43
JOURNAL OF NURSING PRACTICE APPLICATIONS & REVIEWS OF RESEARCH
Evidence-Based Practice: Are Nurses Ready?
Catherine M. Paler & Girlyn Arganza Cachaper
Accepted for publication on July 20, 2020
Correspondence to:
Catherine M. Paler, MSN, RN,
PCCN
Catpaler06@gmail.com
Authors’Affiliation
Catherine M. Paler, MSN, RN,
PCCN
Oncology Staff Nurse and
Evidence-based Council Chair
Sentara Princess Anne Hospital,
Virginia Beach, VA
Girlyn Arganza Cachaper, PhD
Senior Information Analytics
Specialist
Sentara Enterprise Analytics
Virginia Beach, VA
Funding
The authors did not receive a
grant from any funding agency in
the public, commercial, or notfor-profit sectors.
Conflict of Interest
The authors declare that there is
no conflict of interest.
Acknowledgments
The authors sincerely
acknowledge the contributions of
the late Susan Tweed, PhD, RN,
(1949-2019), Sentara Research
Nurse Scientist. Dr. Tweed was
instrumental in initiating the
EBP-readiness surveys at our
health care system.
doi: https://doi.org/10.13178/jnparr.2021.11.01.1006
Abstract
Background: Nurses have an important role in implementing evidence-based practice (EBP)
to deliver high quality care, but they face many challenges. A growing body of research literature focuses on implementing EBP revealing a lack of focus in assessing nurses’ readiness for
EBP.
Objective: The purpose of this study is to explore nurses’ confidence, knowledge, beliefs, and
key barriers to their readiness to implement EBP within a mid-sized acute care hospital in the
Mid-Atlantic United States.
Methods: Researchers conducted a descriptive cross-sectional survey design; 172 registered
nurses completed the 25-item online survey between May and July 2018.
Results: The response rate was 32 percent. Respondents were primarily White (57.6%), baccalaureate-prepared (62.2%), employed full-time (79.7%), and over 40 years of age (56.9%).
The top three organizational barriers included presence of higher priority goals (69.8%), difficulty in recruiting and retaining staff (68.0%), and lack of organizational budget for education
(51.2%). There were three key individual level barriers to using evidence. In addition to time
constraints, nurses identified difficulty in accessing research material (48.3%), followed by the
lack of electronic database knowledge (33.7%), and insufficient skills to synthesize the literature (33.1%). Consistent with previous research, nearly all respondents (87.8%) agreed that
EBP leads to high-quality patient care, yet many sought information frequently from colleagues
(52.3%) or the internet (52.8%).
Conclusion: Nearly all respondents were familiar with EBP and agree that it leads to positive
patient outcomes. Most nurses felt confident in performing patient-centered EBP activities but
reported a lower confidence in critically appraising research. In addition to time, barriers included difficulty accessing research materials and the lack of ability to synthesize the literature.
In this institution, nursing leadership identified areas of need. Nursing leadership can use the
survey findings to develop opportunities to strengthen EBP’s role in nursing practice. Action
can be a significant undertaking. Strategies for implementation are crucial to begin at the leadership level and align with Magnet Recognition Program® standards for increased professional
development and achieve high-quality, evidence-based care.
Keywords: evidence-based practice, nursing, readiness, clinical practice, competency, innovation
J Nursing Practice Applications & Reviews of Research
Vol. 11 No. 1
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44
Evidence-Based Practice: Are Nurses Ready?
Background
Evidence-based practice (EBP) is a decision-making approach that integrates the evidence from well-designed
studies, clinical expertise, and patient preferences to inform clinical practice (Melnyk et al., 2014). The Institute
of Medicine (IOM) recommended that all health professional educational programs include five competencies: (a)
patient-centered care, (b) quality improvement principles,
(c) inter-professional teams, (d) EBP and (e) health information technologies (IOM, 2003). These competencies serve to
infuse EBP, both directly and indirectly, into nursing practice. Yet in many nursing progrmas in the United States, faculty continue teaching nursing research and how to conduct
studies without focusing on the translation of research into
evidence-based care (Melnyk & Fineout-Overholt, 2019).
Oftentimes the translation of best evidence into practice is
challenging, from the organizational level to the individual
nurse level (Stevens, 2013).
In a review of the literature related to nurse’s readiness for
evidence-based practice, four main themes emerged: (1)
nurse’s confidence; (2) nurse’s knowledge and skills with
EBP; (3) nurse’s beliefs and attitudes about EBP; and (4)
key barriers to readiness for the use of research in practice.
Recent studies frequently revealed the following barriers to
implementation of EBP: lack of time, accessibility, and readability of research findings, and a propensity to make decisions based on experience and colleague advice over scientific literature. Nurses consistently reported high knowledge
and skills about EBP, positive attitudes, and beliefs but were
unsure about their ability to engage in EBP (Malik et al.,
2015; Pravikoff et al., 2005; Rahmayanti et al., 2020; Schaefer & Welton, 2017).
Nurses in Magnet® hospitals must continually demonstrate
active engagement in the research process as both consumers and producers of research (ANCC, n.d.). Implementing a
Magnet® framework related to new knowledge, innovation,
and improvement can help pave the way to breaking down
barriers to EBP. Research demonstrates that the most critical factor related to nurses’ EBP is support from the nursing
leadership to provide the resources to incorporate evidence
in their daily practices (Melnyk & Fineout-Overholt, 2019).
The spirit of inquiry, or the ongoing curiosity of best practice,
is best achieved when strategies are developed to increase
adoption of EBP that align with organizational culture.
Strategizing how to best promote EBP required first learning nurses’ views on the organizational barriers, beliefs, and
confidence in implementing EBP. Therefore, an assessment
of nurses’ readiness to incorporate evidence-based practice
(EBP) into patient care to enhance the spirit of inquiry at a
mid-sized acute care hospital was conducted.
J Nursing Practice Applications & Reviews of Research
Purpose of the Study
The purpose of this study is to explore nurses’ confidence,
knowledge, beliefs, and key barriers to nurses’ readiness
to implement evidence-based practice in their setting. The
findings will inform strategies to strengthen EBP’s role in
nursing practice.
Methods
Study Design
This study used a descriptive, cross-sectional design. Data
were obtained through a self-administered electronic survey
completed by registered nurses.
Setting and Sample
This study was conducted at a 174-bed acute care community-based hospital located in southeastern Virginia. The
target population included the 544 registered nurses who
were employed at the time of the study. Upon Institutional
Review Board approval, the research team requested the list
of potential respondents from the organization’s human resources department. The data collection tool administration
occurred through SurveyMonkey®, an online survey development software. Each nurse received an email describing
the study and estimated completion time, along with a link
to the SurveyMonkey® site to complete the survey, on a
voluntary basis. Administration occurred over a six weeks
between May and July 2018. The researchers sent an email
communication in the form of a newsletter to all nurses two
days prior to the survey distribution. The researchers sent
emails at three points: 1) introduction of the survey, 2) follow-up reminder at three weeks, and 3) follow-up reminder
at five weeks. The team received 172 completed surveys,
representing a 32% response rate.
Instrument and Data Collection
The study team adapted previous surveys on nursing EBP
readiness after obtaining the permission from the authors.
The study survey instrument contains 24 items using a variety of formats, including Likert scales, yes or no questions,
and top three choices. It is comprised of 13 EBP-readiness
items, ten demographic questions to characterize the population, and one open-ended item for comments on nursing
research or EBP. The items pertain to nurses’ knowledge and
beliefs, informational needs and seeking behaviors, resource
availability and use, nurses’ confidence related to evidencebased nursing practice, and organizational barriers. Ten demographic items were collected to examine relationships
between nurses’ characteristics and their EBP responses,
including position, practice area, employment status, education, age, race, and membership in a professional nursing organization. The average completion time was nine minutes.
The investigation by Thiel and Ghosh (2008) served as the
primary source for the current study’s survey questions.
They conducted a readiness assessment of factors that facilitate or hinder incorporation of evidence into nursing pracVol. 11 No. 1
January 2021
tice, resulting in the Evidence-Based Practice Readiness
Survey (EBPRS). The psychometrics of the various surveys
used to develop the EBPRS are reported elsewhere (Thiel &
Gosh, 2008). The EBPRS contains questions from the Nursing Evidence-Based Practice Survey (Titler et al., 1999),
which measures EBP culture; the Nurses’ Attitudes Towards
Evidence-Based Practice Scale (NATES), which assesses attitudes and beliefs toward EBP (Thiel & Gosh, 2008); and
items from the Informational Literacy for Evidence-Based
Nursing Practice survey which examines nurses’ informational needs and how they obtain that information (Pravikoff
et al., 2005). The current study instrument also adapted the
work of Salbach and Jaglal (2011), creators of the EvidenceBased Practice Confidence (EPIC) scale, to measure selfefficacy in engaging in EBP behaviors among health care
professionals.
The current study included all items from the EBPRS and
the EPIC instruments. Five items assessed the informational
needs and seeking behaviors of nurses: 1) one rank-order
question assessing the adequacy of resources at work, from
“totally inadequate” to “more than adequate”; 2) one question asking how often they need the information to support
their nursing role; 3) two questions assessing the frequency of respondents’ participation in EBP activities, using a
5-point Likert scale (1 = ”never” and 5 = “always”); and 4)
a yes/no question asking whether they received instructions
on how to use electronic databases. Two survey items assessed respondents’ knowledge and beliefs: 1) a yes/no item
asking about their familiarity with the term EBP, and 2) one
question that assesses the strength of their beliefs across 12
domains using a 5-point Likert scale (1 = ”strongly disagree”
to 5 = ”strongly agree”). The EPIC item asked respondents
to rate their self-efficacy beliefs surrounding 11 EBP activities to capture nurses’ confidence related to EBP and research, using a 5-point Likert scale from “never confident”
to “always confident” (Salbach & Jaglal, 2011). Ability to
use EBP was gauged via three items using a 5-point Likert
scale: 1) one question asked respondents to rate their level
of technology experience (1 = “novice” to 5 = “expert”), 2)
one question asked them to rate their own ability to use specific EBP resources (1 = ”do not search” to 5 = “highly successful”), and 3) one item estimated the frequency in which
they personally seek information from different resources (1
= ”not at all” to 5 = ”several times a day”). Finally, two
questions measured EBP barriers by asking respondents to
choose the top three barriers to using research in their practice, from both an organizational and a personal perspective.
Data Analysis
Descriptive statistics (i.e., frequencies, percentages, and
range) quantified the degree of nurses’ EBP-readiness. Respondents’ characteristics were summarized as percentages
due to the categorical nature of the data. Correlations between educational level and relevant EBP-readiness variJ Nursing Practice Applications & Reviews of Research
Catherine M. Paler & Girlyn Arganza Cachaper 45
ables were performed using the non-parametric measure of
rank correlation, Spearman’s rank correlation coefficient.
IBM SPSS version 25.0 was used for data analyses.
Results
Demographic Characteristics of Project Participants
The majority of respondents were White (57.6%), baccalaureate-prepared (62.2%), full time (79.7%), over 40 years of
age (56.9%), and worked in a Medical-Surgical/Blended or
ED/ Surgical Services unit (55%). Over half (59.9%) had
ten years or more of nursing experience. The vast majority
(74.9%) described their role as a staff nurse. The remaining
were nurse managers (18.0%) or nurse educators (6.4%).
Knowledge and Beliefs Related to EBP
Nearly all respondents (95.3%) were familiar with the term
“EBP.” The majority reported that they believe in EBP
(91.6%), with 87.8% agreeing it is essential to incorporate
EBP into nursing and that it increases the certainty of meeting patient outcomes (67.5%). The majority also disagreed
with statements such as EBP is a fad that will pass in time
(90.7%), that nurses should not use it because nursing is
about people and patients and not statistics (89.0%), and
that EBP disregards clinical experience (73.8%). However,
some respondents reported a degree of uncertainty with their
capabilities to apply EBP findings in their work. One-third
(33.7%) felt uncertain or disagreed with the statement that
they have enough knowledge, and over one-fourth (26.7%)
felt they did not have the skills to engage in EBP.
Informational Needs and Seeking Behaviors
Nearly two-thirds (61.4%) of the respondents reported that
they needed information to support their jobs at least several times a week, if not daily (Figure 1). The frequency of
the need for additional information was consistent across all
levels of education, from diploma nurses (58.3%) to those
with advanced degrees (62.5%). Differences existed based
on their roles in how frequently they sought information.
Over half (54.5%) of the nurse educators reported a daily
need to search for information with their jobs, whereas only
26.3% of the certified respondents reported a daily necessity.
As shown in Figure 2, respondents reported seeking information at least daily from a peer/colleague (52.3%) or the
internet (52.9%), but infrequently requested information
from the librarian or by searching bibliographic databases.
Most nurses indicated they do not use CINAHL (61.6%), the
organization’s library (55.8%), or Medline/PubMed (52.3%)
to gain information. Roles played a factor in where respondents accessed evidence. Nurse educators and managers
most often used EBP resources and attended conferences,
workshops, or programs more often compared to non-certified nurses (72.7% vs. 13.2%, respectively).
A Spearman’s correlation was run to assess the relationship
between education level and 1) success in using EBP reVol. 11 No. 1
January 2021
46
Evidence-Based Practice: Are Nurses Ready?
Figure 1. Frequency of Seeking Information
Seldom (less than once a month)
3%
Regularly (weekly)
13%
Daily
30%
Occasionally (1-2 times a month)
22%
Often (several times a week)
31%
Figure 2. Frequency of Accessing EBP Resources
A#end conferences, workshops, or programs
Read books
Read journal ar9cles
Never
Rarely
Some9mes
Frequently
Always
Search the internet
Search bibliographic databases
Ask colleagues or peers
Seek assistance from the librarian
0.0%
J Nursing Practice Applications & Reviews of Research
15.0%
30.0%
45.0%
Vol. 11 No. 1
60.0%
January 2021
sources, and 2) the frequency of use. Nurses with advanced
degrees rated themselves as more successful in obtaining
information using Medscape compared to those with less
education, rs = .21, p < .05, 95% CI [0.01 – 0.39]. The effect size was small and this difference was not found with
other bibliographic databases or clinical reference tools (i.e.,
EBSCO, PubMed, DynaMed, Micromedex). Higher nursing
education correlated positively with more frequent use of
journal articles and Medline/PubMed databases, rs = .22, p
= .005, 95% CI [0.07 – 0.36]; rs = .24, p = .003, 95% CI
[0.08 – 0.38], respectively. At least half of respondents with
bachelor’s degrees or less reported they did not use bibliographic databases in the past year compared to up to onethird of advanced degree nurses, depending on the database.
Nearly half (45.0%) of the respondents reported they had not
received instruction on using electronic databases. The unit
coordinators (charge nurses) represented the largest group
(55.6%).
Nurses rated the perceived effectiveness of their available
EBP resources highly. Over 90% rated the following as either adequate or more than adequate: EPIC electronic health
record, online resources, and the organization’s intranet.
Over 77.3% rated the library resources as at least adequate.
Print materials were assessed as less than adequate by nearly
one-quarter of the respondents.
Confidence Related to EBP and Research
Most nurses felt confident in performing EBP and research ac-
Catherine M. Paler & Girlyn Arganza Cachaper 47
tivities. Respondents felt most confident in 1) identifying a gap
in their knowledge related to a patient situation (e.g. history,
assessment, treatment) (87.9%); 2) asking their patient about
his/her needs, values, and treatment preferences (80.4%); 3)
continually evaluating the effect of their course of action on
their patient’s outcomes (73.3%); and, deciding on an appropriate course of action based on integrating the research evidence, clinical judgment, and patient preferences (67.1%).
Perceived confidence was low in three areas. These areas
centered on understanding statistical information: 1) interpreting project results obtained using statistical tests such
as t-tests or chi-square tests (55.4%); 2) interpreting project
results obtained using statistical procedures such as linear or
logistic regression (52.8%); and, 3) critically appraising the
measurement properties (e.g. reliability, validity, sensitivity,
and specificity) of standard tests or assessment tools you are
considering using in your practice (35.2%).
Ability to Use EBP
As Figure 3 depicts, most respondents indicated that they
used research findings in their work at least once (68.1%)
in the prior year. The use of research findings in their daily
practice was most endorsed by nurse educators and managers. A notable percentage of respondents (29.7% - 55.2%) did
not personally participate in nursing research EBP activities
in the year before taking the survey, depending on the activity. For example, over half did not participate in research or
evaluate research reports (55.2%, 54.7%, respectively).
Figure 3. Frequency of Participation in EBP/Research Activities in the Last Year
60.0%
45.0%
More than 6 9mes
4-6 9mes
2-3 9mes
Once
Not at all
30.0%
15.0%
0.0%
Performed a Par9cipated in
research
literature
search
J Nursing Practice Applications & Reviews of Research
Evaluated
research
reports
Iden9fied
U9lized
researchable
research
problems findings in your
work sePng
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48 Evidence-Based Practice: Are Nurses Ready?
Barriers
Other than time, the three primary barriers to using research
at the individual level focused on accessing the evidence and
translating it into practice. Specifically, respondents most often cited 1) difficulty accessing research materials (48.3%);
2) lack of understanding of the organization and structure of
electronic databases (33.7%); and 3) lack of skills to synthesize the literature (33.1%) as impediments. Organizational
barriers further compounded these individual level constraints to using research in nursing practice. Nurses chose
the following top three organizational barriers: 1) the presence of other goals with a higher priority (69.8%); 2) difficulty in recruiting and retaining nursing staff (68.0%); and
3) organizational budget for training in resource utilization
(51.2%).
Themes from Comments
Respondents also provided comments that added context
to the quantitative findings. Table 1 lists the three primary
themes noted and examples of each.
Discussion
The survey results paint a vivid picture of the study participants’ readiness to incorporate EBP into their clinical work.
In 2008, Thiel and Ghosh reported a 75% familiarity with
the term “evidence-based practice” compared to 95% from
the current respondents. This near-unanimous response is
highly encouraging, indicating that EBP has become commonly accepted in the nursing lexicon over the last ten
years. Overall, respondents are proponents of EBP, believing it positively influences on patient outcomes. Yet when
respondents need the information to support their nursing
role, most prefer to ask colleagues or search the internet for
nursing information, even though they perceive the available resources, including the in-house library, to be adequate
for their needs. These findings echo previous research that
found staff nurses prefer personal clinical experiences, the
advice of co-workers, and facility policies and procedures,
rather than using evidence-based resources (Thiel & Ghosh,
2008; Yoder et al., 2014).
While peer checking and peer coaching are highly encouraged amongst nurses, the information shared may not always be consistent with evidence-based guidelines. Despite
readily available resources on the organization’s intranet, respondents typically do not seek information from the librarian or bibliographic databases. An often-noted barrier from
the survey results is the nurses’ lack of training in the use
of electronic bibliographic databases and lack of confidence
in their ability to use that evidence to inform care decisions
best. For nurses to become well-informed consumers and
producers of health care evidence, they need a foundation on
obtaining, critiquing, and applying the information available
to them. EBP requires a behavior change from “this is how
we’ve always done it” to a practice supported by current literature and research. As expected, nurse educators and advanced degree nurses tend to use bibliographic databases or
clinical reference tools more often but not necessarily more
successfully than nurses in other roles or with less formal
education, as our analysis indicates. Nurse educators and
clinical specialists should collaborate on developing strategies for building EBP knowledge and skills while providing
mentor development in a training program to increase overall comfort level across all nursing roles.
Table 1. Nursing EBP Readiness: Emerging Themes
Areas of improvement
Example quote
Training in research and the use of
bibliographic databases
“I just completed my BSN. Researching databases can be difficult. …
[need] more promotion and education into searching the databases and
our library, because EBP is very important to the nurses’ job.”
“If I had the time to research, and I knew how to research, my practice
would be improved. As a bedside nurse, this is not practical. If I am
given the result of a research study, I can apply it to my patients.”
Application of EBP into nursing
practice
“Need strategies or education to inform nurses for self-awareness of
evidence-based practice already in place. Would like to see EBP be
second nature.”
“We should require each nursing department to complete an EBP project
(at least every two years).”
EBP promotion in specific units
Respondents noted Peri-anesthesia and Labor and Delivery as units
where EBP projects would most benefit nurses.
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Nurses surveyed feel confident in performing EBP behaviors
in their direct interactions with their patients, such as asking
about patient in treatment preferences and identifying information gaps in their patient’s situation. This observation
makes sense because these skills draw from their nursing
assessment training. However, they feel less confident in the
steps required to search and appraise the current evidence to
fill those gaps needed to inform their course of action best.
These skills often require some familiarity with research
design, methodology, and statistics through coursework or
advanced training. There is a great need for research mentors to be readily available to the point-of-care clinicians to
facilitate evidence-based care and improve patient outcomes
(Melnyk, 2007). This study highlights the need for nurses
to have a basic understanding of how to conduct scholarly
literature searches and be able to critically review journal
articles before implementing them in their clinical practice.
One of the IOM’s recommended competencies for all health
professional educational programs includes inter-professional collaboration. Within our health system exists an applied research group with doctoral-trained staff who serve as
consultants and mentors to the nursing and clinical staff who
engage in EBP or research projects. These research staff also
participate in nurse residency program seminars around the
group EBP projects. A strong collaboration already exists
between the research staff and nursing at the hospital and
system level; however, more targeted use of their expertise
through training events is warranted.
Perceived and actual barriers identified by the nurses included the presence of higher priority goals, difficulty in
recruiting and retaining staff, and the lack of funding for
project time and research training. Limited internal funding
for training may be reflected in the low percentage of floor
nurses who can attend conferences and workshops. Opportunities for funding information-gathering activities for the
bedside provider should be explored. Although time as a
barrier was explicitly excluded from the survey as it is an
understood barrier, leadership as a whole would show great
support for EBP and research by allowing protected time for
nurses to work on nurse-investigator research studies.
Limitations
In general, the self-reported nature of surveys often leads to
questions of reporting bias with respondents providing socially desirable answers rather than accurate responses. Survey responses were received from approximately one-third
of the employed registered nurses. The response rate resulted in an 85% confidence interval of a 5% margin of error.
The results may not reflect the EBP practices and attitudes
of the full target population. Also, the assessment of nursing
readiness occurred in a hospital setting; results from nurses
in ambulatory care may differ. Future research is needed to
gather objective data over time through a follow-up survey
J Nursing Practice Applications & Reviews of Research
Catherine M. Paler & Girlyn Arganza Cachaper 49
in relation to measuring investments in EBP and nursing research utilization.
Nursing Implications
The study findings will serve as a guide to prioritize research-training opportunities to point-of-care clinicians to
develop and strengthen EBP’s role in nursing practice. The
organization’s mission and core values to influence care
through evidence-based practice, innovation, and collaboration remains essential in achieving excellence in patient
outcomes.
Multiple strategies must be considered to facilitate and promote evidence-based practice. Managerial support, facilitation, and a culture that is receptive to change are essential.
These, in turn, lead to strong leaders, empowered professionals, and exemplary practice, which are the building
blocks for Magnet® -recognized organizations. At the system level, nurse leaders can collectively allocate resources
to create a systemwide online EBP education plan with EBP
competencies and a tool kit to increase nurses’ exposure to
EBP and standardize practice. Sharing best practices online
and national forums such as Magnet® conferences will help
lead, educate, and mentor nurses with strategies to increase
EBP uptake systematically.
Conclusions
Most nurses felt confident in performing EBP and research
activities aimed at patient-centered care. However, they feel
less confident in their skills to interpret research findings
related to their practice. The results of this study identified
perceived and actual barriers to the implementation of evidence-based practice. This study determined that our nurses
are ready and hold positive beliefs that EBP leads to better
patient outcomes. However, the different levels of knowledge to engage in EBP, particularly based on expertise,
would indicate more work is needed to develop a systematic
approach to support the enculturation of EBP and overcome
barriers to its implementation. These strategies include participation in EBP council meetings, journal club discussions, inter-professional shared governance meetings, and
the nursing residency program. Providing research-training
opportunities to clinical nurses is a promising strategy for
healthcare organizations seeking to promote EBP, empower
clinicians, and showcase excellence in clinical research.
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