The Journal of Continuing Education in Nursing

Original Article 

Evaluation of a Hospital-Based Nursing Research and Evidence-Based Practice Mentorship Program on Improving Nurses' Knowledge, Attitudes, and Evidence-Based Practice

Ee-Yuee Chan, PhD, MSc, MN, BN, RN; George Frederick Glass, MSc, BN, RN; Koh Ni Phang, MPH, BSc, RN

Abstract

Background:

Evidence-based practice (EBP) is a core requirement for nurses, contributing toward better clinical outcomes. Mentorship could prepare early adopters of EBP to create an EBP culture.

Method:

Nine nurses in an acute hospital in Singapore participated in a mentorship program throughout 2015. Mentees conducted ward-based EBP education sessions for nursing colleagues. The Evidence-Based Practice Questionnaire (EBPQ) was used to measure the program's effect on mentees' and their ward colleagues' knowledge, attitude, and practice of EBP. Both groups completed the EBPQ before and 3 months after completion of the program. Wilcoxon rank-sum tests were performed to compare changes in EBPQ scores.

Results:

Both mentees and ward colleagues reported improved posttest median scores for all EBPQ subscales and the overall score. However, mentees reported a larger magnitude of improvement.

Conclusion:

A hospital-based research and EBP mentorship program increases nurses' knowledge, attitude, and practice of EBP, creating an EBP culture change. [J Contin Educ Nurs. 2020;51(1):46–52.]

Abstract

Background:

Evidence-based practice (EBP) is a core requirement for nurses, contributing toward better clinical outcomes. Mentorship could prepare early adopters of EBP to create an EBP culture.

Method:

Nine nurses in an acute hospital in Singapore participated in a mentorship program throughout 2015. Mentees conducted ward-based EBP education sessions for nursing colleagues. The Evidence-Based Practice Questionnaire (EBPQ) was used to measure the program's effect on mentees' and their ward colleagues' knowledge, attitude, and practice of EBP. Both groups completed the EBPQ before and 3 months after completion of the program. Wilcoxon rank-sum tests were performed to compare changes in EBPQ scores.

Results:

Both mentees and ward colleagues reported improved posttest median scores for all EBPQ subscales and the overall score. However, mentees reported a larger magnitude of improvement.

Conclusion:

A hospital-based research and EBP mentorship program increases nurses' knowledge, attitude, and practice of EBP, creating an EBP culture change. [J Contin Educ Nurs. 2020;51(1):46–52.]

Evidence-based practice (EBP) has been described as the integration of the best research evidence, expert clinical judgement, and the preferences and values of patients (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). It is listed as a core competency in the education of health care professionals, as it has been shown to contribute best clinical decision making and outcomes for patients and families (Black, Balneaves, Garossino, Puyat, & Qian, 2015; Emparanza, Cabello, & Burls, 2015). In addition, EBP ensures the relevance of care delivered, ensuring that resources are used appropriately (Warren et al., 2016). The holistic patient-centered approach of EBP has considerable appeal to nursing, reflecting the scope of research and its application within nursing (Mackey & Bassendowski, 2017). The delivery of evidence-based nursing care has been linked to improved patient outcomes, ranging from reduced length of stay in the hospital to improved pain management and reduced rates of dialysis catheter infections (Wu et al., 2018).

A major barrier toward the application of EBP by nurses is the reported lack of knowledge in searching for published literature, its evaluation, and translation to practice (Farokhzadian, Khajouei, & Ahmadian, 2015; Fowler, 2013). Another limitation is the lack of mentors in the clinical settings, who are individuals who could coach and guide nurses in the application of these skills to generate improvements in their clinical practice, guided by the best evidence obtained (Farokhzadian et al., 2015).

A systematic review on mentorship identified three key characteristics for success—mentors possessing a higher level of experience than their mentees, the provision of personalized support according to the mentees' requirements, and the establishment of a relationship marked by a sense of mutual gain, engagement, and commitment (Abdullah et al., 2014). Through this mentorship, champions can be raised to push the EBP agenda in their areas of influence, such as their clinical departments, thereby influencing learning and the adoption of EBP in their departments (Abdullah et al., 2014). This is a key component to reduce clinical nurses' resistance to EBP, as it would demonstrate EBP's applicability in bedside practice (Wallen et al., 2010).

Mentorship in the clinical settings by clinical nurse specialists or nurse educators was found to increase the implementation of EBP in their clinical settings that remained over time, demonstrating the value of this strategy as it leads to long-lasting effects in the nursing workforce toward the improvement of care delivery (Breckenridge-Sproat et al., 2015; Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011). Such a form of mentorship has improved the organization's readiness toward adopting EBP as well, improving the organizational culture toward supporting EBP (Breckenridge-Sproat et al., 2015). In addition, it can reduce mentored nurses' perceived barriers and improve their knowledge, attitudes, and skills associated with the implementation of EBP (Kim et al., 2013).

The mentorship approach is epitomized in the Advancing Research and Clinical Practice Through Close Collaboration model, with the raising of EBP mentors to champion EBP to their peers and colleagues to improve nurses' perceptions of and overall adoption of EBP in the nursing workforce (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010). Applying Rogers's diffusion of innovation theory, these EBP champions would become the early adopters of EBP. They can advocate that their peers join the early majority of adopting EBP into their practice and thus create a culture change toward EBP (Rogers, 1995). However, this approach is typically led by individuals seen as nursing experts, who are nurses with established clinical credentials by virtue of their position as clinical nurse specialists or nurse educators to be seen as recognized mentors to nurses (Breckenridge-Sproat et al., 2015; Levin et al., 2011).

Our hospital is a 1,600-bed tertiary center with a high bed occupancy rate, limited staff, and with few nurses with postgraduate training in research methodology at the master's and doctorate level. It was recognized that having front-line EBP champions would be needed to support the adoption of an EBP culture in the nursing workforce. Hence, we launched a research and EBP mentorship program for front-line junior RNs in our hospital with the intent they would become EBP champions in their own departments upon completion of the program.

Nursing Research and EBP Mentorship Program

Nine junior RNs participated as mentees in the mentorship program during 2015. A summary of the program is shown in Figure 1. These sessions included classroom lessons, discussions, hands-on sessions on database searching, article critique, data analysis using statistics software, and a one-to-one mentorship on a research project with a mentor experienced in nursing research and EBP. During the program, the mentees also conducted journal clubs for their wards' nursing colleagues on topics such as framing research questions, literature search strategy, and article critique skills. The mentees also learned how to conduct research and EBP consultation clinics and coached ward nurses on their EBP projects. These hands-on application skills in EBP in addition to the knowledge gained helped prepare mentees to become EBP champions and resource people in their departments.

Research and evidence-based practice (EBP) mentorship program.

Figure 1.

Research and evidence-based practice (EBP) mentorship program.

Another unique component of this training program was the use of peer mentors, arranging for each mentee to be assigned a buddy to guide and co-lead together, a much more equalitarian relationship due to their similar background and clinical experience. This is a common strategy in nursing training with senior students mentoring junior students, but based on our literature search we could not find this approach being adopted in EBP mentorship programs to date (Rohatinsky, Harding, & Carriere, 2017).

Program Evaluation

A program evaluation was conducted to examine whether the nursing research and EBP mentorship program improved mentored nurses' and their ward colleagues' knowledge, attitude, and practice toward EBP. The findings will help us to evaluate the program and inform on revisions required on subsequent runs of the program.

Setting

The program evaluation was conducted in a 1,900-bed acute care hospital in Singapore, consisting of approximately 4,000 nurses.

Participants of Program Evaluation

All mentees and their ward nursing colleagues who were RNs with at least 6 months of experience within the ward were invited to complete the Evidence-Based Practice Questionnaire (EBPQ) by an independent data collector. We excluded ward colleagues who were on long periods of absence (e.g., unpaid leave, maternity leave, hospitalization leave) and those on permanent night shift as they would not be exposed to the mentees' teaching sessions.

Procedure

Eligible nurses were given the EBPQ and instructed to complete it within 2 days and to place the completed form in a sealed box left in their ward areas by an independent data collector. The nurses completed the questionnaire twice: at 1 month before the commencement of the program, and at 3 months after the completion of the program. The questionnaires were anonymous, and nurses were reminded not to leave any personal identifiers. This was performed to encourage the nurses to give honest feedback. Daily reminders during roll calls were given to ensure participation.

Instruments

We used the 24-item EBPQ (Upton & Upton, 2006) to measure nurses' EBP knowledge, attitude, and skills. The EBPQ tool is grouped into three subscales: knowledge/skills (14 items), attitude (four items), and practice (six items). Each item is scored on a scale of 1 to 7, with a higher score being associated with a more positive knowledge of EBP and attitude toward EBP. Previous studies demonstrated a Cronbach's alpha coefficient of .87 for the entire questionnaire: .85 for the practice subscale, .79 for the attitudes subscale, and .91 for the knowledge/skills subscale (Upton & Upton, 2006). Permission was obtained from the authors to use the EBPQ. We also collected data on demographics and clinical experience.

Ethical Approval

A waiver of written consent was granted by the National Healthcare Group Domain Specific Review Board, as this was an anonymous survey.

Data Analysis

Descriptive analysis of participants' characteristics was performed using percentages and means. As the EBP scores of the mentees did not follow a normal distribution, distribution-free statistical tests were used to examine the change in EBPQ scores in both mentees and their ward peers (Kirkwood & Sterne, 2003). Wilcoxon rank-sum tests were performed to compare the change in EBPQ scores over the pre- and postprogram time points in both mentees and their ward colleagues. Statistical analyses were conducted using SPSS® version 24. Interpretation of the strength of evidence against the null hypothesis—that there was a change in median EBPQ scores before and after the program, in mentees and ward colleagues—was performed using p < .05.

Results

Two hundred thirty nurses were screened, and the EBPQ forms were given out to all who were eligible. A total of 210 and 214 survey forms were given out preand postprogram, respectively. One hundred ninety seven pre- and 194 postprogram questionnaires were returned, constituting a response rate of 94% and 91%, respectively.

Demographic Data

All EBPQ respondents were either staff nurses or senior staff nurses. All the mentees were front-line RNs and eight of nine of the mentees possessed a bachelor's degree in nursing. They had an average of 2 years of experience at the start of the program. Six of nine mentees reported receiving prior EBP training at preprogram survey phase (Table 1).

Participant Characteristics

Table 1:

Participant Characteristics

One hundred eighty five ward colleagues completed the pre- and postprogram questionnaires. Of these, slightly more than half earned a bachelor's degree or higher. Their mean experience was approximately 6 years. Approximately one of five of the ward colleagues had prior EBP training.

Pre- and Post-EBPQ Subscales and Overall Scores

Table 2 displays the median EBPQ scores of the mentees and their ward colleagues. There was strong evidence that the mentees had improved their knowledge, attitude, practice, and overall EBPQ scores (p < .001). The largest improvement was in the practice subscale, increasing from a median score of 3.0 at pretest to 5.3 at posttest.

Median EBPQ Scores of Mentees and Ward Colleaguesa

Table 2:

Median EBPQ Scores of Mentees and Ward Colleagues

There was also strong evidence that the ward colleagues improved their knowledge scores (p = .005) and their overall score (p = .004). The largest improvement was in the practice subscale, increasing from a median score of 3.3 at pretest to 4.0 at posttest. Comparison of the median and interquartile range values of the preprogram and postprogram knowledge, attitude, and practice subscale scores and overall scores suggest that the improvements in scores for the mentees were greater than their ward colleagues for all three subscales and overall scores.

Pre- and Post-EBPQ Items Scores

The mentees reported higher median scores for all 24 items in the knowledge, attitude, and practice subscales in the EBPQ questionnaire during the postprogram survey. In comparison, their ward colleagues reported increments in median scores for a total of 11 of the 24 items. These 11 items were three of 14 items in the knowledge subscale, three of four items in the attitude subscale, and five of six items in the practice subscale. For the knowledge subscale, the increments were in these items: research skills, Internet technology skills, and converting information needs into a research question. For the attitude subscale, there was an increment for all items except for the item on welcoming questions on their clinical practice. In the practice subscale, there were increments for all items except the item evaluated practice outcomes, which has no change in median score, during the postprogram survey.

Discussion

Mentees in the hospital-based research and EBP mentorship program reported significant improvements in their knowledge, attitude, and practice toward EBP. These findings were aligned to the existing literature on EBP training and mentorship programs on nurses in other tertiary hospital settings in the United States (Kim et al., 2013; Kim et al., 2017). This reflects the observation that mentorship assisted in nurses assimilating and applying information into EBP, which could be carried forward into their clinical practice (Levin et al., 2011).

In addition, their ward colleagues also reported increased knowledge and practice of EBP, and overall EBPQ scores after the mentorship program, although the findings suggest that their improvements were less than in the mentees. The improvements in the ward colleagues' knowledge and skills of EBP could be attributed to a diffusion of knowledge from the mentees to their ward colleagues in the clinical settings. This occurred as the mentees became EBP champions to advocate and increase awareness of EBP in their clinical settings. This was done through educational programs arranged by the mentorship program mentees for their ward colleagues, such as the launch of ward-based journal clubs to equip their colleagues with skills in literature searching and journal critique, as well as peer coaching on EBP skills to colleagues who were conducting their own research projects. An exciting development was the observed improvement in ward colleagues' attitude toward EBP, becoming more open toward questions on their clinical practice. This opens the doorway for further critical inquiry and improved clinical practice through evidence-based nursing care.

The postprogram evaluation was conducted 3 months after its completion. We anticipate that given more time, the mentees would have had even more opportunities to share with their ward colleagues, hence possibly greater improvement in their ward colleagues' knowledge, practice, and attitude toward EBP. Anecdotal feedback of the program from the mentees, their mentors, and their ward supervisors consistently supported the findings that the program was beneficial and assisted toward EBP culture adoption in their departments, reflected in their continuation of journal clubs and conduction of department-level EBP projects.

Our findings suggest the potential of a hospital-based mentorship program on EBP on improving front-line nurses' knowledge, attitude, and practice of EBP. This is particularly encouraging as it reflects that with the right support through a group of mentors, an acute hospital was able to overcome the burden of juggling a heavy workload with EBP activities, identified as one of the largest barriers to the spread of EBP in organizations (Williams, Perillo, & Brown, 2015).

Our program has resulted in the mentees becoming EBP advocates in their own clinical departments, actively conducting educational programs and projects to raise their own EBP knowledge and skills, as well as that of their ward colleagues. In addition, many have since taken up the role of mentoring and coaching more junior nurses on their own EBP projects and training. This reflects the construction of a pipeline of early adopters to prepare a larger pool of nurses actively engaging in evidence-based care to improve the quality of patient care. The importance of expert EBP nurses in guiding and mentoring the participants within the hospital is also seen in the development of nurse practitioners and nurse educators (Hill & Sawatzky, 2011; Slimmer, 2012).

Although its effect was not studied separately, buddying with a fellow mentee could have contributed to the mentees' increased knowledge, attitudes, and practice of EBP. This is linked to the reported benefits of such a mentorship approach, with buddy mentors encouraging and motivating each other to achieve better outcomes, creating a culture of socialized learning outside the didactic teaching sessions (Jacobs, 2017; Rohatinsky et al., 2017). This is a particularly important strategy to continue exploring and using, given the anticipated increased demand for mentorship and guidance of future EBP champions, to ensure that the buddy mentors can function as an added layer of support and guidance to future program mentees in their EBP journeys.

Based on the findings from this program evaluation, the mentorship program in the hospital understudy has been continuing to this day.

Limitations

The study has several limitations. The findings on the nurses' knowledge, attitude, and practice were based on self-reporting using the EBPQ tool (Upton & Upton, 2006). Hence, there may be the inherent bias as with any self-reporting data. Another limitation is that it is not yet clear whether the value of mentorship program has been translated to positive patient outcomes. This could be attributed to the need for more early adopters to be trained and equipped in place, actively engaging and advocating for EBP to allow a shift of the EBP culture into mainstream nursing (Rogers, 1995). In addition, ours was an anonymous evaluation of all nurses working in the same wards as the mentees. As a result, we used a group-level, rather than an individual-level, analysis to evaluate the overall change in pretest and posttest scores.

Implications for Future Runs of the Program and Potential Research

This program evaluation showed that our program's use of a mentor and buddy mentorship approach is feasible in an acute setting to create a culture of EBP adoption. To further grow the pool of EBP champions and future mentors, we have since included the program as one of our hospital's in-house formal training programs, with scheduled training time for mentees to attend the program.

Researchers could consider conducting a trial to determine the effectiveness of such a mentorship program. A key area for further exploration is a longer term follow up with the mentorship program mentees and their ward colleagues to examine their clinical impact. This would help demonstrate the benefit of such a mentor-ship program to hospital administrators. Another area for research is qualitative studies that involve in-depth interviews of mentees, peer-buddy, and mentors to given deeper insights into the use of the mentorship pedagogy for EBP training.

Conclusion

A hospital-based research and EBP mentorship program—coupling classroom sessions with a novel blend of formal mentorship and peer mentorship platforms—can potentially improve mentees' perceived knowledge, attitudes, and practices of EBP, as well as improve that of their ward colleagues. This can assist in the building of an EBP culture through its training and equipping of EBP champions and future mentors to advocate for the application of EBP in their clinical practice. These findings have greatly aided in leading to the mentorship program receiving the support of senior leadership through being recognized as a formal course for the training of nurses in EBP methodology within the hospital. The diffusion of knowledge from the champions to their colleagues ensures the spread of knowledge and support toward EBP throughout the department and eventually, the entire organization.

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Participant Characteristics

VariablesMentees (N = 9)Ward Colleagues (N = 185)
Highest education level, n (%)
  Diploma or certificate1 (11.1)80 (43.3)
  Degree and above8 (88.9)105 (56.7)
Years of experience as an RN
  Mean (SD)2.11 (1.9)6.05 (5.4)
Designation, n (%)
  Staff nurse9 (100)133 (71.5)
  Senior staff nurse53 (28.5)
Type of ward, n (%)
  ICU3 (33.3)86 (45.7)
  General ward6 (66.7)102 (54.3)
Had prior EBP training, n (%)
  Yes6 (66.7)37 (20.5)

Median EBPQ Scores of Mentees and Ward Colleaguesa

SubscaleMentees, N = 9Ward Colleagues, N = 185


(Median IQR)p*(Median IQR)p*


PretestPosttestPretestPosttest
Knowledge subscale4.0 (3.2–4.5)5.4 (5.2–5.7)<.0014.0 (3.1–4.5)4.2 (3.6–4.6).005
Attitude subscale4.0 (3.4–5.0)6.0 (5.7–6.2)<.0014.5 (3.5–5.5)4.7 (4.0–5.5).080
Practice subscale3.0 (2.5–3.7)5.3 (5.2–5.7)<.0013.3 (2.3–4.0)4.0 (2.8–4.3).010
Overall3.9 (3.6–4.1)5.4 (5.4–5.6)<.0013.9 (3.1–4.4)4.2 (3.63–4.61).004
Authors

Dr. Chan is Adjunct Assistant Professor, Alice Lee Centre of Nursing Studies, National University of Singapore, and Assistant Director of Nursing, Mr. Glass is Nurse Researcher, and Ms. Phang is Senior Staff Nurse, Nursing Service, Tan Tock Seng Hospital, Singapore.

This study was supported by the National Healthcare Group HOMER Grant (Ref:FY15/B03).

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the nurses, including the program mentees, who voluntarily participated in this research. The authors also thank the program mentors for taking the time to role model and mentor the mentorship program participants throughout the program, and Ms. Tay Ying for her assistance in data collection.

Address correspondence to Ee-Yuee Chan, PhD, Adjunct Assistant Professor, Alice Lee Centre of Nursing Studies, National University of Singapore, Assistant Director of Nursing, Nursing Service, Tan Tock Seng Hospital, 11 Jan Tan Tock Seng, Singapore 308433; e-mail: ee_yuee_chan@ttsh.com.sg.

Received: February 01, 2019
Accepted: August 06, 2019

10.3928/00220124-20191217-09

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