Attitudes towards and implementation of evidence-based practice

Purpose: Transitioning to an evidence-based practice (EBP) environment is a new and often over-whelming challenge for many organisations. The most effective strategies to implement EBP have yet to be determined. In this study an accelerated development EBP program, which was administered to nurses from five hospitals was evaluated. At each hospital, nurses were selected as an “EBP champion” whose role would be to help facilitate the transition within that organisation.

Aims: The purpose of this study was to evaluate the effectiveness of an accelerated educational program on the attitudes toward and implementation of EBP among nurses employed in acute-care facilities.

Methods: Forty-nine nurses from five acute-care facilities participated in an 8-week program to develop into EBP champions. Participants attended a 2-hour class each week conducted by four faculty members of a local university. Pre- and post-test mean scores of the EBP barriers (EBPB) and EBP implementation (EBPI) scales were compared using paired t tests to determine the effect of the accelerated development program.

Results: Respondents reported higher scores on both the beliefs and implementation scales at the end of the program. Paired t tests indicated a significant difference in means for both the EBPB (p < .01) and EBPI (p < .01).

Conclusions: Nurses who attend an accelerated educational program have the potential to significantly improve beliefs and attitudes about EBP. Administrative support and collaboration between academia and service are essential for successful intervention.

KEYWORDS evidence-based practice, EBP champions, EBP mentors, EBP education

Worldviews on Evidence-Based Nursing 2008; 5(4):172-181. Copyright © 2008 Sigma Theta Tau International

One can argue that when nurses’ knowledge of evidence-based practice (EBP) in clinical settings is well developed and organisational support is present,

more nurses will likely use best evidence in their decision making. What is less clear is the most effective means of instilling the knowledge to change nurses’ beliefs and be-haviours about EBP. Even though the importance of EBP has been well documented in the literature, the Nursing In-

Gayle Varnell, Associate Professor, Assistant Dean for Advanced Practice, Barbara Haas, Associate Professor, Director of Doctoral Program, Gloria Duke, Associate Pro-fessor, Associate Dean for Research, Kathy Hudson, Senior Lecturer, The University of Texas at Tyler, Tyler, Texas.

Address correspondence to Gayle Varnell, The University of Texas at Tyler, 3900 University Blvd., Tyler, TX 75799; gvarnell@uttyler.edu

Accepted 28 November 2007

Copyright © 2008 Sigma Theta Tau International 1545-102X/08

formatics Expert Panel of the American Academy of Nurs-ing reported in a national survey that the majority of regis-tered nurses do not feel competent in EBP (Pravikoff et al. 2005). Barriers to EBP implementation include lack of knowledge of the EBP process, lack of ability to critically appraise research, and lack of administrative support (Para-hoo 2000; McCaughan et al. 2002; Melnyk & Fineout-Overholt 2002). Implementation of EBP is further hindered by increased patient loads, and the extensive proliferation of research findings related to clinical practice (Sackett et al. 1997; Melnyk et al. 2000). The study reported in this pa-per was a test of the effectiveness of an accelerated (in-tense and heavily participatory) and collaborative (univer-sity and local community hospitals) educational program to change existing beliefs about EBP and to increase the frequency that nurses utilised EBP behaviours. The inves-tigators anticipated that the participants would assist their organisations with the necessary cultural change required

172 Fourth Quarter 2008 Worldviews on Evidence-Based Nursing

to effectively implement EBP into patient care throughout the institution.

BACKGROUND

EBP is a process of using best available evidence in the context of individualised needs and values to direct clini-cal decision making with the goal of improving outcomes. Best evidence includes research, benchmarking, and clin-ical expertise (Melnyk & Fineout-Overholt 2005). Some researchers have suggested that the best outcomes for pa-tients and their families occur when nursing-care decisions are based on sound clinical expertise and the best scientific evidence (Heater et al. 1988; Melnyk 1999). A professional expectation is that nurses will use the best available evi-dence in their clinical decision making (Kitson 2004). For example, the International Council of Nurses (ICN) notes that “In the era of evidence based practice and knowledge-driven health care. . .. Nurses have a professional obligation to society to provide care that is constantly reviewed, re-searched and validated” (ICN, nd, p. 1).

Even though the importance of EBP has been well doc-umented in the literature, an Institute of Medicine (2001) report showed that: (1) only 55% of adult patients re-ceived recommended care for prevention, and for acute and chronic conditions; (2) the average lag time between dis-covery and care improvement implementation is 17 years; and (3) providers are inadequately prepared to apply latest knowledge and highest standards of known quality. Even though EBP is now part of the curriculum of most nursing schools, 70% of practicing nurses graduated before 1990 and consequently were not exposed to this information during their education (Spratley et al. 2001). Results of studies in the U.S. and the Netherlands indicate that about 30-40% of patients do not receive care according to present scientific evidence, and about 20-25% of care provided is not needed or is potentially harmful (Schuster et al. 1998; Grol 2001).

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In a survey of 1,097 registered nurses, the Nursing Infor-matics Expert Panel of the American Academy of Nursing found that the majority did not feel competent to conduct EBP (Pravikoff et al. 2005). Researchers reported that the most frequent source of information was a peer or col-league, almost half of the nurses were unfamiliar with the term “EBP,” more than half of the nurses had never identi-fied a researchable problem and did not believe that their colleagues used research findings in practice, and 73% had never had instruction in using electronic databases such as PubMed or CINAHL to search for information. Time and “lack of value for research” were cited as the greatest per-sonal barriers to EBP, and “presence of other goals with a higher priority” was cited as the greatest organisational barrier (Pravikoff et al. 2005).

Educational Intervention Toward Evidence-Based Practice

Collaborating

Given the evolving shift in health care toward EBP, nurses need to develop skills to base their practice on best ev-idence. An ICN statement is that “National Nursing As-sociations, . . . educational institutions, managers and em-ployers can create a climate of inquiry, increase access to education in research methods and increase the applica-tion of research to health care” (International Council of Nurses 1999, paragraph 4). Sigma Theta Tau International’s white paper on clinical scholarship (1999) indicated the environment that was most conducive to clinical practice scholarship. Support of the delivery of high-quality patient care and the evolution of the nursing profession via closer communication between nursing education and practice was clearly advocated.

Valuing

Melnyk and Fineout-Overholt (2002) argue that nurses must first believe that basing their practice on the best evidence will lead to the highest quality of care and out-comes for patients and their families. In order for change to occur, “there must be a clear vision, written goals, and a well-developed strategic plan, including strategies for overcoming anticipated barriers along the course of the change” (Melnyk et al. 2004, p. 83). Additionally, admin-istrators must be committed to provide the necessary re-sources such as EBP mentors, computers, and EBP educa-tion. Some administrators have tried to encourage a change to EBP by integrating EBP competencies into clinical pro-motions. However, Miller & Rollnick (2002) argue that this extrinsic motivational strategy is unlikely to be as effec-tive as when people are intrinsically motivated to change. Melnyk et al. (2004) argue that if people are involved in the strategic planning process, they are more likely to change to EBP.

Additionally Fineout-Overholt, Melnyk, et al. (2005) ar-gue that mentors and “champions” can play a key role in implementing EBP because nurses in the clinical arena are in the best position to question nursing practice. How-ever, they typically need assistance in refining their clini-cal questions, searching for best evidence, and critiquing what they find. The best approach to educating practicing nurses utilises a collaborative partnership that facilitates active learning, thus avoiding a top-down push approach (McWilliam 2007).

Teaching EBP

Fineout-Overholt & Johnston (2005) discuss the advance-ment of EBP in nursing as a major but essential challenge and the need for educators to be informed about the most effective methods and techniques for teaching EBP. Nu-merous authors suggest strategies to meet the challenges

Worldviews on Evidence-Based Nursing Fourth Quarter 2008 173

Educational Intervention Toward Evidence-Based Practice

of successful EBP education (Fineout-Overholt & John-ston 2005; Johnston & Fineout-Overholt 2005; Dewey et al. 2006; Koch et al. 2006; McWilliam 2007; Smith et al. 2007). However, recognising that teaching EBP is different from teaching other more traditional topics is an important first step that includes helping nurses to perceive themselves as “evidence-users” as opposed to “evidence-generators” (Fineout-Overholt & Johnston 2005, p. 38). Educators must generate an enthusiasm about EBP con-cepts to help diminish the commonly found negative at-titudes many nurses have about research. A first step is to facilitate novice clinicians to question their practice, to develop a sense of “uncertainty” about the effective-ness of traditional practices (Johnston & Fineout-Overholt 2005) that leads into the development of what Levin (2006) refers to as the “burning clinical question,” which even-tually leads a clinician to search the literature for evi-dence to answer this question (Melnyk & Fineout-Overholt 2005). This requires a clinician to learn and develop searching skills through a maze of databases and informa-tion, in addition to valuing the importance of document-ing search strategies and organising evidence (Fineout-Overholt, Hofstettler, et al. 2005). Yousefi-Nooraie et al. (2007) demonstrated through a Delphi process that early EBP education should include development of clinical questions, literature searches, and basic information about systematic reviews and critical appraisal, and more in-depth information should be provided in an advanced course about critical appraisal and quantitative decision making.

Learning has three components: knowledge, skills, and attitudes (Dawes et al. 2005). Effective EBP education re-quires more than just a comprehension of skills and knowl-edge approach (Dewey et al. 2006). Learning requires a social, inter-dependent process of shared educator-student experiences (Feldman & Levin 2006). Feldman & Levin (2006) emphasise the importance of the educational pro-cess being learner-centred, not using the “talking head” but rather the “dancing feet” approach, where learners are actively involved in the learning process, and not just passive learners. From a medical perspective Richardson’s (2005) ideas are also applicable to nursing. He suggests that teaching EBP can be best accomplished as an inte-grated component of actual practice that includes role-modelling, the weaving of “evidence in among the other facts and skills being taught” (p. A11) during clinical rounds, and the application of selected EBP skills during clinical rounds (Richardson 2005). This approach along with application of concepts from the Socratic method and Knowles theory of andragogy (Lieb 1991) facilitate a col-laborative/cooperative learning environment (Feldman & Levin 2006).

Several authors have written about the importance of collaboration between academia and practice. Others have emphasised the importance of creating a culture in which EBP is valued. However, few studies exist that have in-dicated the effect of an EBP educational intervention on beliefs and behaviours; representing a critical gap in the literature.

Theoretical Framework

The transtheoretical model of organisational change, which evolved from the transtheoretical model of behavioural change (Prochaska et al. 2001) is a 10-stage matched-interventions approach (Table 1). Individualised interven-tions are implemented at each stage to improve the likeli-hood that participants will incorporate EBP principles into their daily practice. This project was guided by stages I- V of the model and these stages and related activities are described below.

During Stage 1, “Consciousness-Raising,” nurse edu-cators of participating acute-care facilities became active in the East Texas Consortium for Evidence-Based Practice (ETCEBP); a collaborative project among nursing faculty and nurse clinicians to facilitate translation of research into practice within a non-EBP culture. In addition, formal and informal discussions about EBP had been taking place at all of the institutions for at least 6 months to a year. Three of the five institutions were pursuing “magnet” status so nursing research activities were becoming more of a fo-cus. However, no concrete plans to implement EBP had yet been developed. During this phase, the researchers met with chief nursing executives at each of the five acute-care institutions and proposed the accelerated EBP development program.

During Stage 2, “Dramatic Relief,” represents emo-tional arousal and inspiration for successful change. Recog-nising that most clinical nurses are not research-focused and may be intimidated by the term EBP, the researchers asked nurse administrators to select nurses to participate in the educational series who could be potential EBP champi-ons. Attendance at the educational series was by invitation only and those invited knew they would eventually men-tor others. When the nurses were asked to be a part of this project, they knew they had the support of their chief nurs-ing officer and had paid time off to attend the series.

During Stage 3, “Self Re-evaluation,” nurses believe that change is important to one’s success. At this stage the pre-test assessments of attitudes and barriers were con-ducted. During the introductory session and following the pre-test, nurses were challenged to think about their cur-rent practices and the evidence that supported nursing in-terventions. This group activity helped to highlight that much nursing is done by tradition.