Bedside nurses play a key role in implementing evidence-based practice (EBP). The American Association of Colleges of Nursing's (AACN, 2008) The Essentials of Baccalaureate Education for Professional Nursing Practice calls for the adoption of EBP as a competency for nursing practice. An Institute of Medicine (IOM) roundtable recommended that 90% of clinical decisions should be based on evidence by 2020 (Olsen, Goolsby, & McGinnis, 2009). With the implementation of EBP, patient outcomes improve and costs decrease (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012; Orta et al., 2016; Zimmerman, 2017). Health care organizations need to build a culture of EBP to meet the growing demands of health care (Ellen et al., 2013; Melnyk et al., 2012; Melnyk, Fineout-Overholt, Giggleman, & Choy, 2017).
The steady increase of bachelor's-prepared nurses may lead employers to believe that new nurses are well prepared to implement EBP. However, in many nursing programs, there is more concentration on conducting research instead of learning the skills of integrating evidence into practice (Brower, 2017; Orta et al., 2016). Despite data that support the benefits of EBP, nursing faculty may also have a deficit in the knowledge, attitudes, and competencies for teaching EBP (Brower, 2017; Stichler, Fields, Kim, & Brown, 2011). Educators of advanced degree nursing programs are challenged to find effective teaching strategies to prepare nurses in implementing EBP (Kuennen, 2015). For EBP to be successful, it often requires multiple levels of implementation into practice (Gifford, Graham, & Davies, 2013).
Barriers exist for nurses when implementing EBP care (Breimaier, Halfens, & Lohrmann, 2011; Ellen et al., 2013; Makic & Rauen, 2016; Wilson et al., 2015). Barriers include EBP infrastructure, buy-in from key nursing leaders, and individual health care clinicians not implementing EBP interventions due to lack of knowledge, comfort, or confidence. Another barrier to implementing EBP into organizations is that EBP is constantly changing. Health care teams need to stay abreast of new EBP developments to provide the most effective nursing intervention, which often competes with other health care priorities (Makic & Rauen, 2016). It is not surprising that nurses tend to view EBP as a tedious aspect of providing patient care rather than a foundation for nursing practice (Mick, 2014).
Other barriers identified by the nursing literature were lack of time to implement EBP into daily nursing care, lack of information regarding EBP or knowledge of evidence, and a lack of interest in the subject (Breimaier et al., 2011). Limitations regarding RNs' implementation of EBP include lack of knowledge base in practice and difficulty in identifying client values (Ferguson & Day, 2007). Not only is EBP difficult for nurses to understand, but accessing the information or resources to obtain evidence-based research also can be a barrier (Melnyk et al., 2012). Nurses have identified poor technical support and inadequate nursing journals, as well as their own lack of education regarding EBP as barriers. With the lack of education about EBP needed to provide the standard of care for all patients, nurses find it difficult to discover, analyze, and use appropriate EBP interventions in the health care system (Ellen et al., 2013). The education and attitudes regarding EBP need to be increased among nurses if organizations expect EBP to be the standard by which all nurses provide patient care (Allen, Lubejko, Thompson, & Turner, 2015).
New practicing nurses often lack self-confidence (Hosking et al., 2016). New graduates are also pressured to meet performance expectations, and they convey a lack of self-assurance in providing safe patient care (Hosking et al., 2016). RNs who are bachelor's-prepared reported fewer barriers to participating in research or EBP and had a strong desire for EBP, the ability to implement it, and the frequency in which they used research (Wilson et al., 2015). Often, experienced RNs are expected to mentor and precept newer nurses in EBP; yet, experienced RNs have difficulty implementing EBP into their own nursing practices (Mick, 2014).
Nurses' comfort and confidence with implementing EBP is essential to positive patient outcomes (Hosking et al., 2016; Melnyk et al., 2012; Orta et al., 2016). Nurses' comfort and confidence levels regarding implementing EBP should be assessed to identify gaps and implement support where needed (Melnyk et al., 2012; Melnyk et al., 2017). Despite a higher number of baccalaureate nurses in the organization where the study was conducted, there is still a gap in implementing EBP.
This project was conducted to assess the perceptions of nurses at a rural midwestern Magnet® hospital regarding their comfort and confidence in implementing EBP. The aims of this study included measuring RNs' beliefs about the value of EBP, the ability to implement it, the extent to which EBP is implemented, and whether educational level and years of experience are correlated to RNs' reported beliefs.
A non-experimental survey design was used to assess nurses' perceptions of comfort and confidence level and compare results to level of education and years of experience. Institutional review board approval was obtained prior to beginning the study.
A convenience sample of 147 RNs employed at a rural midwestern Magnet hospital were invited to participate in the study and included bedside nurses of all departments in the hospital. RNs who are in leadership roles were not included in this study. RNs within this institution were e-mailed an invitation to participate in an anonymous online survey regarding their perceptions of EBP. The link to the survey was sent through hospital-wide communication methods—not only e-mails but also announcements in Professional Practice meetings and informal reminders by the researcher to staff. After the introductory e-mail, weekly reminder e-mails were sent for 4 weeks. Participants completing the survey constituted consent.
A five-question demographic survey was used in this study. Participants were asked to list their first nursing degree, their highest nursing degree, their age, years of experience, and specialty nursing certifications.
EBP Beliefs Survey and EBP Implementation Survey
Two surveys were used for this study: an 18-item combination survey of the Evidence-Based Practice Beliefs Scale and the Evidence-Based Practice Implementation Scale (EBPIS). Melnyk and Fineout-Overholt developed both survey instruments, and permission was obtained to reuse and reprint the instruments (B.M. Melnyk, personal communication, February 9, 2018). Reliability and validity have been well established for both tools. Reliability was established with a Cronbach's alpha greater than .90 for each scale (Melnyk, Fineout-Overholt, & Mays, 2008). The Evidence-Based Practice Beliefs Scale and EBPIS use a 5-point Likert-scale ranging from 1 = strongly disagree to 5 = strongly agree. This survey was designed to capture the nurse's perspective of his or her current needs regarding EBP.
The EBPIS survey used for this study was developed by asking participants their comfort level, using a 5-point Likert-scale ranging from 1 = very uncomfortable to 5 = very comfortable regarding the 13 EBP competencies for practicing registered professional nurses (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). Descriptive statistics were used to analyze the data. Comparisons were made for RNs with less than 3 years of experience and RNs with 4 or more years of experience.
A total of 89 surveys of a possible 147 were completed, for a response rate of 61%. Demographic data collected included age, first nursing degree, highest nursing degree, years of experience, and specialty certifications. Participants ranged in age from 22 to 64 years old, with an average age of 37. The highest level of education for 71% (n = 63) was a bachelor of science in nursing (BSN) degree. A nursing certification was held by 45% (n = 40). Seventy percent (n = 62) had more than 4 years of nursing experience.
When asked if their education level helped prepare them to implement EBP, 89% of nurses with less than 3 years of experience agreed, compared with 68% of nurses with 4 or more years of experience. When asked if EBP results constitute the best clinical care for patients, 96% of nurses with less than 3 years of experience agreed, whereas 87% of nurses with 4 or more years of experience agreed. All of the less experienced nurses agreed it is important to gain more knowledge and skills in EBP, with 87% of more experienced nurses agreeing. However, 78% of newer nurses reported that they consistently implement EBP with patients, compared with 86% of more experienced nurses. Nurses' self-reported levels of confidence when implementing EBP were 69% for newer nurses and 76% for more experienced nurses. Table 1 presents confidence levels among nurses.
Evidence-Based Practice Beliefs Scale and the Evidence-Based Practice Implementation Scale
Comfort levels with following EBP knowledge and skills were also assessed within this survey. Seventy-three percent of less experienced nurses felt that they were comfortable questioning clinical practice for the purpose of improving the quality of care, whereas 82% of more experienced nurses reported feeling comfortable. Table 2 presents the comfort levels based on experience.
Evidence-Based Practice (EBP) Competencies for Practicing Registered Professional Nurses
Findings indicated that years of experience affects confidence and comfort levels with implementing EBP, as does education, and both together increase nurses' comfort levels even more. This institution promotes and encourages a culture of EBP in everyday practice. This is accomplished by having RNs who serve on EBP committees where they discuss and evaluate bedside nurses' procedures to ensure the most current evidence is used. As in the literature (Wilson et al., 2015), nurses prepared at the BSN level reported that they felt more prepared and comfortable with implementing EBP care, compared with their coworkers with associate degrees.
Nurses need to be aware of their own level of confidence and comfort when implementing EBP. Nurses need to have the confidence to implement changes that are based on current evidence, their clinical competence, and patient preference. Using the knowledge of experienced nurses could improve how new nurse graduates question clinical practice. However, nursing administrators may need to consider the challenges faced by nurses within their institution. Nursing education has evolved, and many nurses (depending on their level of education or number of years as a nurse) may not have received any education on EBP. Also, the quality of education on implementing EBP may vary among nurses (Brower, 2017).
Implementation of EBP within an institution takes an effort from both the individual and the organization (Brower, 2017; Melnyk et al., 2017). To facilitate nurses' implementation of EBP, nurse leaders need to be aware of challenges, understand the process of EBP, and understand how it affects patient outcomes (Warren et al., 2016). Creating a culture of EBP is essential for nurse leaders and nurse executives (Melnyk et al., 2012). The Advancing Research and Clinical practice through close Collaboration (ARCC) model may be useful to assist health care institutions in developing a strong culture of EBP (Melnyk et al., 2017). This model allows for an assessment of the strengths and weaknesses in the current culture of EBP. Then, mentors are used to help facilitate EBP strategies and build confidence with implementing EBP. The ARCC model builds strong EBP among clinicians, which in turn has led to “higher job satisfaction, less staff turnover, and improved patient outcome” (Melnyk et al., 2017, p. 6).
The American Nurses Credentialing Center criteria for demonstrating a culture of nursing excellence is that nurses plan changes in practice new to the organization and revise existing practices based on research evidence (American Nurses Credentialing Center, 2013, 2017). EBP encompasses all five core areas of the Magnet model. It is the responsibility of both leaders and staff nurses to be transformational leaders and engage in EBP; institutions provide structural empowerment through support such as mentors, and certifications and EBP projects are exemplary professional practice. The use of EBP projects and professional development enhance knowledge and provide nurses with the ability to be innovative and improve patient care. Therefore, EBP is essential for Magnet hospitals to uphold their certification and provide the best care possible.
All nurses could benefit not only from education on EBP but also having hands-on experience. Nurses enter the workforce with varying levels of education, and it is important to consider what type of education they received and how much knowledge was gained regarding the use of EBP. Warren et al. (2016) stated that nurses with fewer years of experience tend to have increased positive attitudes when implementing EBP and should be encouraged to participate in councils and in projects that involve EBP. Orientations and nurse residency programs could focus on the application of EBP. After the educational setting, nursing residency programs can help to increase knowledge of EBP. Completing an EBP project during the residency program has been shown to increase leadership skills and knowledge of how to translate research into practice (Hosking et al., 2016). Increased support and feedback from peers, preceptors, and unit managers helps new nurses implement EBP into nursing practice (Hosking et al., 2016).
For more experienced nurses, it is important to continue to build on their knowledge of EBP and give them the opportunity to lead EBP projects. Including nurses in decision making and encouraging them to question practice can also be important to building nurses' confidence and comfort with the implementation of EBP.
The role of EBP and its benefits are well established. However, institutions and nurses need to continue to work to meet the goal set by the IOM to have 90% of clinical decisions based on evidence. An awareness is a start to achieving the IOM goal. To achieve this, nurses need to be aware of their comfort and confidence with EBP. Creating a culture of EBP is the responsibility of every organization. Administrators and educators must continue to assess the comfort and confidence levels of nurses who work directly at the bedside and provide continuing education and hands-on opportunity to increase nurses' comfort and confidence with implementing EBP. Culture is crucial (i.e., administrative support and resources). Hospitals need to create a culture of EBP that encompasses ongoing education and opportunities to apply EBP skills. Professional development to enhance knowledge, skill, and confidence is important given that nurses enter practice with varying degrees of competence in EBP. Nurses need to be aware of the role they play in continuing to improve patient outcomes, which also increases nurses' job satisfaction and, in turn, improves nurse retention rates. Nurses can base their care on evidence.
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Evidence-Based Practice Beliefs Scale and the Evidence-Based Practice Implementation Scalea
|Participants Who Responded Agree to Strongly Agree||All Participants||Participants With >4 Years of Experience||Participants With <3 Years of Experience|
|My educational program prepared me well to consistently implement EBP.||74%||68%||89%|
|I believe that EBP results in the best clinical care for patients.||90%||87%||96%|
|I am clear about the steps of EBP.||73%||72%||74%|
|It is important for me to gain more knowledge and skills in EBP.||91%||87%||100%|
|I am interested in participating in an online distance continuing education fellowship program with EBP experts to enhance my knowledge and skills in EBP.||61%||60%||63%|
|I consistently implement EBP with my patients.||83%||86%||78%|
|EBP is consistently implemented in my health care system or clinical settings.||82%||81%||85%|
|I am interested in receiving more education and skills building in EBP.||83%||81%||89%|
|EBP experts are routinely available in my health care system to mentor me in EBP.||75%||72%||82%|
|I am interested in participating in Web seminars with EBP experts to learn more about EBP.||29%||27%||33%|
|I believe that findings from research studies are routinely implemented to improve patient outcomes in my institution.||80%||77%||85%|
|My organizational culture encourages and supports EBP.||87%||84%||93%|
|My nurse leaders/managers consistently make evidence-based decisions.||81%||77%||89%|
|I am confident in routinely implementing EBP with my patients.||74%||76%||69%|
|My organization has routine educational offerings or an ongoing EBP program to enhance EBP in nurses and other clinicians.||69%||61%||88%|
|My organization routinely recognizes EBP efforts by nurses and other clinicians.||67%||61%||81%|
Evidence-Based Practice (EBP) Competencies for Practicing Registered Professional Nursesa
|Participants Who Responded Comfortable to Very Comfortable||All Participants||Participants With >4 Years of Experience||Participants With <3 Years of Experience|
|Questioning clinical practice for the purpose of improving the quality of care.||79%||82%||73%|
|Describe clinical problems using internal evidence such as assessment data and quality improvement data.||65%||65%||65%|
|Participate in the formulation of clinical questions using the PICOT (Patient population, Intervention of interest, Comparison, Outcome, Time) format.||40%||37%||46%|
|Search for external evidence to answer focused clinical questions.||63%||57%||77%|
|Participate in the critical appraisal of published research studies to determine the strength and applicability to clinical practice.||49%||48%||50%|
|Participate in the evaluation and synthesis of a body of evidence gathered to determine its strength and applicability to clinical practice.||43%||44%||42%|
|Collect practice data (e.g., audits, quality improvement data) systematically as internal evidence for clinical decision making in the care of individuals, groups, and population.||52%||52%||54%|
|Integrate evidence gathered form external and internal sources in order to plan EBP changes.||67%||66%||69%|
|Implement practice changes based on evidence and clinical expertise and patient preferences to improve care processes and patient outcomes.||56%||50%||69%|
|Evaluate outcomes of evidence-based decisions and practice changes for individuals, groups, and populations to determine best practices.||56%||52%||65%|
|Disseminate best practices supported by evidence to improve quality of care and patient outcomes.||56%||58%||50%|
|Participate in strategies to sustain an EBP culture.||63%||63%||63%|