancing Evidence-based Care

Edited By: Bernadette Melnyk

Impact Factor: 2.103

ISI Journal Citation Reports © Ranking: 2016: 11/116 (Nursing)

Online ISSN: 1741-6787

Associated Titles: Journal of Nursing Scholarship

© Sigma Theta Tau International

From the Editor

An abundance of studies have been published that demonstrate when patients receive

evidence-based care, their outcomes substantially improve. Further, consistent implementation

of evidence-based practice by all healthcare providers would result in achieving the quadruple

aim in healthcare, including improving the patient experience through high quality care,

enhancing population health, reducing costs, and empowering clinicians to be more engaged

and satisfied in their roles. This virtual edition of Worldviews contains a landmark series of

studies that further describe some of the existent barriers in healthcare systems that prevent the

advancement of evidence-based practice along with studies that highlight interventions and

factors that propel its implementation and sustainability. As always, Worldviews links the

research presented in its publications with recommended action tactics so readers can put the

evidence in active practice to improve outcomes. Enjoy reading and make use of this virtual

edition.

Bernadette Mazurek Melnyk

PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN

Original Article

A Study of Chief Nurse Executives IndicatesLow Prioritization of Evidence-Based Practiceand Shortcomings in Hospital PerformanceMetrics Across the United StatesBernadette Mazurek Melnyk, RN, PhD, FNAP, FAANP, FAAN •Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Bindu Koshy Thomas, MEd, MS •Michelle Troseth, RN, MSN, DPNAP, FAAN • Kathy Wyngarden, RN, MSN, FNP •Laura Szalacha, EdD

Keywords

evidence-basedpractice,

chief nurse,nurse executive,

performancemetrics,

health care

ABSTRACTBackground: Although findings from studies indicate that evidence-based practice (EBP) results inhigh-quality care, improved patient outcomes, and lower costs, it is not consistently implementedby healthcare systems across the United States and globe.

Aims: The purpose of this study was to describe: (a) the EBP beliefs and level of EBP implementa-tion by chief nurse executives (CNEs), (b) CNEs’ perception of their hospitals’ EBP organizationalculture, (c) CNEs’ top priorities, (d) amount of budget invested in EBP, and (e) hospital perfor-mance metrics.

Methods: A descriptive survey was conducted. Two-hundred-seventy-six CNEs across the UnitedStates participated in the survey. Valid and reliable measures included the EBP Beliefs scale,the EBP Implementation scale, and the Organizational Culture and Readiness scale for EBP.The Centers for Medicare and Medicaid Services Core Measures and the National Database ofNursing Quality Indicators (NDNQI) were also collected.

Results: Data from this survey revealed that implementation of EBP in the practices of CNEs andtheir hospitals is relatively low. More than one-third of the hospitals are not meeting NDNQIperformance metrics and almost one-third of the hospitals are above national core measuresbenchmarks, such as falls and pressure ulcers.

Linking Evidence to Action: Although CNEs believe that EBP results in high-quality care, it isranked as a low priority with little budget allocation. These findings provide a plausible explana-tion for shortcomings in key hospital performance metrics. To achieve higher healthcare qualityand safety along with decreased costs, CNEs and hospital administrators need to invest in pro-viding resources and an evidence-based culture so that clinicians can routinely implement EBPas the foundation of care.

INTRODUCTIONThe evidence is irrefutable: findings from multiple studies indi-cate that evidence-based practice (EBP), compared to care that issteeped in tradition, leads to: (a) a higher quality and reliabilityof health care, (b) improved population health and patient out-comes, including the patient care experience, and (c) reducedcosts, now referred to as the Triple Aim in health care in theUnited States (Fielding & Briss, 2006; McGinty & Anderson,2008; Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan,2012). Despite findings from research supporting the benefitsof evidence-based care and its emphasis in the Affordable CareAct, it is not the standard of practice implemented by manyclinicians and healthcare systems across the United States and

the globe due to multiple barriers that continue to be a deterrentto the translation of research findings into real-world practicesettings (Fink, Thompson, & Bonnes, 2005; Harding, Porter,Horne-Thompson, Donley, & Taylor, 2014; Melnyk, Fineout-Overholt et al., 2012). Among these barriers are: (a) inadequateknowledge and skills in EBP by clinicians, (b) lack of EBPmentors and practice facilitators, (c) misconceptions that EBPtakes too much time, (d) cultures and environments that do notsupport EBP, (e) inadequate resources, and (f) lack of expec-tations and organizational mandates to implement evidence-based care (Harding et al., 2014; Melnyk, Fineout-Overholtet al., 2012; Melnyk et al., 2012; Nagykaldi, Mold, Robinson,Niebauer, & Ford, 2006). Therefore, it is doubtful that the goal

6 Worldviews on Evidence-Based Nursing, 2016; 13:1, 6–14.C© 2016 Sigma Theta Tau International

Original Articleset by the Institute of Medicine (IOM) that 90% of health-care decisions will be evidence-based by 2020 will be achievedunless urgent action is taken to transform current healthcaresystems across the United States (2008).

EBP is a problem-solving approach to clinical decision-making in health care that integrates the best evidence fromwell-designed studies with a clinician’s expertise, which in-cludes internal evidence from patient assessments and practicedata, and a patient’s preferences and values (Melnyk & Fineout-Overholt, 2015). In the landmark summit sponsored by theIOM on health professions education, it was recommendedthat all health professional educational programs should in-clude five competencies, including: (a) providing patient cen-tered care, (b) applying quality improvement principles, (c)working in interprofessional teams, (d) using EBPs, and (e)using health information technologies (IOM, 2003). However,challenges remain in the teaching of EBP in academic pro-grams throughout the United States as many faculty continueto teach health sciences students the rigorous process of howto conduct research instead of how to use research and consis-tently implement evidence-based care (Melnyk, 2013).

In a national survey by Melnyk et al. (2012) with a randomsample of over 1,000 nurses who were members of the Ameri-can Nurses Association, 74% of the respondents indicated theneed for additional education in EBP. Nurses in this surveyalso indicated the persistence of many of the same EBP bar-riers that have been reported for decades (e.g., lack of time,organizational culture, inadequate EBP knowledge and skills).However, one new barrier was identified that had not beenpreviously reported in the literature: manager and leader resis-tance to EBP. Respondents to the national survey expressed aneed for support from their leaders, managers, and interdisci-plinary colleagues in order to be able to implement EBP.

The literature has revealed that leaders who create a visionfor EBP in their organization provide resources to support itand incorporate evidence into their own leadership practices,thus having a key influence on the implementation of evidence-based care (Melnyk & Fineout-Overholt, 2015; Rycroft-Malone,2008). Although findings from a prior study indicated thatChief Nursing Officers (CNOs) and Chief Nursing Executives(CNEs) often believe in the value of evidence-based care, theirown implementation of EBP is low (Sredl et al., 2011). In addi-tion to these known challenges related to leadership and EBP,there are major gaps in the literature regarding how nursingleaders prioritize EBP and the extent to which they invest init. Therefore, a national (US) survey was conducted with CNEsand CNOs throughout the nation to: (a) fill this knowledge gap,(b) assess their EBP beliefs and level of EBP implementation,(c) evaluate their perceptions of organizational culture and en-vironment for EBP, and (d) describe performance metrics intheir healthcare systems. Data from this survey were also in-tended to inform appropriate next steps in working with CNEsand CNOs across the United States to advance and sustain EBPin their healthcare systems to ultimately improve patient careand outcomes.

METHODSThe study was an anonymous online survey of CNEs and CNOsthroughout the United States granted exempt status by the firstauthor’s institutional review board. Elsevier provided an e-maillist of 5,100 CNOs and CNEs, and an e-mail was sent to allof them with an invitation to complete the anonymous survey.Participants were provided a cover letter with a description ofthe study. The e-mail provided a link to the survey. A remindere-mail was sent 1 week following the first contact and anotherreminder was sent 1 day before the survey closed.

The survey participants were offered an incentive to partic-ipate in the study; an opportunity to enter a drawing for 1 of 10$100 gift cards. The gift card recipients were determined us-ing a computer-generated random number list. The recipientsreceived their gift card after the survey closed.

MeasuresData collected on the survey included: (a) demographic ques-tions; (b) three valid and reliable instruments that measuredbeliefs about EBP, EBP implementation, and perceived organi-zational culture of EBP; (c) CNE and CNO priorities and budgetinvestment in EBP, and (d) CMS Core Measures and NationalDatabase of Nursing Quality Indicators (NDNQI) measures.

EBP beliefs were measured with the EBP Beliefs (EBPB)scale, which taps beliefs about the value of EBP and the abilityto implement it (Melnyk, Fineout-Overholt, & Mays, 2008).This is a 16-item Likert-type scale ranging from 1 (strongly dis-agree) to 5 (strongly agree). Sample items include: “I am clearabout the steps in EBP,” “I am sure that I can implementEBP,” and “I am sure that evidence-based guidelines can im-prove care.” The summed total EBP score with higher scoresindicate stronger EBP beliefs. The EBPB scale has establishedface, content, and construct validity, with internal consistencyreliabilities typically above 0.85 (Melnyk et al., 2008).

Implementation of EBP was measured with the EBP Imple-mentation (EBPI) scale (Melnyk et al., 2008), which assessedthe extent to which the CNEs and CNOs implemented EBP.Participants respond to 18-item Likert-type scale items by an-swering how often in the last 8 weeks they have performed cer-tain EBP tasks, including: (a) generated a PICO question aboutmy practice, (b) used evidence to change my clinical practice,and (c) shared outcome data collected with colleagues. Itemscores are summed for a total score range from 0 to 72, withhigher scores indicating greater implementation of EBP. TheEBPI has established face, content, and construct validity withinternal consistency reliabilities reported at above 0.85 (Melnyket al., 2008).

Organizational culture was measured with the Organiza-tional Culture and Readiness for System-Wide Integration ofEBP (OCRSIEP) scale, which taps organizational culture andreadiness for EBP (Fineout-Overholt & Melnyk, 2003). Thisinstrument measures the extent to which cultural factors thatinfluence system-wide implementation of EBP exist in the en-vironment and the overall perceived readiness for integration

Worldviews on Evidence-Based Nursing, 2016; 13:1, 6–14. 7C© 2016 Sigma Theta Tau International

CNE Study: EBP & Performance Metrics

of EBP and how it compares to 6 months ago. Respondents areasked to indicate their agreement with each item on a 5-pointLikert-type scale, with 1 meaning none at all and 5 meaningvery much. Examples of items on the 26-item scale include:(a) To what extent is EBP clearly described as central to themission and philosophy of your institution? and (b) To whatextent do you believe that EBP is practiced in your institution?Items are summed to create a total score, ranging from 25 to125, with higher scores reflecting greater organizational readi-ness for and movement toward a culture of EBP. The scale hasestablished face and content validity, with internal consistencyreliabilities reported at above 0.85 (Melnyk, Fineout-Overholt,Giggleman, & Cruz, 2010).

CNE priorities and budget investment in EBP were assessedwith the following questions: (a) As a CNE, what are the topthree priorities that you are currently focused on in your role?and (b) What percent of your annual operating budget do youspend on building and sustaining EBP in your organization?

Data on core performance measures were gathered withthe following question: In your most recent core measuresreport, at which level did your nursing unit perform in the fol-lowing nurse-related measurements (e.g., catheter-associatedurinary tract infections, pressure ulcer stage III and IV, vascu-lar catheter-associated infections)? Response choices included“below national rate,” “same as national rate,” and “above na-tional rate.” Data on NDNQI measures were assessed withthe following question: In your most recent NDNQI report, atwhich level did your nursing department perform on the fol-lowing nurse sensitive indicators (e.g., falls, falls with injury,hospital-acquired pressure ulcers). Response choices included“below benchmark,” “at benchmark,” and “exceeding bench-mark.”

DATA ANALYSISBecause this was a descriptive national survey, descriptivestatistics (e.g., means, standard deviations, and percentages)were conducted on the study’s variables. Cronbach alphas werecomputed on the EBP scales used. Prior to beginning the study,a decision was made to only include data on fully completedsurveys in the analysis.

RESULTSA convenience sample of 5,100 e-mails from a data base ofCNEs and CNOs from Elsevier were disseminated, and 1,199(24%) were returned as undeliverable. Therefore, the actualsample comprised 3,901 CNEs and CNOs. Although 327 CNEsand CNOs started the survey (8%), it was fully completed by276 (a 7% response rate) who were from 45 states in the UnitedStates and the District of Columbia. Ninety-three percent ofthe respondents were currently in the chief nurse role andwere an average of 55 years of age. The majority were whiteand female, with over two-thirds having a master’s degree astheir highest level of education (Table 1). Sixty-eight percentof the hospitals had less than 301 beds and 18% had Mag-

Table 1. CNO and CNE & Organizational Demo-graphics

CNO/CNE Demographic Data Frequency Percent

Gender

Male 21 8%

Female 255 92%

Ethnicity

American Indian 2 1%

Asian 4 1%

African American 10 4%

White 260 94%

Education

Diploma 4 1%

Associate’s degree 5 2%

Bachelor’s degree 17 6%

Master’s degree 189 69%

PhD 22 8%

DNP 29 10%

Other 10 4%

Currently CNO/CNE

Yes 255 93%

No 21 7%

Age Minimum Maximum Average

32 68 55

Organizational data Percent

Size

Fewer than 100 beds 37%

100-300 beds 31%

301-500 beds 14%

501-800 beds 9%

801-1,000 beds 4%

Greater than 1,000 beds 4%

Other 1%

Magnet designated

Yes 18%

No 82%

BSN preparation

Less than 25% 26%

(Continued)


Original ArticleTable 1. Continued

CNO/CNE Demographic Data Frequency Percent

26-50% 42%

51-75% 26%

76-100% 6%

Nursing satisfaction

Very dissatisfied 1%

Somewhat dissatisfied 11%

Somewhat satisfied 62%

Satisfied 26%

net status designation, which is a credential awarded by theAmerican Nurses Credentialing Center to healthcare organiza-tions for quality patient care, nursing excellence, and innova-tions in nursing practice. More than two-thirds of the hospitals(n = 188) had less than 51% baccalaureate prepared nurses.Sixty-two percent (n = 172) of the CNEs and CNOs reportedthat their nurses were “somewhat satisfied” with only 73 CNEsand CNOs (26%) reporting that their nurses were “satisfied”on their nurse satisfaction surveys (Table 1).

Although the CNOs and CNEs’ beliefs about the value ofEBP were high (Table 2), approximately 25% were not clearabout the steps of EBP and nearly 44% reported that they werenot sure they could implement EBP in a time efficient man-ner. More than 50% of CNEs and CNOs believed that EBP ispracticed in their organization from “not at all” to “somewhat.”Furthermore, 48% of the chief nurses reported that they wereunsure of how to measure the outcomes of services deliveredto patients.

The CNEs and CNOs’ own implementation of EBP was low(Table 2). Specifically, over half of the CNEs and CNOs reportedthat they had not accessed important databases for evidence-based guidelines or systematic reviews of evidence during thepast 8 weeks. Organizational culture and readiness for EBPacross the hospitals was low to moderate (Table 2). Specifi-cally, nearly 60% of the chief nurses reported they believedEBP is practiced in their organizations “not at all” to “some-what.” In response to the question, “compared to 6 monthsago, how much movement in your organization has there beentoward EBP culture?” 52% of the chief nurses said “not at all”to “somewhat.” In response to the question on the EBP cul-ture scale regarding to what extent fiscal resources were usedto support EBP, 72% of the respondents said “not at all” to“somewhat.”

Regarding performance metrics, the chief nurses reportedthat more than one-third of their hospitals are not meetingbenchmarks for NDNQI measures (Figure 1), and almost one-

third of the hospitals are above national benchmarks for coremeasures (e.g., falls, pressure ulcers; Figure 2).

The top priorities as stated by the chief nurses were qualityand safety, yet EBP was cited as a top priority for only 3% of thechief nurses (Figure 3). Regarding budget, 74% of the CNOsand CNEs invested only 0% to 10% of their annual operatingbudgets on building and sustaining EBP in their organizations.

DISCUSSIONThe results of this survey indicate that, although the CNEsand CNOs reported that they believe in the value of EBP, theirown implementation of EBP is relatively low. More than halfof the CNEs and CNOs also reported that there is a low level ofevidence-based care practiced in their organizations. This lowlevel of EBP can be partially explained because the majority ofhospitals had less than a 51% baccalaureate prepared workforceand only 18% of the hospitals had achieved Magnet status. Inthe United States, research has supported that hospital out-comes (e.g., lower mortality and failure to rescue rates) are bet-ter with baccalaureate prepared nurses and they exhibit higherlevels of EBP than nonbaccalaureate prepared nurses (Aiken,Clarke, & Cheung, Sloane, & Silber, 2003; Wilson et al., 2015),which is the impetus for the IOM recommendation that 80%of nurses in the United States are baccalaureate prepared by2020 (IOM, 2011). Furthermore, a recent study of 136 Penn-sylvania hospitals (11 emerging Magnets and 125 non-Magnets)indicated that Magnet recognition is associated with significantimprovements over time in quality of the organization’s workenvironment as well as patient and nursing outcomes that ex-ceed those of non-Magnet hospitals, including fewer deathsper 1,000 patients (Kutney-Lee et al., 2015).

Although the CNEs and CNOs stated that their highest pri-orities were quality and safety, EBP was not listed as a toppriority and very little of their budgets were allocated to imple-menting and sustaining evidence-based care. These findingsprovide another explanation for the shortcomings revealed incore performance and NDNQI metrics in a substantial portionof the hospitals. The findings also indicate a disconnection orlack of understanding by chief nurses that EBP is a key driver toachieving quality and safety in health care. Without a prioritiza-tion on EBP and necessary investment in an infrastructure tosustain it by CNEs and CNOs and chief executive officers, keyquality and safety outcomes in healthcare systems are unlikelyto be achieved.

In order for the Triple Aim to be reached in the US health-care system, EBP needs to be the foundation of care deliveredby all healthcare professionals across disciplines, using an in-terprofessional team-based model of care. However, the litera-ture abounds with studies that indicate this type of practice isfar from reality. Findings from research have indicated that, al-though health professionals from a variety of disciplines believein the benefits of EBP, only a small percentage consistently usethis approach in caring for their patients (Harding et al., 2014;Melnyk, Fineout-Overholt et al., 2012; Melnyk et al., 2012). In



Table 2. CNO/CNE Scores on EBP Scales

Minimum Maximum

Possible Possible Standard

Score Score Mean Deviation

EBPB scale 16 80 60.17 11.22

EBPI scale 0 72 27.8 14.97

Organizational culture & readiness scale 14 70 41.9 11.80

0%

10%

20%

30%

40%

50%

60%

Falls Falls withinjury

Pressureulcers

Pressureulcers (Stage2 and above)

Restraints Nursing carehours

RN education RNcertification

Below benchmark

At benchmark

Exceeding benchmark

Figure 1. NDNQI Metrics.

a recent study, Harding and colleagues (2014) found that bothclinicians and managers did not view EBP as a core componentof clinical care because higher priorities took precedent (e.g.,maintaining patient flow).

Although nurse executive leadership competencies includethe implementation and sustainability of evidence-based im-provements in quality and costs, including creating structuresto ensure access to information, resources, and support (Amer-ican Organization of Nurse Executives, 2004; Everett & Sitter-ding, 2011), this study reflects that these executive activitiesare not routinely occurring in real-world clinical organizations.Nurse executives must be provided with the knowledge thatEBP should be the consistent foundation of care delivery be-cause it is linked to improved outcomes, which are measurableand meaningful returns on the investment in EBP. This knowl-edge would assist chief nurses in understanding the value ofallocating more of their budgets to creating an infrastructure

to support and sustain EBP. Nurse executives also must beactively engaged in EBP in their own decision making androle model it for their directors, managers, and point of carestaff as prior research has indicated that role modeling andvaluing of research by nursing management increases the useof evidence in practice (Gifford, Davies, Edwards, Griffin, &Lybanon, 2007).

It is critical for nursing and other interprofessional health-care executives to build a culture and environment that sup-ports the implementation and sustainability of evidence-basedcare in order to achieve best outcomes, which includes the pro-vision of necessary EBP resources and tools (Melnyk, 2014a;Rycroft-Malone et al., 2013). Organizations need to provideevidence that their policies and procedures are based uponthe best evidence and that clinicians are provided with rig-orous evidence-based guidelines and mechanisms to supporttheir implementation. Evidence-based councils comprised of


Original Article

0%

10%

20%

30%

40%

50%

60%

Catheter associatedurinary tractinfections

Pressure ulcers(Stage 3 and 4)

Vascular catheterassociated infections

Falls and trauma Manifestations ofpoor glycemic

control

Below national rate

Same as national rate

Above national rate

Figure 2. Core Measures.

0%

5%

10%

15%

20%

25%

Quality Patient safety Benchmarks Finance Recruitmentand retention

Staffing Patientsatisfaction

Vision/culture Evidence-basedpractice

Summarized from the survey question: “As a CNO/CNE, what are the top 3 priorities that you are currently focused on in your role?”

Figure 3. CNO/CNE Top Priorities.

transdisciplinary clinicians also can be instrumental for en-hancing EBP throughout the organization through an inter-professional team-based approach, which has been supportedto lead to a higher quality of care. Research supports that trans-disciplinary teamwork leads to a higher quality of care and bet-ter patient outcomes (Raab, Will, Richards, & O’Mara, 2013).Furthermore, time must be allocated for clinicians to engagein the EBP process. The time invested in EBP should be pro-

moted as essential and valuable as opposed to being labeled as“nonproductive” time as is the case in many hospitals acrossthe United States (Melnyk, 2014a).

It is not enough to disseminate evidence-based guidelinesand expect clinicians to readily implement them. For manyclinicians, EBP requires behavior change from practice steepedin tradition and organizational cultures of “this is the way wedo it here” to practice that is supported by science. Behavior



change in clinicians cannot be achieved by the provision ofinformation alone; often it is precipitated by an emotional rea-son to change (e.g., a compelling story) along with educationaland skill-building workshops to learn the EBP process (Mel-nyk, 2014a). Transformation to an EBP culture also requiresan exciting team vision and clear expectations from healthcareleaders that EBP is the foundation of all care delivered withinthe healthcare system. This expectation should be integratedinto the vision, mission, and strategic plan of the institutionand incorporated into the onboarding of all new clinicians.Furthermore, nurses should be expected to achieve the newEBP competencies for practicing nurses and advanced prac-tice nurses within their organizations (Melnyk, Gallagher-Ford,Long, & Fineout-Overholt, 2014), which means that baccalau-reate and associate degree academic programs must teach theirstudents EBP, not the complex process of how to conduct rig-orous research. For those clinicians who fall short on some ofthe competencies at the start of their employment, continuingeducation workshops with skill-building activities should beprovided until full competence is achieved. Integration of theseEBP competencies into job descriptions and clinical ladder pro-motion systems can also establish clarity of performance expec-tations and serve as an incentive for clinicians to attain them.A critical mass of EBP mentors also should be made availableto point of care clinicians throughout healthcare systems asresearch has indicated that they facilitate evidence-based careand improve patient outcomes (Levin, Fineout-Overholt, Mel-nyk, Barnes, & Vetter, 2011; Melnyk, 2007; Wallen et al., 2010).These mentors should document the “so what” outcomes (i.e.,outcomes that the current healthcare system is most focusedon, including cost, complications, length of stay, and rehos-pitalizations) to support the benefits of their work (Melnyk,2014b).

As a follow-up to our national survey of nurse executives,a national forum with over 150 CNEs and CNOs throughoutthe country was held at the 2014 national conference of theAmerican Organization of Nurse Executives. The purpose ofthis national forum was to share the findings from the recentsurvey and generate solutions to assist nurse executives withimproving their own EBP skills along with determining the bestresources and tools to help them to build strong EBP culturesand environments within their own hospitals and healthcaresystems.

The nurse executives at the national forum called for a bridg-ing of the knowledge gap between EBP and healthcare qualityand patient safety as well as the need for educational offer-ings, specifically for them, to enhance their own knowledgeand skills in EBP and assist them in creating stronger culturesand environments for EBP. They emphasized that it is criticalfor nurse executives and other healthcare administrators to behelped to understand the gap between EBP and its impact onclinical outcomes and return on investment (ROI).

Limitations to this study include a convenience sample andlow response rate, which decreases generalizability of the find-ings. In addition, the survey was a single snapshot of the state of

care and outcomes in hospitals across the United States alongwith self-reported data by the CNEs and CNOs. Future researchis needed that gathers objective data over time along with self-reported data and measures that tap EBP and investments inevidence-based care.

Although there has been progress in EBP over the pastdecade, there is much to be accomplished yet. In efforts to speedthe translation of research into real-world clinical settings, it iscritical to focus on nurse executives as they have important in-fluence over the clinical enterprise and budgetary responsibil-ity for nurses within their healthcare systems. Chief executiveofficers and other healthcare administrators also must under-stand the link between EBP and improved healthcare systemoutcomes. They must be assisted in understanding and valuingthe importance of EBP in reaching their high-priority goals ofhealthcare quality and safety. Only through accelerated effortsin working with executives to build cultures and environmentsthat support EBP and intensive skill building with point of caretransdisciplinary clinicians will EBP become the foundationfor high-quality, safe, and cost-effective care throughout theUnited States healthcare system and the globe. WVN

LINKING EVIDENCE TO ACTION

� Findings from this national survey indicate thatCNEs and CNOs need education and skill buildingin EBP and outcomes management so that theythemselves implement and role model EBP.

� Evidence regarding ROI with EBP is necessary sothat chief nurses and hospital administrators re-alize that healthcare outcomes are improved andcost savings are generated with EBP, and that it iskey to quality and safety.

� CNEs and CNOs and healthcare administratorsneed to build cultures and environments that pro-mote and sustain EBP, which requires financialinvestment.

� Healthcare systems need to provide support fortheir nurses to obtain baccalaureate degrees andbe encouraged to embark on the Magnet journey.

� The new EBP competencies for practicing nursesand advanced practice nurses need to be integratedinto job descriptions and organizational expecta-tions.

� All associate degree and baccalaureate nursingprograms need to prepare their students to meetthe new EBP competencies for practicing nursesand graduate nursing programs should preparetheir students to meet the EBP competencies foradvanced practice nurses.


Original ArticleAuthor information

Bernadette Mazurek Melnyk, Associate Vice President forHealth Promotion, University Chief Wellness Officer, Deanand Professor, College of Nursing, Professor of Pediatrics andPsychiatry, College of Medicine, The Ohio State University,Columbus, OH, USA; Lynn Gallagher-Ford, Director, Centerfor Transdisciplinary Evidence-Based Practice, Clinical Asso-ciate Professor, The Ohio State University, College of Nursing,Columbus, OH, USA; Bindu Koshy Thomas, Technology Coor-dinator, Center for Transdisciplinary Evidence-Based Practice,The Ohio State University, College of Nursing, Columbus, OH,USA; Michelle Troseth, Chief Professional Practice Officer, El-sevier Clinical Solutions, Grand Rapids, MI, USA; Kathy Wyn-garden, Manager, Elsevier CPM Consortium, Elsevier ClinicalSolutions, Grand Rapids, MI, USA; Laura Szalacha, Director ofResearch Methods and Statistics, University of Arizona Collegeof Nursing, Tucson, AZ, USAFunding for this project was provided by Elsevier Clinical So-lutions

Address correspondence to Dr. Bernadette Mazurek Melnyk,The Ohio State University, 1585 Neil Avenue, Columbus, OH43210; [email protected]

Accepted 4 August 2015Copyright C© 2016, Sigma Theta Tau International

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doi 10.1111/wvn.12133WVN 2016;13:6–14


Original Article

Empowering Nurses With Evidence-BasedPractice Environments: Surveying Magnet R©,Pathway to Excellence R©, and Non-MagnetFacilities in One Healthcare SystemMarian Wilson, RN-BC, PhD, MPH • Martha Sleutel, RN, PhD, CNS •Patricia Newcomb, RN, PhD, PNP • Deborah Behan, RN-BC, PhD • Judith Walsh, RN,PhD • Jo Nell Wells, RN-BC, PhD, OCN • Kathleen M. Baldwin, RN, PhD, FAAN,ACNS-BC, ANP-BC, GNP-BC, FAACM

Keywords

evidence-basedpractice,

nurses,readiness,

survey

ABSTRACTBackground: Nurses have an essential role in implementing evidence-based practices (EBP) thatcontribute to high-quality outcomes. It remains unknown how healthcare facilities can increasenurse engagement in EBP.

Purpose: To determine whether individual or organizational qualities could be identified thatwere related to registered nurses’ (RNs’) readiness for EBP as measured by their reported EBPbarriers, ability, desire, and frequency of behaviors.

Methods: A descriptive cross-sectional survey was used in which a convenience sample of 2,441nurses within one United States healthcare system completed a modified version of the Infor-mation Literacy for Evidence-Based Nursing questionnaire. Descriptive statistics, t tests, one-wayANOVA, and regression modeling were used to analyze the data.

Results: RNs employed by facilities designated by the American Nurses Credentialing Center(ANCC) as Magnet R© or Pathway to Excellence R© reported significantly fewer barriers to EBPthan those RNs employed by non designated facilities. RNs in Magnet organizations had higherdesire for EBP than Pathway to Excellence or non designated facilities. RNs educated at thebaccalaureate level or higher reported significantly fewer barriers to EBP than nurses with lesseducation; they also had higher EBP ability, desire, and frequency of behaviors. A predictivemodel found higher EBP readiness scores among RNs who participated in research, had specialtycertifications, and engaged in a clinical career development program.

Linking Evidence to Action: Education, research, and certification standards promoted by theMagnet program may provide a nursing workforce that is better prepared for EBP. Organiza-tions should continue structural supports that increase professional development and researchopportunities so nurses are empowered to practice at their full capacity.

BACKGROUNDHealthcare leaders and institutions have increased expectationsfor evidence-based practice (EBP) in the quest to improve out-comes, boost quality, and lower costs. An Institute of Medicine(IOM) aim is that 90% of clinical decisions will be evidence-based by 2020 (IOM, 2010). As the largest group of healthcareproviders, nurses have a pivotal role in meeting this goal. Cul-tivating a “spirit of inquiry” to support an EBP culture has beenrecognized as the first step for EBP (Melnyk, Gallagher- Ford,Long, & Fineout-Overholt, 2014). Identifying individual andorganizational qualities facilitating EBP is imperative to focuspatient care improvement efforts and spend resources wisely.

Frameworks developed by the American Nurses Creden-tialing Center (ANCC) for the Magnet Recognition Program R©

and Pathway to Excellence R© designations require nurses toengage in the process of incorporating new evidence intopractice (ANCC, 2014). While research has linked thesedesignations to quality and safety outcomes (Drenkard,2010; Messmer & Turkel, 2011), less is known about howANCC-designated organizations’ characteristics are linked togreater EBP implementation. To increase understanding, wesurveyed nurses employed by Magnet-designated, Pathway toExcellence-designated, and non designated facilities withinone large healthcare system in the southwest United States


Original Articleon barriers to EBP, EBP ability, desire, and frequency ofbehaviors. By exploring both individual and organizationalqualities, we were able to identify conditions facilitating EBP.This knowledge can guide efforts to reinforce or build a strongEBP culture at healthcare facilities.

Factors influencing EBP have been extensively reported.Individual nurse qualities include EBP beliefs, confidence,time, knowledge, and skills (Melnyk, 2013). Clinical nurses’varying backgrounds, education, and attitudes can influencetheir motivation and ability to integrate evidence into practice(Swenson-Britt & Berndt, 2013). Organizational qualities thatimpact EBP include administrative support and access toresources (Melnyk, 2013). Two categories of organizationalfactors are infrastructure aspects such as library resources,and unit or facility climate such as authority to make changes,resistance or support by colleagues and leaders (Kelly, Turner,& Speroni, 2012; Melnyk, Fineout-Overholt, Gallagher-Ford,& Kaplan, 2012; Swenson-Britt & Berndt, 2013). Consistentlycited barriers to research utilization are organizational factorsand difficulty understanding research findings (Kajermo et al.,2010).

Much work has been done to identify characteristics oforganizations that are both highly reliable (i.e., safe) andsupport a culture of EBP. As presented by Melnyk (2012),those characteristics are multifactorial and complex. Theyinclude: commitment to delivering high-quality care andpatient safety, trans disciplinary teamwork, standardizationof best practices and policies, and an environment thatpromotes a spirit of inquiry and continuous learning. Studiessuggest that organizational leadership, opinion leaders,and role models may increase the use of EBP (Flodgrenet al., 2011; Thorsteinsson, 2013). The challenge lies indetermining specific actions to build and strengthen an EBPculture.

The Promoting Action on Research Implementation inHealth Services (PARIHS) conceptual framework (Kitson et al.,1998; Rycroft-Malone, 2004) guided the present study andconsiders both the context and facilitation required for change.Context includes culture, leadership, and evaluation (De Pedro-Gomez et al., 2012). Facilitation can occur through specificindividuals or processes that empower healthcare providersto incorporate new evidence into practice. Once differences incontext or facilitation among settings are identified, it may thenbe possible to detect and manipulate variables associated withcultures most supportive of EBP.

Our healthcare system recently instituted hospital-basedpositions for nurse scientists (doctorally prepared nurse re-searchers) in each hospital to improve nurses’ use of EBP andresearch. With a long-term goal of seeking system-wide Mag-net status, greater understanding of nurses’ perceptions of EBPwas needed to guide strategies to increase use of research evi-dence. The majority (n = 11; 78.6%) of the 14 hospitals withinthe system had received ANCC designation as Magnet (n = 3;21.4%) or Pathway to Excellence (n = 8; 57.1%) at the time ofdata collection.

PURPOSEThe purpose of this study was to describe the current climate ofEBP as reported by registered nurses (RNs) employed across allacute care settings within one of the largest hospital networksin the southwest United States. The specific aims of this studywere fourfold:

� Describe self-reported EBP behaviors, abilities, de-sires, and barriers among RNs employed in the tar-geted hospital system;

� Determine if significant differences exist in scoresamong hospitals with various ANCC designation sta-tuses;

� Determine if significant differences exist in scoresamong RNs with various individual qualities (educa-tional level, certification status); and

� Determine whether individual and organizationalvariables can be identified that predict positive EBPscores (including job role, length of time as a nurse,and research experience).

We obtained permission to use and adapt the InformationLiteracy for Evidence-Based Nursing Practice (ILNP) question-naire (Pravikoff, Tanner, & Pierce, 2005). Nurse scientists fromeach hospital were involved in this minimal risk study andensured equitable access for RNs. An introductory e-mail ex-plained the voluntary nature of the online survey and stepstaken to ensure respondents’ anonymity and privacy. All datawere collected and reported in aggregate form to preserve con-fidentiality. The healthcare system Institutional Review Boardapproved the study and determined that completion of the sur-vey implied informed consent.

METHODSThe study was an exploratory cross-sectional descriptive survey.Participants were asked to complete a revised version of theILNP. Data were collected over a 3-month period in 2013. RNsworking at the 14 hospitals within the healthcare system (N =6,873) comprised the targeted population.

The ILNPThe ILNP was originally developed as a 71-item measurementto assess U.S. nurses’ readiness for EBP, use of EBP, andperceived barriers to EBP. The ILNP content validity was estab-lished by a panel of experts and the development and validationare described elsewhere (Pravikoff et al., 2005). While the toolhas been widely used, construct validity and reliability have notbeen previously reported (Pravikoff et al., 2005; Thorsteins-son, 2013). After receiving permission to use and modify thetool, we removed sections related to computer and library re-sources because those are standard throughout our system.We also modified demographic items to reduce potential for


Empowering Nurses With EBP Environments

respondent identification, and updated some items to alignwith current literature, such as barriers and EBP activities.

ProcedureThe nurse scientist at each hospital sent a weekly e-mail for4 weeks to all RNs listed on the hospital e-mail distributionlists. A web link imbedded within the e-mail allowed nurses tocomplete the survey from their home or work computers. Asan incentive, participants were given the option to click on aseparate link if they wished to enter a drawing to win one ofeight e-book readers.

Data AnalysisWe analyzed the data using SPSS, version 18 (2009; SPSSInc. Chicago, IL, USA). Descriptive statistics provided responsefrequencies and distributions. Survey items were categorizedinto subscales that represented four constructs of interest. Re-sponse formats for the subscales included:

� Frequency of behaviors (“In the past year, how fre-quently have you participated in the following activ-ities?” e.g., “Identified a researchable problem”). Re-sponse choices for five items include 1 (not at all) to 4(more than three times).

� Abilities (“How would you rate your ability to dothe following?” e.g., “Critique or evaluate a researchstudy”). Response choices for 5 items include 1 (notable) to 5 (highly able).

� Desire (“How would you rate your desire to be ableto do the following?” e.g., “Use research findings inpractice”). Response choices for 5 items include 1 (nodesire) to 5 (high desire).

� Barriers (“Rate how much these factors are barriersto your participating more in research or evidence-based nursing practice.” e.g., “I don’t understand theresearch process”). Response choices for 8 items in-clude 1 (not at all true) to 5 (highly true).

We calculated an EBP readiness score from the mean ofthe combined 15 subscale items for frequency, ability, and de-sire. To examine differences between groups of nurses withvarious certification statuses, t tests were used. We determinedeffect sizes between groups using Cohen’s d with values inter-preted as small = .20, medium = .50, and large = .80 (Cohen,1988). ANOVA tests examined differences between hospitalsand nurses’ varying educational levels using eta squared (η2) tocalculate effect sizes using small = .01, medium = .06, and large= .14 (Cohen, 1988). A regression model was constructed topredict the effects of selected variables on EBP readiness scores.Listwise deletion was used for missing data and it was deter-mined that missing data were random. Due to the exploratorynature of the study with no a priori hypotheses, multiple com-parisons adjustments were not required (Saville, 1990).

RESULTSRespondentsA convenience sample of 2,441 RNs comprised the final sam-ple, a response rate of 35.5%. The majority of respondents(81.0% or n = 1,977) identified themselves as clinical bed-side nurses. About 24% (n = 597) of the sample had been anurse for five years or less, while 45% (n = 1,105) had beena nurse for 5–20 years and 28% (n = 684) for more than20 years (missing data 2% [n = 55]). The majority (59.8%; n =1,459) reported holding at least one national nursing certifica-tion and were prepared at the baccalaureate level (44.9%; n =1,095). Respondents from rural hospitals were 17.9% (n = 412)of our sample, while participants from large urban centers andmedium suburban centers represented 43.2% (n = 995) and38.9% (n = 895), respectively. Table 1 compares respondentdata with available state RN data and shows similar propor-tions in education levels and roles.

INLP ResultsApproximately 80% (n = 1,961) of respondents stated theyhad a moderate or high understanding of the term “evidence-based nursing practice,” whereas .9% (n = 21) said they hadno understanding of it. Cronbach’s alpha for the revised 34item INLP was .85 (n = 2,276) indicating an acceptable levelof internal consistency reliability. Full sample mean scoreswith reliability values for the four EBP subscales (behaviorfrequency, ability, desire, and barriers) are presented in Table 2.

Comparisons of HospitalsSignificant differences were detected on INLP subscales whencomparing RNs in Magnet or Pathways designated hospitalsto those working in non designated hospitals (see Table 2).Post hoc comparisons using Tukey’s HSD test indicated highermean EBP barrier scores for non designated hospitals com-pared to both Pathways and Magnet hospitals at the .05 level ofsignificance. Magnet hospitals also scored significantly higherthan Pathway and non designated hospitals on EBP desirescores. The largest EBP desire differences when comparingdesignated and non designated hospitals were for the items“use research findings in practice,” and “participate in a re-search project.” Scores on EBP ability, frequencies, and overallreadiness did not differ significantly based on Magnet status.

Comparisons of Groups of NursesNursing education. Significant differences were detected onINLP subscales when comparing RNs of varying educationalpreparation. Mean scores for EBP barriers, frequency, abilities,readiness, and desire improved as educational level increasedas presented in Table 3. Post hoc comparisons using Tukey’sHSD test indicated that RNs with a bachelor’s degree or higherreported significantly fewer barriers to participating in researchor EBP compared to RNs with less educational preparation atthe .05 level of significance. Nurses with a bachelor’s degree orhigher degrees also scored significantly higher on EBP desire,


Original ArticleTable 1. Participant Demographics (N = 2,441) with State and Survey Comparisons

Survey respondents State data*

Education and employment % (n) % (n)

Highest level of education

Bachelor’s degree 44.9 (1,095) 43.3 (114,345)

Associate degree 32.9 (803) 40.02(106,143)

Diploma 6.5 (158) 6.9 (18,204)

Master’s degree 8.8 (215) 9 (23,802)

Doctoral degree .7 (18) .1 (1,470)

Not reported 6.2 (152) < 0 (20)

Nurse unit or role

Direct care, bedside RNs 81.0 (1,977) 82.9 (131,343)

Administration/management RNs 8.6 (211) 16.4 (31, 403)

Staff education RNs 2.5 (60) .7 (6,846)

Medical surgical/telemetry 25.0 (610)

Administration 8.6 (211)

Educator 2.5 (60)

Other Roles 6.2 (169)

Women/infant/children 20.3 (496)

Critical care 14.2 (346)

Perioperative/post-anesthesia/day surgery 11.7 (285)

Emergency 10.3 (252)

Mental health 2.0 (48)

Nurse certification 59.8 (1,459)

*Texas State Board of Nursing (2014)

ability, and frequency. At levels above the bachelor’s degree,significant increases were noted on EBP frequency and desirefor RNs with doctorate degrees compared to those with mas-ter’s degrees. EBP ability, readiness, and barriers scores didnot differ significantly between those two groups of RNs withadvanced education.

Nursing certification. Registered nurses who held a nursingcertification reported: (a) Higher frequency of EBP behaviors(M = 2.79, SD = .58) than non certified RNs (M = 2.58, SD =.53, t(1509) = –8.17, p � .001, d = .38); (b) higher desire forEBP (M = 3.35, SD = 1.07) compared to non certified RNs(M = 3.20, SD = 1.06, t(2165) = –3.19, p = .001, d = .14);and (c) higher EBP ability (M = 3.62, SD = .90) compared tonon certified RNs (M = 3.53, SD = .89, t(2152) = –2.39, p =.017, d = .10). In contrast, specialty-certified RNs identified

stronger barriers to participating in research or EBP (M = 2.11,SD = .71) compared to non certified RNs (M = 2.00, SD = .71,t(2119) = –3.173, p = .002, d = .15).

Predicting EBP ReadinessResults of regression modeling showed that a set of 12 variablespredicted 38% (adjusted R2 = .375) of the variance in the EBPreadiness score. Table 4 provides the coefficients, error, t-testvalues, and significance values for each variable. A history ofparticipation in a research project was the strongest positivepredictor of EBP readiness scores. Other positive predictorsincluded a perceived frequent need for information to supportclinical practice, specialty certification, and participation in thesystem career development (clinical ladder) program. Negativepredictors included difficulty understanding research articles,



Table 2. One-way ANOVA Exploring Differences in EBP Barriers, Desire, Ability, and Frequency among Magnet,Pathway to Excellence and Non-Magnet Hospitals

Number of EBP barriers EBP desire EBP ability EBP frequency EBP readinessDesignation status hospitals mean (SD) mean (SD) mean (SD) mean (SD) mean (SD)

Magnet 3 2.04 (.73) 3.38 (1.09) 3.57 (.92) 2.12 (.76) 3.02 (.76)

Pathway to Excellence 8 2.09 (.67) 3.14 (1.03) 3.63 (.87) 2.07 (.77) 2.94 (.74)

Non-Magnet/Non-Pathway 3 2.23 (.75) 3.22 (1.03) 3.56 (.89) 2.07 (.73) 2.95 (.74)

Full sample 14 2.07 (.72) 3.28 (1.07) 3.57 (.91) 2.71 (.57) 3.02 (.62)

Cronbach’s alpha .81 .91 .89 .82 .92

df 2, 2409 2, 2383 2, 2364 2, 2339 2, 2262

F statistic 15.424 9.836 .762 .871 3.158

p value <.0001 <.0001 .467 .419 .043

Eta squared .01 .01 .00 .00 .00

SD= standard deviation. Low scores are most desirable for EBP barrier scale; high scores most desirable for EBP desire, ability, frequency.

Table 3. One-way ANOVA Exploring Differences in EBP Barriers, Desire, Ability, and Frequency by EducationalPreparation

EBP barriers EBP desire EBP ability EBP frequency EBP readinessEducational preparation mean (SD) mean (SD) mean (SD) mean (SD) mean (SD)

Associate degree or diploma 2.02 (.76) 3.13 (1.07) 3.42 (.93) 1.91 (.66) 2.83 (.73)

Bachelor’s degree 2.08 (.72) 3.29 (1.05) 3.58 (.88) 2.12 (.76) 2.99 (.73)

Master’s degree 1.87 (.65) 3.87 (.95) 4.14 (.71) 2.66 (.73) 3.57 (.65)

Doctorate 1.89 (.60) 4.08 (.90) 4.41 (.62) 3.23 (.66) 3.92 (.65)

df 3, 2409 3, 2383 3, 2364 3, 2339 3, 2262

F statistic 14.124 32.335 42.181 76.075 66.045

p value <.0001 <.0001 <.0001 <.0001 <.0001

Eta squared .02 .04 .05 .09 .08

SD= standard deviation.

lack of understanding of the research process, length of timesince most recent nursing degree, and bedside RN role.

In summary, RNs who believed they frequently needed in-formation to support practice, who had participated in research,and were involved in the system career development programwere more likely to perceive themselves as ready to engage inEBP. Nurses less likely to perceive themselves as ready to en-gage in EBP were those who worked at the bedside, had notearned their last nursing degree recently, and reported diffi-culty understanding the research process and research articles.

DISCUSSIONEducation and Certification Support a Climateof EBP

In our sample, more highly educated and certified RNs hadhigher ratings for EBP readiness as measured by self-reportedability, desire, and frequency of behaviors. Nurses with abachelor’s degree or higher reported fewer barriers to EBP.Magnet standards for designation require organizations toset and meet higher goals for formal education and nurse


Original Article

Table 4. Association Between Variables and Personal Readiness Scores. Model Adjusted R2 = .38

Variable Unstandardized beta regression coefficient Standard error t-test value p value

Role: Bedside RN −2.73 .540 −5.055 .0001

History of participation in a research project 7.633 .426 17.904 .0001

Frequency of need for information to support practice 2.98 .249 11.950 .0001

Barrier: Lack of understanding of research process −1.486 .269 −5.516 .0001

Barrier: Difficulty understanding research articles −1.839 .278 −6.610 .0001

Barrier: Perception that nurses do not want to change practice .644 .189 3.417 .001

Barrier: Difficulty finding research or library services −.684 .240 −2.847 .004

RN Certification 1.068 .440 2.427 .02

Career Advancement Program level (clinical ladder) .751 .280 2.682 .007

Number of years since most recent nursing degree −.191 .031 −6.085 .0001

Number of years nursing experience .122 .031 3.902 .0001

certification (ANCC, 2008). These expectations have addedto a growing emphasis on nurses obtaining the BSN, withmore organizations preferring to hire BSN-prepared graduates(O’Connor, 2012). Nurses are often skeptical that increasededucation and the time and money investment will have valuefor them, yet many change views during or after completingthe BSN (Hawkins & Shell, 2012). While research has shownlinks between higher nurse education and quality outcomes,less is understood about how those shifts occur and EBP isinfluenced. When scrutinizing budget practices related tonurse tuition and certification reimbursement, healthcaresystem leaders need evidence to understand how highereducation and certification can contribute to improved patientoutcomes and the work environment.

Magnet and Pathways Designation Relate to EBPIn our sample, nurses from hospitals with either Magnetor Pathways designation reported fewer barriers to EBP andMagnet hospitals had the highest desire for EBP. Similarfindings were reported by Melnyk et al. (2012) regardingbarriers, suggesting that Magnet facilities have a culturesupportive of EBP. The largest differences between nursesin designated and non designated hospitals in our samplewere in response to the barrier items “I don’t understand theresearch process,” along with “I don’t see the value of researchin practice,” and “physicians do not want to change practice.”The final two of these items may reflect organizational culture,while the first one indicates individual EBP education. TheANCC requires designated organizations to provide evidencethat nurses incorporate new evidence into practice (ANCC,2014). Therefore, these organizations can be considered as (a)

context that supports an EBP culture, and (b) supportive offacilitators or change agents who can engage clinicians in EBP.Striving for Magnet designation may serve to operationalizethe PARIHS framework by development of both context andfacilitation necessary for successful implementation of EBP.

Nurses’ subordinate role in many healthcare organizationscan be a hindrance to implementing EBP (Atkinson, Turkel,& Cashy, 2008; Brown, Wickline, Ecoff, & Glaser, 2009; DePedro-Gomez et al., 2012). Without empowerment to takeaction, nurses cannot practice professionally and respond tochallenges using their professional skill and knowledge (Rao,2012). Lacking power to change practice, nurses may rely oninflexible bureaucratic structures to guide practice (Rao, 2012).Therefore, it is reasonable to propose that strategies aimed to-ward building nurse autonomy and engaging nurses to thefullest extent of their capabilities may lead to improvementsin quality outcomes. In our sample, RNs who took advan-tage of clinical ladder and research opportunities and increasedknowledge-based skills through certification and advanced de-grees were more likely to feel prepared to engage in EBP. Thesefindings align with others across the globe that show increasedEBP self-efficacy and workplace research support are linkedto greater EBP behaviors (Bostrom, Rudman, Ehrenberg,Gustavsson, & Wallin, 2013; Eizenberg, 2011; Thorsteinsson,2013).

Numerous articles relate the impact of positive work envi-ronment on nursing empowerment and improved patient out-comes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; SpenceLaschinger & Leiter, 2006; Stimpfel, Rosen, & McHugh, 2014).The Magnet Model component of Structural Empowermentrequires leadership to provide systems, policies, and pro-grams to empower autonomous professionals who engage in



Figure 1. Influence of Structural Empowerment on Individual Nurse Factors.

continuous learning. Structural Empowerment further sup-ports the Magnet Model component of New Knowledge, Inno-vation, & Improvements that requires applying new evidenceand contributing to the science of nursing (ANCC, 2014). Thus,it is not surprising that mounting evidence links Magnet des-ignation to improved outcomes (McHugh et al., 2013; Stimpfelet al., 2014.) Figure 1 depicts how components of the Mag-net Model and its supporting standards impact nurses’ EBPbehaviors, ability, desire, and barriers through culture change.

Implications for PracticeMany influential professional organizations are in agreementwith Magnet standards that promote increased educationalpreparation of nurses. The IOM, the Tri-Council for Nursing,and the Carnegie Foundation for the Advancement of Teach-ing issued statements stressing the importance of highereducation to promote quality patient care and safety (AmericanAssociation of Colleges of Nursing [AACN], 2014). Autonomyand opportunities for professional development are identifiedas key ingredients for positive practice environments by theInternational Council of Nurses (ICN, 2008). Further argu-ments are strengthened by evidence that higher percentages ofBSN staff nurses are linked to reduced mortality and improvedpatient outcomes in diverse settings (Aiken, Clarke, Cheung,Sloane, & Silber, 2003; Aiken et al., 2008; Estabrooks, Midodzi,

Cummings, Ricker, & Giovanetti, 2005; Tourangeau et al.,2007; You et al., 2013). Globally, healthcare system leadersremain challenged by nurses’ job dissatisfaction and burnout,with one quarter of all U.S. nurses reporting intentions to leavetheir job (ICN, 2008; Neff, Cimiotti, Heusinger, & Aiken,2011; You et al., 2013). Hospital administrators must attend tothese critical issues to retain the nurse workforce (Neff et al.,2011). Future efforts to increase educational requirements fornurses may be overshadowed by priorities to keep positionsfilled, while budgetary constraints may curb efforts to providetuition and certification reimbursements. Our predictivemodel suggests that EBP readiness is advanced throughopportunities for nurses to engage in research projects;however, research activities are resource-intensive as well.

Certified RNs had higher mean EBP behavior, ability, anddesire scores, yet also had higher EBP barrier scores in our sam-ple. This finding may seem contradictory, but could indicategreater nurse awareness of EBP opportunities following certi-fication and an increased perception of barriers. By contrast,RNs with a BSN or higher education did not follow this patternand reported lower barrier scores. Specialty certification hasbeen associated with lower mortality and failure to rescue inprior research (defined as preventing a clinically important de-terioration, death, or disability; AHRQ, n.d.); however, this onlyheld true for nurses with a BSN or higher (Kendall-Gallagher,


Original ArticleAiken, Sloane, & Cimiotti, 2011). Future studies could examinewhether the achievement of the BSN gives nurses tools to over-come barriers, and how the addition of specialty certificationcontributes to desired behaviors.

LimitationsAlthough our sample closely matched state RN demograph-ics, convenience sampling methods may introduce bias. It isunknown how responses from those who did not participatewould alter findings. Self-report survey methods may be less ac-curate than other forms of measurement. Of note, most scoresfell into moderate ranges on average (e.g., 3 = some desire,somewhat able) indicating opportunities for improvements inall groups of nurses. Differences between groups were modest.It is unknown how they translate into meaningful clinical vari-ations. Sampling from one institution limits generalizability,however, our large healthcare system includes diverse culturesand a wide geographic range. Finally, our design limits causeand effect conclusions so further experimentation is needed tobuild confidence in findings.

CONCLUSIONSUsing current research in clinical care is an essential skill forhealthcare professionals. Organizations are challenged by howto increase EBP to meet quality outcomes goals. Our findingsadd support for continued efforts to increase nurse educationand certifications, and create opportunities for nurses to partic-ipate in career advancement opportunities and research. Thefindings also provide validation of Structural Empowermentstandards required for organizations designated with Magnetand Pathway to Excellence. Higher levels of education and certi-fication may empower nurses to act as autonomous practition-ers who advocate for evidence-based innovations, and allow aspirit of inquiry to flourish. WVN


� RNs with higher education and specialty certifica-tion feel more prepared for EBP.

� RNs with research experiences have increasedreadiness for EBP activities.

� Organizations should align with Magnet standardsfor increased professional development strategiesto achieve high-quality, evidence-based care.

Author information

Marian Wilson, Pain Management Board Certified Nurse,Nurse Scientist, Texas Health Presbyterian Hospital, Allen,Dallas, and Kaufman, TX, USA; Assistant Professor, Wash-ington State University, College of Nursing, Spokane, WA,USA; Martha Sleutel, Perinatal Clinical Nurse Specialist,

Nurse Scientist, Texas Health Arlington Memorial and TexasHealth Denton, TX, USA; Patricia Newcomb, Pediatric NursePractitioner–Board Certified, Nurse Scientist, Texas HealthHarris Fort Worth, Texas Health Azle, and Texas HealthSpecialty Hospitals, Fort Worth, TX, USA; Deborah Be-han, Medical-Surgical Board Certified Nurse, Nurse Scien-tist, Texas Health Hurst-Euless-Bedford, Bedford, TX, USA;Judith Walsh, Nurse Scientist, Texas Health Resources Plano,Plano, TX, USA; Jo Nell Wells, Oncology Certified Nurse(OCN), Medical-Surgical Board Certified Nurse, Nurse Scien-tist, Texas Health Resources, Alliance Hospital Argyle, TX,USA; Kathleen M. Baldwin, Adult Clinical Nurse Specialist–Board Certified, Adult Nurse Practitioner–Board Certified;Gerontologic Nurse Practitioner–Board Certified, Nurse Sci-entist, Texas Health Harris Hospital Southwest, Fort Worthand Texas Health Harris Hospital, Cleburne, TX, USA.The authors acknowledge the Texas Health Resources Foun-dation for grant funding to support our participant incentivesand the Texas Health Resources medical library services forassistance with literature retrieval.

Address correspondence to Dr. Marian Wilson, WashingtonState University, College of Nursing, P.O. Box 1495, Spokane,WA 99210; [email protected]

Accepted 26 October 2014Copyright C© 2015, Sigma Theta Tau International

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doi 10.1111/wvn.12077WVN 2015;12:12–21


Original Article

Effectiveness of a Brief, Basic Evidence-BasedPractice Course for Clinical NursesAntonio J. Ramos-Morcillo, RN, MSc, PhD • Serafın Fernandez-Salazar, RN, MSc •Marıa Ruzafa-Martınez, RN, MSc, PhD • Rafael Del-Pino-Casado, RN, MSc, PhD

Keywords

evidence-basedpractice,nursing,

effectiveness,education,

intervention

ABSTRACTBackground: Barriers to the implementation of evidence-based practice (EBP) by nursing profes-sionals include a lack of knowledge, inadequate skills in searching for and appraising evidence,and consulting research articles. However, few studies have addressed the effectiveness of edu-cational interventions to improve their competence.

Aims: To evaluate the effectiveness of a brief basic online and face-to-face educational interven-tion to promote EBP attitudes, knowledge and skills, and practice in clinical care nurses.

Methods: This study was quasi-experimental, pretest-posttest design with a comparison group.The sample included registered nurses enrolled in the free continuing education courses offeredin 2013 by the Nursing Council of Jaen (Spain). The study included 109 participants (54 in theintervention group and 55 in the comparison group). The intervention was a brief, basic EBPcourse with online and face-to-face learning. The comparison group received an educationalintervention with different content. The evidence-based practice questionnaire (EBPQ) was usedto evaluate EBP attitude, knowledge and skills, and practice before the intervention, and at 21and 60 days following the intervention. Two-way mixed analysis of variance was conducted.

Results: There was a significant difference between intervention and comparison groups in theknowledge and skills dimension. The difference between groups was not significant in the EBPpractice dimension. Both groups had high scores in the attitude dimension that did not changeafter the intervention.

Linking Evidence to Action: A brief basic educational intervention on EBP with online andface-to-face learning can produce improvements in the knowledge and skills of clinical nurses.

INTRODUCTIONEvidence-based practice (EBP) is an essential element in thedelivery of optimal care quality. In EBP, healthcare profession-als make clinical decisions based on the best available researchresults while considering the preferences and clinical circum-stances of their patients. EBP implementation has been relatedto improved health outcomes (Meijers et al., 2006) and reducedhealth costs (McGinty & Anderson, 2008). It is also reported toincrease the satisfaction of nursing professionals (Maljanian,Caramanica, Taylor, MacRae, & Beland, 2002), who must meetincreasingly high expectations of care quality on the part of pa-tients and healthcare organizations.

Experts (Frenk et al., 2010) and international organiza-tions have emphasized the need for healthcare professionalsto possess adequate knowledge, skills, and attitudes for EBPimplementation. The Institute of Medicine of the United Statesconsiders EBP to be a central competency for all healthcare pro-fessionals and aims for 90% of health decisions to be basedon optimal evidence by 2020 (McClellan, McGinnis, Nabel,& Olsen, 2007). The International Council of Nurses (2007)

considers EBP a professional responsibility and a central char-acteristic of the work of nurses.

Incorporation of EBP into the clinical practice of nursesinvolves a highly complex behavioral change influenced by var-ious factors, and it has proceeded at a slower pace than desirablesince its inception 20 years ago (Melnyk, 2006). The adoptionand implementation of EBP by nurses has been described asinadequate (Sandstrom, Borglin, Nilsson, & Willman, 2011).A recent study showed that 34.5% of nursing professionals re-ported that their colleagues implemented EBP in their care,46.4% believed that EBP was routinely applied in their insti-tution, 76.2% reported a need for more knowledge and skillsin EBP, and 72.9% wanted online training on EBP (Melnyk,Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012).

BACKGROUNDThere have been numerous studies on attitudes, knowledge,and skills in relation to EBP, including the practice and uti-lization of EBP (Melnyk et al., 2012; Pravikoff, Pierce, &Tanner, 2005) and the barriers against and opportunities for

Worldviews on Evidence-Based Nursing, 2015; 12:4, 199–207. 199C© 2015 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided theoriginal work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Effectiveness of an EBP Course on Clinical Nurses

its implementation, which were generally classified in relationto the professionals themselves, organizations, and institutionpolicies (Sadeghi-Bazargani, Tabrizi, & Azami-Aghdash, 2014).The main barriers to EBP faced by healthcare professionalsinclude lack of time, inadequate authority to implement thechanges, inadequate numbers of EBP mentors along with aculture and environment that does not support EBP (Melnyk,2014), and a lack of knowledge and skills in searching for andappraising research articles (Sadeghi-Bazargani et al., 2014).Related to the knowledge and skills in EBP, disparities also ex-ist among nurses´ perceptions. In our context, higher scores inknowledge and skills were obtained among nurses with shorterprofessional experience (Gonzalez-Torrente et al., 2012). Withrespect to attitudes toward EBP, several studies show moder-ate to high scores (Koehn & Lehman, 2008), and highlightthat nurses with positive attitudes are more likely to use EBP(Estabrooks, Floyd, Scott-Findlay, O’Leary, & Gushta, 2003;Melnyk et al., 2004).

FrameworkThe Theory of Planned Behavior (TPB; Ajzen, 1991) is consid-ered appropriate to explain the behavioral intentions of health-care professionals (Eccles et al., 2006; Godin, Belanger-Gravel,Eccles, & Grimshaw, 2008). According to this theory, behav-ioral intention is explained by attitude, subjective norms, andperceived behavioral control. Attitudes refer to the general eval-uation of behavior and are determined by beliefs about it and byperceptions of its consequences. Subjective norms refer to theperceived social approval of the behavior and are determinedby expectations of approval or disapproval by key referencegroups. Perceived behavioral control refers to the confidenceof individuals in their capacity (knowledge and skills) to carryout a specific behavior and is determined by their perceptionof the opportunities, barriers, and resources involved.

Review of LiteratureVarious educational programs for clinical nurses have beendesigned to reduce the barriers and promote their acquisitionof EBP knowledge and skills (Schulman, 2008; Soukup & Mc-Cleish, 2008). The duration and content of these courses vary,but they all impart basic information on the EBP paradigmand its implementation, and discuss the behavioral changesinvolved. The teaching methodology also differs among pro-grams and includes face-to-face classes, discussion groups, on-line learning, and journal clubs, among others.

Despite the major potential benefits of education and skillsbuilding in EBP and the large number of instruments for itsevaluation (Leung, Trevena, & Waters, 2014), there has beenlittle investigation of its effectiveness (Hart et al., 2008; Kimet al., 2013; Mollon et al., 2012). In contrast, there have beennumerous studies and systematic reviews on educational inter-ventions for physicians and medical students (Ilic & Maloney,2014; Young, Rohwer, Volmink, & Clarke, 2014).

Among published studies on EBP courses for nurses, somedid not yield conclusive results (Mollon et al., 2012; Sherriff,

Wallis, & Chaboyer, 2007), some did not include a controlgroup (Kim et al., 2013; Varnell, Haas, Duke, & Hudson, 2008),and some used instruments with no established psychometricvalidity to measure EBP competence (Reviriego et al., 2014).However, other studies have offered more consistent resultson factors that facilitate EBP learning, including a higher nurseeducational level (Hart et al., 2008), the presence of EBP men-tors or leaders with EBP expertise (Wallen et al., 2010), and thepromotion of student self-learning (Zadvinskis, 2008).

There have been recent calls for further studies to investi-gate the effectiveness of educational interventions to improveEBP implementation in relation to their duration, target popu-lation, methodology, clinical setting, and other influential fac-tors (Kim et al., 2013; Upton, Upton, & Scurlock-Evans, 2014).With this background, this study was designed to evaluate theeffectiveness (change in EBP attitudes, knowledge, skills, andpractice) of a brief, basic, online, and face-to-face educationalintervention for clinical care nurses.

METHODOLOGYDesignThis study was a two group quasi-experiment with an inter-vention group and a comparison group using a pre-and post-test design, which lacked random assignment (Melnyk & Cole,2011).

Sample and SettingsThe study included a convenience sample of 109 nursing pro-fessionals who attended free continuing education courses of-fered by the Nursing Council of Jaen (Spain) in 2013. Therewere 54 participants in the intervention group and 55 in thecomparison group. The nurses came principally from teachinghospitals.

Calculation of the sample size was based on the estima-tions of Bausell and Li (2002) for a two-way mixed analysis ofvariance (ANOVA) design (between-subject factor: EBP inter-vention yes or no, within-subject factor: Repeated measures).The calculation supported 106 participants (53 + 53) were re-quired to detect a standardized mean difference of at least .30between intervention and comparison groups with 80% powerand 95% confidence. Calculation of the standardized meandifference considered a minimum difference of 6 points inthe EBP Questionnaire (EBPQ) score (De Pedro Gomez et al.,2009) and an estimated standard deviation of 20.8, taken froma previous study of the EBPQ in Spanish nurses (Gonzalez-Torrente et al., 2012).

ProcedureThe nurses in the intervention group attended the EBP coursein February of 2013, and the comparison group attended adifferent course during the same time frame. The attitude,knowledge and skills, and practice in EBP were each evaluatedusing a questionnaire before the course began (time O1) andafter at 21 (time O2) and 60 (time O3) days thereafter.

200 Worldviews on Evidence-Based Nursing, 2015; 12:4, 199–207.C© 2015 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.

Original ArticleAll the data were collected the first day of the course in

both groups. The questionnaire was completed and deliveredanonymously. Participants selected a private code to identifytheir questionnaires, blinding the researchers to their identity.The questionnaire was self-administered, avoiding researcherbias.

EthicsThe study was approved by the provincial ethics committee.The objective of the study and its anonymity were explainedto participants before administration of the questionnaire, andtheir informed consent was obtained.

Data AnalysisAfter a descriptive analysis was conducted calculating percent-ages and means, the effectiveness of the intervention was an-alyzed by two-way mixed ANOVA, with a within-subject factor(time O1, O2, and O3), and a between-subjects factor (inter-vention). The researcher conducting the statistical analysis wasblinded to the group membership of participants.

InterventionThe intervention group received a brief, basic EBP course. Thetraining activity included two face-to-face sessions of 5 hourseach and online learning for 30 hours.

The face-to-face sessions developed attitudes, cognitive as-pects, and skills related to EBP issues, including the formula-tion of a clinical question in PICO (Patient or Population, Inter-vention, Comparison, Outcome) format, knowledge of primaryand secondary sources, information recovery, Boolean opera-tors, main databases, and PubMed searches. This learning wasreinforced by the home study. Incorporation of this knowl-edge was evaluated by the completion of different exercisesand by providing an individual report to the student with anassessment of each exercise. Students were asked to set eachexercise in the routine clinical care setting. An online specificplatform was designed and used to support the online learning(consultations, tutoring, and exercise feedback); it included acompulsory discussion forum and offered documentary andreference resources.

The comparison group received a course whose contentsdiffered from those of the EBP course. The course for thecomparison group was about digital resources and informa-tion technology for clinical practice. However, to facilitate thecomparison between the intervention group and the compari-son group, the course given to the comparison group had thesame duration and the same methodology (online and face-to-face learning, home study exercises, and strategies to supportteaching) as the course given to the intervention group. Table 1shows the characteristics and contents of both educational in-terventions.

InstrumentEBP attitudes, knowledge and skills, and practice were evalu-ated with the validated Spanish adaptation by De Pedro Gomez

et al. (2009) of the EBPQ (Upton & Upton, 2006), a self-administered 19-item questionnaire with each item scored ona 7-point Likert scale (1-7), with a higher score indicating amore positive attitude toward EBP or greater implementation,or knowledge and or skills of EBP.

The Spanish version of the EBPQ reproduces the originalstructure of the tool, showing three dimensions (attitudes: 3items; knowledge and skills: 10 items; and practice: 6 items)both in the exploratory factor analysis (62.3% of total varianceexplained) and in the confirmatory factor analysis (acceptablefit indices), with a proper internal reliability of each dimension(above .7; De Pedro Gomez et al., 2009). In our sample, ex-ploratory factor analysis with principal axis factors and Varimaxrotation showed the previous three dimensions, which accountfor 72.5% of the variance. Regarding internal reliability in oursample, Cronbach’s alpha values were .71 for attitudes, .95 forknowledge and skills, and .92 for practice.

RESULTSSample DescriptionTable 2 exhibits the descriptive data of the study sample andthe comparison between groups. The mean age of the samplewas 35.7 years and 77% were females. All participants had abachelor’s degree in nursing, 21.1% also had a master’s or an-other university degree, and 16.5% had completed training ina nursing specialty. The average length of professional experi-ence was 12 years, and 42.2% had received previous trainingin EBP. No significant differences were observed between theintervention and comparison groups in these study variables,which are listed in Table 2.

Effect of the InterventionTable 3 reports the mean scores of the three EBPQ dimensions(knowledge and skills, attitude, and practice) in each group ateach measurement time point. At baseline (01), no significantdifference in any study dimension was found.

The analysis of the effect of the intervention on EBP di-mensions met the assumptions of sphericity and homogeneity(p � .05 for Mauchly’s test of sphericity and for Levene’s testof homogeneity). Table 4 exhibits the between-subject effects(EBP intervention) and the interaction between interventionand time for each dimension. The results for knowledge andskills significantly differed, both between the groups and in theinteraction of intervention with time. Post hoc analysis of thesedifferences with the Bonferroni test revealed a greater effect onthe intervention group versus the comparison group both atO2 (p = .002) and O3 (p = .005). No significant differenceswere observed in the dimensions of attitude and practice.

DISCUSSIONThis study shows the degree to which a basic EBP course withan online and face-to-face learning can increase the compe-tence of nursing professionals. The students were clinical carenurses with a bachelor’s degree in nursing. The course had

Worldviews on Evidence-Based Nursing, 2015; 12:4, 199–207. 201C© 2015 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.


Table 1. Characteristics and Contents of the EBP (Intervention Group) and Digital Resources (ComparisonGroup) Educational Interventions

Educational intervention characteristic Intervention group Comparison group

Face-to-face sessions 5+ 5 (10 h) 5+ 5 (10 h)

Online learning 15+ 15 (30 h) 15+ 15 (30 h)

Total duration educational intervention 40 h 40 h

Electronic tutoring Yes Yes

Specifically designed online learning platform Yes Yes

Documentary and reference resources in the online learning platform Yes Yes

Discussion forum Yes Yes

Weekly exercises and home study Yes Yes

Individual report with an assessment of each exercise Yes Yes

Contents

Intervention group (EBP) Comparison group (digital resources)

Session 1 (face to face): Session 1 (face to face):

• Introduction to EBP• Formulation of the clinical question (PICO)• Hierarchy evidence search:– Meta search engine: trip database, epistemonikos, evidence portal, evidence search,exploraevidencia

– Clinical practice guidelines online databases: NGC, NICE, SIGN, RNAO, Guiasalud

– Systematics reviews databases: Cochrane Library, JBI, CRD

• Introduction to the Web 2.0 and e-health• Collaboration tools applied to health– Community of practice

– Google docs

– Social network

– Survey (Survey Monkey, Google forms)

– File-hosting service (Dropbox, Google Drive, etc.)

Session 2 (face to face): Session 2 (face to face):

• Search strategies:– Controlled vocabulary (thesaurus/MeSH)

– Keywords

– Boolean operators

– Limit function

– Searching databases: PubMed/Medline, CINAHL, PsycINFO, SciELO

• Communication and dissemination information tools applied tohealth:

– Google groups, Webinars (Wiziq), Twitter, Skype, Blogs

• Selection and management information tools applied to health:– Really Simple Syndication (RSS), Feedly, Diigo

• Audio-visual management tools applied to health:– YouTube, Flickr, Slideshare, Podcast

Online learning (30 h) Online learning (30 h)

• Study of the contents with the documentary and reference resources• Resolution of the exercises related to:– Formulate the clinical PICO question

– Identify two clinical practice guidelines and two systematic reviews about your PICOquestion

– Describe 10 recommendations about your clinical question and identify the level ofevidence and grades of recommendation

– Identify the original articles of the recommendations described previously

– Find three documents (include in a list) in any database (full text)

– Describe the hierarchy search of your clinical question. Detail your search strategies(controlled vocabulary, keywords, limit function, and Boolean operators)

– Search four original articles with several limits in PubMed

• Discussion forum:– First week: “How do you implement in your service the best practice X?”

– Second week: About the implementation in your service the best practice X: “What doyou think would be the answer of the colleagues of your service? And, what would bethe role of the leaderships?”

• Study of the contents with the documentary and reference resources• Resolution of the exercises related to a clinical case (diabetes orpressure ulcer):

– Design of collaborative files (word processor, survey, etc.)

– Create an account in the different resources

– Identify resources 2.0 about safety patient, association of patients,recommendations of lifestyles

– Select two videos from YouTube for education for health

– Self-report about resources 2.0 and health

• Discussion forum:– First week: "Barriers and Facilitators for the use of resources 2.0 inyour workplace"

– Second week: "Safe use of the Internet in health care"


Original ArticleTable 2. Descriptive Data of the Study Sample and Comparison Between Groups

Total IG CG p-value

Age in years (SD) 35.7 (12.2) 36.6 (10.1) 34.7 (8.3) .295

Gender (% females) 77 70.4 83.6 .100

Educational level (% with master’s or additional university degree) 21.1 18.5 23.6 .513

Nursing specialty (%) 16.5 18.5 14.5 .576

Previous EBP training (%) 42.2 48.1 36.4 .213

Professional experience in years (SD) 12.2 (9.8) 13.43 (10.8) 10.9 (8.6) .193

Note. IG= intervention group. CG= comparison group. SD= standard deviation.

Table 3. Mean Scores for EBPQ Dimensions in the Intervention and Comparison Groups at the Three Mea-surement Time Points

O1 O2 O3

Outcomes Groups Mean 95% CI Mean 95% CI Mean 95% CI

Knowledge and skills IG 3.65 3.29, 4.01 4.89 4.65, 5.13 4.92 4.69, 5.15

CG 3.61 3.28, 3.93 4.07 3.68, 4.47 4.3 4.02, 4.59

p p� .05 p< .05 p< .05

Attitude IG 5.88 5.63, 6.13 6.05 5.87, 6.23 5.85 5.58, 6.11

CG 5.97 5.73, 6.21 5.85 5.56, 6.13 5.99 5.78, 6.21

p p� .05 p� .05 p� .05

Practice IG 3.56 3.13, 3.98 4.14 3.70. 4.58 4.72 4.36, 5.08

CG 3.77 3.37, 4.17 4.31 3.90, 4.72 4.47 4.11, 4.82

p p� .05 p� .05 p� .05

Note. O1= before the intervention. O2= at 21 days. O3= at 60 days. IG= intervention group. CG= comparison group. CI= confidence interval.

impact on their EBP knowledge and skills but had no im-pact on the dimensions of attitude and practice. According tothe TPB, our educational intervention improves the dimen-sions of subjective norms and perceived behavioral control ofnurses, because increases in the nurses’ confidence to per-form their clinical practice were observed in the interventiongroup.

Related to the attitude dimension, also included in the TPB,the participants receiving the EBP course and the comparisongroup both had a high mean baseline score in attitudes to-ward EBP, and this score was not affected by the intervention.Few studies have evaluated the effectiveness of educational in-terventions aimed at nursing professionals. The design anddevelopment of this study followed expert recommendations

for studies on the effectiveness of EBP training in healthcareprofessionals, with the utilization of control groups and vali-dated measurement instruments (Melnyk et al., 2004; Uptonet al., 2014; Varnell et al., 2008; Young et al., 2014). The nursesin both groups received an educational intervention with differ-ent contents but similar formal characteristics (duration, onlineand face-to-face learning, and teaching support), improvinggroup comparability. We used a validated Spanish adaptation(De Pedro Gomez et al., 2009) of the 19-item version of theEBPQ (Upton & Upton, 2006), which was reported to possessoptimal psychometric characteristics in a recent review (Leunget al., 2014). In addition, its availability in different languages(Upton et al., 2014) facilitates the comparison of findings withthose in other countries.



Table 4. Effect of the Intervention on EBP Knowledgeand Skills, Attitudes, and Practice (Two-Way MixedANOVA)

Between-subjecteffects (EBPintervention)

Interaction:intervention× time

F (df) p F (df) p

Knowledgeand skills

6.6 (1) .01 8.73(2)

<.001

Attitude 0.01(1)

.92 2.26(2)

.11

Practice 0.04(1)

.85 2.16(2)

.12

Note. df= degrees of freedom.

EBP knowledge and skills in nurses have been improved byeducational interventions with different durations and method-ologies, including online self-learning courses (Hart et al.,2008; Reviriego et al., 2014), courses within a tutoring program(Kim et al., 2013), and face-to-face courses with a “workshop”format, although these only improved skills in the search forevidence (Sherriff et al., 2007). In contrast, EBP knowledge andskills were not improved by an exclusively online educationalintervention (Mollon et al., 2012), which may be attributable tothe lack of student feedback or learning assessment.

The few studies found on changes in the practice of EBPpublished varied results, with Mollon et al. (2012) finding nosignificant changes after their online program, whereas Kimet al. (2013) reported an important improvement after a 9-month multicomponent EBP implementation program thatincluded an educational intervention. However, the degree towhich this improvement can be attributed to the educationalintervention is not known. Substantive improvements in EBPpractice were also reported by Varnell et al. (2008) after aneducational course and by Wallen et al. (2010) after a multi-component intervention.

In this study, scores for the attitude of all participants to-ward EBP were high (range: 5.83 to 5.99), both before and afterthe intervention, consistent with reports by authors applyingthe EBPQ in nurses (Kim et al., 2013; Mollon et al., 2012)and other healthcare professionals (range: 5.22 to 5.75; Mollonet al., 2012; Upton & Upton, 2006). The score for EBP attitudesin this study is close to a previous finding in primary care inour region (Gonzalez-Torrente et al., 2012). These high scoresamong nurses may explain why the intervention did not ap-pear to affect their attitudes. Alternatively, it is possible that theEBPQ offers inadequate precision in the estimation of attitudes(De Pedro Gomez et al., 2009; Leung et al., 2014; Sese-Abadet al., 2014) and requires further improvement (Upton et al.,2014). It did not even detect any effect on attitude after the 9-month course studied by Kim et al. (2013); measurement of thisdimension is known to be influenced by differences in organi-

zational, geographic, cultural, and professional settings, (Mol-lon et al., 2012). Special efforts have been made to improve theevaluation of attitudes toward EBP (Melnyk, Fineout-Overholt,& Mays, 2008; Ruzafa-Martınez, Lopez-Iborra, & Madrigal-Torres, 2011), and two quasi-experimental studies were ableto discriminate differences in the attitude of nursing profes-sionals after an educational intervention (Varnell et al., 2008;Wallen et al., 2010).

LimitationsThe participants of this study were not randomly selected, al-though a comparison group was included and no differencesbetween groups were found in potential confounders. The vol-untary participation of the professionals may also imply a spe-cial interest in the topic. In addition, only short-term effectswere evaluated (45 days postintervention), although analysis ofthe longer-term impact of the course would likely be compli-cated by the influence of other uncontrolled factors on scores inthe three EBPQ dimensions. The instrument is based on self-report for knowledge and skills as opposed to observation or ob-jective measurement. However, Taheri, Mirmohamadsadeghi,Adibi, and Ashorion (2008) have shown a positive correlationbetween the EBP competence assessed by self-reported andobjective tools. Finally, comparisons with the results of otherstudies are limited by the wide differences in design, educa-tional intervention, and evaluation instruments.


� The incorporation of EBP into nursing practice isslow and its implementation by nurses is inade-quate. Barriers to EBP implementation include alack of knowledge and inadequate skills in search-ing for and critically appraising research articles.

� A brief basic EBP educational intervention withonline and face-to-face learning can produce im-provements in the knowledge and skills of clinicalnurses.

� Advantages of this educational approach includeits low use of resources, its adaptability to worktimetables, and its favoring of the active role ofparticipants.

� The intervention targets graduate nurses whowork directly with patients, and it can be recom-mended in any clinical setting.

IMPLICATIONSOur results are highly relevant to the design of continuingeducation programs for nursing professionals and health-care organizations, given the limited data available on the


Original Articleeffectiveness of educational interventions to improve thecompetence of healthcare professionals in EBP (Nabulsi et al.,2007).

For the Continuing Education of Nursing Profes-sionalsThe present findings endorse the value of this educational in-tervention on EBP, aimed at professionals who are graduatesand work directly with patients. The course content focuses onimproving knowledge of the EBP paradigm, formulating PICOquestions, and searching electronic bibliographic resources,as proposed by Balakas and Fineout-Overholt (2011, p. 339).The objective is to encourage nurses in their self-perception as“evidence-users” rather than “evidence-generators” (Fineout-Overholt & Johnston, 2005). More advanced courses are war-ranted to expand learning on the critical appraisal of scientificarticles (Yousefi-Nooraie, Rashidian, Keating, & Schonstein,2007).

The relatively short duration of the course along with itsonline and home learning components allow it to be readilyadapted to the timetable of nurses and reduce the training costburden. Finally, the personalized feedback favors interactionwith teachers, facilitates self-learning, and fosters an active rolein learning (Zadvinskis, 2008).

For Healthcare OrganizationsHealthcare organizations should include educational interven-tions within a wider conceptual framework, as that provided bythe TPB, developing multicomponent strategies for healthcareprofessionals to implement EBP in their routine clinical prac-tice. According to the TPB, the present educational interven-tion keeps the same attitudes and effects with the dimensionsof subjective norms and perceived behavioral control, althoughboth would require further contributions.

Numerous studies have shown the efficacy of variousinterventions. Subjective norms of nurses could be im-proved by the provision of systematic support by profes-sionals with administrative responsibilities (Brown, Wick-line, Ecoff, & Glaser, 2009; Newhouse, Dearholt, Poe,Pugh, & White, 2007). Improvements in perceived behav-ioral control through reducing the barriers to EBP adoptioncould be achieved through incentives (Flodgren et al., 2011)and the screening of reminders on point-of-care computers(Shojania, Jennings, Mayhew, Ramsay, & Eccles, 2009). In ad-dition, changes in organizational culture (Parmelli et al., 2011),audits, and feedback (Jamtvedt, Young, Kristoffersen, O’Brien,& Oxman, 2006) have been found to exert an influence onsubjective norms and perceived behavioral control.

CONCLUSIONSHealthcare centers share the responsibility of training health-care professionals about EBP. Our findings demonstrate thata brief, basic, online and face-to-face course on EPB is suffi-cient to produce improvements in the knowledge and skills

of clinical nurses. Further research is required to determinethe long-term impact of educational interventions, their cost-effectiveness, and to evaluate the effects of evidence-based careon health outcomes. WVN

Author information

Antonio J. Ramos-Morcillo, Clinical Nurse of PrimaryHealth Care, Murcian Health Service, Murcia, Spain;Serafın Fernandez-Salazar, Clinical Nurse, Hospital de AltaResolucion Sierra de Segura, Jaen, Spain; Marıa Ruzafa-Martınez, Associate Professor, Nursing Department, Faculty ofNursing, University of Murcia, Murcia, Spain; Rafael Del-Pino-Casado, Associate Professor, Nursing Department, School ofHealth Sciences, University of Jaen, Jaen, Spain

This research was grant funded by Nursing Council of Jaen(Reference Number: 01-2014 CEJ). Address correspondenceto Dr. Antonio J. Ramos-Morcillo, Clinical Nurse of PrimaryHealth Care, Murcian Health Service, Area de Salud VI, VegaMedia del Segura, Avenida Marques de los Velez s/n, 30008,Murcia, Spain; [email protected]

Accepted 14 February 2015Copyright C© 2015, Sigma Theta Tau International

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doi 10.1111/wvn.12103WVN 2015;12:199–207


CEOriginal Article

Evidence-Based Practice Beliefs andImplementation Before and After anInitiative to Promote Evidence-Based Nursingin an Ambulatory Oncology SettingMeghan Underhill, RN, PhD, AOCNS • Kristin Roper, RN, PhD • Mary Lou Siefert, RN,DNSc, AOCN • Jean Boucher, RN, PhD, ANP • Donna Berry, RN, PhD, AOCN, FAAN

Keywords

evidence-basedpractice,nursing,

cancer care

ABSTRACTBackground: The purpose of evidence-based practice (EBP) in nursing is to improve patientoutcomes, providing the best and most up-to-date care practices. In 2011, a nurse-led committeeconvened to develop an institute-wide initiative to promote EBP with oncology nurses at theDana-Farber Cancer Institute.

Aims: Compare and describe oncology nurse beliefs and perceived implementation of EBP andexplore beliefs and implementation before and after implementing an institutional EBP initiative.

Methods: Based on the Advancing Research and Clinical practice through close Collaboration(ARCC) Model, the Evidence-Based Practice Beliefs (EBP-B) and Implementation (EBP-I) scaleswere distributed to all Dana-Farber Cancer Institute registered and advanced practice nursesthrough an online survey in 2011 (T1) and again in 2013 (T2) after the implementation of aninstitute-wide nursing EBP initiative (orientation, poster presentations, education). Descriptive andcorrelation statistics were completed on total scores and demographics. Differences in beliefs andimplementation scores based on demographics were analyzed with Mann–Whitney U tests. Open-ended item responses at each time point (T) were summarized for EBP barriers and promoters.

Findings: Thirty-two percent (n = 112 at T1; n = 113 at T2) of 350 nurses began the survey.A history of formal EBP education and nurse role were associated with higher EBP-B and EBP-Iscores (p < .05). Highest level of education was significantly correlated with both EBP-B (r = .25;p = .03) and EBP-I (r = .32; p = .01). Narrative responses to open-ended questions describedperceived personal and environmental barriers to engaging in EBP.

Linking Evidence to Action: Although no significant differences were noted in beliefs and im-plementation after the EBP initiative, nurses reported valuing EBP. Respondents acknowledgeda lack of full preparation in the EBP process to engage in and implement EBP consistently. Nurserole, formal EBP education, and highest level of education were associated with perceptionsof EBP beliefs and implementation. Nurses should be provided the mentorship and support toobtain continuing education about how to engage in EBP and about implementing EBP change.

INTRODUCTIONEvidence-based practice (EBP) in nursing is the synthesis ofclinical expertise, research evidence, and patient preference tocreate effective patient care strategies (Fineout-Overholt, Mel-nyk, & Schultz, 2005; Schaffer, Sandau, & Diedrick, 2012).EBP is an important element of nursing care that guides clini-cal practice. The purpose of EBP is to improve clinical care andpatient outcomes, providing the best most up-to-date care prac-tices. Additionally, EBP is important from an administrativeaspect, as it is a requirement to maintain Magnet designationstatus (Reigle et al., 2008). Magnet designation is granted by

the American Nurse Credentialing Center which is associatedwith the American Nurses Association. It is a recognition givento hospitals that meet specific criteria for high quality nursing.EBP is specifically important within the oncology specialty asclinical management is continuously advancing and generat-ing new research evidence. Therefore, it is an objective for mostoncology institutes to promote the development of EBP as wellas to provide the most up-to-date care in their own practice(Titler & Everett, 2006).

In 2009, the Dana-Farber Cancer Institute (DFCI) nurs-ing governance implemented the Science and Practice Aligned


Original Articlewith Nursing (SPAWN) process and structure (Boucher, Roper,Underhill, & Berry, 2013) aimed at supporting and facilitatingEBP within nursing and patient care services (NPCS). The pur-pose of this study was to describe and compare nurse beliefsabout the value of EBP and to explore beliefs and implemen-tation of EBP before and after introducing strategies to informnurses of EBP across the institute.

BACKGROUNDThough literature supports that nurses value and understandthe importance of improving practice (Johansson, Fogelberg-Dahm, & Wadensten, 2010; Melnyk et al., 2004), applyingevidence to practice and practical implementation of EBP canbe challenging (Facchiano & Snyder, 2012; Pravikoff, Tanner,& Pierce, 2005). Certain barriers interfere with translatingevidence into direct nursing care. Common individual nurselevel barriers include limited time away from direct care(Brown, Wickline, Ecoff, & Glaser, 2009; Koehn & Lehman,2008; Pravikoff et al., 2005), inadequate EBP knowledge(Brown et al., 2009; Koehn & Lehman, 2008; Linton & Prasun,2012; Melnyk et al., 2004) and training (Pravikoff et al., 2005),limited ability to locate evidence for implementation (Gerrishet al., 2007; Pravikoff et al., 2005), and a lack of autonomy andempowerment to change practice (Solomons & Spross, 2011).

Factors that promote EBP have also been identified. In a de-scriptive study that included 458 nurses practicing in a singleU.S. academic medical center, Brown and colleagues (2009)found factors that facilitate EBP-included opportunities for pro-fessional growth or learning and a nursing culture that pro-vided institutional support for EBP. Koehn and Lehman (2008)surveyed a sample of 422 registered nurses and reported thatnursing education level was significantly positively associatedwith positive attitudes toward EBP. Additionally, nurses thathave EBP mentors to help them search for and use evidenceare related to more favorable EBP beliefs (Melnyk et al., 2004;Melnyk, 2007).

Early efforts of the Phyllis F. Cantor Center for Researchin Nursing and Patient Care Services at DFCI created the sup-port resources for oncology nurses to address clinical practiceconcerns. The structure is intended to create an environmentthat supports clinical inquiry and to change clinical practicebased on evidence. Ideas for EBP projects are introduced to theEvidence Based Practice and Innovations Committee (EBPIC),a part of the nursing council structure and led by doctorallyprepared Clinical Inquiry Specialists (CISs). The role of theCIS is to facilitate the translation of evidence into clinical nurs-ing practice through direct care nurses. Therefore, the CISleads the synthesis of evidence and literature in collaborationwith the clinical nursing team who has identified a clinicalproblem. During this process, the CIS mentors the clinicalnursing team in all aspects of the EBP project. While work-ing with the teams of unit-based nurses, termed SPAWNinggroups (Boucher et al., 2013; Underhill, Boucher, Roper, &Berry, 2012), the Cantor Center CISs recognized that a sound

knowledge base was critical for applying EBP and was currentlya limitation at the institute. Therefore, a plan to address the bar-riers to EBP implementation and organizational readiness wasinitiated. The purpose of this study was to evaluate nurses’ per-ceptions of the value of EBP and to explore EBP beliefs andimplementation at DFCI before and after instituting the ini-tiative. Additionally, the project aimed to identify demographicfactors associated with EBP beliefs and implementation.

METHODSDesignThe unpaired pretest-posttest survey design study was ap-proved by the Dana-Farber/Harvard Cancer Center Institu-tional Review Board. The theoretical framework for this studywas based on the Advancing Research and Clinical practicethrough lose Collaboration (ARCC) Model (Melnyk & Fineout-Overholt, 2002; Melnyk, Fineout-Overholt, & Mays, 2008).ARCC is a model that has been widely used as a methodto implement EBP. The aim of ARCC is to address barriersto implementing EBP by promoting strategies that facilitateEBP, such as mentorship and education (Melnyk & Fineout-Overholt, 2002; Melnyk, Fineout-Overholt, & Mays, 2008).

Leaders from ARCC developed and tested the EBP beliefsquestionnaire (EBP-B) and EBP Implementation questionnaire(EBP-I) measures, which were utilized for this study (Melnyket al., 2008). Permission was granted from ARCC prior to use ofthe measures. The survey was structured so that demographicdata were solicited first, followed by the EBP-B scale and thenthe EBP-I scale. Participants could skip items and could exit thesurvey at any time. The initiative took place over a 24-monthperiod and the survey was made available online in August2011 and again in August 2013 to all DFCI nurses.

MeasuresEBP-beliefs (EBP-B). The EBP-B questionnaire is a 16-itemLikert scale measuring beliefs and attitudes about EBP. Re-sponses range from 1 (strongly disagree) to 5 (strongly agree) andinclude two reverse scored items. A summative score is cal-culated for this measure and can range from 16 to 80; higherscores indicate more positive beliefs. Reliability of the scale hasbeen reported as adequate; α = .90 (Melnyk et al., 2008).

EBP-implementation (EBP-I). The EBPI is an 18-item Likertscale measuring nurse engagement in EBP. It includes do-mains such as sharing outcomes from data collected or fromliterature reviewed with colleagues and patients, synthesizingliterature, changing practice based on data, generating PICOquestions, and collecting data on a clinical problem. Frequencyof EBP performance in the past 8 weeks was reported. The itemresponses can range from 0 (zero times) to 4 (> 8 times). A sum-mative score is calculated and can range from 0 to 72; higherscores indicate more frequent implementation. Reliability ofthe scale has been reported as adequate; α = .96 (Melnyk et al.,2008).


Evidence-Based Practice Beliefs and Implementation

Institutionalinitiative to raise EBP awarenessfrom 2011-

2013

EBP posterViewed by 55 nurses at staff meetings and

92 nurses at orientation

Nursing Scholarship Day

Attended by 75 nurses. 15 posters and 51 publications were

prsented by DFCI nurses

Online EBP educational module Viewed by 384 DFCI

nurses

SPAWN projects Ongoing EBP projects

engaging 22 DFCI nurses

Figure 1. Institutional initiative to promote EBP.

Additional items. To assess barriers to EBP at DFCI, oneopened-ended item was included, “Please describe barriers toyour involvement in EBP.” Facilitating factors were assessedthrough one open-ended item, “Please describe factors that arecurrently available to help you take part in EBP at DFCI.” Afinal open-ended question allowed nurses to provide sugges-tions, “Please provide feedback as to how EBP can be betterincorporated into DFCI nursing practice.” Demographic itemswere asked and included highest level of education, nursingrole (direct care nurse or direct care nursing leadership or sup-port), length time as a nurse, participation in SPAWN projects,and history of formal evidence-based practice education. Thestudy team purposely did not ask potentially identifying ques-tions such as age or gender, to maintain anonymity of thesurvey responses and to reduce risk for bias in the answersprovided by participants.

Institutional InitiativeAn EBP education sub committee was assembled in 2011 toaddress the Time 1 (T1) survey results, which was based on theARCC model and helped us to determine the needs of the DFCInursing community. The sub committee was comprised of twoclinical nurse specialists (CNS) and two CISs who identifiednecessary resources for education as well as the continuedfacilitation of EBP projects. Figure 1 summarizes this initiativeand the number of DFCI nurses who engaged in the process.

The first step of the institutional initiative consisted ofstrategies that would serve to initiate face-to-face discussionswith direct care nurses to provide an introductory sessionabout EBP and EBP resources available at DFCI. The pro-cess of EBP was presented to current nursing staff during

regularly scheduled practice rounds or staff meetings by meansof a traveling poster entitled EBP 101. Content included: exam-ples of a clinical population-intervention-comparison-outcome(PICO) question (Fineout-Overholt et al., 2005); explanationsof the levels of evidence; differences between quality im-provement, nursing research and evidence-based definitions;methods; and the tools used for each process. The preliminaryfindings of the T1 survey, accessible institutional resourcelocations, and telephone numbers were also available forviewing on the poster. The presentation was brief andinteractive, lasting approximately 20 minutes. The contentwas presented in a quick-look poster format. Attendees wereasked to describe examples of EBP in nursing and to answerquestions based on the content of the topic. At the completionof each session, the staff and CIS engaged in discussion aboutpotential topics for EBP; the CIS provided tips for how to getstarted with EBP at DFCI. Copies of the poster were displayedon each clinical unit for continued reference by nursing staff.The CNSs also implemented an overview of EBP at orientationfor new nursing staff using the poster, as well as informationabout past and present EBP projects across DFCI. Integratingthis content into orientation began in the spring of 2012.

Additionally, nursing leadership held a “Scholarship Day”in 2012 inviting all NPCS members to present posters ofany scholarly activities that they had presented at a confer-ence within the past 3 years. This included oral presentations,posters, and manuscripts about completed research, qualityimprovement, and evidence-based practice projects. This was adaylong event that was coordinated with a regularly schedulednursing council meeting and included scholarly presentationsand networking opportunities.


Original ArticleFinally, a formal online EBP education module was created

by the sub committee that included the content of the quick looklearning poster in an online audio visual presentation formatand was implemented in the summer of 2013. The module in-cluded basic definitions of EBP, examples of EBP at DFCI, andcontact information for EBP resources. All DFCI nurses wererequired to complete this module which took approximately 10minutes.

Concurrently, SPAWN projects were continuing to occur atDFCI. During the time of the institutional initiative, one EBPSPAWN project was finished and four projects began; all werefocused on symptom management in the oncology patient. Thestudy team was aware of all other initiatives, events, and policesthat were occurring across the institute and did not identifyany occurrences that would historically impact results of thestudy.

Sample and RecruitmentAll DFCI nursing staff were invited to participate in this study(N = 350) and were recruited through a DFCI-wide nursinge-mail list with an aim to capture as many members of thenursing staff as possible. A power analysis was not completedprior to implementing this study as the aim was exploratory.At each survey time point, the chief nursing officer announcedthe survey by e-mail approximately 1 week prior to sending thesurvey. Study staff sent an e-mail to all DFCI nurses invitingthem to complete the anonymous EBP survey. This e-mail pro-vided elements of consent, an introduction to the study, and adirect link to the survey. Data were anonymous and unpairedto reduce risk for social desirability bias and to maintain partic-ipant confidentiality. Additionally, the survey e-mail was sentfrom a researcher who is not in a leadership role to minimizerisk for coercion or bias.

AnalysisData were entered and managed through IBM SPSS StatisticalSoftware 20 (SPSS Inc., Amonk, NY). Descriptive statistics(box-plots, mean, median, standard deviation, and range) werecalculated with all survey items and total scores, as well asdemographic data. All available data were used for analysis andno participants were removed from the analysis due to missingdata. Mann–Whitney U tests were used to evaluate differencesin EBP-B and EBP-I mean rank scores between nursing role(direct care nurse vs. nurse leaders), history of formal EBPeducation (yes, no), and participation in SPAWN (yes, no) wereevaluated for differences at T2 only. Spearman’s correlationsbetween beliefs and implementation scores, length of timeas a nurse, and level of education were calculated. Responsesto open-ended questions were summarized and counted tocategorize common statements. Instrument performancemeasures were calculated using Cronbach’s α. All tests aretwo-sided and considered significant at the .05 level.

RESULTSOf the 350 nurses invited, 112 and 113 accessed the survey atT1 and T2, respectively, a 32% response rate. Participants atboth time points were similar in demographic backgrounds.Because responses at both time points were anonymous, wedid not know whether the participants had responded atone time point or both. We were unable to assess if therewere differences between those who did and did not completethe survey. The percentages of respondents working at DFCIfor 10 years or more was about 40% of the sample (Table 1) ascompared to about 30% of the DFCI nurse population (DFCIHuman Resources, personal communication, March 2014).

A total of 90 nurses completed the EBP-B scale at T1 with amedian score for 56.5 and a range of 37–77, with higher scoresindicating more positive perceptions. The 25th and 75th per-centile ranged from 50 to 61. A total of 75 nurses completed theEBP-I at T1 with a median of 11 and a range of 0–70, with higherscores indicating higher perceptions of implementation. The25th and 75th ranged from 4 to 26. A total of 87 nurses com-pleted the EBP-B scale at T2 with a median score 57 and a rangeof 38–76. The 25th and 75th ranged from 51 to 63. A total of 68nurses completed the EBP-I at T2 with a median of 12 and arange of 0–66. The 25th and 75th ranged from 5 to 20.75. Therewere no significant differences between T1 and T2 beliefs andimplementation scores observed within the descriptive analy-sis. The Cronbach’s α scores for the EBP-B (α = .84) and forEBP-B (α = .95) demonstrated adequate scale reliability.

Due to the graphically similar distribution of T1 and T2scores, and the balance of demographic information at eachtime point, further exploration analyses were conducted on T2data (Table 2). There was a significant difference in EBP-B andEBP-I score distribution for those who have and have not re-ceived formal EBP education, indicating that nurses who havehad formal education had higher perceived levels of EBP beliefsand implementation. There were also differences in EBP-B andEBP-I scores based on nursing role, indicating that those whoreported as nurse leaders had higher perceived scores. Therewere no significant differences in scores between those whohad or had not participated in SPAWN projects. Level of nurs-ing education was positively correlated with EBP-B (r = .25; p =.03) and EBP-I (r = .32; p = .01), indicating the higher level ofreported education was associated with higher scores. Time asa nurse was not significantly correlated with EBP-B (p = .38)or EBP-I (p = .16).

Written responses to the open-ended items were consistentwith the survey results at both time points and 36 nurses pro-vided responses at T1 and 47 at T2. Respondents stated thatEBP was an important part of their practice but experiencedchallenges with implementation. Commonly cited barriers in-cluded time, knowledge, and access to resources such as onlinejournals or databases, or lack of evidence-based information.Additionally, nurses requested more time resources, education,and awareness about EBP. Factors found to benefit participa-tion in EBP included: the SPAWN process, individuals fromnursing leadership, and leaders from nursing research.



Table 1. Nurse Self-reported Demographic Information From T1 and T2

T1 T2

Variable n % n %

Length of time asa nurse

< 6 years 3 2.7 7 6.2

6–10 years 12 10.7 9 8.0

>10 years 81 72.3 80 70.8

missing 16 14.3 17 15.0

Length of time asa nurse at DFCI

< 6 years 44 45.8 45 48.4

6–10 years 15 15.6 12 12.9

>10 years 37 38.5 36 39.8

missing 16 20

Nursing role Direct care nurse 67 59.8 66 58.4

Nurse leader 29 25.9 30 26.5

missing 16 14.3 17 15.0

Highest level ofeducation*

Bachelor’s degree 47 52.8 44 38.9

Master’s degree 38 33.9 38 33.6

Doctoral degree 4 3.6 4 3.5

missing 23 20.5 27 23.9

Have you everreceived formalEBP education?

Yes 46 41.1 49 43.4

No 50 44.6 47 41.6

missing 16 14.3 17 15.0

Are you currently,or have you in thepast, taken part ina SPAWN group orevidence basedpractice project atDFCI?

Yes 22 19.6 15 13.3

No 74 66.1 81 71.7

missing 16 14.3 17 15.0

*n= 7 participants in T1 and n= 10 participants in T2 reported “other” for highest level of education, this was coded as missing.

DISCUSSION

Overall, responding nurses believed that EBP is valuable topatient care. The nurses agreed that the care that they providedwas evidence based. However, the nurses were neutralin reporting whether they could or could not implement

components of EBP such as searching for literature, imple-menting EBP in a time effective way, or evaluating outcomesfrom an EBP initiative. Institutional efforts implemented be-tween the first and second administration of the survey did notsignificantly impact perceived EBP beliefs or implementationactivities.


Original ArticleTable 2. Mann–Whitney Test (U) Differences in the Distribution of EBP-B & I Mean Rank Scores BetweenGroups at T2

EBP-B n Mean Rank U P

Received formalEBP education(yes/no)

Yes 44 53.57 525.0 p< .01

No 43 34.21

Nursing role(direct care/nurseleader)

Direct care 61 554.5 p= .03

Nurse Leader 26

SPAWNparticipation(yes/no)

Yes 15 43.65 515.0 p= .78

No 72 45.67

EBP-I

Received formalEBP education(yes/no)

Yes 37 39.22 399.0 p= .03

No 31 28.87

Nursing role(direct care/nurseleader)

Direct care 47 30.48 304.5 p= .01

Nurse Leader 21 43.50

SPAWNparticipation(yes/no)

Yes 13 39.0 299.0 p= .36

No 55 33.44

Our findings are similar to those reported by 1,015 Amer-ican Nurses Association members using a survey with itemsselected from the original EBP-B and EBP-I scales (Melnyk,Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Melnykand colleagues (2012) found that nurses valued and imple-mented EBP and sought structured education and guidance toimprove their utilization of evidence in practice, but faced barri-ers including lack of time, EBP knowledge, access to evidence,and resistance from colleagues or managers. The participantsin our study indicated similar needs for education, access toinformation, and time; all of which will be important to addressin future institutional strategies and policy. Also similar to ourfindings, in a study administering the EBP-B and EBP-I scale,Stokke, Olsen, Espehaug, and Nortvedt (2014) found in 185Norwegian nurses that having more training and also havingprevious knowledge about EBP resulted in higher perceivedscores of EBP beliefs.

The importance of exposure to formal EBP educationand current nursing role may reflect the historical context ofnursing education. Nurses who completed their educationprior to the integration of EBP into curriculum or standardcare may not have had the same opportunities to learn theapplication of EBP. Additionally, those without advancedpractice degrees may not have had academic exposure to EBP.As recent as 11 years ago, the Institute of Medicine includedproficiency in EBP as an essential competency in education forhealth professionals in Health Professions Education: A Bridgeto Quality (Greiner & Knebel, 2003). In response to this, in2008 the American Association of Colleges of Nursing (2008)updated The Essentials of Baccalaureate Education to include thetranslation of evidence into practice for professional nursingpractice. Therefore, though an integral component of nursingeducation and practice, EBP is a relatively new addition tocurriculum and therefore practicing nurses who have been



out of the classroom and in the workforce for 10 years or moremay not have had exposure to and education in EBP. Thesenurses rely on continuing education and career developmentopportunities to advance their knowledge of EBP.

The Oncology Nursing Society has developed an online cur-riculum with available faculty to educate oncology nurses inEBP. Additionally, a recent publication by Melnyk et al. (2014)provided a list of EBP competencies for both registered andadvanced practice nurses that could be incorporated into fu-ture institutional initiatives. Importantly, these competenciesare practically based and demonstrate not only a didactic un-derstanding of concepts but also the practical application ofthe skill (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt,2014). Including mentors as part of a multi phased interven-tion to support nurses engaging in EBP has been found to leadto higher EBP-B and EBP-I scores in a pilot randomized con-trol trial (Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter,2011). The DFCI SPAWN process and use of the CIS to mentornurses in EBP and facilitate EBP project engagement has beena consistent approach to ensure such mentorship (Boucheret al., 2013; Underhill et al., 2012).

There is a need for large scale, multi site randomized trials totest the effect of various approaches to promoting or support-ing EBP. The best approach to promoting EBP is unknown.Despite institutional education efforts and opportunities forEBP projects, DFCI nurses reported a lack of time away fromdirect patient care in order to access resources and engagein EBP processes. Melnyk et al. (2014) provided strategies forthe integration of EBP into nursing organizations that focuson promoting a culture of EBP, establishing performance ex-pectations, and sustaining EBP activities. One component ofa culture for EBP certainly may be scheduling time for nurseengagement.

In summary, findings from the pre survey led to a multi-phase response at our institution to address the barriers iden-tified. Our continued efforts include working with leadershipat DFCI to promote EBP nursing, continued engagement inthe SPAWN process, and ongoing initiatives to inform nursesacross the institute of EBP and EBP resources available. Wecontinue our work as we further develop our process of pro-moting and sustaining EBP oncology nursing practice.


� Institutions that aim to engage nurses in EBPshould provide the environment, time, and re-sources for nurses to ask clinical questions andengage with mentors in literature review, evidencesynthesis, and data collection or interpretation.

� Nurses should be provided the mentorship andsupport to obtain continuing education about howto engage in EBP and about implementing EBPchange.

� Individual nurses should be aware of available re-sources to learn more about EBP, such as thoseprovided through the Oncology Nursing Society,and about how to carry out EBP at the institutelevel.

� Future randomized control trials are needed toevaluate the best approach to improving EBP.

LimitationsThe purpose of this study was to explore current EBP beliefsand implementation at DFCI before and after implementingan institutional focus on promoting EBP in oncology nursingin ambulatory care. Therefore, results cannot be generalizedto other types of institutions and nursing departments. Also,due to the exploratory nature of our study we cannot directlycompare T1 and T2; however, we were able to summarize thetime points independently. Only about a third of the popula-tion of DFCI nurses responded, leaving the possibility that re-ports from non respondents may have differed. Respondentsself-reported perceptions of EBP implementation and actualimplementation was not measured. Therefore, there may bedifferences in what nurses perceive they implement and whatthey actually implement. Additionally, because our survey wasanonymous to protect the confidentiality of the participants,we were unable to pair data and evaluate individual changes inEBP beliefs and implementation or evaluate information aboutthose participants who did not respond.

CONCLUSIONSOncology nurse participants in this study valued EBP. How-ever, they did not report full engagement or preparation for theprocess of EBP before or after an educational initiative. EBPbeliefs and implementation were associated with formal EBPeducation, nursing role, and level of education. Understandingneeds at the institutional level can help guide an action plan toimprove EBP beliefs and implementation. WVN

Author information

Meghan Underhill, Nurse Scientist and Instructor, Phyl-lis F. Cantor Center for Research in Nursing & PatientCare Services, Dana-Farber Cancer Institute, Boston, MA,USA; and Instructor, Harvard Medical School, Boston, MA,USA; Kristin Roper, Clinical Inquiry Specialist, PhyllisF. Cantor Center for Research in Nursing & Patient CareServices, Dana-Farber Cancer Institute, Boston, MA, USA;Mary Lou Siefert, Nurse Specialist, Center for Clinical andProfessional Development; Phyllis F. Cantor Center for Re-search in Nursing & Patient Care Services, Dana-Farber Can-cer Institute, Boston, MA, USA; Jean Boucher, Clinical In-quiry Specialist, Phyllis F. Cantor Center for Research inNursing & Patient Care Services, Dana-Farber Cancer Insti-tute, Boston, MA, USA; and Assistant Professor of Nursing


Original Articleand Medicine, University of Massachusetts Worcester,Graduate School of Nursing, Worchester, MA, USA;Donna Berry, Director, Phyllis F. Cantor Center for Researchin Nursing & Patient Care Services, Dana-Farber Cancer In-stitute, Boston, MA, USA; and Associate Professor, HarvardMedical School, Boston, MA, USA.The authors acknowledge: Susanne Conley, MS, RN, CPON,AOCNS, for assistance with the design and implementationof the EBP initiative; Dr. Ellen Fineout-Overholt and Dr.Bernadette Melnyk, for use of the EBP-B and I measures;Traci Blonquist, MS, for statistical consultation during thestudy analysis; and the Evidence Based Practice and Innova-tions Committee at DFCI along with the DFCI Nursing Councilfor ongoing support.

Address correspondence to Dr. Meghan Underhill, Dana-Farber Cancer Institute, Phyllis F. Canter Center, 450Brookline Ave., Boston, MA 02115; [email protected]


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Original Article

Barriers and Enablers to ImplementingClinical Treatment Protocols for Fever,Hyperglycaemia, and SwallowingDysfunction in the Quality in Acute StrokeCare (QASC) Project—A Mixed MethodsStudySimeon Dale • Christopher Levi, PhD • Jeanette Ward, PhD •Jeremy M. Grimshaw, PhD • Asmara Jammali-Blasi • Catherine D’Este, PhD •Rhonda Griffiths, PhD • Clare Quinn, MSc • Malcolm Evans, MN •Dominique Cadilhac, PhD • N. Wah Cheung, PhD • Sandy Middleton, PhD

Keywords

barriers,enablers,

implementation,implementation

research,process analysis,evidence-based,

clinical guidelines,clinical protocols

ABSTRACTBackground: The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementationof clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acutestroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia.

Aim: To describe perceived barriers and enablers preimplementation to the introduction of theFeSS protocols and, postimplementation, to determine which of these barriers eventuated asactual barriers.

Methods: Preimplementation: Workshops were held at the intervention stroke units (n = 10).The first workshop involved senior clinicians who identified perceived barriers and enablers toimplementation of the protocols, the second workshop involved bedside clinicians. Postimple-mentation, an online survey with stroke champions from intervention sites was conducted.

Results: A total of 111 clinicians attended the preimplementation workshops, identifying 22 bar-riers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c)lack of equipment, and (d) education and logistics of training staff. Preimplementation enablersidentified were: support by clinical champions, medical staff, nursing management and alliedhealth staff; easy adaptation of current protocols, care-plans, and local policies; and presenceof specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preim-plementation were reported as actual barriers to adoption of the FeSS protocols, namely, noprevious use of insulin infusions; hyperglycaemic protocols could not be commenced withoutwritten orders; medical staff reluctance to use the ASSIST swallowing screening tool; poor levelof engagement of medical staff; and doctors’ unawareness of the trial.

Linking Evidence to Action: The process of identifying barriers and enablers preimplementationallowed staff to take ownership and to address barriers and plan for change. As only five of the22 barriers identified preimplementation were reported to be actual barriers at completion of thetrial, this suggests that barriers are often overcome whilst some are only ever perceived ratherthan actual barriers.

INTRODUCTIONIn the early poststroke period elevation of both body temper-ature and blood glucose is associated with significantly worsestroke outcomes (Azzimondi et al., 1995; Greer, Funk, Reaven,Ouzounelli, & Uman, 2008; Pulsinelli, Levy, Sigsbee, Scherer,

& Plum, 1983; Wang, Lim, Levi, Heller, & Fisher, 2000; Weir,Murray, Dyker, & Lees, 1997). In the first days of an acutestroke, elevation of temperature above 37.5°C occurs in one-fifth to almost one-half of patients (Castillo, Davalos, Marrugat,& Noya, 1998) and the detrimental effects of fever following


Barriers to Protocol Implementation in the QASC Trial

stroke are attributed to increased cerebral metabolic demands(Ginsberg & Busto, 1998), changes in the blood-brain barrierpermeability, acidosis, and an increased release of excitatoryamino acids (Busto et al., 1989) which causes infarct expansion(Boysen & Christensen, 2001). There also is a significant asso-ciation between poststroke hyperglycaemia and poor recovery(Williams et al., 2002). Up to 68% of all patients experiencehyperglycaemia with the first 24 hours of their acute stroke(Allport et al., 2006; Scott et al., 1999). Hyperglycaemia fol-lowing stroke has been shown to increase infarct size (Allport,Baird, & Davis, 2008; Pulsinelli et al., 1983) and lead to pooreroutcomes independent of the patient’s prestroke history of di-abetes (Pulsinelli et al., 1983; Weir et al., 1997). The incidenceof dysphagia in the acute poststroke period ranges from 37% to78% (Martino et al., 2005) and stroke patients with dysphagiaare three times more likely to develop pneumonia than thosewithout dysphagia (Doggett et al., 2001; Martino et al., 2005).Thus, optimal management of these three common physiologi-cal disturbances, namely, fever, hyperglycaemia and dysphagiaare important elements of organised stroke care with poten-tial to significantly influence outcomes. All three have beenidentified in international guidelines, as priority care issuesfor inpatient stroke management (Adams et al., 2007; Euro-pean Stroke Organisation [ESO] Executive Committee & ESOWriting Committee, 2008; National Institute for Health andClinical Excellence, 2008; National Stroke Foundation, 2007,2010).

Changing clinician practice remains a challenge (Morris,Wooding, & Grant, 2011). Successful translation of evidenceinto practice requires redress of barriers that generally mightinclude disagreement among experts about best practice, at-tractiveness of alternative practices, inapplicability of guide-lines to certain patient subgroups, institutional inertia, vestedinterests and ineffective continuing education (Grimshaw, Ec-cles, & Tetroe, 2004; Grol & Grimshaw, 2003). Production ofup-to-date evidence-based clinical guidelines without targetedimplementation strategies does not ensure practice change(Grimshaw, Thomas et al., 2004). The need to identify andovercome barriers during implementation is well accepted(Grol & Grimshaw, 2003).

In an effort to improve management of fever, hypergly-caemia and swallowing following stroke, the Quality in AcuteStroke Care (QASC), a cluster randomised control trial, eval-uated the effectiveness of implementation of evidence-basedclinical treatment protocols for the management of fever,glucose (sugar) and swallowing difficulties (the fever, sugar,swallow [FeSS] protocols) to improve 90-day patient outcomes.In brief, the protocols consisted of: monitoring and treatmentof temperatures > 37.5°C; treatment of major hyperglycaemia(fingerprick blood glucose levels > 11 mmol/L for diabetics and>16 mmol/L for nondiabetics) with saline initially or insulin;and the training of nurses to undertake swallowing screeningusing the ASSIST screening tool (Managers of Great Metropoli-tan Speech Pathology Services in NSW Health, 2004) with re-ferral to a speech pathologist for full swallowing assessment

only when patients failed the screen. Evidence-based strate-gies used to facilitate implementation were: Multidisciplinaryteam building workshops (Hamilton, McLaren, & Mulhall,2007) to identify barriers and enablers (Grol, Wensing, & Ec-cles, 2005); identification of a clinical site champion (Flodgrenet al., 2011); use of a standardised interactive education pro-gram (Forsetlund et al., 2009; O’Brien et al., 2007); and useof reminders (Grimshaw, Thomas et al., 2004). Following theworkshops, sites were asked to address these barriers and self-nominate a date for commencing use of the FeSS protocolsonce barriers had been addressed. Nineteen acute stroke unitsin New South Wales (NSW) Australia participated, providingdata from 1696 patients. Our results showed that patients caredfor in stroke units who received implementation support were15.7% more likely to be alive and independent 90-days follow-ing their stroke. They also had fewer episodes of fever, lowermean temperatures, lower mean blood glucose levels, and im-proved screening for swallowing difficulties (Middleton et al.,2009; Middleton et al., 2011).

In this paper, we report the perceived barriers and enablersidentified by clinicians prior to implementation of the FeSSprotocols. At the conclusion of the trial, we revisited theseperceived pretrial barriers to determine which, if any, wereactual barriers as reported by the clinical site champions, whoalso were our local trial contacts at our intervention sites. Thisinformation may be useful for clinicians seeking to implementsimilar protocols.

METHODSA mixed method design was used comprising a qualitativephase using workshops to identify perceived barriers and en-ablers prior to implementation of the FeSS protocols, and aquantitative approach postimplementation using an online sur-vey to elicit actual barriers and enablers to use of the FeSSprotocols.

Preimplementation Identification of Perceived Bar-riers and Enablers to FeSS Protocol UptakeTwo interactive multidisciplinary workshops were conductedat each of the ten intervention stroke units. At both workshops,following presentations to clinicians regarding the QASC trialand the clinical protocols, the clinicians were asked two ques-tions as follows: What are the perceived barriers and enablersto use of these protocols (a) within the stroke unit; and (b) atthe hospital (organisational) level. Senior clinicians within thestroke team were invited to attend the first workshop, namely,the medical director, nurse unit manager, stroke unit coordi-nator, director of speech pathology. The second workshop washeld with a convenience sample of multidisciplinary bedsideclinicians and both were held at a time convenient to all. Theseworkshops were conducted by SM, CL, and SD, 2 to 4 weeksapart and approximately 6 weeks prior to implementation ofthe FeSS protocols.


Original Article

Postimplementation Actual Barriers and Enablersto FeSS Protocol UptakeAn online survey was sent to the clinical site champion ateach of the 10 QASC intervention stroke units in June 2011, 6months postcompletion of the main QASC trial. Our survey in-cluded questions about respondent demographics (four ques-tions) and specific questions derived directly from perceivedbarriers identified by clinicians at the QASC Trial preimple-mentation workshops. These were grouped as follows: policybarriers (five questions), workforce barriers (six questions),equipment barriers (four questions) and education barriers(five questions). Next, participants were asked to list any addi-tional actual barriers not previously identified (one question).Each survey item was rated on a five-point Likert scale rangingfrom “strongly agree” to “strongly disagree.”

In addition, clinical site champions were asked whetherthey were still using each of the FeSS protocols (“Yes,” “No,”“Don’t know/Can’t remember”) and if they would recommendthe FeSS protocols to other stroke units (“highly likely” to “highlyunlikely”) whether the FeSS protocols empowered nursing staffto approach the multidisciplinary team about patient manage-ment (“strongly agree” to “strongly disagree”); and if they wouldrecommend the FeSS protocols for use in emergency depart-ments (“Yes,” “No,” “Don’t know/can’t remember”). Respon-dents were also able to provide comments in this section.

Data AnalysisParticipants responses from the preimplementation work-shops were transcribed into lists following the workshops andthen were coded according to barriers, enablers and strategiesto overcome barriers by one of the researchers. The codingframe was developed iteratively as two researchers reviewedthe feedback. We undertook a content analysis grouping bar-riers, both at the stroke unit level and the organisational levelinto relevant categories. Responses from the two workshops ateach site were grouped together. Recurrent factors were notedand feedback excerpts were allocated to these codes. In addi-tion, differences in the feedback between the sites were noted.Participant quotes were used to illustrate meaning in the mainfactors derived.

Frequencies from the postimplementation survey were de-termined. Each of the perceived barriers was defined as be-ing an “actual barrier” where greater than or equal to 50% ofparticipants so agreed postimplementation. Ethical approvalto conduct the trial was obtained from the Human ResearchEthics Committee of the Australian Catholic University andthe relevant ethics committees of all 19 participating hospitals.

RESULTSPreimplementation: Perceived BarriersA total of 20 preimplementation workshops were conducted(two at each of the 10 intervention stroke units). The numberof participants per site ranged from 4 to 13 and the majorityof the 111 clinicians that attended the workshops were nurses

Table 1. Clinical Designations of Workshop Atten-dees (Pre- and Postimplementation)

Designation Preimplementation Postimplementation

(n= 111) (n= 10)n (%) n (%)

Nurses

Registered nurse 32 (29) 0 (0)

Clinical nurse consultant 13 (12) 7 (70)

Nurse unit manager 11 (10) 0 (0)

Endorsed enrolled nurse 7 (6.3) 0 (0)

Clinical nurse specialist 5 (4.5) 0 (0)

Stroke liaison nurse 1 (0.9) 1 (10)

Enrolled nurse 1 (0.9) 0 (0)

Clinical nurse educator 0 (0) 2 (20)

Allied health

Speech pathologist 14 (13) 0 (0)

Physiotherapists 3 (2.7) 0 (0)

Stroke unit coordinator 1 (0.9) 0 (0)

Medical 15 (14) 0 (0)

Other 2 (1.8) 0 (0)

(n = 70, 63%; Table 1). Preimplementation perceived barrierswere centred on four categories: policy, workforce, equipmentand education as outlined below (Table 2). The majority of bar-riers were uniform between sites with the equipment barriersdiffering in which equipment issues were barriers at each site.

Policy-Related BarriersThere were three policy barriers related to the implementationof the FeSS protocols. The need for written orders from doctorsfor nurses to commence saline or insulin according to thehyperglycaemic protocol was identified as a barrier, as was noprevious use of insulin infusions, “The doctors won’t want tocome up in the middle of the night to write up insulin.”

In addition, the requirement for nurses to obtain a writtenorder for all but the first dose of paracetamol was also consid-ered a likely barrier (Table 2). In all NSW hospitals, nursingstaff were permitted by NSW Department of Health protocol toadminister only the first dose of paracetamol without a writtenmedical order.

Workforce-related barriers. There were eight barriers iden-tified related to workforce issues. Patient safety, largely asso-ciated with management of insulin infusions, was perceivedto be a potential barrier. “What happens when we have more



Table 2. Perceived Barriers Identified Preimplementation and Results of Postimplementation Survey (n = 22)

Perceived barriers identifiedpreimplementation

Postimplementation survey results

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree

n (%) n (%) n (%) n (%) n (%)

Policy barriers to the FeSS protocols

Fever

Inability to administer more than firstdose of paracetamol without awritten order

0(0.0) 3(30.0) 3(30.0) 2(20.0) 2(20.0)

Sugar

Insulin infusions not previouslyallowed on stroke unit

4(40.0) 2(20.0) 1(10.0) 1(10.0) 2(20.0)

Hyperglycaemic protocols could notbe commenced without a writtenorder

2(20.0) 3(30.0) 1(10.0) 3(30.0) 0(0.0)

Workforce barriers to the FeSS protocols

Sugar

Insufficient staff to safely look aftermore than one insulin infusionpatient.

1(10.0) 0(0.0) 6(60.0) 1(10.0) 1(10.0)

Endorsed Enrolled Nurses are notaccredited to adjust insulininfusions or to test BGLs

1(10.0) 2(20.0) 3(30.0) 3(30.0) 1(10.0)

Patients with insulin infusionsrequiring a nurse escort to leavethe stroke unit

1(10.0) 0(0.0) 5(50.0) 2(20.0) 2(20.0)

Not enough nurses to do hourlyobservations

1(10.0) 1(10.0) 2(20.0) 4(40.0) 2(20.0)

Swallow

Insufficient speech pathology staff totrain and assess nurses inperforming swallow screens

0(0.0) 1(10.0) 2(20.0) 3(30.0) 4(40.0)

Generic

High number of agency staff on thestroke unit

1(10.0) 1(10.0) 1(10.0) 5(50.0) 2(20.0)

Finding a staff member torecannulate out of hours

1(10.0) 3(30.0) 1(10.0) 3(30.0) 2(20.0)

Potential increase in nursingworkload

0(0.0) 1(10.0) 6(60.0) 2(20.0) 1(10.0)

Equipment barriers to the FeSS protocols

Fever

Not enough thermometers on thestroke unit

0(0.0) 1(10.0) 2(20.0) 3(30.0) 4(40.0)

(Continued)


Original ArticleTable 2. Continued

Perceived barriers identifiedpreimplementation

Postimplementation survey results

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree

n (%) n (%) n (%) n (%) n (%)

Sugar

Not enough syringe drivers on thestroke unit

1(10.0) 2(20.0) 1(0.0) 5(50.0) 1(10.0)

Not enough blood glucose monitorson the stroke unit

0(0.0) 0(0.0) 3(20.0) 6(60.0) 1(10.0)

Not enough fluid pumps on thestroke unit

0(0.0) 0(0.0) 2(10.0) 7(70.0) 1(10.0)

Education barriers to the FeSS protocols

Swallow

Time needed to undergo swallowingeducation

2(20.0) 2(20.0) 2(20.0) 3(30.0) 1(10.0)

Medical staff reluctance to use theformal ASSIST tool

2(20.0) 6(60.0) 1(10.0) 0(0.0) 1(10.0)

Reluctance of nursing staff toundertake screening role

0 (0.0) 1 (10.0) 2 (20.0) 5 (50.0) 2 (20.0)

Generic

Poor level of engagement withspeech pathology staff

(0.0) 0(0.0) 1(10.0) 1(10.0) 8(80.0)

Poor level of engagement of medicalstaff

1(10.0) 4(40.0) 1(10.0) 4(40.0) 0(0.0)

Doctors not aware of trial 1(10.0) 4(40.0) 2(20.0) 3(30.0) 0(0.0)

Feasibility of educating night dutystaff

1(10.0) 3(30.0) 2(20.0) 4(40.0) 0(0.0)

aBolded items are those considered to be actual barriers both pre- and postimplementation, i.e., greater than 50% strongly agree or agree postimplementation.

than one patient with an insulin infusion, how can we maintainpatient safety?”

Finding a member of staff to recannulate patients afterhours was identified as a possible workforce barrier, as wasthe shortage of speech pathologists to train nurses to performand access swallow screens (Table 2). Increased workload wasa concern with particular reference to the possible need forhourly blood glucose monitoring for glycemically unstable pa-tients. There was also concern that there could be a result-ing insufficient number of staff to safely look after more thanone patient requiring an insulin infusion. Patients with in-sulin infusions require a nurse escort should they need toleave the stroke unit for any tests (e.g., imaging) and this thencould leave the stroke unit short staffed. Endorsed enrollednurses’ (enrolled nurses in Australia obtain a 1-year diplomaof enrolled nursing from a Technical and Further Education

College; endorsed enrolled nurses can also administer somemedications) inability to administer insulin was identified asa factor potentially increasing the workload of the registerednurse.

In addition, on some stroke units where use of casual nurs-ing staff occurred, the transient nature of their employmentwas seen as possibly increasing the workload of the regularstroke unit nurses as casual nursing staff may not have under-gone any local education or necessarily be aware of the FeSSprotocols.

Equipment-related barriers. Equipment barriers were iden-tified with concerns about lack of thermometers, blood glucosemonitors, fluid pumps, and syringe drivers on the stroke units(Table 2). “What if we are unable to get a fluid pump from thehospital supply?”



Organisational support: • Having clinical site champions for the trial• The support of neurologists in addition to the Stroke Unit

Director• The support of senior staff

Integration of the FeSS clinical treatment protocols into care: • Nurses ability to adapt local care plans• Being able to augment implementation with local strategies• Having staff exclusively allocated to the stroke unit

Figure 1. Preimplementation enablers (n = 6).

Education-related barriers. Seven barriers were identified re-lating to education. The logistics of training all the clinical staffincluding those who worked only weekend shifts and nightduty was highlighted. Since our swallowing management pro-tocol consisted of nurses being trained to undertake swallowingscreening (previously the remit solely of speech pathologists)clinicians were concerned that this would result in reluctance ofnursing staff to undertake the screening role and training re-quired to use the Acute Screening of swallow in Stroke/TIA(ASSIST) tool (Table 2). Some concern also was expressedabout the possibility of poor levels of engagement with bothdoctors and speech pathologists associated with the changedwork practices. “The speechies won’t be happy we are takingover their jobs!”

The issue of medical staff not being aware of the trial wasalso raised. Other barriers specific to swallow managementincluded concern about the time needed to undergo swallowscreen education and reluctance on behalf of the medical teamsto use the ASSIST tool (Table 2).

Preimplementation: EnablersEnablers identified during the workshops fell into the two maincategories of organisational support and integration of the FeSSprotocols into routine care. Enablers’ related to organisationalsupport included the concept of having champions for the trial,having the support of the other neurologists (in addition toStroke Unit Director) and having the support of the seniorstaff (e.g., Director of Allied Health).

Enablers related to integration of the FeSS protocols intocare were: nurses’ ability to adapt their own local care plansand policies to reflect the FeSS protocols; being able to augmentimplementation with the use of local strategies (i.e., laminatingthe protocols and placing them at the bedside as suggested byone site); and having staff that were always allocated to thestroke unit (Figure 1).

Postimplementation: Actual BarriersAll clinical site champions from our ten intervention strokeunits participated in our online postimplementation survey(100% response rate), the majority of whom were clinical

nursing consultants (n = 7, 70%; see Table 1). All also hadattended the preimplementation workshops. Only five ofthe 22 perceived barriers identified preimplementation werelisted as actual barriers and are outlined below using the samecategories from the preimplementation survey (Table 2).

Policy-related barriers. In relation to hospital policy, only twoof the perceived barriers: no previous use of insulin infusions(n = 6, 60% “agreed” or “strongly agreed”); and requiring writ-ten orders for the insulin infusions (n = 5), 50% “agreed” or“strongly agreed”) were considered to be actual barriers postim-plementation. Participants no longer considered the require-ment for written orders for paracetamol beyond the first doseto be an actual barrier (n = 3), 30% “agreed” or “strongly agreed”(Table 2).

Workforce-related barriers. There were no workforce-relatedpreimplementation barriers that were found to be actualpostimplementation barriers. Only 10% (n = 1) of participants“agreed” or “strongly agreed” that increased workload had beenan actual barrier. The issue of high numbers of casual staffworking on the stroke unit was not considered an actual bar-rier (n = 2, 20% “agreed” or “strongly agreed”). Examination ofworkforce barriers showed that less than half of the participantsconsidered finding staff to recannulate patients after hours as abarrier (n = 4, 40% “agreed” or “strongly agreed”) and only 20%(n = 2) “agreed” or “strongly agreed” that not enough nursesto carry out hourly observations was a barrier. When lookingspecifically at workforce barriers related to the swallow proto-col, only one person (n = 1, 10%) “agreed” or “strongly agreed”insufficient numbers of speech pathologists to carry out theeducation was an actual barrier. With regard to the sugar pro-tocol, 10% (n = 1) “agreed” or “strongly agreed” that insufficientstaff to safely look after more than one patient on an insulininfusion was a barrier.

Equipment-related barriers. Lack of equipment was not con-sidered to be an actual barrier by participants. Specifically, 10%(n = 1) “agreed” or “strongly agreed” lack of thermometers wasan actual barrier; 30% (n = 3) “agreed” or “strongly agreed” lackof syringe drivers was an actual barrier (Table 2).

Education-related barriers. Three educational barriers iden-tified preimplementation that were found to be actual barrierspostimplementation. Medical staff not being aware of the trialand related protocols (n = 5, 50% “agreed” or “strongly agreed”);poor level of engagement of the medical staff (n = 5, 50%“agreed” or “strongly agreed”); and medical staff reluctance touse the ASSIST tool (n = 8, 80% “agreed” or “strongly agreed”)were considered to be actual barriers (Table 2). Less than halfof participants (n = 4, 40%) “agreed” or “strongly agreed” thatthe time needed by nurses to undergo training and competencyassessment by speech pathologists was an actual barrier. Poorlevels of engagement by speech pathology staff was not con-sidered to have been an actual barrier (n = 0, 0% “agreed” or“strongly agreed”; Table 2).


Original ArticleTable 3. Postimplementation Additional Questions (n = 10)

Yes No Don’t Know/Can’t remember

n (%) n (%) n (%)

Current use of FeSS protocols:

Fever 9 (90) 1 (10) 0 (0)

Sugar 7 (70) 3 (30) 0 (0)

Swallowing 10 (100) 0 (0) 0 (0)

Recommendation for use of FeSSprotocols in the ED

9 (90) 1 (10) 0 (0)

Highly likely Likely Don’t know Unlikely Highly unlikely Don’t know/can’t remember

n (%) n (%) n (%) n (%) n (%) n (%)

Likelihood of recommending FeSSprotocols to other ASUs

6 (60) 3 (30) 0 (0) 0 (0) 1 (10) 0 (0)

Strongly agree Agree Neither agree or disagree Disagree Strongly disagree Don’t know/can’t remember

n (%) n (%) n (%) n (%) n (%) n (%)

Agreement that the FeSS protocolsempowered nursing staff toapproach the MDT team aboutpatient management:

Fever 3 (30) 3 (30) 4 (40) 0 (0) 0 (0) 0 (0)

Sugar 3 (30) 4 (40) 2 (20) 1 (10) 0 (0) 0 (0)

Swallowing 3 (30) 6 (60) 1 (10) 0 (0) 0 (0) 0 (0)

Ongoing use of FeSS protocols. Over three quarters of par-ticipants (n = 7) were currently using the FeSS protocols ontheir unit, with all respondents currently using the swallow-ing element of the FeSS protocol (n = 10, 100%). In addition,90% of participants (n = 9) recommended that the FeSS pro-tocols be used in the emergency department, and would be“highly likely” or “likely” to recommend the FeSS protocols toother stroke units. Over half of all participants “strongly agree”or “agree” that the three elements (fever: n = 6, 60%; sugar: n= 7, 70%; swallowing: n = 9, 90%) of the FeSS protocols em-powered nursing staff to approach the multidisciplinary teamregarding patients management (Table 3). Overall, open-endedresponses gathered from the participants indicated underlyingchallenges with medical teams in engaging with the adoptionand use of the FeSS protocols at the local level: “The challengewas with rotating medical staff who were not aware or did notwant to become aware of the protocols.”

Participants also identified that initial uptake of the FeSSprotocols required ongoing support, monitoring and educa-tion in order for them to become part of everyday practice:“Implementation of the protocols required strong leadershipand constant monitoring to ensure the processes became daily

business”; and “Nurses require continual education on theprotocols so they remember to implement these protocols.”

DISCUSSIONThis paper outlines results of our barrier assessment prior toand following preplanned implementation of new evidence-based clinical protocols for acute stroke management. Barrierassessment has been shown to be a crucial step in successfulimplementation of evidence to practice (Grol & Grimshaw,2003; Hamilton et al., 2007; Scott et al., 2009). Our approachis novel, in that, at the end of the trial, we re-examined theperceived barriers identified preimplementation to determinewhich, if any, had been actual barriers to protocol uptake.This study was limited by the small sample size in thepostimplementation survey which included only clinical sitechampions. However the role of the clinical site championwas instrumental to the implementation of the FeSS protocolsand we believe their ongoing engagement with the study at allstages gives a valid and reliable representation of key barriersand enablers. The QASC trial preimplementation perceived



barriers and actual barriers fell into four main categories;policy, workforce, education and equipment.

While all of three protocols required new ways of workingwithin the intervention stroke units, it was the fever and sugarprotocols that were identified preintervention as potential toexperience barriers from a policy perspective. Indeed, in rela-tion to the sugar protocol, the use of insulin infusions as a newprocedure was found postintervention to have been an actualbarrier to implementation. In relation to the fever protocol, itis important to note that in the QASC trial settings, nursesfrom all intervention units were permitted by a Department ofHealth policy to administer the first dose of oral paracetamolfor fever without a presigned written medical order and, hence,rapid administration of an initial paracetamol dose by a nursefor fever was not perceived as a preintervention barrier in oursetting. However, this may be a barrier in other jurisdictions orhospitals where such practices may not be policy. Second andsubsequent administration of paracetamol was not an actualbarrier.

Eight workforce-related perceived barriers were identifiedpreintervention across the three elements of the intervention.The use of insulin infusions and the preimplementationconcern that this might result in extra observations beingrequired was considered to be a potential impact upon protocoladoption. This was not unexpected as work overload andinadequate staffing have been seen to be a barrier in otherstudies (Hamilton et al., 2007). However, of interest, ourpostimplementation survey did not find any of the workforceconcerns to be actual barriers to uptake of the protocols.

None of the equipment perceived barriers identified prein-tervention were found to be actual barriers. It is important torecognise that some perceived barriers that were identified inthe preimplementation workshop were successfully addressedprior to the trial commencement (i.e., lack of equipment) andindeed, this is the purpose of undertaking a barrier assessment.It is likely this is why lack of equipment was not perceived as anactual barrier and encouraging that nurses were able to over-come this obstacle with no additional resources provided bythe trial for this purpose.

Our findings also demonstrated that a number of educa-tional perceived barriers related to the implementation of theFeSS protocols directly involved medical staff, in particularthe continuous engagement of the doctors. Future nurse-ledand multidisciplinary studies in this area should aim toaddress issues surrounding the local engagement of medicalstaff. This is an issue that has been identified in a numberof previous studies investigating patient safety and qualityinitiatives (Gollop, Whitby, Buchanan, & Ketley, 2004) but canbe difficult to achieve over the life of a trial such as ours (thatran for 5 years) due to frequent junior medical staff rotations.

The importance of teamwork has been documented in theliterature, particularly in stroke (Baxter & Brumfitt, 2008; In-dredavik, Bakke, Slordahl, Rokseth, & Haheim, 1999; StrokeUnit Trialists’ Collaboration, 2007) and this was a key ele-ment of our trial, and addressed by inclusion of all relevant

disciplines in the workshops. This was also emphasised by theenablers that the staff identified, in particular, the importanceof clinical site champions and supportive management. Suchfindings are supported by the Cochrane review examining opin-ion leaders (Flodgren et al., 2007) which found that the use ofopinion leaders can help evidence-based practice by promotingthe evidence and bridging the evidence-practice gap.

Our results show that not all perceived barriers eventuateas actual barriers. There are a number of instances where thisis reflected (e.g., potential increased workload, equipment sup-plies and paracetamol administration policies). As previouslymentioned, this could be a result of the barriers being suc-cessful addressed throughout the trial (i.e., purchasing of newequipment) or the willingness of the particular staff to activelyaddress issues. However, preintervention identification of per-ceived “nonbarriers” may also reflect overcautiousness by staff.Examination of perceived and subsequent actual barriers to ev-idence implementation presents a number of challenges dueto the paucity of high quality process evaluations (Drury et al.,2014) undertaken alongside these kinds of clinician practicechange trials (Grant, Treweek, Dreischulte, Foy, & Guthrie,2013), and as such, our trial is significant because it presentsa novel perspective. This is an area where future study is war-ranted to better guide similar implementation studies and, inparticular, to expunge preconceived attitudes to changing clin-ician behaviour.

CONCLUSIONSPerceived barriers to the implementation of new protocols maynot always eventuate as actual barriers. Nonetheless, identifi-cation of perceived barriers and enablers prior to an imple-mentation strategy to enhance evidence-based clinical practiceis especially valuable in a multidisciplinary context. An oppor-tunity for staff to identify, plan for and overcome barriers isa critical part of maximising clinical practice change. In turn,this promotes clinician ownership over quality improvementinitiatives and may accelerate successful implementation andtranslation of evidence into practice. Ours is one of the fewstudies to compare the perceived barriers identified preimple-mentation with actual barriers that were encountered. Thisvaluable process could assist with introduction of new inter-ventions by helping to convince clinicians that not all barrierswill eventuate. WVN


� Identification of barriers to practice change hasbeen shown to improve evidence uptake.

� Perceived barriers identified preimplementationmay not always turn out to be actual barriers.

� Education and engagement of the multidisci-plinary team supports successful implementation


Original Article

of relevant clinician behaviour change interven-tions.

� Local opinion leaders can assist in promoting andimplementing evidence-based interventions.

Author information

Simeon Dale, Clinical Research Fellow, Nursing ResearchInstitute, St Vincent’s & Mater Health, Sydney and Schoolof Nursing (NSW & ACT), Australian Catholic University,Darlinghurst, NSW, Australia; Christopher Levi, Professor,Senior Staff Neurologist, John Hunter Hospital, ConjointProfessor of Medicine (Neurology) & Director, Centre forTranslational Neuroscience and Mental Health, University ofNewcastle/Hunter Medical Research Institute; Jeanette Ward,Professor, Adjunct Professor, Department of Epidemiologyand Community Medicine, University of Ottawa, Ottawa, ON,Canada; Jeremy M. Grimshaw, Director, Clinical Epidemiol-ogy Program, Ottawa Health Research Institute, and Professor,Department of Medicine, University of Ottawa, Ottawa, ON,Canada; Asmara Jammali-Blasi, Research Assistant, NursingResearch Institute, St Vincent’s & Mater Health Sydney andSchool of Nursing (NSW & ACT), Australian Catholic Univer-sity, Darlinghurst, NSW, Australia; Catherine D’Este, Profes-sor, Centre for Clinical Epidemiology and Biostatistics, Schoolof Medicine and Public Health, Faculty of Health, The Uni-versity of Newcastle, Newcastle, NSW, Australia; Rhonda Grif-fiths, Professor, Head, School of Nursing and Midwifery, Uni-versity of Western Sydney, Penrith South DC, NSW, Australia;Clare Quinn, Speech Pathology Department, Prince of WalesHospital, Randwick, NSW, Australia; Malcolm Evans, PriorityCentre for Brain & Mental Health Research, The University ofNewcastle, Newcastle, NSW, Australia; Dominique Cadilhac,A/Professor, Head, Translational Public Health Unit, Strokeand Ageing Research, Southern Clinical School, Monash Uni-versity, and Public Heath, Stroke Division, the Florey Insti-tute of Neuroscience and Mental Health, Heidelberg, Australia;N. Wah Cheung, A/Professor, Co-Director, Centre for Diabetesand Endocrinology Research, Westmead Hospital, and Univer-sity of Sydney, Westmead, NSW, Australia; Sandy Middleton,Professor, Director, Nursing Research Institute, St Vincent’s& Mater Health Sydney, and School of Nursing (NSW & ACT),Australian Catholic University, Darlinghurst, NSW, Australia.Trial Registration: Australia New Zealand Clinical Trial Reg-istry (ANZCTR) No: ACTRN12608000563369

Address correspondence to Ms. Simeon Dale, Aus-tralian Cathollic University–Nursing Research Institute,Darlinghurst, New South Wales, Australia; [email protected]


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