Recent draft: Effect of Evidence-Based Practice Programs on Individual Barriers of Workforce Nurses: An Integrative Review
Effect of Evidence-Based Practice Programs on Individual Barriers of Workforce Nurses: An Integrative Review
Reginald Middlebrooks, Jr., LCDR, NC, USN, DNP, MSN, RN, CRNA; Heather Carter-Templeton,
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Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Objectives
Identify individual barriers in the implementation of evidence-based practice (EBP) by nurses.
Describe interventions of the programs reviewed in the article that directly affect barriers to clinical nurses’ adoption of EBP or the use of research.
Disclosure Statement
Neither the planners nor the author have any conflicts of interest to disclose.
abstract
Background: Individual barriers such as a lack of research awareness, electronic database navigation skills, and research comprehension prevent nurses from implementing evidence-based practice (EBP). The aim of this review article is to examine EBP programs and their influence on individual barriers among workforce nurses.
Method: A keyword search of online databases was conducted for original research published from 2004– 2015. A review of cited references and footnote searching of significant articles was conducted to identify additional relevant articles.
Results: Twenty articles met the inclusion criteria. Although there was great variation among EBP programs, the majority of participants reported increased awareness, value, belief, knowledge, and skill as it relates to research utilization and EBP.
Conclusion: This review suggests that individual barriers to EBP may be influenced by clinically based EBP programs. However, a lack of randomized controlled studies and inconsistencies in measurement make it difficult to recommend best practices for developing EBP programs for nurses in the clinical setting.
J Contin Educ Nurs. 2016;47(9):398-406.
PhD, RN-BC; and Angela R. Mund, DNP, MS, APRN, CRNA
Dr. Middlebrooks is Assistant Professor and Assistant Clinical Site Director, Graduate School of Nursing, Uniformed Services University of the Health Sciences, D.K. Inouye Graduate School of Nursing, Bethesda, Maryland; Dr. Carter-Templeton is Assistant Professor, Capstone College of Nursing, The University of Alabama, Tuscaloosa, Alabama; and Dr. Mund is Associate Professor and Division Director, Anesthesia for Nurses, Medical University of South Carolina, Charleston, South Carolina.
The authors thank Dr. Kay Sackett for her guidance and her support of this manuscript.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Reginald Middlebrooks, Jr., LCDR, NC, USN, DNP, MSN, RN, CRNA, Assistant Professor and Assistant Clinical Site Director, Graduate School of Nursing, Uniformed Services University of the Health Sciences, D.K. Inouye Graduate School of Nursing, 4301 Jones Bridge Rd., Bethesda, MD 20814; e-mail: reginald.
middlebrooks@usuhs.edu.
Received: August 10, 2015; Accepted: June 1, 2016 doi:10.3928/00220124-20160817-06
E
vidence-based practice (EBP) is a systematic problem-solving approach that integrates the best evidence available with clinical expertise. It is combined with patient preferences and values when making clinical decisions (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2009). The Institute of Medicine’s (IOM) Future of Nursing report (2010) states that research and EBP are among the required competencies nurses must have to care for increasingly complex patients. Various methods of teaching EBP exist; however, effective strategies leading to nurses’ adoption of EBP into their daily practice have not been clearly identified (RamosMorcillo, Fernández-Salazar, Ruzafa-Martínez and Del-Pino-Casado, 2015; Solomons & Spross, 2011). The purpose of this integrative review was to identify, summarize, and communicate the teaching strategies used in EBP programs and describe their effect on the individual barriers of workforce nurses. Performing an integrative review enabled the authors to consider the disparate information reported in the literature.
BACKGROUND
Leaders in nursing agree that the ability to access and synthesize evidence-based information is imperative for today’s nurses (Alien et al., 2008). Yet, the challenge of preparing nurses to access, analyze, and implement evidence into practice has been a complex and arduous task. A tremendous amount of research has been done on the topic of nurses’ use of research and implementation of EBP. Much of the research has been aimed at identifying EBP barriers and facilitators. Carlson and Plonczynski (2008) reviewed 45 studies, spanning 15 years, related to EBP barriers and concluded there has been little change in the barriers perceived by nurses. Barriers such as not having enough time to read research, difficulty understanding statistical analysis, and being unaware of the research were frequently cited throughout the included reports.
The terms individual and personal are used in this review and are often used interchangeably in the literature to describe characteristics intrinsic to the nurse (Alzayyat, 2014; Bartelt et al., 2011). Although organizational barriers consist of aspects that may be out of the nurses’ control, such as insufficient time to address clinical questions, lack of EBP information sources, and insufficient tools related to research, individual barriers include lack of knowledge and skills related to research, as well as perceiving a lack of influence to change practice and unsupportive colleagues (Black, Balneaves, Garossino, Puyat, & Quin, 2015). In addition, familiarity with, attitude toward, and belief about EBP are individual characteristics that determine a nurse’s readiness for EBP (Saunders & Vehviläinen-Julkunen, 2015).
A landmark study by Pravikoff, Tanner, and Pierce (2005) stated that the lack of information literacy, computer skills, and attitudes toward research are preventing nurses in the United States from embracing EBP. In a survey of 760 clinical nurses, they found that nurses do not value or have the skills necessary to access, appraise, or interpret research for clinical decision making. Pravikoff et al. (2005) concluded that these barriers may be addressed through information literacy education. Despite improvements in technology and access to information in the decade since that study, nurses continue to lack the skills necessary to retrieve and translate the best evidence into their daily practice (Saunders & Vehviläinen-Julkunen, 2015).
Nurse leaders and administrators cannot solely rely on formal undergraduate academic education to provide the knowledge and skills necessary for nurses to navigate evidence-based information throughout their career. EBP skills, much like any other skill, require continued practice to be effective (Mollon et al., 2012). Further, curriculum changes that incorporate the teaching of information literacy skills in colleges and universities will not affect nurses already in practice, who need current and up-to-date information (Hart et al., 2008).
RESEARCH INQUIRY QUESTION
The question guiding this integrative review was: What strategies have been implemented to reduce individual barriers to EBP of clinically based nurses, as reported in the literature reviewed from 2004 to 2015?
INTEGRATIVE REVIEW RESEARCH CRITERIA
Search and retrieval yields are shown in the Figure. A computerized search of PubMed® and CINAHL® databases was performed using key search terms from the research question. Inclusion criteria for this review were that the articles:
l Described an intervention that directly affected individual barriers to clinical nurses’ adoption of EBP or research utilization. l Were limited to original research. l Were written in English and published in peerreviewed journals from 2004 to 2015.
The level of evidence was evaluated using Melnyk’s and Fineout-Overholt’s (2011) Hierarchy of Evidence scale. Although critical appraisal of quality is not a requirement of integrative reviews due to its diverse sources and increased complexity (Whittemore & Knafl, 2005), the level of evidence and methodology was considered during the analysis of the reports.
Figure. Search and retrieval yields for the current integrative review.
METHOD
Several key words were used to search for published reports that described EBP programs and their influence on nurses’ individual barriers to the adoption of EBP. The following key words were searched individually and in combination with each other: evidence-based, research utilization, information literacy, nursing practice, barriers, facilitat*, educat*, intervention, strategies, and individual.
Whittemore and Knafl (2005) stated that computerized database searches may yield 50% of eligible studies due to indexing problems and inconsistent search terminology; thus, additional search strategies, such as footnote searching, are recommended. In this phase, 11 additional articles were retrieved through a reference search of relevant articles and systematic reviews.
During the eligibility phase, articles were excluded if the target sample consisted of only nurses in nonclinical roles, such as students, educators, or administrators. Articles that focused on specific guideline or protocol implementation without addressing the individual barriers to implementation of EBP were also excluded.
Integrative Review Sample
A total of 36 articles were eligible for full-text review. Sixteen of those 36 articles were ineligible for the current review. Seven articles lacked clear outcome statements to determine the program’s success on nurses’ individual characteristics. Nursing students were the sole subjects of three articles, and nonclinical nurses were the sole subjects of two articles. Three reports were omitted because they contained theoretical descriptions of potential interventions. Finally, one article was removed because it described the implementation of a new protocol and did not address any individual EBP barriers.
Analysis
The final sample consisted of 20 studies describing programs for clinical nurses that were used to address EBP and the application of skills that support EBP. Data were collected using a table of evidence that contained predetermined criteria by which to objectively analyze the literature and prevent an unbiased interpretation of the diverse sources (Cronin, Ryan, & Coughlan, 2008; Whittemore & Knafl, 2005). Collectively, the level of evidence of the identified articles was moderate at best, according to Melnyk’s and Fineout-Overholt’s (2011) Hierarchy of Evidence scale, with only one level II (experimental design with randomized controlled sample) study (Toole, Stichler, Ecoff, & Kath, 2013). All 20 articles met inclusion criteria and provide relevant information to this topic and thus were included in this review.
FINDINGS
A summary of the reviewed articles describing an intervention that directly affected individual barriers to clinical nurses’ adoption of EBP or research utilization is shown in Table A (available in the online version of this article). The Findings section provides a synthesis of the separate data points collected by the authors to present a unified account of the research literature addressing the barriers of EBP among nurses working in clinical environments. This section is divided into elements that may help the reader to consider various approaches when addressing individual barriers of EBP through educational programs.
Sample sizes of studies included in this review range from 6 to 744 participants. The 20 articles included in the current review used multiple study designs to attain their results and conclusions; thus, the outcomes reported are not necessarily in a comparable format (Polit & Beck, 2012). A narrative synthesis and an analytic table (Table A) have been used to articulate the findings of this review.
The first study included in this review was published in 2004 (Cullen & Titler). The purpose of that study was to promote the use of evidence by staff nurses. Through a descriptive study using questionnaires and focus group questions over a 12-month period, staff nurses began to use and apply the Iowa model of EBP. The study concluded that participants rated professional growth and innovation higher than comprehension of EBP.
Fink, Thompson, and Bonnes (2005) conducted a descriptive study using a pre- and posttest design to examine the effect of complex strategies used to help RNs use research to change practice in an academic hospital during a 2-year period. A total of 239 RNs participated, and positive findings occurred with 65% of participants increasing awareness of research and 48% increasing their use of research.
In 2007, Milne, Krishnasamy, Johnston, and Aranda used a Clinical Research Fellowship Program during a 12-week period to help increase awareness of research. Through a quantitative and qualitative survey, it was determined that participants thought the program increased their awareness, knowledge, skill, and ability to analyze research. Sherriff, Wallis, and Chaboyer also reported findings of their educational program in 2007. Through a quasi-experimental design, they determined there was an increase in skill level pertaining to locating and evaluating research. In addition, they concluded that didactic sessions must be supplemented with other learning strategies to foster understanding of EBP. In another quasi-experimental design study (Wells, Free, & Adam, 2007), qualitative data were collected from 47 nurses to evaluate a nursing research internship program. Participants reported increased ability to use digital libraries and application of research findings to their clinical practice.
Hart et al. (2008) used computer-based learning modules as an intervention in a quasi-experimental study using a pre- and posttest design to examine changes in participants’ perceptions of knowledge, skills, and attitudes related to EBP and research utilization. They noted a significant increase in participants’ perceptions of knowledge, skills, and attitudes related to EBP and research utilization. In addition, they determined that computer-based learning modules were an effective and cost-efficient way to educate and involve large numbers of nurse participants. Another study that year explored the implementation of EBP to determine the best practice for clinical issues identified in practice settings (Neville & Hobart, 2008). That study used a case method approach to assess Patient–Intervention–Comparison– Outcome (PICO) questions. The process and quality of the questions were evaluated. Participants gained confidence in search techniques throughout the program. In addition, the authors concluded that having a librarian as a mentor was valuable. In addition, participants found it crucial to have a mentor assist with explanation of statistics and EBP. Varnell, Haas, Duke, and Hudson (2008) sought to evaluate the effectiveness of a program on the attitudes toward and implementation of EBP with nurse participants. Using a quasi-experimental design, they recruited 49 nurses to participate in the program. Through using measures related to EBP beliefs and implementation, they determined that participants attending the educational program had the aptitude to significantly improve their beliefs and attitudes related to EBP. Previous exposure to EBP led to higher scores on the EBP beliefs scale but not the implementation scale.
In 2010, Melnyk et al. reported results from a dissemination–implementation study, in which they used EBP measures to assess changes at baseline and 6 months after an 8-hour educational intervention. At the 6-month mark, nurses who had participated in the educational intervention had higher EBP beliefs than those who did not participate.
In 2011, Bartelt et al. explored the effectiveness of an EBP education series through four 4-hour workshops. They used a questionnaire to assess participants and nonparticipants regarding information literacy skills and EBP. The results indicated that those who participated in the workshop reported higher EBP engagement and skills in the specific areas covered by the workshop. O’Nan (2011) studied the effects of a journal club on nurses’ perception of barriers to using research to inform their practice. The study used a weekly journal club for 10 consecutive weeks. A research utilization scale given to participants pre- and postintervention was used to determine the findings. The author suggested that unitbased journal clubs may help decrease perceptions of barriers to research utilization. Rutledge and Skelton (2011) used a year-long intervention to enhance nurses’ knowledge, attitudes, and competence related to EBP. In their descriptive study, 11 nurse participants engaged in a 4-day course with follow-up activities. The findings indicated that all measured skills improved immediately after the course and all decreased after 1 year.
Grant, Hanson, Johnson, Idell, and Rutledge (2012) used a 1-day course to educate nurses about EBP. In their study, 155 nurse participants used quantitative evaluations, although specifics about the measures used were not reported. Many participants completed an evidencebased nursing practice project that was evaluated 12 months after completing the educational intervention. The authors of the study reported that positive changes in knowledge and attitude after each course were noted by the participants and they received high participant satisfaction scores. Mollon et al. (2012), used a descriptive pre- and postsurvey design method to assess the affects of an online EBP educational intervention on the practice, attitudes, knowledge, and skill of 609 clinical staff participants. They found no significant changes in any of the measured outcomes. They concluded that a self-learning online module for EBP may not be the most effective method for teaching EBP. Morgan (2012) also published study results that year. She used a mentoring model to assess for reduction of barriers to EBP. Fifteen nurses participated in the quasi-experimental study using a pre- and posttest design employing the BARRIERS scale and National Database of Nursing Quality Indicator tools. Noted improvements of barriers related to research evaluation and statistics comprehension occurred.
Edward and Mills (2013) reported their results from a study designed to evaluate the effectiveness of a program created to enhance nurses’ awareness and access to research. The measurement used to evaluate the program by participants included Likert scale questions, such as the prospect of recommending the program to colleagues and open-ended questions inviting participants to share the effects of the education on their clinical practice. Findings suggest participants’ appreciation, awareness, and access to research improved as a result of the research. Kim et al. (2013) reported the results of their program evaluating the effectiveness of a regional fellowship program focused on EBP implementation. Using a quasi-experimental design with pre and posttest measures, 142 nurse participants were recruited. Findings suggest significant improvement in the practice of EBP and in the knowledge and skills of EBP among fellows at the posttest. All perceived barriers were reduced at posttest. Toole et al. (2013) used a randomized controlled study, with a total of 596 nurse participants to determine whether there were significant differences in two different educational methods used to improve knowledge, attitudes, and practices of EBP. Findings indicated that both types of educational intervention are effective in improving self-report of EBP. No statistically significant increase in core knowledge was found despite the intervention used.
In 2015, Black et al. designed a mixed-methods study to evaluate a research training program on the research and EBP knowledge, attitudes, and practices of clinicians in a Canadian health organization. Participants completed a survey (a Knowledge, Attitudes, and Practice Survey) at three different points in time. Focus groups were also conducted. Results indicated a statistically significant increase in research knowledge and ability. Participants recognized that a benefit of the program was a positive impact on EBP. Ramos-Morcillo et al. (2015) performed a quasi-experimental study to evaluate the effectiveness of a basic online EBP course and face-to-face education on knowledge, skills, attitude, and practice of 109 RNs who attended a free continuing education course in Spain. They found that the online course with face-to-face education produced a statistically significant difference in EBP knowledge and skill, compared with nurses that attended a similar course on digital information. However, no differences were noted in practice or attitude.
SYNTHESIS
Outcomes
Thirteen of 20 studies reported an improvement in EBP knowledge or research utilization skills (Bartelt et al., 2011; Black et al., 2015; Cullen & Titler, 2004; Grant, Hanson, Johnson, Idell, & Rutledge, 2012; Hart et al., 2008; Kim et al., 2013; Milne et al., 2007; Morgan, 2012; Neville & Horbatt, 2008; O’Nan, 2011; RamosMorcillo et al., 2015; Rutledge & Skelton, 2011; Sherriff et al., 2007). However, Mollon et al. (2012) and Toole et al. (2013) suggested there was no significant difference in knowledge when comparing their pre- and postintervention assessments. Eight studies stated there was an improvement in nurse’s attitudes, beliefs, or values as related to EBP (Bartelt et al., 2011; Edward & Mills, 2013; Grant et al., 2012; Hart et al., 2008; Melnyk et al., 2010; O’Nan, 2011; Varnell et al., 2008; Wells, Free, & Adams, 2007). Five studies indicated there was not a significant increase in nurses’ attitudes toward EBP, likely due to the high baseline scores of this variable (Fink et al., 2005; Mollon et al., 2012; Ramos et al., 2015; Sherriff et al., 2007; Toole et al., 2013). Improvement in research awareness was reported in four studies (Edward & Mills, 2013; Fink et al., 2005; Grant et al., 2012; O’Nan, 2011). Research awareness may have extended beyond the participants in studies that required dissemination of project results (Grant et al., 2012).
Seventy percent (14 of 20) of studies included in this review employed the use of at least one reliable and valid instrument used to measure variables associated with using evidence in practice. The use of reliable and valid instruments among these studies varies with regard to content, format, and points in which they were administered in the study. However, results were reliant on participants completing the instruments and responding honestly and accurately to the measurements.
Programs
Components of each program can be found in Table 1. The most prominent component of the EBP programs was didactic instruction. Seventeen of the 20 articles reported EBP information presented by a subject matter expert. Hands-on computer based training, primarily for online database navigation, was reported in 11 of the 20 studies. EBP projects were part of eight of the programs.
TABLE 1
COMPONENTS OF EVIDENCE-BASED PRACTICE INTERVENTIONS
Study (Year) Didactic Instruction Mentor Librarian Computer-
Based
Learning Reference Materials Journal Club Project Long-Term Follow-Up Conference
Bartelt et al. (2011) X X X
Black et al. (2015) X X X
Cullen & Titler (2004) X X X X
Edward & Mills (2013) X X
Fink et al. (2005) X X X X
Grant et al. (2012) X X X X X
Hart et al. (2008) X
Kim et al. (2013) X X X X
Melnyk et al. (2010) X X X X
Milne et al. (2007) X X X X X
Mollon et al. (2012) X
Morgan (2012) X X X X
Neville & Horbatt (2008) X X X
O’Nan et al. (2011) X
Ramos-Morcillo et al. (2015) X X
Rutledge & Skelton (2011) X X X X X
Sherriff et al. (2007) X X X X X
Toole et al. (2013) X X
Varnell et al. (2008) X X
Wells et al. X X X X
(2007)
Of note, most of the EBP programs consisted of multiple methods of teaching EBP. Only three studies (Hart et al., 2008; Mollon et al., 2012; O’Nan, 2011) did not incorporate multiple strategies within their EBP program.
Participants
Nurses represented in this review cover a wide range of clinical specialties, ages, and ethnicities, as well as geographic regions. All of the articles include workforce nurses; however, some studies include other health care professionals, such as occupational therapists, physical therapists, and social workers. (Bartelt et al., 2011; Black et al., Milne et al., 2007; Mollon et al., 2012). Several articles included nurses who were nonclinical (Bartelt et al., 2011; Cullen & Titler, 2004; Kim et al., 2013; Sherriff et al., 2007; Toole et al., 2013; Varnell et al., 2008); nonethe-
TABLE 2
IMPLICATIONS FOR FUTURE RESEARCH
Areas of Future Research Needs
A need exists for the development of an objective tool or instrument to assess nurses’ evidence-based practice competencies.
Future research is needed to assess long-term effects of programs designed to improve evidence-based practice use among workforce nurses.
A need exists for experimental studies with randomized samples to eliminate bias associated with volunteers and convenience samples.
less, those articles were included because a majority of the participants were workforce nurses. The majority of the studies relied on convenience or selective sampling. One study used randomized sampling.
Key Personnel
Mentors, or mentorship, was identified as a key factor in seven of the 20 studies (Table 1). Melnyk et al. (2010) reported that mentors were a critical factor and reduced many organizational barriers to implementing EBP. Six of the studies included the expertise of a librarian to help facilitate online database searching, as well as the formulation of searchable questions. The instruction provided by the librarian was of significant interest by the participants and helped improve participants’ information literacy and computer skills.
DISCUSSION
This review article highlights the variation of interventions used to increase nurses’ knowledge of research and EBP. It indicates that standard methods of teaching EBP in the clinical setting have not yet been recognized. Furthermore, 11 different published data collection tools were used in these studies. This does not include the various quantitative, qualitative and demographic questionnaires, focus groups, interviews, or author observations that were used to gather information. A need exists for consistent methods of measuring nurses’ readiness and knowledge of EBP so researchers can establish evidencebased methods of teaching EBP. Leung, Trevena, and Waters (2014) performed a systematic review of instruments used to measure nurses’ knowledge, skills, and attitudes of EBP. They found 24 different instruments and concluded that an objective tool to assess the competency of nurses in regard to EBP needs to be developed.
The dearth of experimental studies and the prevalence of self-selected samples in this review may be problematic when attempting to determine causality of outcomes. In addition, there was a heavy reliance on self-reports by the participants in these studies. The accuracy and reliability of self-reports is questionable because they are susceptible to recall and social desirability biases (Leung et al., 2014). Nurses may overestimate the amount of evidence-based care they provide, as well as their knowledge and skill of EBP, before participating in an educational program (Kim et al., 2013; Linton & Prasun, 2013). In addition, nurses may experience a postintervention decrease in their perception of knowledge and skill as a result of more realistic perceptions or greater appreciation of the complexity of EBP (Bartelt et al., 2011; Rutledge & Skelton, 2011).
Sherriff et al. (2007) stated that “educational courses in a clinical setting is useful in improving clinicians’ attitudes to and perceptions of knowledge and skills related to EBP” (p. 363). However, the long-term effect of the programs in this review is unclear. In the study by Rutledge and Skelton (2011), nurses’ skills in finding, reviewing, and using evidence decreased 1 year after the intervention. Future studies conducted to assess longterm effects of the interventions on knowledge and skill sustainability are recommended (Table 2).
SUMMARY
Findings from this review, although limited, have implications for nursing practice. Nurse leaders and educators should be cognizant of the importance of information literacy skills, which facilitate EBP. Nurses have an obligation to provide the highest quality care based on evidence. Developing a skill set related to EBP keeps one poised to provide care based on evidence. The current review suggests that the individual barriers to the implementation of EBP may be modifiable. Although great variation in the application of information and education, as well as assessment, exists, it is clear that approaches such as didactic instruction from an expert in EBP, computer-based instruction especially from a librarian, and EBP projects that allow the nurses to practice the skills they learned have resulted in positive outcomes for participants. Reporting program design, details, approach, and results vary among the articles included in this review, which adds to the complexity of the analysis. Given the state of the literature and the results of this review, it would be premature to provide specific conclusions on best practices and suggestions for developing EBP programs for nurses in the clinical setting.
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Table A Evidence-Based Practice (EBP) Programs for Workforce Nurses, 2004-2015
Study (Year) Purpose Sample
Size
Study Design
(LOE)
Data Collection
Method and
Instruments Intervention Findings and Conclusions Comments
Bartelt et al. (2011) To explore the effectiveness of an EBP education series. 56 HCPs
(including
40 RNs) Descriptive crosssectional study (VI)
Information Literacy for Evidence-Based Nursing Practice questionnaire
(Pravikoff et al., 2005)
EBP educational
series
Four (4-hour) workshops
Attendees more likely to use credible sources for information.
“Lack of search skills” and “lack of skill to critique and/or synthesize the literature” remain major individual barriers. Persistent individual barriers may be result of increased awareness.
Fairly high level of education of study participants.
Asking a colleague or the Internet remains the primary method of seeking new information.
Black ,
Balneaves,
Garossino,
Puyat, &
Qian
(2015) To evaluate the impact of knowledge, attitudes, and practices related to
EBP in clinicians 136
clinicians (78 RNs) Mixed-methods (pre-post design and focus groups)
(III) KAP Survey
(van Mullem et al.,
1999)
Focus group questions
Demographic form
Teams attended 3 workshops focused on research concepts.
Groups generated research proposals and competed for funding. Research of funded proposals was conducted. Statistically significant improvement in research knowledge.
A positive impact on EBP was noted by clinicians. This study was one of the first to implement and evaluate EBP interventions at the pointof-care.
Cullen &
Titler
(2004) To promote the use of evidence by staff nurses to improve outcomes 6 RN interns Descriptive (VI)
Questionnaires and
focus group questions
EBP Staff Nurse
Internship program
12 meetings over first 12 months and quarterly meetings thereafter; 18-24 months total Staff nurses learned and applied the Iowa Model of EBP to Promote Quality Care.
Partnership and mentorship critical to success of program and projects. Participants rated professional growth and innovation higher than comprehension of EBP and preparation to complete EBP project.
Edward &
Mills
(2013) To describe the development of a hospital-based research enhancement model, a strategy used to enhance nurses’ awareness, access, and use of research 78 nurses and midwives Survey design with both quantitative and qualitative data
(VI)
Quantitative and qualitative survey
ROWS seminars
Twenty (15-minute) seminars over a 9month period
Participants stated the ROWS program increased their appreciation, awareness and access to research.
Session timing and location were well received by the staff. Pamphlets and booklets were given to staff on several subjects allowed for reflection after seminar.
Increased appreciation of research despite short length of seminars.
Increased desire for more training by participants.
Fink,
Thompson,
& Bonnes
(2005) To examine the effect of multifaceted
organizational strategies on RNs use of research findings to change practice in an academic hospital 215 baseline RNs; 239 postintervention RNs Descriptive crosssectional presurvey and postsurvey
design (VI)
BARRIERS to Research Utilization Scale (Funk
et al., 1991)
Research Factor
Questionnaire
(Thompson, 1997) Multifaceted
approach
2-year period
65% of participants had increased awareness of research findings.
48% believe their use of research findings increased as a result of participation. Continued barriers to research utilization include (a) difficulty changing practice, (b) lack of support and mentoring, (c) insufficient time, (d) lack of education related to research utilization.
Grant,
Hanson,
Johnson,
Idell, &
Rutledge
(2012) To describe the
development of a 1-day EBP course for staff nurses 155 RNs Descriptive survey design (VI)
Pre- and postworkshop survey. Satisfaction survey, Postworkshop qualitative comments and conversations. 12month postworkshop evaluation. EBP course
9 (1-day) courses spread out over 3 years and unitbased project
Positive changes in knowledge and
attitude after each course
High participant satisfaction scores.
29 of 77 projects canceled for various reasons. Program successful at raising awareness of EBP of participants and those exposed to completed projects.
Inclusion of librarian was of particular value.
Lack of time and support a major barrier to completing projects.
Hart et al. (2008) To examine the effectiveness of a CBE program on nurses’ perceptions of knowledge, attitude, and skill level related to EBP and research utilization 744 RNs Descriptive quasiexperimental design; one group pre- and postintervention survey method (III) Evidence-Based
Nursing Questionnaire
(Nagy, Lumby,
McKinley, &
Macfarlane, 2001)
Demographic
questionnaire
Computerizedbased learning modules.
3 (15- to 20-minute) modules; 1 per month for 3 months.
Significant improvement in RN’s perception of knowledge, attitude and skill level related to EBP and research utilization.
CBE is effective and cost-efficient way to educate and engage large numbers of RNs. Majority of nurses felt confident understanding research language but less so in ability to understand statistics.
Learning may be affected by interruptions while completing CBE modules at work.
Other EBP initiatives occurred concurrently
Kim et al. (2013) To evaluate the effectiveness of a collaborative regional fellowship program on implementation of EBP 142 RNs Quasi-experimental, pre- and posttest method (III) EBP Questionnaire
(Upton & Upton, 2006)
BARRIERS to Research Utilization Scale (Funk
et al., 1991)
Demographic form and questionnaire EBP Fellowship
Program
9-month program consisting of 6 (8hour) sessions and a clinical practice project Significant improvement for Practice of EBP and Knowledge/Skills of EBP among fellow’s posttest.
All perceived barriers were reduced post-test.
Adopter and Communication subscales reduced most.
Educated and experienced sample. 48.6% with graduate degrees; mean of 16 years of experience.
Fellows less confident in ability to critically appraise, understand, and synthesize research articles posttest.
Barrier reduction and research utilization should focus on specific subset of RNs.
Melnyk et al. (2010) To determine the impact
of translating an evidence-based program into clinical practice on nurses’ EBP beliefs and implementation; to determine the barriers and facilitators 81 NICU
RNs Dissemination-onImplementation study (VI) EBP Beliefs Scale
EBP Implementation
Scale (Melnyk &
Fineout-Overholt,
2005)
Demographic questionnaire EBP/COPE
Workshop
8-hour workshop on EBP and the COPE program
At 6-month follow-up RNs in the COPE pods had higher EBP beliefs than nonCOPE pod RNs.
No significant difference in EBP implementation between two groups.
Small to medium positive effect for being in the COPE pods. COPE mentor significant in implementing the COPE program. Mentor decreased barriers.
Unable to determine effects on RNs due to program or mentor alone.
Surveys were anonymous thus unable to compare baseline data with 6-month followup.
Milne, Krishnasamy,
Johnston, &
Aranda
(2007) To describe the structure and content of a Clinical Research
Fellowship program. 15 participants (including
10 RNs) Quantitative and qualitative survey design (VI) A quantitative and qualitative survey was
e-mailed to all participants. Clinical Research
Fellowship program
15 classes over a 12week period Participants felt the program increased their awareness, knowledge, skill, and ability to analyze research.
Changes in future programs include greater emphasis in critical appraisal skills.
10 of 16 projects supported a practice change
Mollon et al. (2012) To evaluate the effect of an online educational program on the practice,
attitudes, and knowledge/skills related to EBP. 609 participants (including
488 RNs) Pre- and postsurvey design (VI) EBP Questionnaire
(EBPQ) (Upton &
Upton, 2006)
Demographic questionnaire Online educational module No significant change in EBP practice, attitudes, knowledge/skill after taking
the online module
Self-learning online modules may not be the most effective method for introducing and expanding EBP
Graduate-level education is predictive of better practice, attitude, and knowledge/skill regarding EBP
Morgan (2012) To determine whether a mentor-led EBP quality improvement project would reduce RNs perceptions of barriers to using best practice research findings in their practice 15 RNs Quasi-experimental pre- and postintervention design (III) BARRIERS to Research Utilization Scale (Funk
et al., 1991)
National Database of
Nursing Quality
Indicators tool
(Montvalo, 2007) 5 (2-hour) educational sessions Individual barrier “RN not capable to evaluate research” decreased 60% from pretest to posttest.
“Statistics not understandable” number 1 barrier postintervention; formerly 5th highest barrier. Perceptions of barriers decreased significantly.
Mentor-led EBP supports best practices and reduces perceptions of barriers.
Educating a core group of EBP mentors will provide sustainability to future EBP projects.
Neville &
Horbatt
(2008) To explore the implementation of EBP to determine the best practice for clinical issues identified in professional nurses’ practice settings. 10 RNs Case method approach; pilot study (VI) Assessment of studentformulated PICO questions and supporting evidence.
Author observation. Independent nursing practicum. RNs gained confidence and competence in search techniques.
Participants found it crucial to have a mentor explain advanced statistics and EBP process. The major barrier identified in this study was the nurses’ lack of experience in retrieval of EBP literature.
Having a librarian as a mentor and support was invaluable and largely facilitated nurses’ acquisition of information.
O’Nan (2011) To determine whether participation in a journal club reduces staff nurses’ perceptions of barriers to using research findings to inform their practice. 14 RNs Quasi-experimental pre- and postintervention design (III) BARRIERS to Research Utilization Scale (Funk
et al., 1991)
Demographic questionnaire Weekly journal clubs for 10 consecutive weeks. Prejournal club barriers were contained mostly within the characteristics of the organization. Postjournal club barriers were mixed among all subscales.
Adopter, communication, and organization barrier subscales were lower postjournal club. Study suggests RNs’ perceptions of barriers to research utilization are modifiable as a result of journal clubs.
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