Issues in Mental Health Nursing, 35:134–143, 2014
Copyright © 2014 Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2013.848385
Barriers to Evidence-Based Practice Utilization
in Psychiatric/Mental Health Nursing
Abdulkarim Subhi Alzayyat, RN, MSN
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The University of Jordan, Faculty of Nursing, Amman, Jordan
Many psychiatric/mental health nursing (PMHN) practices
have been affected by old traditions and haphazard trial and error instead of by established scientific evidence. The purpose of
this article is to explore and analyze the barriers surrounding
evidence-based practice (EBP) in PMHN. I identify some strategies to overcome these barriers in an attempt to incorporate EBP
within the framework of PMHN services. Barriers explain the lack
of EBP in today’s PMHN environment. The barriers identified in
this research are: the nature of the evidence, the contribution of
the psychiatric nursing researchers to EBP, the personal characteristics of psychiatric nurses, and organizational factors. While
the barriers to EBP for PMHN practice are clearly apparent, the
challenge, now, is to build up creative strategies through which
psychiatric nurses are better able to provide EBP care as part
of their everyday performance. Adaptation of a more dynamic
form of EBP, increasing the number of PMHN researchers, conducting clinical research projects, choosing suitable journals for
publication, training the psychiatric nurses about computer skills,
integrating the EBP principles into nursing curricula, developing
journal clubs, and offering organizational facilitators are essential prerequisites for the achievement of EBP in the PMHN field.
It is no longer justifiable for psychiatric nurses to be deficient in
knowledge and skill since the advantages of EBP for patients are
well-documented.
Evidence-based practice (EBP) is defined as the organized
use of the existing best available evidence in making clinical decisions concerning patient care (Boyd, 2012). Using
EBP in the clinical setting leads to several benefits, including enhancing the quality of care and patient outcomes, offering professional development chances, guiding the recruitment and retention of nursing staff, and economizing health care
budgets (Leasure, Stirlen, & Thompson, 2008; Wallin, Ewald,
Wikblad, Scott−Findlay, & Arnetz, 2006). The need for EBP in
Psychiatric/Mental Health Nursing (PMHN) is well recognized
in the literature (Yadav & Fealy, 2011a, 2011b; Zauszniewski,
Suresky, Bekhet, & Kidd, 2007). Furthermore, the use of EBP
is advocated by many PMHN organizations (American Nurses
Address correspondence to Abdulkarim Subhi Alzayyat, Department of Community Health Nursing, Faculty of Nursing, The University of Jordan, Amman 11942, Jordan. E-mail: A.alzayyat@gmail.com
Association, 2009; American Psychiatric Nurses Association,
2008; International Society of Psychiatric Nursing, 2009).
Historically, PMHN practice has been affected by old traditions and haphazard trial and error, instead of established
scientific evidence (Zauszniewski, Bekhet, & Haberlein, 2012;
Zauszniewski & Suresky, 2004). Although many of these practices are questionable, some of these traditions have been passed
down through generations and still contribute to numerous
PMHN practices nowadays (Zauszniewski et al., 2007). Indeed, the application of EBP when caring for a mentally ill
person is not a simple process because psychiatric nurses must
breach a number of barriers before depending completely on
the EBP approach to enhance PMHN practice (Yadav & Fealy,
2011a).
The purpose of this study is to explore and analyze the barriers surrounding EBP in PMHN. I identify some strategies to
overcome these barriers in an attempt to incorporate EBP within
the framework of PMHN services. Although barriers to EBP
utilization among general nurses are reported adequately in the
literature (Kajermo et al., 2008; Schoonover, 2009; Tan, Sahin,
& Özdemir, 2012), the reporting of those barriers among psychiatric nurses is limited in the current literature (Bahtsevani,
Khalaf, & Willman, 2005; Koivunen, Välimäki, & Hätönen,
2010). Therefore, this study should be considered one of the
first efforts to address such problem in the international PMHN
literature.
BARRIERS TO EBP IN PMHN
Several barriers may explain the lack of EBP in today’s
PMHN environment globally (Koivunen et al., 2010;Yadav &
Fealy, 2011a; Zauszniewski et al., 2007). The reviewed literature revealed that these barriers can be classified into four major
categories: the nature of the evidence (Lines, 2008; Stickley
& Phillips, 2005), contribution of the PMHN researchers to
EBP (Beebe, Adams, & El-Mallakh, 2011; Zauszniewski et al.,
2007), personal characteristics of psychiatric nurses (Koivunen
et al., 2010), and organizational factors (Wells, Free, & Adams,
2007). The discussion of these barriers may help PMHN
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BARRIERS TO EVIDENCE-BASED PRACTICE
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personnel (including researchers, educators, and practitioners)
in establishing a literature-based background about the factors
that hinder psychiatric nurses from applying EBP in the clinical
context.
The Hierarchical Nature of Evidence
EBP is essential for PMHN, but its successful realization
may be disturbed by the ladder of evidence (Mantzoukas, 2008).
EBP rests on the notion that some evidence is superior to others
(Malloch, & Porter-O’Grady, 2010). The hierarchy of evidence
is presented in Figure 1.
Randomized controlled trials (RCTs) are recognized as the
gold standard, and the meta-analysis of RCTs is the summit of
the evidence hierarchy (Polit & Beck, 2013). Less controlled
research designs are commonly recognized as weaker evidence
(Mantzoukas, 2008). The EBP leaves a place for clinical expertise, by which psychiatric nurses utilize their individual clinical
proficiency and expertise in making judgments. This, however,
is located at the bottom of the hierarchy (Polit & Beck, 2008).
Regardless of the great support EBP hierarchy has, it is subjected to a number of critiques in the PMHN field (Fisher &
Happell, 2009). To begin, the use of RCTs as the gold standard of evidence has progressively been the matter of dispute in
PMHN literature (Lines, 2008). Ellis (2005) argues that RCTs
have slight importance outside of drug trials, mainly in terms
of psychosocial interventions. Therefore, RCTs are restricted in
their ability to notify psychiatric nurses of what psycho-social
interventions are more helpful, for whom, in what conditions,
and in representing what psychiatric nurses should do to improve patient outcomes (Ellis, 2005). Moreover, the RCT design
tries to reduce the surrounding noise of context; nevertheless, in
FIGURE 1 The Hierarchy of Evidence Adopted From Sampaio and Mancini
(2007) Permission to use this figure was obtained from the Brazilian Journal of
Physical Therapy as the publisher for this table.
135
PMHN practice, this context is important (Stickley & Phillips,
2005). In other words, in PMHN settings, accessible resources,
expertise, and even individual service user preferences, may not
match those assigned under the RCT, making the usefulness and
suitability of RCT evidence in PMHN conditions questionable
(Fisher & Happell, 2009); the application of the RCTs’ findings
in PMHN is like trying to put a square peg into a round hole
(Stickley & Phillips, 2005). Another contradiction is that the
EBP hierarchy is based on generalizations about service users,
mental illnesses, and therapy approaches (Franks, 2004). On
the contrary, effective PMHN care is predicated on the distinctiveness of the nurse-service user relationship and an eagerness
to familiarize oneself with the individual and his or her family
unit (Boyd, 2012). Historically PMHN has, since the days of
Peplau, developed mutually, theoretically, and practically from
the nurse-patient relationship (i.e., case study) (Peplau, 1952).
However, the EBP hierarchy possibly minimizes the importance of this historical evolution of PMHN because case study
has been disregarded as evidence (Stickley & Phillips, 2005).
Accordingly, few researchers have carried out studies on this
therapeutic relationship in the light of the current EBP agenda
(Fisher & Happell, 2009).
The Contribution of The PMHN Researchers
It has been reported that intervention research represents a
small percentage of PMHN studies (Beebe et al., 2011). For
example, in a recent review of 486 publications in five popular international PMHN journals (Zauszniewski et al., 2007)
merely 77 (16%) of the publications examined PMHN interventions. This finding illustrates the scarcity of published intervention research in the psychiatric nursing journals and advocates
the necessity of more research projects that build up evidence
for effective PMHN interventions globally. Indeed, many of the
psychiatric nurses do not read PMHN journals because they are
about research not practice (Krauss, 2004). This barrier was recognized in 2001, as Stuart reported that “psychiatric nurses are
not contributing to evidence-based psychiatric care” (p. 109).
However, this barrier remained because of the shortage of competent researchers in this field, restricted connections between
practice and academic institutions, and research-related barriers
in the community (Beebe et al., 2011). From a different perspective though, Stein (2009) has reported that the researchers’
selection of journals for publication of their research works
may be an issue of concern. The majority of PMHN studies
are published chiefly in journals that are seldom read by practicing psychiatric nurses. Several factors affect the researchers’
selection of a journal for publishing; researchers may think that
their work needs to be in journals that (a) are reachable to those
colleagues from multidisciplinary team; (b) have a high impact,
and (c) reveal a high quality of scholarly activity that boost
decisions for tenure and promotion (Stein, 2009).
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A. S. ALZAYYAT
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Even though these factors may be justifiable, the questions
remain: What is our duty as researchers in the PMHN field to
our practicing colleagues and how we can improve the quality
of PMHN care for the children, teenagers, and adults who receive such care? Boyd (2012) stated that the main objective of
PMHN (including both researchers and clinicians) is to promote
mental health and well-being of people across their life spans
by providing high-quality and optimal nursing care. Therefore,
based on Stein’s (2009) observations, I recommend that PMHN
researchers reconsider their existing emphasis on the promotion
criteria and journal impact factors in favour of more convincing issues that hold potential for enhancing PMHN practice and
patient outcomes.
The Personal Characteristics of Psychiatric Nurses
The implementation of EBP in PMHN may by further
hindered by the personal characteristics of psychiatric nurses
(Koivunen et al., 2010). In order for EBP to take place, practicing psychiatric nurses should be competent in searching, appraising, and synthesizing the empirical literature associated
with their clinical practice (Jutel, 2008; Shaneyfelt et al., 2006;
Zauszniewski et al., 2012). Accessing the empirical literature necessitates psychiatric nurses to be computer literate and skillful
in information retrieval, which requires them to have the ability to utilize information technology, particularly the Internet
and literature databases (Hamer & Collinson, 2005). In PMHN
specifically, practicing nurses have inadequate computer skills
and competencies (Koivunen, Välimäki, Jakobsson, & Pitkänen,
2008). For instance, Koivunen et al. (2010) conducted a study
to evaluate practicing nurses’ skills in using the Internet and
the literature databases in Finnish psychiatric hospitals. The results illustrated obvious shortages in the information retrieval
skills among practicing psychiatric nurses. Therefore, psychiatric nurses’ search competencies do not support the fulfillment
of evidence-based practice. To overcome this issue, I advocate
increasing practicing psychiatric nurses’ information retrieval
skills by developing continuing education programmes.
Assuming the psychiatric nurses have adequate skills for accessing the empirical literature, implementation of EBP requires
competency in appraising the evidence in order to determine
whether it is suitable for use (Gerrish et al., 2007). Appraising
the retrieved evidence necessitates familiarity with the terminology and the language of scientific clinical research (Rice,
2009). All practicing psychiatric nurses, for example, need to
able to discuss concepts such as sample size and the significance
level (α) to decide the clinical meaningfulness of the study findings (Polit & Beck, 2008). However, in PMHN many practicing
nurses still report problems in understanding research language
and face difficulties in judging the quality of evidence (Yadav &
Fealy, 2011b). Taylor and Allen (2007) suggest this inadequacy
in research appraisal skills may be attributed to the pressure of
educating a great number of nurses with practical skills. Another
possible explanation for the limited appraisal skills is that the
teaching of research in nursing curricula has concentrated on the
research process—such as the designs of the studies—instead of
focusing on the appraisal and implementation of research findings in the clinical context (Burke et al., 2005). Consequently,
the nursing education programmes should make steps towards
integration of EBP and research appraisal into nursing curriculum (Omer, 2012).
Organizational Barriers
The organizations where psychiatric nurses work might make
it difficult for them to carry out EBP activities (Wells et al.,
2007). One identified organizational barrier is insufficient time
to achieve the entire EBP process (Wells et al., 2007; Yadav
& Fealy, 2011b). Implementing EBP is a time-consuming process predominantly involved with accessing, locating, reading,
and appraising research reports, and implementing warranted
changes (Omer, 2012). Moreover, the process of obtaining local agreement of innovations evolution and practice development may be lengthy (Timmins, McCabe, & McSherry, 2012).
Nevertheless, given today’s fast-paced, short-staffed care delivery environment, and the resultant workload commitments,
organizations may not allow sufficient time for their psychiatric
nurses to conduct such necessary EBP activities (Thomas, 2005;
Timmins et al., 2012). Enough time for the psychiatric nurses
to engage in EBP activities should be provided for the purpose
of attainment of EBP within PMHN organizations.
Another identified organizational barrier is inadequate organizational and leadership support (Bahtsevani et al., 2005;
Brown, Wickline, Ecoff, & Glaser, 2009; Kajermo et al., 2008).
It has been evident that lack of authority (of the practicing
nurses) and resistive ward culture were seen to struggle against
changing the routine practice in the favor of EBP (Wells et al.,
2007). Furthermore, EBP-associated activities were not considered as “valid work” by those nursing managers in the psychiatric settings (Rice, 2008). PMHN organizations need to reflect
on many strategies to promote and facilitate the EBP. These
strategies may include: managerial/leadership support, boosting the nurses’ autonomy, and establishing a ward culture that
is amenable to change.
A final organizational barrier is the limited organizational
infrastructures that are designed to promote EBP (French, 2005;
Hannes et al., 2007). For example, in Yadav and Fealy’s (2011a)
study, Irish psychiatric nurses stated that they faced difficulty
in reaching the research evidence. This is because the limited
Internet access in the hospital does not provide them access
to those databases that include the huge body of research in
PMHN. Therefore, the author recommends that promoting the
infrastructures of the PMHN settings is essential.
STRATEGIES TO OVERCOME THESE BARRIERS
While the barriers to EBP for PMHN practice are clearly
apparent, the challenge now is to build up creative strategies through which psychiatric nurses can be better enabled to
137
BARRIERS TO EVIDENCE-BASED PRACTICE
TABLE 1
Barriers to EBP in PMHN alongside Proposed Strategies to Overcome Barriers
Barriers to EBP
1. Nature of the Evidence
Hierarchical structure of the evidence (Mantzoukas, 2008)
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2. Contribution of PMHN Researchers to EBP
Limited account of interventional studies in PMHN
(Beebe et al., 2011)
The researchers’ selection of journals for publication
(Stein, 2009)
3. The Personal Characteristics of Psychiatric Nurses
Inadequate computer skills and competencies (Koivunen
et al., 2008)
Problems in understanding the research language and
appraising the quality of evidence (Yadav & Fealy, 2011b)
4. Organizational Factors
Insufficient time to achieve the entire EBP process
(Wells et al., 2007; Yadav & Fealy, 2011b).
Inadequate organizational and leadership support
(Bahtsevani et al., 2005; Brown et al., 2009; Kajermo et al.,
2008).
Limited organizational infrastructures for EBP (Yadav &
Fealy, 2011a)
provide EBP care as part of their everyday performance (Fisher
& Happell, 2009). Adaptation to a more dynamic form of EBP,
increasing the number of PMHN researchers, conducting clinical research projects, choosing suitable journals for publication,
training the psychiatric nurses on computer skills, integrating the
EBP principles into nursing curricula, developing journal clubs
and offering organizational facilitators are essential strategies
for the achievement of EBP in the PMHN field. The barriers to
EBP, combined with the resolving strategies, are summarized in
Table 1.
Dynamic Form For EBP Hierarchy
An essential barrier to EBP is rooted in its hierarchical structure, as it is incongruous with contemporary PMHN practice
(Mantzoukas, 2008). There is, therefore, a necessity to reconceptualize the hierarchical approach to evidence (Fisher & Happell 2009). Instead of choosing such a conservative position,
Overcoming Strategies
Adaption of a more dynamic form of EBP that incorporates
empirical evidence, available resources in the practice
context, the patients’ values, and the clinical expertise of
psychiatric nurses (Egerod & Hansen, 2005; Fisher &
Happell, 2009)
Increasing the number of PMHN researchers (Zauszniewski
et al., 2007); Collaboration between the PMHN
researchers and clinicians to conduct clinical research
projects (Tansella et al., 2011)
Publishing research findings in journals that are read by the
practicing psychiatric nurses (Stein, 2009; Zauszniewski
et al., 2007)
Practical training under the direction of a computer
specialist (Alquraini et al., 2007; Eley et al., 2009).
Integrating the EBP principles in the nursing curricula
(Fortinash & Holsay-Worret, 2012); Developing journal
clubs for the psychiatric nurses (Mahoney, 2009; Yadav &
Fealy, 2011b)
Offering enough time for the psychiatric nurses to be
engaged in EBP activities (Brown et al., 2009);
Improving the nurses’ autonomy (Brown et al., 2009).
Offering a work milieu that encourages psychiatric nurses
to look for the best available evidence (Brown et al.,2010)
Establishing the necessary infrastructures (like access to the
international PMHN databases) (Brown et al., 2010)
EBP should support the application of suitable methodology to
handle the clinical problem (Stickley & Phillips, 2005). Following this approach, RCTs can be the most proper evidence
for clinical trials of drug efficacy. However, RCTs, obviously,
might not be the proper choice to reflect the lived experience of
those individuals who suffer from mental illnesses and receive
PMHN care (Ellis, 2005). A more dynamic form of EBP would
better satisfy this intent (Fisher & Happell, 2009). Psychiatric
nurses should be aware that available research evidence (including RCTs and other forms) present merely one ingredient
of the evidence for PMHN practice (Polit & Beck, 2013). This
ingredient must be integrated with and complemented by other
accessible evidence, for example the evidence of what fits best
in the clinical context (Yadav & Fealy, 2011b).
Furthermore, clinical judgments are supposed to take into
consideration the best available empirical evidence; available
resources in the practice context; the patients’ values, expectations, and concerns; and the clinical expertise of psychiatric
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nurses (Egerod & Hansen, 2005). The combination of all these
diverse ingredients is essential for the success of EBP process in
the PMHN field (Yadav & Fealy, 2011b). In summary, it seems
suitable that psychiatric nurses should leave the hierarchy of
evidence as it is described by the current literatures and carry
out EBP processes in a reflective way, and thus base their clinical decisions on conscious, explicit, and justifiable evidence
(Mantzoukas, 2008).
Increasing The Number of PMHN Researchers
Concerning the limited account of interventional studies in
PMHN literature, effective strategies are supposed to be implemented to address this issue. More PMHN researchers with
mutual research expertise and clinical knowledge are required,
and these PMHN researchers should boost the scope and the
depth of their research. (Zauszniewski et al., 2007). Difficulties
in raising the number of PMHN researchers include the existing
nursing shortage in the PMHN field and the shortage of nursing faculty members (Boyd, 2012). Therefore, those who are
in both academic and practice settings have to work together
to persuade undergraduate nursing students to become psychiatric nurses in particular (Zauszniewski et al., 2007). Increasing
the number of competent PMHN researchers and practicing
psychiatric nurses is central to the EBP process (Fortinash &
Holsay-Worret, 2012).
Conducting Clinical Research Projects
The quality of PMHN research work is another issue (Beebe
et al., 2011). Several PMHN researchers have a series of projects
and scholarly activities. However, these academic works do not
usually reflect the clinical needs of the PMHN field (Cleary,
Hunt, Walter, & Jackson, 2010). These researchers need to collaborate with practicing psychiatric nurses who can recognize
clinical research needs and guide, enthuse, and inspire others
to be engaged in well-designed studies (Tansella, Thornicroft,
Barbui, Cipriani, & Saraceno, 2006). Thus, PMHN researchers
must actively engage in research activities that can provide appropriate evidence of these communicated needs (Cleary et al.,
2010).
Choosing Suitable Journals For Publication
Given the energy and the time spent to perform research, it is
vital to disseminate the findings report to the suitable target audience (Cleary, Hunt, Freeman, & Walter, 2007). Research findings should be published in journals that are read by nurses who
are practicing in PMHN clinical areas so they can best utilize
these findings (Stein, 2009; Zauszniewski et al., 2007). Moreover, research findings must be reported in an understandable
language, not in sophisticated research jargon and statistical terminology (Hamer & Collinson, 2005). Including the suggested
clinical implications in the research report can facilitate the application of the EBP activities for practicing nurses (Melnyk,
& Fineout-Overholt, 2011). Polit and Beck (2008) stated that
if an implications section with suggestions for clinical practice
became a standard feature of research reports, then the burden
of using research evidence would be lighter for nurse clinicians.
Ongoing evaluation of the development and the dissemination of
psychiatric PMHN intervention research will be significant for
reporting long-lasting advancement toward EBP in the PMHN
field (Zauszniewski et al., 2012).
Computer Training For Psychiatric Nurses
Supposing that qualified PMHN researchers conducted research projects that are related to the clinical practice and properly disseminated findings to those psychiatric nurses in the
practice settings, the issue of concern now is the readiness
for implementation of EBP activities on the part of psychiatric nurses (Zauszniewski et al., 2007). Given the limited computer and Internet skills of the practicing psychiatric nurses,
upgrading these skills is vital for the successful implementation of EBP (Koivunen et al., 2008). The literature revealed that
practical training under the direction of a computer specialist
is considered the most helpful method to become competent
in using a computer, the Internet, and the literature databases
(Alquraini, Alhashem, Shah, & Chowdhury, 2007; Eley, Fallon,
Soar, Buikstra, & Hegney, 2009). Such training can be composed of the following tasks: assessing the learning barriers to
psychiatric nurses’ computer use (in order to develop proper
learning strategies), inspiring those nurses by offering information on the benefits of computer use (in relation to EBP), active
learning sessions held in computer-supported classrooms in the
hospital, generating and distributing helpful written material
and training directions, and evaluating nurses’ computer and
Internet skills upon completing the training program (Koivunen
et al., 2008).
Integrating EBP Principles into Nursing Curricula
Other personal barriers to EBP utilization among psychiatric
nurses include the inadequate ability to read, interpret, and appraise data found in published research reports (Koivunen et al.,
2010; Yadav & Fealy, 2011a). The classical methods of teaching research have led to a pervasive shortage of appraisal skills
and application abilities among nursing students and subsequently new psychiatric nurses (Crowe & Carlyle, 2007). Based
on this notion, there is an urgent need to re-build the research
course in the nursing curriculum (Florin, Ehrenberg, Wallin, &
Gustavsson, 2012). Nursing educators, researchers, and practitioners should work together to modify the research teaching
methods to satisfy the objectives of EBP in general nursing
and in PMHN in particular (Fortinash & Holsay-Worret, 2012).
Nursing students should be taught about the essential steps of
EBP during their research course (Malloch & Porter-O’Grady,
2010). These steps include: identifying clinical problems or
clinical questions; searching for the available evidence that addresses the clinical problem; critically appraising the retrieved
evidence to chose the one with the best fit; integrating the best
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evidence with the clinical expertise of the nursing student, the
patients’ preferences, and available resources to formulate an
implementation plan; implementing this plan and evaluating the
outcomes of the practice change; and disseminating the EBP results (e.g., sharing the experience with colleagues) (Melnyk &
Fineout-Overholt, 2011). These steps challenge nursing students
to apply research principles to problems encountered throughout
their clinical training and support the skills required to review
the published findings on a clinical problem, appraise the literature, and disseminate their findings broadly (Florin et al., 2012;
Hamilton, 2010).
Developing Journal Clubs
It has been recognized that participation in journal clubs may
help psychiatric nurses who, having already completed their
undergraduate education, require experience in reading published research, distinguishing well-conducted studies through
appraising evidence, and developing an environment that fosters
basing PMHN clinical practice on the best available evidence
(Mahoney, 2009; Yadav & Fealy, 2011b). Literature shows that
effective journal clubs provided regular and predictable meetings, obligatory attendance, obvious purposes, suitable meeting
incentives and timing, and a qualified journal club leader to determine pertinent articles and lead discussions. This journal club
leader would also disseminate articles for the members before
the meeting, use established well-known critical appraisal methods and structured worksheets, sum up the journal club findings,
and evaluate knowledge−uptake by the members (Deenadayalan, Grimmer−Somers, Prior, & Kumar, 2008; Patel et al.,
2011). In the Appendix, I provide two examples of the structured worksheets: The first one is for evaluating quantitative
studies and the other one is for evaluating qualitative studies.
Organizational Facilitators
Individual psychiatric nurses are not the only group held accountable for the achievement of EBP; organizations also have
a major responsibility in the realization of EBP (Koivunen et al.,
2010). Therefore, organizations must play a role in offering the
infrastructure to facilitate evidence to be readily available (such
as access to international PMHN databases) and must also play
a role in establishing an organizational milieu that encourages,
positively values, and fosters PMHNs to look for the best available evidence (Brown et al., 2010). Psychiatric nurses require
time away from bedside care, more autonomy in relation to their
practice, training in finding and appraising the evidence, and
mentorship to guide them during the implementation process of
EBP (Brown et al., 2009).
Organizational support for the PMHNs may also include
developing official links with the PMHN department at the university as a source of knowledge and as a possible partner in
research (Timmins et al., 2012). Bradley, McSherry, and McSherry (2010) recommend mutual appointments between clinical
sites and a university as a way of boosting EBP utilization among
139
nurses. The academic staff can work in conjunction with both
nurses and nurse managers, giving valuable data about EBP utilization, as well as participating actively in integrating EBP into
daily practice (Timmins et al., 2012). Moreover, PMHN organizations can cooperate with these academic staff in conducting
evaluative research projects that address the barriers of utilizing
EBP activities in the clinical settings (Bolen & Hall, 2007).Outcomes of these research projects should be used as a foundation
for organizational strategic planning efforts that aim to support
EBP (Brown et al., 2009).
CONCLUSION
The use of research evidence to guide patient care is a difficult
mission. This is evident in the PMHN specialty, where EBP is
barely implemented. In spite of the recognized value of EBP
standards, psychiatric nurses express difficulty in integrating
the concept into their professional activities. So far, numerous
barriers have provided a valid rationale for psychiatric nurses’
slow advancement in the direction of evidence-based nursing
practice. These barriers explain the psychiatric nurses’ overdependence on historical means of clinical decision-making in
preference to research-based ones. As long as these barriers
are identified and strategies to overcome them acknowledged,
the present-day situation is rendered untenable. It is no further
justifiable for psychiatric nurses to remain deficient in EBP
knowledge and skill since the advantages of EBP for patients
are well-documented in the literature.
It is obligatory for current PMHN researchers and clinicians
to investigate solutions to the barriers of EBP implementation to
patient care and apply strategies that will eliminate these barriers. PMHN personnel have to further expand and evaluate their
models of practice, perform research projects that adhere to the
rules of EBP, and can validate the efficacy and effectiveness of
their interventions, disseminate the outcomes of their research
projects to the target audience properly, familiarize themselves
with research appraisal skills, teach nursing students based on
EBP principles instead of the traditional ways of nursing research, abandon the hierarchy approach of evidence, and be
true patient advocates by integrating EBP in their daily performance. This will not be achieved unless there is a great support
from PMHN organizations that play a vital role in facilitating
the EBP application process.
Declaration of interest: The author reports no conflicts of
interest. The author alone is responsible for the content and
writing of the paper.
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Appendix
Guidelines for Critiquing a Qualitative Research Study
Elements influencing the believability of the research
Elements
Questions
Writing style
Is the article well written—concise, grammatically correct, avoid use of
jargon? Is it well laid out and organized?
Title
Is the title clear, accurate, and unambiguous?
Abstract
Does the abstract offer a clear overview of the study including the research
problem, sample, methodology, findings, and recommendations?
Elements influencing the robustness of the research
Elements
Questions
Purpose/research problem
Is the purpose of the study/research problem clearly identified?
Logical consistency
Does the research report follow the steps of the research process in a
logical manner? Do these steps naturally flow and are the links clear?
Literature review
Is the review logically organized? Does it offer balanced critical analysis of
the literature? Is the majority of the literature of recent origin? Is it
mainly from primary sources and of an empirical nature?
Theoretical framework
Has the conceptual or theoretical framework been identified? Is the
Aims/objectives/research
framework adequately described? Is the framework appropriate?
question/hypotheses
Have aims, objectives, and a research question or hypothesis been
identified? If so are they clearly stated? Do they reflect information
presented in the literature review?
Sample
Has the target population been clearly identified? How was the sample
selected? Was it a probability or a non-probability sample? Is it an
adequate size? Are the inclusion/exclusion criteria clearly identified?
Ethical considerations
Were the participants fully informed about the nature of the research? Was
the autonomy/confidentiality of the participants guaranteed? Were the
participants protected from harm? Was ethical permission granted for the
study?
Operational definitions
Are all the terms, theories and concepts mentioned in the study clearly
defined?
Instrumentation
Is the instrumentation used to assess subjects described? Were instrument
reliability and validity discussed?
Procedures
Is there a description of the procedures used to administer the instrument?
Are any of the study’s administrative or procedural limitations discussed?
Variables
Are variables adequately described? Was a rationale provided for their use?
Were the variables chosen appropriate for answering the research
question(s)?
Data analysis/results
What type of data and statistical analysis was undertaken? Was it
appropriate? How many of the sample participated? Were tables and
graphs presented in clear and understandable fashion? Significance of the
findings?
Discussion
Are the findings linked back to the literature review? If a hypothesis was
identified was it supported? Were the strengths and limitations of the
study, including generalizability discussed? Was a recommendation for
future research made?
References
Were all books, journals, and other media alluded to in the study accurately
referenced?
Adapted from Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1: Quantitative research. British
Journal of Nursing, 16(11), 658–663. Permission to use this table was obtained from the British Journal of Nursing as the publisher for this table
BARRIERS TO EVIDENCE-BASED PRACTICE
143
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For personal use only.
Guidelines for Critiquing a Qualitative Research Study
Elements influencing the believability of the research
Elements
Questions
Writing style
Is the article well written—concise, grammatically correct, avoid use of
jargon? Is it well laid out an organized?
Title
Is the title clear, accurate, and unambiguous
Abstract
Does the abstract offer a clear overview of the study including the research
problem, sample, methodology, findings, and recommendations?
Elements influencing the robustness of the research
Elements
Questions
Purpose/research problem
Is the purpose of the study/research problem clearly identified?
Logical consistency
Does the research report follow the steps of the research process in a
logical manner? Do these steps naturally flow and are the links clear?
Literature review
Is the review logically organized? Does it offer balanced critical analysis of
the literature? Is the majority of the literature of recent origin? Is it
mainly from primary sources and of an empirical nature?
Theoretical framework
Has the conceptual or theoretical framework been identified? Is the
framework adequately described? Is the framework appropriate?
Method and philosophical
Has the philosophical approach been identified? Why was this
underpinnings
approach/method chosen? Does the author describe or reflect upon their
role or positionality?
Research setting
Was the setting properly and completely described? Were the
circumstances under which the data was collected described?
Sample
Is the sampling method and sample size described? Is the sampling method
appropriate? Were the participants properly and completely described?
Were the participants suitable for informing the research purpose as
described?
Ethical considerations
Were the participants fully informed about the nature of the research? Was
the autonomy/confidentiality of the participants guaranteed? Were the
participants protected from harm? Was ethical permission granted for the
study?
Data collection/data analysis
Are the data collection strategies described? Are the strategies used to
analyze the data described? Did the researcher follow the steps of the
data analysis method identified? Was data saturation achieved?
Rigor
Does the researcher discuss how rigor was assured? Were credibility,
dependability, and transferability described?
Findings/discussion
Are the findings presented appropriately? Was sufficient descriptive
information given to allow the reader to conclude that the author’s
interpretations were grounded in the data? Does the researcher address
internal validity through “triangulation,” that is, verification of the
findings via member checks/other documentation/other sources/other
researchers? Does the author acknowledge the lack of generalizability of
the study findings, and/or suggest a replication of the study? Has the
original purpose of the study been adequately addressed?
Conclusions/implications and
Are the importance and implications of the findings identified? Are
recommendations
recommendations made to suggest how the research findings can be
developed?
References
Were all books, journals, and other media alluded to in the study accurately
referenced?
Adapted from Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2: Qualitative research. British
Journal of Nursing, 16(11), 738–744. Permission to use this table was obtained from the British Journal of Nursing as the publisher for this
table.