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Evidence-based practice knowledge, attitudes, practices, and barriers

Crable, Jane DNP, APRN, CNS, CCRN-K; Highfield, Martha E. Farrar PhD, RN; Patmon, Frances PhD, RN, FNP-C

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doi: 10.1097/01.NURSE.0000754000.05371.65
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NURSE LEADER SUPPORT of evidence-based practice (EBP) is pivotal in promoting positive patient and organizational outcomes. EBP improves professional nurse performance, reduces healthcare costs, and limits unhelpful practice variations by narrowing the gap between research and practice.1-6 The research team conducted a baseline assessment of nurses' EBP knowledge, attitudes, practices, and perceived barriers at their facility with the goal of designing site-specific leader interventions to promote EBP.

Background

EBP differs from scientific research and quality improvement processes. EBP is the process of integrating evidence, clinical judgment, and patient/family values and preferences, and then applying that customized plan to practice.7 Scientific research produces new knowledge for times when evidence is too limited or unavailable; quality processes include improvements to, and the monitoring of, care already consistent with evidence.5 In contrast, EBP allows nurses to adapt existing evidence to the unique characteristics of their patients and healthcare facilities.

Two recent developments in the modern landscape of healthcare research are particularly supportive of EBP. First, nurses now have access to numerous EBP models that can guide them through the process. Some models support individual use of evidence in practice, while others emphasize teamwork in making institutional changes.8,9 Some institutions adopt an existing model, and others develop their own.10-12

The second development with a positive impact on EBP is the increase in systematic reviews and well-established evidence-based clinical guidelines or protocols that can be used across settings. Examples include clinical practice guidelines from professional organizations, practice bundles, systematic literature reviews, and meta-analyses or meta-syntheses.13-15

Despite these resources, nurses often encounter individual and organizational barriers to EBP. In a recent integrative review of nine English-language publications, Camargo and colleagues identified EBP barriers such as “workplace overload,” lack of desire to change practice, and a limited ability to understand research and statistical analysis.16 Although findings suggested that nurses valued EBP, the research found that nurses consulted colleagues and local protocols more often than research.16

Such EBP barriers are not new. In earlier research, 391 Australian nurses self-reported their top EBP barriers as lack of time to read, lack of time to implement ideas, lack of awareness of research, limited authority to make changes, difficulty reading statistical results, scattered literature, and limited physician cooperation.17 Pravikoff and colleagues, who wanted to go beyond the well-documented barrier of nurse time, found that their national sample of 760 US nurses used collegial advice more than literature.18 They documented that nurses encountered both individual EBP barriers (such as misunderstanding the value of research or not knowing how to access and interpret it) and institutional barriers (such as organizational priorities, inadequate staff retention and recruitment, limited budget, lack of awareness of nurse interest, and lack of ability to incorporate evidence into practice).18 Additionally, Barends and colleagues found that 2,789 nurse leaders in the US, Europe, and Australia reported similar barriers of time, organizational climate, accessibility and readability of studies, and a propensity to make decisions based on experience and colleague advice over scientific literature.19

Given the value of nurse EBP, consistent nurse reports of barriers, a nurse preference for experience and collegial consultation over research, and a desire to strengthen EBP within the hospital system, the research team sought first to identify their nurse colleagues' baseline EBP abilities. Specific research questions were:

  • What are the self-reported levels of nurses' EBP knowledge, attitudes, and practices?
  • How do barriers to EBP affect those levels?

Methods

In order to facilitate customized planning for staff, the research team surveyed an inclusive, convenience sample of all regularly employed nurses in two California hospitals. Excluded from the sample were contracted/temporary nursing staff and those unable to access the electronic survey for any reason, such as extended leave.

The two hospitals are part of the same nonprofit health system. Hospital A is a 342-bed community-based tertiary cardiac referral center, where no formal nursing EBP model was used. Hospital B is a 424-bed community-based teaching facility, where nurses had adopted the Iowa Model, employed a part-time PhD research facilitator from a local university, and hosted 9 years of annual collaborative Research/EBP Days with a nearby university.9 Neither hospital was on the Magnet® journey or Magnet-recognized.

Both hospitals already had implemented select research-based practices, such as Institute for Healthcare Improvement bundles (for example, central line-associated bloodstream infection and ventilator-associated pneumonia bundles) and organizational clinical practice guidelines.13 The hospitals or regulatory agencies mandated many of these EBPs, so their use was unlikely to reflect nurse attitudes, skills, or knowledge of EBP.

Instrument

The research team collected nurse self-report data using an investigator-modified version of the Clinical Effectiveness and Evidence-Based Practice Questionnaire (EBPQ).20,21 The widely used EBPQ includes three subscales measuring nurses' EBP knowledge, attitudes, and practices on 7-point Likert scales. The tool has demonstrated strong construct and discriminant validity, as well as good reliability for the overall scale (alpha = .87) and its three subscales (alpha = .79 to .91). At the same time, reliability of the attitude subscale over time is inconsistent; and while EBPQ authors have not yet proposed scale revisions, they suggest that their use of whole sentence anchors uniquely on the attitude subscale may be creating respondent confusion.20,21

With permission, the research team adapted the original 24-item paper-and-pencil EBPQ into a 26-item SurveyMonkey electronic version. The two added items were an item that asked respondents to check all that applied from a list of seven barriers with an option to identify others, and a multipart demographics question.

Procedure

Following Institutional Review Board approval, the research team advertised the study for 2 weeks using email, flyers, and in-house newsletters. Researchers then used organizational email to distribute consent information and a SurveyMonkey link to the EBPQ. In Hospital A, managers sent emails to staff, and the research team visited individual nursing units on nonconsecutive days to encourage completion of the survey. In Hospital B, a mix of administrative assistants and managers sent emails to unit staff, and the research team encouraged participation at tables outside the cafeteria during lunch hours on nonconsecutive days.

Data were collected over 30 days at both hospital locations. Online instructions asked respondents to complete the survey just once and asked non-regularly employed nurses, such as travelers, to exclude themselves. Anonymous survey completion documented consent.

Results

Descriptive and inferential analyses were conducted using Statistical Package for Social Sciences (SPSS, version 26). Measures of distribution and central tendency, percentages, and analyses of variance (ANOVA) were used.

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n %
Gender Male 40 15
Female 232 85
Clinical specialty Clinical nurse 212 77
Other 66 24
Employment status Full-time 243 86
Part-time 29 10
Per diem 7 3
Travelers 2 <1
Highest degree Diploma 13 5
Associate's 57 21
Bachelor's 167 61
Master's 35 13
DNP 2 <1
Location Hospital A 202 57
Hospital B 154 43
Barriers to EBP None 62 22
One 105 37
Two or more 119 42
Note: Totals may not equal 100% due to missing data and rounding.

A total of 356 surveys were returned for an estimated response rate of 22% from total nurses at both hospitals. More nurses returned the EBPQ from Hospital A (n = 202) than from Hospital B (n = 154). For the combined samples, mean years of age was 42 (SD = 12), and mean years of practice was 15 (SD = 13). Most respondents were female (85%; n = 232), reported working full time (77%; n = 243), and held a BSN (60%; n = 167). Some (14%; n = 37) had postgraduate education. Finally, two nurse travelers participated despite the request to self-exclude. (See Respondent demographics.)

In order to determine nurses' self-reported EBP knowledge, attitudes, and practices, the research team descriptively analyzed responses to each EBPQ question on its 7-point, anchored, Likert scale. Scores ranged from 1 as least favorable to 7 as most favorable. No overall or subscale scores were calculated for EBPQ because examining individual items provided more skill-specific details than would overall scale and subscale scores. (See EBPQ results and Attitude subscale.)

To determine respondents' EBP knowledge, the research team analyzed item data from the EBPQ knowledge subscale. That subscale asked respondents to rate their knowledge on a list of 14 items on a numbered scale with anchors of “Poor” (1) and “Best” (7). Mean knowledge item scores ranged from 4.77 to 5.64, and the two highest self-reported scores on the EBPQ were within the knowledge subscale: “Sharing of ideas and information with colleagues” and “Ability to review own practice.” Additionally, the second lowest item score was also within this subscale, with 42% self-rating their knowledge of “Converting information needs into a question” as 1 to 4 on the “poor” end of the scale. Almost one-third (32%) also rated themselves from 1 to 4 on the item “research skills,” and one-fifth (20%) reported scores of 1 to 4 on 12 of 14 knowledge items (n = 286).

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Subscale and items n Mean SD % nurses responded 1-4
Knowledge
Sharing of ideas and information with colleagues 286 5.64 1.16 18
Ability to review your own practice 286 5.63 1.15 18
Dissemination of new ideas about care to colleagues 286 5.47 1.17 21
Ability to apply information to individual cases 286 5.43 1.26 21
Ability to identify gaps in your professional practice 286 5.36 1.15 21
Ability to determine how useful the material is 286 5.35 1.22 21
Monitoring and reviewing of practice skills 286 5.33 1.03 20
Informational technology skills 286 5.24 1.08 25
Ability to determine how valid the material is 286 5.23 1.20 25
Knowledge of how to retrieve evidence 286 5.21 1.16 21
Ability to analyze evidence against set standards 286 5.21 1.22 26
Awareness of major information types and sources 286 5.09 1.24 30
Research skills 286 5.01 1.26 32
Converting information needs into a question 286 4.77 1.42 42
Practice
Shared [EBP practices] with colleagues 295 5.53 1.50 22
Integrated the evidence you have found with your expertise 295 5.45 1.46 25
Evaluated the outcomes of your practice 295 5.39 1.54 27
Tracked down the relevant evidence 304 5.39 1.54 27
Formulated a clearly answerable question 304 5.30 1.48 30
Critically appraised literature against set criteria 304 4.57 1.74 46
n = number of responses
SD = standard deviation
This is the percentage of participants that reported a value of 1—4 (1 poor – 7 excellent)

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Scale anchor (low) % RNs % RNs Scale anchor (high)
1. My workload is too great for me to keep up to date with all the new evidence. 13 87 New evidence is important, so I make time.
2. I resent having my clinical practice questioned. 1 99 I welcome questions on my practice.
3. EBP is a waste of time. 1 99 EBP is fundamental to professional practice.
4. I stick to tried-and-trusted methods rather than changing to anything new. 1 99 My practice has changed because of evidence I have found.
n = 65

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No barriers One barrier Two or more barriers P-value
Mean SD Mean SD Mean SD
Knowledge
Ability to review your own practice 6.10 1.04 5.57 1.02 5.45 1.25 .001a,b
Sharing of ideas and information with colleagues 6.02 0.97 5.56 1.14 5.52 1.24 .02a,b
Ability to identify gaps in your professional practice 5.89 1.01 5.23 1.16 5.20 1.14 <.001a,b
Ability to apply information to individual cases 5.95 1.08 5.33 1.15 5.24 1.13 <.001a,b
Dissemination of new ideas about care to colleagues 5.90 0.97 5.34 1.18 5.34 1.20 .003a,b
Monitoring and reviewing of practice skills 5.79 0.85 5.24 1.00 5.18 1.09 <.001a,b
Ability to determine how useful the material is 5.92 1.03 5.24 1.17 5.15 1.27 <.001a,b
Information technology skills 5.65 1.01 5.14 1.06 5.13 1.09 .004a,b
Knowledge of how to retrieve evidence 5.90 1.02 5.26 1.15 5.22 1.16 <.001a,b
Awareness of major information types and sources 5.63 1.03 4.96 1.23 4.92 1.29 <.001a,b
Ability to determine how valid the material is 5.77 1.03 5.11 1.15 5.05 1.25 <.001a,b
Ability to analyze evidence against set standards 5.79 1.03 5.09 1.25 5.01 1.21 <.001a,b
Research skills 5.55 0.99 4.78 1.29 4.93 1.30 <.001a,b
Converting information needs into a question 5.31 1.39 4.69 1.27 4.56 1.49 .002a,b
Practice
Shared this information with colleagues 5.84 1.37 5.43 1.48 5.51 1.51 .20
Evaluated the outcomes of your practice 5.74 1.54 5.23 1.49 5.36 1.52 .10
Tracked down the relevant evidence 5.69 1.33 5.33 1.50 5.34 1.59 .26
Integrated the evidence you have found 5.63 1.48 5.36 1.44 5.36 1.41 .51
Formulated a clearly answerable question 5.56 1.31 5.17 1.40 5.38 1.46 .21
Critically appraised literature against set criteria 5.05 1.62 4.35 1.76 5.45 1.73 .04a
SD = standard deviation
a = significant difference between no barriers and one barrier
b = significant difference between no barriers and two or more barriers

To assess practices, the research team analyzed individual item data from the EBPQ practice subscale. The practice subscale asked nurses to report how often they engaged in six activities “in relation to an individual patient's care over the past year.” Responses were recorded on an unnumbered, 7-point anchored scale from “Never” to “Frequently.” Mean practice subscale scores ranged from 4.57 to 5.53. Nurses reported their weakest EBPQ score on this subscale: How did you “Critically appraise, against set criteria, any literature you have discovered.” Just under half of nurses (46%) scored themselves 1 to 4 on that item, and many (22% to 30%) scored themselves 1 to 4 on the remaining five practice items.

Finally, in order to ascertain attitudes toward EBP, the research team analyzed attitude subscale items. That scale asked nurses to respond to four items on an unnumbered, 7-point scale that was anchored by full sentences. Only 65 nurses responded to the attitude scale and most reported extreme scores, leading the research team to analyze item results as a yes-no, dichotomous scale. EBP attitudes were almost entirely positive (87% to 99%).

To answer the second research question of how EBP barriers affect nurse EBP engagement, the research team used descriptive and ANOVA testing. Our modified EBPQ asked nurses to check all barriers that applied from this list: a) There are no barriers, b) No time, c) Too costly, d) No knowledge/limited knowledge of research, e) No nurse with research knowledge in my practice setting, f) No interest by nursing leader, and e) Other reason(s). “Other reasons” was accompanied by space for explanation.

The research team divided nurses into three groups: those who identified no barriers (41%, n = 119), one barrier (36%, n = 105), and two or more barriers (21%, n = 62). Using these categories for ANOVA testing, the team found that one or more barriers were related statistically to a lower score in all items under EBP knowledge (P < .02) and to one practice item (P < .04). (See EBP barriers.)

Limitations

The project was limited by convenience sampling from one hospital system in one US state, potential self-selection bias of participation, potential social desirability bias that could inflate self-reported scores, and potential reliability issues with the EBPQ attitude subscale.20 Additionally, the adaptation of the EBPQ to SurveyMonkey structure may have impacted responses.

Discussion

In essence, this study invites discussion of the research team's two major questions:

  • What are the self-reported levels of nurses' EBP knowledge, attitudes, and practices?
  • How do barriers to EBP affect those levels?

Knowledge, attitudes, and practices. First, this project provides valuable data that add to existing literature on nurse EBP knowledge, attitudes, and practices, as well as yielding site-specific data for nurse leaders' strategic planning. Nurses at the research team's facilities had almost entirely positive attitudes toward new evidence, questioning, and changing personal practice; consequently, respondents' view of EBP as fundamental to practice bodes well for promoting EBP. The unexpectedly high percentage of nurses with graduate training (14%) may have contributed to these respondents' vibrant interest in promoting EBP and possibly reflects a skewed sample if those who held positive attitudes toward EBP participated and those who held negative views did not. No data exist on nurses who elected not to participate in the survey.

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Content Resources (publicly available online)
  1. Formulate a clearly answerable question:

    1. Identify gaps in practice

    2. PICO(T)

      1. Population/Patient Problem: Who is your patient? (Disease or health status, age, race, sex)

      2. Intervention: What do you plan to do for the patient? (Specific tests, therapies, medications)

      3. Comparison: What is the alternative to your plan? (No treatment, different type of treatment, etc.)

      4. Outcome: What outcome do you seek? (Less symptoms, no symptoms, full health, etc.)

      5. Time: What is the time frame? (This element is not always included.)

    3. In-house resources

    4. The role of the EBP team

  • Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs. 2010;110(1):51-53.

  • Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice, step by step: asking the clinical question: a key step in evidence-based practice. Am J Nurs. 2010;110(3):58-61.

  • Highfield M. You got a problem with that? Try PICO. Discovering your inner scientist. 2015. https://discoveringyourinnerscientist.com/2015/02/12/you-got-a-problem-with-that-try-pico.


The reported attitude scores also may reflect a limitation of the EBPQ tool itself. While it is possible that the sample possesses highly positive EBP attitudes given their graduate training and self-selection, other explanations should be considered. First, using socially desirable and socially undesirable sentences as anchors may have created an extreme response-set bias among participants; second, participants may have been confused by the survey's different structure.20 Less than 20% of respondents completed attitude items, and those who did recorded the “right” positive answer.

Most respondents placed themselves in positive alignment with the attitude, “Evidence-based practice is fundamental to professional practice.” Crano and Prislin describe attitudes as evaluative integrations of cognitions that affect experience in relation to an object.22 Because assessed attitudes can guide leaders in both understanding and predicting behavior change, such positive attitudes suggest an opportunity for increasing nurse EBP through coaching and mentoring.23

Self-reported EBP knowledge was relatively strong, with nurses rating all but one subscale item above 5 on its 7-point scale. This encouraging finding both suggests a strong foundation for building EBP practice and hints at a knowledge-practice gap. Knowledge alone cannot produce desired patient and organizational outcomes but must be translated into practice “know-how.” As with attitude findings, higher knowledge scores with lower practice also may reflect the graduate education of many respondents who have not yet applied their learning.

The two lowest self-reported scores, the practice of critically appraising literature “against set criteria” and the knowledge of how to convert “information needs into a research question,” suggest key areas for improvement. Other practice areas may need special attention given the finding that one-fifth or more of nurses rated themselves as weak in all EBP practices. At the same time, EBPQ scores are not precisely diagnostic, and nurse leaders would be well served to examine all extant data to determine what EBP support might create the biggest impact.

Yet EBP is not as easily encultured as it would seem. Such practice confronts our second major question regarding barriers.

EBP barriers. The need to remove EBP barriers was highlighted by the unique finding that one or more respondent-identified barriers were negatively related to knowledge and less so to practice. EBP barriers of time, limited knowledge, and resistance to change as identified by 77% of respondents matched others' findings.16-18 Moreover, every less-than-perfect score on EBPQ items reveals some level of EBP weakness that is ostensibly a barrier to EBP.20 For example, any reported limitation in the practice of “tracking down relevant evidence” will slow EBP efforts unless ameliorated by some intervention, such as hands-on education, mentoring, or by a colleague with that expertise.

Conclusion

Survey findings suggest several implications for nurse leaders. First, this study illustrates the value of EBPQ, or a similar tool, to yield site-specific information useful to leaders, or assist in gap analysis for those on the Magnet journey. The research team's site-specific findings contribute to the growing body of literature on nurse EBP knowledge, practice, and attitudes that warrants critical appraisal by leaders.

Additionally, findings demonstrate the need for resources that can bolster nurse EBP strengths and improve weaknesses. For instance, for this project the authors drafted an EBP tool kit that reflects the specific knowledge, practice, and attitude content of the EBPQ. The tool kit will be provided to nurse leaders along with reports on this study. (See Tool kit sample.) Leaders can then focus on those elements that they deem most heuristic in their setting, as well as remove barriers; for example, by designating structured worktime for EBP efforts on organizational priorities. EBPQ can be used for follow-up evaluation at an appropriate time. Finally, EBPQ's attitude subscale weakness suggests the need to compare it with other measures of staff attitude.

Nurse leaders are uniquely positioned to foster evidence-based care, to remove EBP barriers, and to facilitate nurses' changing practice interventions to reflect current knowledge. Combining current literature with site-specific evidence provides a foundation for action toward better patient and organizational outcomes.

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        Keywords:

        Clinical Effectiveness and Evidence-Based Practice Questionnaire; EBP; EBPQ; evidence-based practice; nurse leader; practice gap; survey

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