RNs have access to professional standards, identified competencies, credentialing criteria, and guiding targets to facilitate implementation of evidence-based practice (EBP) (American Nurses Association, 2015; American Nurses Credentialing Center, 2019; Case Western Reserve University, 2019; Melnyk et al., 2014). Yet, knowledge and application of EBP among hospital-based RNs remains variable. In fact, national evidence shows that practicing RNs' self-reported competence in EBP remains low and not significantly different in Magnet® versus non-Magnet organizations (Melnyk et al., 2018).
Underlying the limited use of EBP by hospital RNs are reports that in many nursing education programs, EBP often is buried in complex research courses, hindering adequate comprehension, particularly among new graduates (Aglen, 2016; Fiset et al., 2017; Hosking et al., 2016). Coupled with this documented misunderstanding of EBP, support for hospital RNs' use of EBP is constrained by the low priority and insufficient budget allocation nursing leaders assign to it (Melnyk et al., 2016).
In response, hospital-based clinical educators employ resource-intensive residency programs and continuing education programs to help RNs improve their EBP competence and ultimate use. To minimize expenses, such programs often are adapted by shortening the content, focusing only on some of the EBP steps, or disregarding the evaluation of competencies and learning outcomes (Albarqouni et al., 2018). More importantly, whether hospital-based EBP continuing education programs improve or sustain nurses' values, knowledge, and use of EBP remains unknown. Thus, the specific aims of this study were:
- To compare differences in values, knowledge, and implementation of EBP for nurses who attended a comprehensive EBP continuing education program and nurses who did not.
- To examine relationships between nurse characteristics and values, knowledge, and implementation of EBP.
- To determine whether differences in values, knowledge, and implementation of EBP between those nurses who attended a comprehensive EBP continuing education program and those who did not were sustained over time.
Eight studies were found that examined the effectiveness of continuing education programs to improve EBP use in nurses. All of the studies except one were nursing studies. The majority of the studies used a quasiexperimental pretest-posttest design (N = 6), one study was experimental with randomization of online EBP education to three groups (Moore, 2017), and two were systematic reviews. All of the studies evaluated continuing education programs, although the types of continuing education programs differed. More specifically, in-person and online education programs, mentor training, and an academic-service partnership were evaluated. All of the studies used psychometrically sound instruments to assess nurses' values, knowledge, and use of EBP. Although the overall findings of the studies showed some improvement in EBP knowledge, EBP attitudes remained the same or higher despite the continuing education programs (Duffy et al., 2015; Friesen et al., 2017; Ramos-Morcillo et al., 2015), and EBP skills improved only in those studies that evaluated mentor training as the intervention (Friesen et al., 2017; Melnyk et al., 2017; Spiva et al., 2017). Only one study (Melnyk et al., 2017) demonstrated improvement in EBP use. Notably, no studies were found that specifically examined long-term improvements in hospital RNs' EBP implementation.
Critical to this review is the conclusion that most of the studies examined suffered from limited or poorly documented descriptions of the continuing education interventions being tested, included low sample sizes or nonprobability samples, and contained incomplete descriptions of data collection methods and analyses. Thus, evidence for how best to teach and sustain hospital nurses' EBP values, knowledge, and implementation remains weak. Although findings of the two systematic reviews corroborated this, they did offer some recommendations (Albarqouni et al., 2018; Hines et al., 2015). Specifically, suggestions for more robust study of interactive and activity-based continuing education interventions underpinned with theory were recommended. Moreover, the authors advocated for including all steps of the EBP process in continuing education programs, ongoing mentoring, and measuring EBP competencies resulting from continuing education interventions. These recommendations and our own prior work provided a springboard for this study.
Adult learning theory (Knowles, 1984) was used to develop the study intervention (a comprehensive EBP continuing education program), as well as to guide the study as a whole. The theory assumes that learning and using new information is different in adults compared with children. More specifically, taking prior learning into account, providing the education rationale, and applying learning activities directly related to one's work and career goals are theorized to facilitate understanding, recall, and application of new information. In addition, using an individualized and engaging approach benefits adult learners. Finally, providing continuing education within a safe environment, including using mistakes as learning opportunities, is advocated (Greenberg, 2016). After participating in the comprehensive EBP continuing education program, learners were expected to better value, understand, and implement EBP and sustain these behaviors over time (study outcomes).
Design and Setting
A two-group, nonexperimental longitudinal study was conducted at a 455-bed, not-for-profit, Magnet-designated, Level II trauma center in the mid-Atlantic region.
A convenience sample of 115 RNs with two groups (51 RNs in the intervention group and 64 RNs in the nonintervention group) comprised the sample. Inclusion criteria were permanent full-time and part-time RNs (Table 1).
Characteristics of Study Sample
Using Knowles' adult learning theory, a comprehensive EBP continuing education program was developed and offered on-site to all RN employees with the overall goal of sustaining EBP use. Course content (Table 2) assumed prior knowledge and was linked not only to current nursing standards but also to the institution's clinical advancement program. Specific interactive learning activities directly related to nursing work were integrated throughout the program. For instance, practice examples, individual and group problem-solving situations, and case studies applicable to the clinical environment were delivered. Feedback provided in a safe environment was shared with participants. The program was delivered by one doctorally-prepared RN over four 8-hour days. Nurses who attended at least 80% of the program were considered consistent with the intervention. Upon completion, learners were awarded continuing education units.
Content Outline for Comprehensive EBP Continuing Education Program
A demographic tool including eight items (age, gender, education level, work experience, years employed on unit, hours worked per week, primary shift, and perceived managerial support for EBP) was used to summarize the sample. The Quick-EBP-VIK Survey (Connor et al., 2017) was used to assess nurses' values, knowledge, and implementation of EBP. The tool contains 19 items that are rated on a five-point Likert type scale ranging from 1 (lower) to 5 (highest), with higher scores corresponding to stronger values, greater knowledge, and higher levels of EBP implementation. Content validity was established via an expert panel (N = 6), with all items showing an item-level content validity index of >0.80 for both clarity and relevance (Paul et al., 2016). Exploratory factor analysis revealed three dimensions, with Raykov's rho values of 0.66 (implementation) and >0.7 for the dimensions of value and knowledge. Test-retest reliability at an item-level (intraclass correlations of 0.43 to 0.80) was deemed sufficient (Connor et al., 2017).
After receiving institutional review board (IRB) approval, the comprehensive EBP continuing education program was publicized, and all hospital nurses were invited to attend. At the end of the program, the study was explained to course attendees who were offered the opportunity to participate 6 months after completing the comprehensive EBP continuing education program. Simultaneously, a nonintervention group of RNs was generated. Using a list of RN employees for each hospital unit obtained from the Human Resources Department, the researchers randomly selected at least five RNs per unit (using a table of random numbers). The selected nurses were e-mailed information about the study and offered the opportunity to participate.
Six months postintervention, RNs who attended at least 80% of the comprehensive EBP education program (the intervention group) and those who were randomly selected (the nonintervention group) were approached in person by the researchers and provided a letter explaining the study. Implied informed consent was gathered via the explanatory letter and completion of study instruments (per IRB approval).
After reading the explanatory letter, those RNs who wanted to participate in the study were administered written questionnaires at 6 months and again at 12 months after the education program. Investigators administered the study tools, and participants were asked to return the tools in a sealed envelope within 1 week of administration. The same questionnaire administration method was used for both data collection periods. All data were collected by the same study investigators and coded for confidentiality. A single list of study participants was kept in a locked file cabinet in a locked office; only study investigators had access to the data.
Data were analyzed using SPSS® version 24. A total of 136 participants were approached; of those, 134 provided informed consent, and 117 questionnaires were returned at 6 months. Two of these were omitted for missing data, for a participation rate of 85%. At 12 months, 89 questionnaires were returned; one was omitted for missing data and 25 were lost to follow up, for a participation rate of 65%.
Characteristics of the participants are summarized in Table 1. Both the intervention and nonintervention groups were similar in terms of demographics, with the exception of highest degree earned. The intervention group included significantly more master's-prepared RNs (χ2 = 21.82; p < .000). Study participants ranged in age from 23 to 67 years; mean age was 41.37 years (SD, 12.48). The majority of participants were women with a bachelor's degree who worked 30 hours or more per week on the day shift; RNs with a master's degree or an associate degree represented 45% of the sample. Many of the RNs were more experienced in their role, and the majority of the sample perceived managerial support for EBP.
Comparison of participants' values, knowledge, and implementation of EBP (Aim 1) between the intervention and nonintervention groups was conducted via independent samples t test. At 6 months, there was a statistically significant difference in knowledge scores between the two groups (t = 3.283; p < .001). Average scores for the values and implementation subscales did not differ between the two groups at 6 months. Means and standard deviations for subscale scores and total scale scores for both groups at both time points are displayed in Table 3.
EBP Values, EBP Knowledge, and EBP Implementation Scores
To assess Aim 2, independent samples t tests were conducted to examine differences by gender and by hours worked per week (< 30 hours versus ≥ 30 hours. Oneway analysis of variance was performed to detect differences by highest degree earned, shift worked, number of years of experience in the role, years on current unit, and perceived level of support for EBP by management. The only nurse characteristic demonstrating statistical significance with the outcomes was highest degree earned. At 6 months, participants with a master's degree had the highest knowledge scores (24.13); this was significantly higher than the knowledge score (20.11) for participants with either a bachelor's (p < .005) or an associate degree (17.23, p < .001). This difference in knowledge scores was maintained at 12 months, at which time the average knowledge score for participants with a master's degree was 24.95 compared with 20.91 for participants with a bachelor's degree (p = .020) and 20.63 for participants with an associate degree (p = .028). At 6 months following the education program, participants with a master's degree had the highest level of implementation on average (16.39); this was significantly higher than the implementation score for participants with either a bachelor's degree (13.09; p = .017) or an associate degree (13.12; p = .054). The difference in average implementation scores between participants with a master's degree (17.11) and participants with a bachelor's degree (12.61) was sustained at 12 months (p = .002), but not for participants with an associate degree (14.25). There were no significant differences by highest degree earned in average EBP values scores at 6 months or at 12 months.
Age was not associated with any of the subscale scores. At 6 months, those participants who perceived they were always supported by management showed a higher score for EBP values than those who said they were often supported (p < .022) and were sometimes or rarely supported (p < .001). This difference was not present at 12 months. Although EBP knowledge and implementation scores were moderately related to each other at 6 months (r = .476; p ⩽ .000) and at 12 months (r = .520; p < .000), neither was related to the values subscale at either time point.
Using a paired t test, no difference in average knowledge scores over time (p = .094) was found for the group that received the intervention (Aim 3). No changes in average EBP values or implementation scores between 6 months and 12 months for either group were observed.
Despite the study intervention, this sample's EBP values were higher than the mean of possible scores throughout the study period. In addition, EBP knowledge remained at or slightly above the sample mean. Finally, EBP implementation was lower than the mean of possible values throughout the study period in both groups. Although the comprehensive EBP continuing education intervention may have influenced EBP knowledge that was sustained at 6 and 12 months, this finding must be considered in context, as more nurses in the intervention group had a master's degree. To that end, the only nurse characteristic demonstrating a statistically significant relationship with the outcomes was highest degree earned. At 6 months and 12 months following the comprehensive EBP continuing education program, those with a master's degree had the highest knowledge scores and the highest level of EBP implementation. Interestingly, although EBP knowledge and implementation scores were moderately related to each other at 6 months, neither was related to the EBP values subscale at either time point.
The study was limited by the single community hospital, the nonprobability study sample, the self-reported questionnaire, and the sample demographics (mostly female BSN-prepared RNs who worked the day shift). Thus, study findings are limited to the sample or similar samples with caution.
Study findings are consistent with the literature. Because the increased EBP knowledge between the intervention and nonintervention groups cannot be explained by the intervention alone, further study is needed with more robust study designs (e.g., randomized assignment to groups and use of a pretest). Conducting relevant longitudinal comparative designs in larger, more diverse samples also is recommended. For instance, in this study, the sample included more experienced BSN-prepared RNs, with mostly day shift nurses represented. It would be interesting to examine differences in EBP knowledge in those RNs working distinctly different shifts and at more than one site. In addition, because advanced education was the only study variable tied to sustained EBP knowledge and use, supporting RNs' advanced education beyond the baccalaureate degree and maintaining a supportive infrastructure of master's-prepared RNs to facilitate clinical RNs' EBP knowledge and use is encouraged.
Although nurses in both groups valued EBP, the finding that valuing EBP was not related to EBP knowledge or implementation in this sample warrants further investigation. Educators at all levels often associate values held with related behaviors; however, valuing EBP may not necessarily translate into improved knowledge or new behaviors (Skela-Savic et al., 2017).
Finally, continuing to search for best strategies to advance hospital RNs' EBP knowledge and use is crucial. Using the continuing education strategies previously recommended (Albarqouni et al., 2018; Hines et al., 2015) and cultivating partnerships with schools of nursing to advance and sustain EBP (Duffy et al., 2015) may be beneficial. Replicating and extending the EBP mentoring study for educators and leaders (Melnyk et al., 2017) may facilitate clinical educators' repertoire of strategies to better support RNs' use of EBP.
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- Albarqouni, L., Hoffmann, T. & Glasziou, P. (2018). Evidence-based practice educational intervention studies: A systematic review of what is taught and how it is measured. BMC Medical Education, 18, 177 doi:10.1186/s12909-018-1284-1 [CrossRef]
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- American Nurses Credentialing Center. (2019). Magnet model—Creating a Magnet culture. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/
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- Knowles, M. (1984). The adult learner: A neglected species (3rd ed.). Houston, TX: Gulf.
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- Melnyk, B.M., Gallagher-Ford, L., Long, L.E. & Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11(1), 5–15.
- Melnyk, B.M., Gallagher-Ford, L., Thomas, B.K., Troseth, M., Wyngarden, K. & Szalacha, L. (2016). A study of chief nurse executives indicates low prioritization of evidence-based practice and shortcomings in hospital performance metrics across the United States. Worldviews on Evidence-Based Nursing, 13(1), 6–14.
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- Moore, L. (2017). Effectiveness of an online education module in improving evidence-based practice skills of practicing registered nurses. Worldviews on Evidence-Based Nursing, 14(5), 358–366.
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- Ramos-Morcillo, A.J., Fernández-Salazar, S., Ruzafa-Martínez, M. & Del-Pino-Casado, R. (2015). Effectiveness of a brief, basic evidence-based practice course for clinical nurses. Worldviews on Evidence-Based Nursing, 12(4), 199–207.
- Skela-Savic, B., Hvalic-Touzery, S. & Pesjak, K. (2017). Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. Journal of Advanced Nursing, 73(8), 1910–1923.
- Spiva, L.A., Hart, P.L., Patrick, S., Waggoner, J., Jackson, C. & Threatt, J.L. (2017). Effectiveness of an evidence-based practice nurse mentor training program. Worldviews on Evidence-Based Nursing, 14(3), 183–191.
Characteristics of Study Sample
|Highest degree earned|
|Hours worked per week|
| > 30||103||89.6|
| < 30||12||10.4|
| Rotates between days and nights||18||15.7|
|Total experience as RN|
| ≤ 6 months||3||2.6|
| > 6 months to 2 y||21||18.3|
| > 2 to 5 y||22||19.1|
| > 5 to 10 y||23||20|
| > 10 y||37||32.2|
|Employed on current unit|
| ≤ 6 months||12||10.4|
| > 6 months to 2 y||21||18.3|
| > 2 y to 5 y||22||19.1|
| > 5 y to 10 y||23||20|
| > 10 y||37||32.2|
|EBP managerial support|
Content Outline for Comprehensive EBP Continuing Education Program
|What is EBP?|
|PICOT—The Key to EBP|
|Conducting a Comprehensive Literature Review|
|Appraising the Evidence|
|Sampling and Data Collection|
|Implementation of Practice Changes|
EBP Values, EBP Knowledge, and EBP Implementation Scores
|Outcome||Intervention||6 Months||12 Months|