The authors are Assistant Professors, Faculty of Nursing, Department of Basic Nursing, Al Isra University, Amman, Jordan.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Lourance A. Al Hadid, PhD, MSN, RN, Assistant Professor, Al Isra University, Faculty of Nursing, Department of Basic Nursing, P.O. Box 22, Isra University 11622, Airport Highway, Amman, Jordan; e-mail: email@example.com.
For the past two decades, evidence-based practice (EBP) has been recognized as a necessity to nursing practice to promote excellence in health care (Adib-Hajbaghery, 2009; Brown, Wickline, Ecoff, & Glaser, 2009). Undergraduate education prepares nurses to use EBP. However, this has not been the case in many countries around the world (Adib-Hajbaghery, 2007). Factors influencing the adoption of EBP in nursing education have not been fully addressed in literature. Therefore, assessing these factors is becoming crucial to facilitate the adoption of EBP, especially in nursing education. This requires the development of a valid and reliable instrument. The aim of this study was to measure the psychometric properties, reliability, and validity of a newly developed composite measuring instrument, the Evidence-Based Education Questionnaire (EBEQ), that was developed to assess the perceived factors influencing the adoption of EBP principles in nursing education programs.
Background and Significance
Emerging from evidence-based medicine, according to Staffileno and Carlson (2010), EBP in nursing finds its answers in the recommendations and findings of research-based literature as a primary source of information. According to McSherry, Artley, and Holloran (2006), this emphasis is based on a combination of political, professional, and societal factors, all of which form the driving forces directing present and future requirements for the nursing profession, as well as other health professions. These include budget constraints, standardized care, and quality patient outcomes.
Despite the plethora of literature surrounding what evidence-based nursing is and is not, EBP nursing education is still struggling and has not been addressed adequately. Several reasons for this have been reported in the literature, including a lack of adequate understanding of technologies associated with the teaching strategies promoting EBP, such as the use of human simulation in the nursing laboratories (Hart et al., 2008), and a lack of consensus on the best strategies, material, and time and the level of students to engage in EBP (Burns & Foley, 2005; Kim, Brown, Field, & Stichler, 2009; Mattila & Eriksson, 2007). Other studies reported that the teaching process in nursing, especially in undergraduate education, has focused mainly on the process of deducting evidence from research, rather than conducting research (Burke et al., 2005; Ciliska, 2005), and thus abandoning an essential component of EBP.
Although still limited in its application, EBP in nursing has been strongly presented in the agendas of many professional organizations as an undergraduate requirement in countries such as the United States and Canada (Baumbusch et al., 2008; Elcoat, 2000). Among these is the Jordanian Nursing Council, which emphasizes the adoption of EBP as one crucial component of nursing practice and education. However, at the time this study was conducted, the researchers could not locate any literature demonstrating the result of this emphasis in nursing education. The search included all available university libraries, expert nurses’ opinions, and the available Jordanian nursing literature.
Although the Jordanian Nursing Council (2010) provided the futuristic requirements of quality nursing education, it did not explain the steps of this process. It also did not include the adoption of EBP in education within the process of accreditation of the Jordanian nursing programs. Quality improvement in nursing education includes the main components of developing evidence-based culture by offering strategic directions for developing, applying, and evaluating the skills in practice and determining the process of developing nursing graduates capable of participating in producing the evidence actively.
The decisions to implement EBP in nursing education programs in Jordan have not been made explicit to encompass the discourse and strategies of innovative nature to enhance critical thinking and decision making skills along the didactic teaching methods. This could be related to the large financial investment required to adopt EBP, whereas its efficacy is still not well known to the policy makers and stakeholders (Mattila & Eriksson, 2007; Melnyk, 2006). Although many nursing experts in Jordan emphasize the need to adopt EBP, factors delaying the discourse of EBP in nursing education represent an area of limited knowledge.
Adopting EBP in nursing education commences in the undergraduate program and is emphasized in the graduate program, which provides the skills required to find, analyze, and, later, synthesize best evidence for practice (Balakas & Sparks, 2010). Therefore, assessing factors influencing the adoption of EBP in nursing programs, which train future nurses, is crucial to prepare those graduates to adopt and implement EBP principles in their work.
On the other hand, many researchers, especially those from the United States, have identified factors influencing the adoption of EBP in nursing practice, especially barriers to the uptake of research in practice (Brown et al., 2009; Fink, Thompson, & Bonnes, 2005). These include insufficient educators’ skills, insufficient time to find research studies, inadequate knowledge on how to evaluate research findings, and a lack of organizational support (Bahtsevani, Khalaf, & Willman, 2005). Nursing education programs have elements determining its scope that differ from the clinical settings. Therefore, some of these factors may not apply to academic organizations such as universities. In addition, the researchers could not locate an instrument assessing factors influencing the adoption of EBP principles in nursing education. Thus, the need to develop this instrument is evident.
A descriptive, cross-sectional research design was used in the current study.
A convenience, non-probability, purposive sample of 180 nurse educators from 10 Jordanian universities received the study questionnaire; 85 completed the questionnaire.
All data analyses were performed using SPSS version 17 software. The central tendency and distribution of scores of the EBEQ examined were mean, median, standard deviation, and minimum and maximum responses. The normality of distributions of the EBEQ scores was tested using the Kolmogorov–Smirnov goodness of fit statistic and the quantile-quantile probability plot. Exploratory factor analysis using principal components with listwise deletion of missing data was used on the 45 items of the EBEQ scale (Nunnally & Bernstein, 1994); five factors were extracted. Item loadings greater than 0.60 were used as the cut-off point for significant loading on the factor (Field, 2000; Tabachnick & Fidell, 2007). The internal consistency of the scale was calculated using Cronbach’s alpha.
The first task in the process of developing the EBEQ was a review of current literature to determine how the concept of EBP in nursing education had been used in existing instruments and in instruments closely related to this concept (Goodwin, 2002). The review revealed that all instruments had different definitions for the categories of EBP in nursing practice and education. They primarily focused on EBP use in clinical settings and practice (Koehn & Lehman, 2008). Many were still in their early stages of development, and there was hardly any instrument providing a reliable and accurate measure of EBP in nursing education. Because the researchers were not able locate an instrument that serves the aim of this study, they decided to develop the EBEQ.
Development of the content validity of the EBEQ involved three steps. First, to ensure a comprehensive search, a range of databases were selected to conduct this search, including PubMed, CINAHL, ProQuest, Science Direct, Wiley Online Library, Web of Science, and the Cochrane Database of Systematic Reviews. The following terms were used as the initial search criteria: evidence-based, nursing, nursing practice, and nursing education. The terms were then cross-referenced so that the maximum number of documents could be retrieved. When an article was found, the provided links to related studies were explored. Additional searches were performed using the names of authors of research articles found in the initial search, as well as the names of their projects.
Second, thematic analysis of the retrieved documents from the first step was performed. General and specific themes were examined, and similar themes were collected into groups. Then, these groups were transformed into statements that reflected their meanings, each under its underlying general theme. Six experts in EBP nursing developed a semi-structured questionnaire to collect data on themes influencing EBP in nursing education. The questionnaire consisted of five main themes: knowledge in educational principles; finding and reviewing evidence; faculty practices; change in the educational practices; and finding and judging evidence. Over 4 weeks, they produced as many descriptions as they deemed necessary for each level and category of the themes. Then, these descriptions were matched with the themes. The researchers highlighted the similarities and discussed the differences with the experts. Finally, the researchers and the experts reached a consensus on the themes and their related factors. They all agreed that these items adequately assessed factors influencing EBP in nursing education. This resulted in identification of five themes affecting EBP in nursing education.
Third, the logical consistency of the statements representing the themes of EBP in nursing education was evaluated by 10 individuals with doctoral degrees in nursing. The researchers continued the content analysis, and 10 overlapping factors were deleted. A 45-item set of factors influencing EBP in nursing education was critically reviewed to evaluate their relevance by using a self-administered questionnaire submitted to six nurse educators. They were asked to judge and quantify the validity of the items individually and, as a set, to suggest revisions and to identify areas that were missing. They were asked the following questions:
- “Do these statements belong together under each factor?”
- “Do these statements belong to the factor where they have been put?”
- “Do these factors and the underlying statements cover the factors influencing EBP in nursing education?”
Relevance was validated using a 4-point scale, where 0 = not relevant/complete
, 1 = mildly relevant/complete
, 2 = moderately relevant/complete
, and 3 = strongly relevant/complete
. No change was introduced on the 45 items.
The first version of the EBEQ was then pilot-tested with eight nurse educators (four with PhDs and four with master’s degrees). Cronbach’s coefficients of the EBEQ categories in the pilot test ranged from 0.84 to 0.94. These reliability estimates were encouraging, so no changes were made to the scale. Although the nurse educators had no problems responding to the items, they did suggest some changes for greater clarity. Hence, the relevant wordings were reviewed by the expert group. When the clarity of the expressions of the scale was reviewed by the pilot-tested group, six items were reworded. This work yielded the 45-item questionnaire that was then used for subsequent data collection.
The study was approved by the universities’ institutional review boards. Consent was implied by returning the completed questionnaire. Participation was entirely voluntary, and the survey was anonymous.
The questionnaires were distributed and collected over a 10-week period between October and December 2010. To increase the response rate, oral and electronic reminders were made on the second and the fourth week of data collection. Completed questionnaires were placed in the Dean’s office, sent by interdepartmental mail, or collected anonymously by the researchers.
The questionnaires were distributed to 180 nurse educators who were teaching in different nursing fields, including adult, maternity, community, and psychiatric nursing. Eighty-five questionnaires were completed, for a 47% response rate. The average age of the participants was 37 years (range = 24 to 60 years). The participants have been working in the teaching role for a mean of 13 years (range = 1 to 25 years). Approximately half of the participants were doctoral prepared and taught full time in the classroom and in the clinical setting (49.4%) (Table 1).
Table 1: Demographic Characteristics of Participants (N = 85)
A principal components analysis with a varimax rotation was performed with the original five factors (representing 45 items) of the EBEQ (Table 2). The Cattell’s Scree plot test was performed. The first five items explained more than 66% of the total variance (Table 3). The Kaiser–Meyer–Olkin measure of sampling adequacy result was 0.874, indicating a high level of interrater correlation among the items and an adequate sample size (Kaiser & Rice, 1974). This result was consistent with Bartlett’s test of sphericity, which showed that the correlations between the items were sufficient to perform factor analysis, approximate chi-square of 1,147.04 (p < 0.000). The communality values ranged between 0.584 and 0.86.
Table 2: Factors and Items of the Evidence-Based Education Questionnaire
Table 3: Principal Factor Analysis of the Evidence-Based Education Questionnaire
Reliability and Normality
Cronbach’s alpha was calculated for the total EBEQ to determine internal consistency of the scale, which was 0.926 (representing a good value); starting factor analysis was then a reasonable step (Tabachnick & Fidell, 2007). Items underwent principal factor analysis, and the result determined 5 factors with 24 items (Figure 1). The factors on the scale correlations ranged from 0.86 to 0.89. The Spearman–Brown coefficient was 0.82 for both equal and unequal length. The Guttman split-half coefficient was 0.84, indicating an acceptable item correlation. The quantile-quantile probability plot in Figure 2 shows scores close to the normal line, indicating scores close to normal distribution (skewness = −0.552, kurtosis = 1.739, Komolgrov–Smirnov = 0.066 [the lower bound of the true significance is 0.200]). Normality in this case is accepted; it is often rejected when kurtosis is higher than ±2, skewness is higher than ±1, or both, indicating that the distribution departs significantly from the normal distribution (Nunnally & Bernstein, 1994). The total area under the receiver operating characteristic curve was 0.663; this value is considered acceptable (Fawcett, 2006).
Figure 1. The Scree plot of the eigenvalues of scores on the Evidence-Based Education Questionnaire.
Figure 2. Quantile-quantile probability plot of the participants’ scores on the Evidence-Based Education Questionnaire.
The study aim was met in that an instrument was developed and proven to be valid and reliable. The EBEQ underwent principal factor analysis to determine the statements that best represent EPB in nursing education. This method proves useful in the early stages of an empirical enquiry (Tabachnick & Fidell, 2007). The results of this study revealed the factors that influence the adoption of EBP in nursing education programs: knowledge in educational principles, finding and reviewing evidence, faculty practices, change in education strategies and practices, and finding and judging evidence. These factors were assessed using 24 statements, all of which represented their respective factors.
The work of other researchers, such as Melnyk (2004), Olade (2004), Özdemir and Akdemir (2009), and Pravikoff, Tanner, and Pierce (2005), has focused mainly on the barriers affecting the adoption of EBP in nursing practice. However, the current study focused on the factors that influence the adoption of EBP in nursing education, which has specific structure and functions that differ from those of the health care and clinical settings.
Content Validity of the Evidence-Based Education Questionnaire
Content validity refers to the degree to which the items included within an instrument adequately represent the universe of the content of a particular concept. According to Polit and Beck (2008), this is an important type of validity because it ensures a match between research purpose and the data collection instrument of the study. This is performed based on the logical analysis of the content and the experts’ opinions on the components of the instrument (Goodwin, 2002). The evidence supporting content validity of the EBEQ was first based on the review of the literature conducted by the researchers and then based on the professional opinion of the six EBP experts. All items included in the instrument were based on the literature; thematic analysis was performed to include all items pertinent to EBP in nursing.
In the process of validation, face validity also was obtained by assessing that the instrument truly measured the concept (Streiner & Norman, 1999). This was performed when the experts deleted or reworded some items and, finally, agreed on all the items included in the questionnaire (Strickland, 2000). In addition, the experts reviewed the items for sufficiency, relevancy, and clarity of the components, all of which are evidence of items adequately assessing the factor (Goodwin, 2002). The final scale consisted of 24 items subsumed within the five factors.
Psychometric Properties of the Questionnaire
Reliability and validity are essential characteristics of any measuring instrument. Internal consistency of the EBEQ was tested by item analyses to examine the extent to which all of the items measure the same factor (Polit & Beck, 2008). The internal consistency of the EBEQ was found to be reasonably high for a new instrument (Nunnally & Bernstein, 1994). However, internal consistency does not provide an adequate basis to judge reliability. The experts’ opinions have, in fact, been the main source of decisions on which omissions and modification occurred; this also determined the face validity for the instrument.
Furthermore, construct validity was also assessed to ensure theoretical adequacy of the questionnaire items by assessing the collected empirical data for their relatedness to other observed variables in a way that is consistent with theoretically derived predictions (Streiner & Norman, 1999). The factorial analysis, selecting items of powerful representation, and setting a relatively high cut-off value are all performed to ensure the psychometric properties and construct validity of the questionnaire. The deletion of overlapping items, items of weak representation, and irrelevant items added to the statistically supported values. All statistical values have then indicated that the EBEQ is a valid and reliable instrument. However, caution is needed because this is a new instrument that has been used only once.
This descriptive study was limited by four factors. First, it was limited by the use of a convenience sample and survey method of data collection. Although the response rate (47%, n = 85) was lower than the desired rate of at least 65%, it falls within the norm (Polit & Beck, 2008). Second, the educators who responded perceived their potential higher than the actual practice and experience. This may have skewed the results to depict more favorable outlooks on EBP. Third, the EBEQ is new and needs further testing. Fourth, this study was cross-sectional, and the EBEQ was not retested to add another measure to its reliability. Test–retest reliability is used to assess the consistency of a measure from one time to another (Nunnally & Bernstein, 1994). As explained above, Cronbach’s alpha was used to measure internal consistency in the current study.
The goal of assessing factors influencing the adoption of EBP in nursing education is to provide a mechanism for faculty members to focus interdisciplinary team research attention on the area of preparing nursing graduates and promoting quality education. A methodical assessment is essential in determining the most applicable and appropriate interventions to promote the adoption of EBP.
The results of this study indicate that EBEQ is a valid and reliable instrument that determines the factors influencing EBP in nursing education. However, this is a new instrument that requires further evaluation and possible revision. Validating instruments is an ongoing research activity, and our testing of this instrument can be considered an important contribution to the study of EBP and nursing knowledge.
Finally, addressing factors influencing the adoption of EBP in nursing education may increase experts’ awareness of the need to develop strategies to promote the use of this model and increase the probability of faculty adopting EBP in their practice.
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Demographic Characteristics of Participants (N = 85)
| Male||31 (36.5)|
| Female||54 (63.5)|
| Baccalaureate in Nursing (clinical instructors)||8 (9.4)|
| Masters (clinical and classroom educators)||35 (41.2)|
| PhD (clinical and classroom educators)||42 (49.4)|
| Public||54 (63.5)|
| Private||31 (36.5)|
| 20–30||24 (29)|
| 31–40||35 (41)|
| 41–50||21 (24)|
| ≥51||5 (6)|
Factors and Items of the Evidence-Based Education Questionnaire
|Knowledge in educational principles||K1||My undergraduate preparation supports evidence-based practice.|
|K2||As an undergraduate student, I was taught how to utilize research findings.|
|K3||The focus of my undergraduate education was on how to conduct research.|
|K4||My graduate preparation supports evidence-based practice.|
|K5||I know how to find evidence for practice.|
|K6||My effort as an educator could promote evidence-based practice.|
|K7||The educational model in my organization supports adopting evidence-based practice.|
|K8||Resources are adequate to implement evidence-based practice.|
|K9||We have enough authority to base student education on evidence.|
|K10||I have adequate knowledge of principles of evidence-based practice.|
|Finding and reviewing evidence||F1||I have sufficient time to find research reports.|
|F2||Research reports are readily available.|
|F3||I feel confident in judging the quality of research reports.|
|F4||Databases are readily available.|
|F5||I can understand research reports easily.|
|F6||I can identify research implications for my own practice.|
|F7||I find it difficult to understand statistics.|
|F8||I know how to find appropriate research reports.|
|Faculty practices||P1||I get my evidence through intuition.|
|P2||My educational practices are based on literature.|
|P3||I get my information from textbooks.|
|P4||There is sufficient time at work to implement changes in practice.|
|P5||There are sufficient resources to change practice.|
|P6||I can overcome barriers to apply evidence-based practice.|
|P7||I lack the authority in the workplace to change practice based on evidence.|
|P8||The culture of my department is receptive to changing practice based on evidence.|
|P9||I feel confident about beginning to change practice.|
|P10||I think that evidence-based practice affects my practice positively.|
|P11||Lack of consensus recommendations of evidence promotes disparity (lack of agreement) in my area.|
|P12||Affirmed experiences in clinical practice promote strong evidence for my practice.|
|Change in education strategies/practices||C1||Empirical evidence is acceptable as mode of change of practice in my faculty.|
|C2||My colleagues are supportive of changing practice based on evidence.|
|C3||My superiors are supportive of changing practice based on evidence.|
|C4||My organization supports changing practice based on evidence.|
|C5||The continuous education activities support adopting evidence-based principles.|
|C6||Evidence-based practice applies in all situations in my area of practice.|
|C7||The model adopted in my faculty supports applying evidence-based practice.|
|Finding and judging evidence||J1||I am familiar with the process of selecting evidence for my practice.|
|J2||I can participate in the process of selecting evidence for our practice.|
|J3||I can determine the quality of evidence.|
|J4||I can verify the evidence applicable to my area of practice.|
|J5||I can judge evidence applicability in my area of practice.|
|J6||I can deduct evidence through knowledge translation.|
|J7||I update my practices by applying reliable and valid research findings.|
|J8||Implementing evidence-based practice in education promotes better student quality.|
Principal Factor Analysis of the Evidence-Based Education Questionnairea
|Knowledge in Educational Principles (alpha = 0.865)||Finding and Reviewing Evidence (alpha = 0.840)||Faculty Practices (alpha = 0.894)||Change in Education Strategies/Practices (alpha = 0.912)||Finding and Judging Evidence (alpha = 0.942)|