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.
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).
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.
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.
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.
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.
A waiver of written consent was granted by the National Healthcare Group Domain Specific Review Board, as this was an anonymous survey.
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.
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.
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).
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 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.
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.
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.
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.
- Abdullah, G., Rossy, D., Ploeg, J., Davies, B., Higuchi, K., Sikora, L. & Stacey, D. (2014). Measuring the effectiveness of mentoring as a knowledge translation intervention for implementing empirical evidence: A systematic review. Worldviews on Evidence-Based Nursing, 11(5), 284–300. doi:10.1111/wvn.12060 [CrossRef]25252002
- Black, A.T., Balneaves, L.G., Garossino, C., Puyat, J.H. & Qian, H. (2015). Promoting evidence-based practice through a research training program for point-of-care clinicians. Journal of Nursing Administration, 45, 14–20. doi:10.1097/NNA.0000000000000151 [CrossRef]
- Breckenridge-Sproat, S.T., Throop, M.D., Raju, D., Murphy, D.A., Loan, L.A. & Patrician, P.A. (2015). Building a unit-level mentored program to sustain a culture of inquiry for evidence-based practice. Clinical Nurse Specialist, 29, 329–337. doi:10.1097/NUR.0000000000000161 [CrossRef]26444511
- Emparanza, J.I., Cabello, J.B. & Burls, A.J. (2015). Does evidence-based practice improve patient outcomes? An analysis of a natural experiment in a Spanish hospital. Journal of Evaluation in Clinical Practice, 21(6), 1059–1065. doi:10.1111/jep.12460 [CrossRef]26516021
- Farokhzadian, J., Khajouei, R. & Ahmadian, L. (2015). Evaluating factors associated with implementing evidence-based practice in nursing. Journal of Evaluation in Clinical Practice, 21(6), 1107–1113. doi:10.1111/jep.12480 [CrossRef]26563564
- Fowler, S.B. (2013). Evidence-based practice readiness of ASORN members. Insight, 38(4), 5–12.24319821
- Hill, L.A. & Sawatzky, J. (2011). Transitioning into the nurse practitioner role through mentorship. Journal of Professional Nursing, 27, 161–167. doi:10.1016/j.profnurs.2011.02.004 [CrossRef]21596356
- Jacobs, S. (2017). A scoping review examining nursing student peer mentorship. Journal of Professional Nursing, 33(3), 212–223. doi:10.1016/j.profnurs.2016.09.004 [CrossRef]28577814
- Kim, S.C., Brown, C.E., Ecoff, L., Davidson, J.E., Gallo, A.M., Klimpel, K. & Wickline, M.A. (2013). Regional evidence-based practice fellowship program: Impact on evidence-based practice implementation and barriers. Clinical Nursing Research, 22, 51–69. doi:10.1177/1054773812446063 [CrossRef]
- Kim, S.C., Ecoff, L., Brown, C.E., Gallo, A.M., Stichler, J.F. & Davidson, J.E. (2017). Benefits of a regional evidence-based practice fellowship program: A test of the ARCC model. Worldviews on Evidence-Based Nursing, 14, 90–98. doi:10.1111/wvn.12199 [CrossRef]28178389
- Kirkwood, B. & Sterne, J., (2003). Essential medical statistics (2nd ed.). Malden, MA: Blackwell Science.
- Levin, R.F., Fineout-Overholt, E., Melnyk, B.M., Barnes, M. & Vetter, M.J. (2011). Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: A pilot test of the advancing research and clinical practice through close collaboration model. Nursing Administration Quarterly, 35, 21–33. doi:10.1097/NAQ.0b013e31820320ff [CrossRef]
- Mackey, A. & Bassendowski, S. (2017). The history of evidence-based practice in nursing education and practice. Journal of Professional Nursing, 33, 51–55. doi:10.1016/j.profnurs.2016.05.009 [CrossRef]28131148
- Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L. & Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410–417. doi:10.1097/NNA.0b013e3182664e0a [CrossRef]22922750
- Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B. & Williamson, K.M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110, 51–53. doi:10.1097/01.NAJ.0000366056.06605.d2 [CrossRef]
- Rogers, E.M. (1995). Diffusion of innovations. New York, NY: Free Press.
- Rohatinsky, N., Harding, K. & Carriere, T. (2017). Nursing student peer mentorship: A review of the literature. Mentoring & Tutoring: Partnership in Learning, 25, 61–77. doi:10.1080/13611267.2017.1308098 [CrossRef]
- Slimmer, L. (2012). A teaching mentorship program to facilitate excellence in teaching and learning. Journal of Professional Nursing, 28(3), 182–185. https://doi.org/10.1016/j.profnurs.2011.11.006 doi:10.1016/j.profnurs.2011.11.006 [CrossRef]22640950
- Upton, D. & Upton, P. (2006). Development of an evidence-based practice questionnaire for nurses. Journal of Advanced Nursing, 53, 454–458. doi:10.1111/j.1365-2648.2006.03739.x [CrossRef]16448488
- Wallen, G.R., Mitchell, S.A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J. & Hastings, C. (2010). Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. Journal of Advanced Nursing, 66(12), 2761–2771. doi:10.1111/j.1365-2648.2010.05442.x [CrossRef]20825512
- Warren, J.I., McLaughlin, M., Bardsley, J., Eich, J., Esche, C.A., Kropkowski, L. & Risch, S. (2016). The strengths and challenges of implementing EBP in healthcare systems. Worldviews on Evidence-Based Nursing, 13, 15–24. doi:10.1111/wvn.12149 [CrossRef]26873372
- Williams, B., Perillo, S. & Brown, T. (2015). What are the factors of organizational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review. Nurse Education Today, 35(2), e34–e41. doi:10.1016/j.nedt.2014.11.012 [CrossRef]
- Wu, Y., Brettle, A., Zhou, C., Ou, J., Wang, Y. & Wang, S. (2018). Do educational interventions aimed at nurses to support the implementation of evidence-based practice improve patient outcomes? A systematic review. Nurse Education Today, 70, 109–114. https://doi.org/10.1016/j.nedt.2018.08.026 doi:10.1016/j.nedt.2018.08.026 [CrossRef]30179782
|Variables||Mentees (N = 9)||Ward Colleagues (N = 185)|
|Highest education level, n (%)|
| Diploma or certificate||1 (11.1)||80 (43.3)|
| Degree and above||8 (88.9)||105 (56.7)|
|Years of experience as an RN|
| Mean (SD)||2.11 (1.9)||6.05 (5.4)|
|Designation, n (%)|
| Staff nurse||9 (100)||133 (71.5)|
| Senior staff nurse||53 (28.5)|
|Type of ward, n (%)|
| ICU||3 (33.3)||86 (45.7)|
| General ward||6 (66.7)||102 (54.3)|
|Had prior EBP training, n (%)|
| Yes||6 (66.7)||37 (20.5)|
Median EBPQ Scores of Mentees and Ward Colleaguesa
|Subscale||Mentees, N = 9||Ward Colleagues, N = 185|
|(Median IQR)||p*||(Median IQR)||p*|
|Knowledge subscale||4.0 (3.2–4.5)||5.4 (5.2–5.7)||<.001||4.0 (3.1–4.5)||4.2 (3.6–4.6)||.005|
|Attitude subscale||4.0 (3.4–5.0)||6.0 (5.7–6.2)||<.001||4.5 (3.5–5.5)||4.7 (4.0–5.5)||.080|
|Practice subscale||3.0 (2.5–3.7)||5.3 (5.2–5.7)||<.001||3.3 (2.3–4.0)||4.0 (2.8–4.3)||.010|
|Overall||3.9 (3.6–4.1)||5.4 (5.4–5.6)||<.001||3.9 (3.1–4.4)||4.2 (3.63–4.61)||.004|