Healthcare organizations are experiencing continuous change owing to research and innovations. Nurses, representing the largest group of healthcare providers in the United States, can improve the quality of healthcare, patient safety, and efficiency by incorporating research into their standard practice.1 Although rural nurses value evidence-based practice (EBP), they often have more limited resources (eg, continuing education opportunities, protected time, mentors) to engage in EBP activities compared with urban-based nurses.2 Research is needed to identify how EBP can be incorporated into rural and remote areas.3
In 2007, the Institute of Medicine set a goal that 90% of clinical decisions be evidence based by the year 2020.4 Nurses, as well as other healthcare clinicians, realize the importance and value of EBP, but research indicates that less than half actually engage in EBP activities.5,6 A number of studies have reported that nurses prefer to use knowledge from personal experiences and information obtained through conversations with colleagues over information obtained from a source of evidence, such as a published journal article.2,5,7,8 Although nurses and other healthcare workers believe in the importance of EBP, perceived barriers impede their ability to integrate EBP into their daily practice. Moreover, nurses who perceive more barriers to research report less use of EBP, less positive attitudes toward EBP, and limited knowledge/skills for EBP.9
One of the biggest barriers to EBP is time. Nurses report a lack of time to find and read sources of evidence, as well as insufficient time to incorporate that evidence into a practice change.6-8,10 Other barriers include a lack of training in EBP, lack of confidence in appraising research articles, lack of awareness about research, difficulty understanding statistics and other technical terminology, and lack of ability to generalize the results to current practice.6-8,11 Similar to their urban counterparts, nurses working in 1 critical access hospital (CAH) reported a positive attitude toward EBP and recognized its importance to their practice but identified a lack of educational preparation regarding the process of research utilization as a barrier to EBP.12 In addition to time and educational preparation barriers, a systematic review identified lack of support by staff and management as a significant barrier to EBP.11 Nurses felt that they lacked the authority and resources to change the way they provided patient care.9-11
Although several barriers to EBP have been identified, strategies to engage staff and sustain EBP also have been identified, including: a) adequate EBP training; b) support from nursing management; c) access to literature and other sources of evidence; and d) time devoted to learn and implement EBP.6,8 In addition, mentor support has been identified as essential for implementing an EBP change.8,13,14 Nurses who participated in a mentorship program had an increased belief in the value and understanding of EBP and their perceived organizational culture and readiness for EBP.15,16 Not only did the use of EBP mentors increase beliefs about EBP, but it also increased the implementation of EBP.17
Although much is known about the perceived barriers to EBP, studies that test interventions to engage staff in EBP have primarily focused on nurses and other healthcare clinicians working in large, urban academic medical centers. Little interventional research has been done to identify strategies for successfully implementing and sustaining EBP for nurses working in small rural hospitals, who are challenged by even greater access and resource limitations.18 The purpose of this study was to determine the effect of an EBP education and mentoring program on the knowledge, practice, and attitudes toward EBP among staff nurses and clinicians in a rural CAH.
Design, Setting, and Sample
A single site, nonexperimental pretest-posttest study was conducted in a rural, 25-bed CAH located in the Midwestern United States. An email was sent to staff in ambulance, birthing center, emergency, medical-surgical, and surgery complex units, as well as 6 outpatient clinics for recruitment into the study. Interdisciplinary staff who provided direct patient care (eg, registered nurses, licensed practical nurses, certified nursing assistants, certified medical assistants, technicians, paramedics, emergency medical technicians, advanced emergency medical technicians, surgical assistants) were invited to participate. A total sample of 10 participants was recruited. The sample was limited to a maximum of 10 participants because of study logistics and anticipated time restrictions. Staff members with an anticipated leave of absence during the study period were excluded from the study. The study was approved by the New England institutional review board.
The intervention included a series of classroom instruction, small group activities, and mentoring with an EBP mentor. The participants were divided into 3 groups. Each group was assigned an EBP project and a mentor to guide and support the process. The projects were selected for their relevance to an identified need in the CAH, including use of disposable blood pressure cuffs, use of routine fundal massage in postpartum women, and use of best method to obtain pediatric temperature. Over the course of 5 months, participants attended 7 education sessions and 1 session to disseminate the results of their projects (Table 1). Five of the sessions also had designated work time. The education content was based on The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care, which serves as a guide for nurses and other healthcare providers to use research and other evidence-based findings for the improvement of patient care.19,20 The steps of the model include: a) identify triggering issues or opportunities; b) state the question or purpose; c) form a team; d) assemble, appraise, and synthesize the body of evidence; e) design and pilot the practice change; f) integrate and sustain the practice change; and g) disseminate results. Within the model, there are 3 decision points to help guide the EBP process: a) is this topic a priority; b) is there sufficient evidence; and c) is change appropriate for adoption in practice? If the answer to any of the decision point questions is “no,” then the model's feedback loops suggest that more work needs to be done before moving to the next step. The education sessions focused on each step of the model. Some steps were combined into 1 session while other steps were divided into 2 sessions to allow more time to focus on the content. The study researchers, which included the chief clinical and nursing officer, associate director of nursing practice, education manager, education specialist, and administrative coordinator, provided the classroom instruction and also served as the mentors. Content experts (education and outreach librarian and nursing research faculty) were consulted for 2 of the sessions focused on how to search and appraise the literature.
Sessions 1 through 7, which contained all of the EBP education, ranged in length from 2 to 3 hours. The last session, in which the results of the group projects were disseminated and the posttest questionnaire was completed, was 1.5 hours in length. Most of the education sessions were conducted in-person and used PowerPoint presentations to deliver the content. The education and outreach librarian provided an in-person, hands-on demonstration on how to conduct a search of the literature. The session led by a nursing research faculty was conducted via conference call. The participants had the support of their manager to be part of the study. Sessions were held midday to accommodate the varying shifts (eg, night, day, pay per diem/as needed [PRN]) that the participants worked. Participants were paid their hourly wage to attend the education and work sessions. Some participants found coverage for themselves, if they were scheduled to work during the time of the sessions. Other participants came in on their day off to participate in the sessions. If participants were unable to attend, they were required to watch a video of the missed session before the next scheduled session. Additional group time (5 hours on average) was required to work on the EBP projects outside of the planned 8 sessions.
The Evidence-Based Practice Questionnaire (EBPQ)21 was used to collect pretest and posttest data for this study. The EBPQ is a self-reported questionnaire that consists of 24 items, divided into 3 subscales: knowledge/skills associated with EBP, practice of EBP, and attitude toward EBP. Each item is scored on a scale from 1 = never to 7 = frequently. A higher score indicates greater knowledge of EBP, more use of EBP, and a more positive attitude toward EBP. The EBPQ has established reliability and validity. Reliability was established using Cronbach's α (α = .87 full questionnaire; α = .91 knowledge/skills associated with EBP subscale; α = .85 practice of EBP subscale; and α = .79 attitude toward EBP subscale). Construct validity of the measure was assessed by correlating the questionnaire scores with an independent measure of EBP awareness. Correlation coefficients ranged from 0.3 to 0.4. Participants in our study completed the EBPQ at the start of the 1st session before the education and mentoring intervention and again at the last session after completing the intervention. Demographic data (professional role, age, highest nursing or nonnursing degree, years in the profession, years in current position, primary shift, and full-time equivalent [FTE]) were also collected.
Descriptive statistics were used to analyze and describe the study population and EBPQ scores. The Wilcoxon matched-pairs test was used to test for statistically significant differences between pretest and posttest median EBPQ scores. The Wilcoxon matched-pairs test is similar to the paired t test but is a nonparametric test that compares medians rather than means of 2 correlated groups and is appropriate for testing smaller sample sizes, provided the total sample size contains at least 5 pairs (eg, pretest-posttest pairs) of measures.22 Pretest-posttest differences in total EBPQ score and for each subscale were analyzed. A 2-tailed test was used, with a P value of .05 set for statistical significance. Data analysis was conducted using SPSS Statistics version 23 (Armonk, New York).
A total of 10 individuals were enrolled to participate in the study. One participant was unable to complete the full intervention and posttest questionnaire, and his/her data were therefore excluded from the analysis. As shown in Table 2, at the conclusion of the study, participants were primarily nurses (7/9; 77.8%), and most varied in age from 30 to 59 years. Most participants reported their highest nursing degree as associate (ADN) (4/9; 44.4%) or baccalaureate (BSN) (3/9; 33.3%). Years in the profession ranged from 0 to 30 years, with most participants working 11 to 30 years (6/9; 66.6%). Participants reported working from 0 to 11 years in their current position, and most (5/9; 55.6%) reported working primarily on the day shift. One-third of participants worked full-time, and the remainder worked 0.5 to 0.8 FTE (4/9; 44.4%) or PRN to 0.4 FTE (2/9; 22.2%).
Table 3 displays findings of the EBPQ analyses. Total EBPQ scores increased significantly (P = .011) from pre (median, 3.83) to post (median, 5.21) intervention. Knowledge of EBP significantly increased (P = .008) after the EBP education and mentoring intervention (pretest median, 4.14; posttest median, 5.50). Practice of EBP also increased significantly (P = .015) from pre (median, 2.67) to post (median, 4.83) intervention. Although attitudes toward EBP increased from pre (median, 5.00) to post (median, 6.00) intervention, this increase was not statistically significant (P = .106).
In this study, postintervention scores increased in all categories (total EBPQ score, knowledge, practice, and attitudes), and the change in scores was statistically significant for all categories except attitudes. The change in attitudes may not have been significant because participants' attitudes toward EBP were relatively positive/high before the intervention. This supports previous studies that clinicians value or see the importance of EBP but do not have the knowledge or resources necessary to feel confident in practicing EBP.6-8,10,11 The greatest areas of improvement were in knowledge and practice. This finding supports that an EBP education and mentoring intervention can be an effective strategy for increasing knowledge and use of EBP in practice.
In addition to significant improvements in knowledge and practice of EBP, this study resulted in a change in clinical practice throughout the CAH. At the start of the study, only 1 department was using disposable blood pressure cuffs. Based on an evaluation of the evidence in the literature, use of disposable blood pressure cuffs became the focus of 1 of the EBP projects in the study. At the conclusion of the study, the use of disposable blood pressure cuffs was implemented into several other departments within the CAH, a practice change that has been sustained for 3 years. Not only was this practice change safer for patients with less risk of acquiring a hospital-acquired infection, but it also resulted in financial savings for the CAH. When comparing the cost of disinfecting reusable blood pressure cuffs to the cost of the disposable blood pressure cuffs, we estimate the cost savings for the 2 departments in the CAH with the highest volume of patients to be $8088 annually.
A systematic review found that interventions that are well planned, intensive, and clinically relevant; address the specific needs of the group; encourage active participation; and provide opportunities for professional development are likely to be effective.23 Our study tested an intervention that provided a well-planned, intensive education and mentoring program targeted to the specific needs of nurses working in rural CAHs. Because the participants investigated processes from their current practice, relevance to clinical practice was incorporated into our program. This clinical relevance could have positively impacted participant engagement in the project and EBPQ scores. The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care was valuable in providing a standard process to follow and a structure to build the education plan on. The use of outside resources (education and outreach librarian and nursing research faculty) onsite and remotely was a key support in providing expert content to the group during the educational sessions. One of the biggest challenges was developing a plan to support staff attendance and participation at each session. In a CAH where there may be minimal staff scheduled, it can be difficult to take someone out of patient care to attend class. Manager support of the education and scheduling to support attendance was necessary for effectiveness. If staff had to miss a session, we provided the educational content via a recorded presentation; however, they missed the work session with their team and mentor.
The findings from this study indicate that the education and mentoring intervention was successful in improving knowledge, practice, and attitudes toward EBP. However, we realize it may be challenging to replicate this intervention in other CAHs because of the amount of time and resources needed. Participants and mentors were paid for their time to participate in the education and mentoring intervention, and the costs associated with this intervention were estimated to be $8000. We collaborated with outside resources (education and outreach librarian and nursing research faculty) to lead 2 of the education sessions at no cost to the CAH. This could be an additional cost to other CAHs, which would further increase the amount of resources needed. To address these challenges, a scaled-back program focused on EBP could be offered and tested and should include: a) nursing leadership advancement programs; b) interdisciplinary staff leadership programs; c) nurse residency programs; and d) clinician management. Research is needed to study whether the positive effects of an intervention such as the one used in this study can be sustained over time. Future studies should measure knowledge, practice, and attitudes at 6 months and 1 year after completion of an education and mentoring intervention.
Nurse managers must have clinical expertise and research training, serve as role models or mentors, and advocate for protected time for their staff to engage in research activities.24 Findings from this study support previous evidence of the important role nurse leaders play not only in supporting EBP but also in promoting and facilitating EBP activities.6,11 Support from nurse managers and administrators is essential for building research efforts of nurses at the frontline of patient care.24
One limitation of this study was that a convenience sample was used. This may have led to a sampling bias in which those staff who participated may have had an interest in EBP, thereby making them more engaged and eager to learn. In addition, 2 of the mentors were unable to complete the study and were replaced by other mentors near the end of the study. This could have affected participants' postintervention scores. Lastly, the study was completed at a single site, and the sample size was small because of the size of the study site (a 25-bed CAH) and availability of resources. These factors limit the generalizability of the study results. Although the study did include a representative sample of the CAH, future studies that include multiple CAHs are recommended to increase the sample size and generalizability of the results.
Education and mentoring of healthcare clinicians in rural settings are crucial to the translation of evidence-based research into practice to improve patient outcomes. Findings from this study indicate that education and mentoring can have a positive effect on the knowledge and practice of EBP among direct care nurses and clinicians working in rural CAHs. Implementation of EBP depends on strategic planning and empowerment programs designed at the organization level.25 Hospital administrators should develop a comprehensive plan for implementing and sustaining EBP tailored to the unique challenges of their organization.
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