Factors influencing evidence-based practice among ...€¦ · factors influencing the development...

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98 JCN 2013, Vol 27, No 4 IMPROVING PRACTICE D espite the importance of nursing practice being based on robust evidence, nurses encounter considerable challenges to achieving evidence-based practice at an individual and an organisational level (Bryar et al, 2003; Gerrish et al, 2008). One study examining barriers to using research evidence in clinical decision- making (McCaughan et al, 2002) identified that hospital nurses may: Be willing to use research but lack the skills to do so Encounter problems with interpreting research publications, which are seen to be too complex Perceive that research publications lack clinical credibility and fail to provide sufficient clinical direction Prefer to access research-based information through a third party rather than seek it out for themselves Factors influencing evidence-based practice among community nurses Experience a lack of organisational support and/or unsupportive colleagues. Nurses working in the community may encounter similar problems. They can lack the knowledge and skills to use research findings to inform their decision-making, have insufficient time to access, interpret and apply research and, therefore, need research information to be presented in a format that is easily accessible with the implications for practice made clear (Thompson et al, 2005). Nurses can also find it hard to use research evidence to influence changes in primary care (McKenna et al, 2004). While research findings are an important source of evidence, expert clinical opinion, organisational information and patient preferences are additional forms of ‘evidence’ that nurses use in practice (Bucknall and Rycroft-Malone, 2010, Gerrish, 2010). Most studies to date have focused on nurses’ use of research, however, there is a need to understand how nurses use other sources of evidence. Hospital nurses tend to rely heavily on informal, interactive sources of evidence (Spenceley et al, 2008), but little is known about community nurses’ use of different sources of evidence. The survey reported in this article seeks to address this gap in knowledge. AIM The aim of this survey was to identify factors influencing evidence-based practice among community nurses. METHODS A postal survey was sent to community nurses across six primary care trusts (PCTs) in South Yorkshire. The questionnaire was a validated instrument (Gerrish et al, 2007), which sought to identify factors influencing the development of evidence-based practice. These factors included: Sources of knowledge that nurses use to inform their practice Perceived barriers to finding and reviewing research and organisational information Perceived barriers to changing practice based on ‘best’ evidence Perceived factors that facilitate nurses to provide evidence- based practice Self-assessment of nurses’ skills in finding, reviewing and using different sources of evidence. The sample included district nurses, community nurses, practice nurses, health visitors and school nurses. Questionnaires were distributed to a random sample from each group in each PCT. Responses were coded for computer analysis and statistical testing was performed using SPSS (Statistical Package for the Social Sciences). Kate Gerrish, Professor of Nursing Research, University of Sheffield/Sheffield Teaching Hospitals NHS Foundation Trust, School of Nursing and Midwifery; Jo Cooke, Programme Manager NIHR Collaborations and Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY), Sheffield Teaching Hospitals NHS Foundation Trust Nurses working in the community may have insufficient time to access, interpret and apply research, and, therefore, need information to be presented in a format that is easily accessible. As community nurses rise to the challenges outlined in recent health policy, it is increasingly important that they maximise their potential to deliver evidence-based practice. This article looks at a survey that aimed to identify factors influencing evidence-based practice among community nurses. The findings indicate that in order to make progress it is important to adopt a multifaceted approach, taking into account the real world in which nurses currently practice. While it is important to develop nurses’ skills in accessing and reviewing research information, constraints on time mean that it will be difficult to achieve a nursing workforce where all nurses are active in reviewing research evidence. KEYWORDS: Evidence-based practice Research Practice development Kate Gerrish, Jo Cooke © 2013 Wound Care People Ltd

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Page 1: Factors influencing evidence-based practice among ...€¦ · factors influencing the development of evidence-based practice. These factors included: Sources of knowledge that ...

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IMPROVING PRACTICE

Despite the importance of nursing practice being based on robust evidence, nurses

encounter considerable challenges to achieving evidence-based practice at an individual and an organisational level (Bryar et al, 2003; Gerrish et al, 2008). One study examining barriers to using research evidence in clinical decision-making (McCaughan et al, 2002) identified that hospital nurses may: Be willing to use research but lack

the skills to do so Encounter problems with

interpreting research publications, which are seen to be too complex

Perceive that research publications lack clinical credibility and fail to provide sufficient clinical direction

Prefer to access research-based information through a third party rather than seek it out for themselves

Factors influencing evidence-based practice among community nurses

Experience a lack of organisational support and/or unsupportive colleagues.

Nurses working in the community may encounter similar problems. They can lack the knowledge and skills to use research findings to inform their decision-making, have insufficient time to access, interpret and apply research and, therefore, need research information to be presented in a format that is easily accessible with the implications for practice made clear (Thompson et al, 2005). Nurses can also find it hard to use research evidence to influence changes in primary care (McKenna et al, 2004).

While research findings are an important source of evidence, expert clinical opinion, organisational information and patient preferences are additional forms of ‘evidence’ that nurses use in practice (Bucknall and Rycroft-Malone, 2010, Gerrish, 2010). Most studies to date have focused on nurses’ use of research, however, there is a need to understand how nurses use other sources of evidence.

Hospital nurses tend to rely heavily on informal, interactive sources of evidence (Spenceley et al, 2008), but little is known about community nurses’ use of different sources of evidence. The survey reported in this article seeks to address this gap in knowledge.

AIM

The aim of this survey was to identify factors influencing evidence-based practice among community nurses.

METHODS

A postal survey was sent to community nurses across six primary care trusts (PCTs) in South Yorkshire. The questionnaire was a validated instrument (Gerrish et al, 2007), which sought to identify factors influencing the development of evidence-based practice. These factors included: Sources of knowledge that

nurses use to inform their practice

Perceived barriers to finding and reviewing research and organisational information

Perceived barriers to changing practice based on ‘best’ evidence

Perceived factors that facilitate nurses to provide evidence- based practice

Self-assessment of nurses’ skills in finding, reviewing and using different sources of evidence.

The sample included district nurses, community nurses, practice nurses, health visitors and school nurses. Questionnaires were distributed to a random sample from each group in each PCT. Responses were coded for computer analysis and statistical testing was performed using SPSS (Statistical Package for the Social Sciences).

Kate Gerrish, Professor of Nursing Research, University of Sheffield/Sheffield Teaching Hospitals NHS Foundation Trust, School of Nursing and Midwifery; Jo Cooke, Programme ManagerNIHR Collaborations and Leadership in Applied Health Research and Care for South Yorkshire (CLAHRC SY), Sheffield Teaching Hospitals NHS Foundation Trust

Nurses working in the community may have insufficient time to access, interpret and apply research, and, therefore, need information to be presented in a format that is easily accessible. As community nurses rise to the challenges outlined in recent health policy, it is increasingly important that they maximise their potential to deliver evidence-based practice. This article looks at a survey that aimed to identify factors influencing evidence-based practice among community nurses. The findings indicate that in order to make progress it is important to adopt a multifaceted approach, taking into account the real world in which nurses currently practice. While it is important to develop nurses’ skills in accessing and reviewing research information, constraints on time mean that it will be difficult to achieve a nursing workforce where all nurses are active in reviewing research evidence.

KEYWORDS:Evidence-based practice Research Practice development

Kate Gerrish, Jo Cooke

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FINDINGS

Of the 766 questionnaires distributed, 337 were returned giving an overall response rate of 44%. Respondents were evenly distributed across the nursing groups (Table 1). The sample comprised 331 (98.2%) women and 6 (1.8%) men, of which 48.1% (162) worked full time, and 51.6% (175) part time. The average age of respondents was 44.3 years (range 23–66 years).

SOURCES OF KNOWLEDGE

Nurses were asked to identify the

extent to which they used 22 different sources of knowledge to inform their practice by rating them on a five-point scale, ranging from ‘never’ (score 1) to ‘always’ (score 5). The frequency with which nurses used various sources of knowledge is reflected in the mean (average) scores for each item. These scores, ordered from most to least frequent use, are shown in Table 2.

Nurses drew most frequently on experiential sources of knowledge gained through interactions with patients (ranked 1 and 5). Workplace sources of knowledge such as protocols and guidelines (ranked 2

and 3) and training and conferences (ranked 4) were also often used.

Knowledge gained from

colleagues, including senior nurses (ranked 6), fellow practitioners (ranked 7), and doctors (ranked 9) also featured prominently. Less frequently used sources of knowledge included journal articles, textbooks, the internet and pharmaceutical literature.

BARRIERS TO REVIEWING RESEARCH AND INFORMATION

This section of the questionnaire asked nurses to rate the extent to which 10 items concerned with finding and reviewing research and organisational information were perceived to be barriers to evidence-based practice. Each item was scored on a five-point scale against the statement, ranging from ‘strongly agree’ (score 1) to ‘strongly disagree’ (score 5). The extent to which nurses perceived different items to be a barrier is reflected in the mean scores. These scores, ordered from the greatest to the least barrier, are shown in Table 3.

The greatest barriers to nurses accessing and reviewing evidence-based information relate to time and their skills in judging the quality of information. Nurses were generally more confident about where to locate protocols and organisational information. Research information appeared to be more difficult to find.

Identifying implications for practice was less of a barrier for nurses in both research and organisational information. These observations highlight the need for strategies that ensure that evidence-based information is readily available to nurses in a format that is easy to understand and which includes an indication of the quality of the research.

BARRIERS TO CHANGING PRACTICE

Nurses were asked to rate the extent to which they encountered barriers in using evidence to change practice. Items were scored on a scale of 1 (‘strongly agree’) to 5 (‘strongly disagree’). The mean scores, ordered

Table 1: Respondents by nursing group

Nursing group Number of responses % of sample Response rateDistrict nurses 68 20.2% 47.5

Community nurses 77 22.8% 46.9

Health visitors 72 21.4% 44.7

Practice nurses 67 19.9% 37.6

School nurses 53 15.7% 42.0

Total 337 100%

Table 2: Sources of knowledge used to inform practice

Rank order Source of knowledge Mean score1 Information that I learn about each patient/client as an individual 4.41

2 Information I get from local policy and protocols 4.25

3 Information I get from national policy initiatives/guidelines 4.13

4 Information I get from attending in-service training/conferences 4.09

5 My personal experience of caring for patients/clients over time 4.03

6Information senior clinical nurses share, e.g. clinical nurse specialists, nurse practitioners

3.88

7 Information my fellow practitioners share 3.71

8 Information I learned in my training 3.53

9 What doctors discuss with me 3.5

10 Articles published in nursing journals 3.46

11 Information I get from local audit reports 3.38

12New treatments and medications that I learn about when doctors prescribe them for patients

3.27

13 My intuitions about what seems to be ‘right’ for the patient/client 3.19

14 Information in textbooks 3.13

15 Articles published in research journals 3.06

16 Articles published in medical journals 3.04

17 Information I get from the internet 3.02

18 Information I get from pharmaceutical or equipment literature 3.01

19 What has worked for me for years 2.9

20Medications and treatments I gain about/from pharmaceutical or equipment company representatives

2.61

21 The ways that I have always done it 2.43

22 Information I get from the media (e.g. popular magazines, television) 2.13

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from the greatest to the least barrier, are shown in Table 4.

The findings highlight how time is a major constraint in achieving evidence-based practice. Lack of resources is also problematic. Barriers to changing practice were less problematic than those relating to finding and reviewing information, indicated by the higher mean scores (higher score = less of a barrier).

Transferring these figures to the percentage of nurses who perceived these items a barrier highlights that the workforce is quite empowered. Only 5% of the sample agreed that lack of confidence was a barrier; 8.6% agreed that the culture of the team was a barrier to changing practice; and 13.2% thought that lack of authority was a barrier.

FACILITATORS TO CHANGING PRACTICE

This section of the questionnaire examined the extent to which nurses perceived other staff to be supportive of changing practice. A 5-point

scale was used to judge the degree of support ranging from ‘always supportive’ (score 1) through to ‘never supportive’ (score 5). The mean scores, ordered from the greatest to the least lack of support, are shown in Table 5. These findings indicate that community nurses generally work in an environment where colleagues, managers and doctors are supportive of changing practice.

USING DIFFERENT SOURCES OF EVIDENCE TO CHANGE PRACTICE

Nurses were asked to rate how experienced they were in finding, reviewing and using different sources of evidence to change practice using a 5-point scale ranging from ‘complete beginner’ to ‘expert’. The percentage of nurses falling into each category is shown in Table 6.

Nurses felt most skilled at finding information from the internet and the library. The areas where nurses perceive themselves as less skilled (novice/complete beginner) related to finding, reviewing and using research evidence.

IMPLICATIONS FOR PRACTICE

This study highlights that nurses use a range of information sources to inform their practice, including patients, protocols, experience, in-service training and conferences. Face-to-face discussions with colleagues were also a highly used source of knowledge. Nurses used journal articles less frequently than other sources of knowledge.

While barriers to finding and reviewing information existed, those to changing management and practice were less evident, with most nurses feeling that they had the authority and confidence to instigate such changes.

The greatest barrier to evidence-based practice was lack of time. Nurses also lacked confidence in finding research evidence, reviewing it, and judging its quality, with over 40% feeling that they were at the level of a complete beginner/novice. High levels of skills were reported around using the internet, even though it was rated low in terms of being a source of evidence. These findings indicate that strategies to promote evidence-based practice should consider the constraints that community nurses are working under, and ensure that evidence-based information is readily available and the implications for practice made clear.

Care protocols and guidelines were frequently used by nurses. Therefore, it is important that these are based on the best available evidence and regularly updated, as new evidence becomes available.

Table 3: Barriers to finding and reviewing information

Rank order Barrier Mean score1 I do not have sufficient time to find research reports 2.49

2 I do not feel confident in judging the quality of research reports 2.96

3 Research reports are not easy to find 3.03

4 I find it difficult to understand research reports 3.14

5I do not have sufficient time to find organisational information (guidelines/protocols, etc)

3.20

6I find it difficult to identify the implications of research findings for my own practice

3.37

7I find it difficult to identify the implications of organisational information for my own practice

3.50

8 Organisational information (protocols, guidelines etc) is not easy to find 3.69

9 I do not know how to find appropriate research reports 3.72

10I do not know how to find organisational information (guidelines, protocols, etc)

4.18

Table 4: Barriers to changing practice

Rank order Barrier Mean score1 There is insufficient time at work to implement changes in practice 3.00

2 There are insufficient resources (i.e. equipment) to change practice 3.09

3 I lack the authority in the work place to change practice 3.75

4 I do not feel confident about beginning to change my practice 3.95

5 The culture of my team is not receptive to changing practice 3.97

Table 5: Facilitators to changing practice

Rank order Facilitator Mean score1 Nursing colleagues are supportive of my changing practice 2.23

2 Nurse managers are supportive of my changing practice 2.41

3 Practice managers are supportive of my changing practice 2.67

4 Doctors with whom I work are supportive of my changing practice 2.71

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Some community nurses are more skilled than others at finding and appraising research evidence. However, there is a need for more nurses to develop expertise in appraising evidence and in using evidence to develop protocols, care pathways etc, and implementing change in practice. Nurses in advanced practice roles, such as clinical nurse specialists and nurse consultants, have an important role to play in promoting evidence-based practice (Gerrish et al, 2011a,b). It is important that they have the requisite knowledge and skills to facilitate learning among community nurses.

Accessing knowledge using the internet is becoming increasingly important. The majority of nurses felt they were competent at finding information on the internet, although this was ranked relatively low as a source of information for practice. Community nurses, therefore, need to be aware of evidence-based resources such as those supported by the National Institute for Health and Clinical Excellence (NICE) and Social Care Institute for Excellence (SCIE), in producing quality appraised research briefings.

CONCLUSION

As community nurses rise to the challenges outlined in recent health policy (Department of Health [DH], 2011; 2013), it is increasingly important that they maximise their potential to deliver evidence-based practice. The findings from this survey indicate that to make progress with evidence-based practice, it is

important to adopt a multifaceted approach, considering the real world in which nurses currently practice.

While it is important to develop nurses’ skills in accessing and reviewing research information, constraints on time mean that it will be difficult to achieve a nursing workforce where all nurses are active in reviewing research evidence. A pragmatic approach is needed, whereby those nurses working in the community are enabled to access research-based guidance in the form of up-to-date protocols and pathways, through in-service training, and their interactions with senior clinical nurses.

Due to the multiple locations of community nurses, the internet is a useful source of information, which needs investment in terms of developing nurses’ skills in retrieving online evidence. It is also crucial that the environment in which nurses work is receptive to change.

REFERENCES

Bryar R, Closs S, Baum G, et al (2003) The Yorkshire BARRIERS project: diagnostic analysis of barriers to research utilisation. Int J Nurs Stud 40: 73–85

Bucknall T, Rycroft-Malone J (2010) Evidence-based practice: doing the right thing for patients. In: J Rycroft-Malone, T Bucknall, eds. Models and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action. Wiley Blackwell, Chichester: 1–21

Department of Health (2011) Health Visitor Implementation Plan 2011–2015: a call for action. DH, London

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Table 6: Skills appraisal

Skill rating Complete beginner/novice

Quite skilled Competent/expert

% % %

Using the internet to search for information 25.1 29.6 45.3

Using the library to locate information 22.6 36.6 40.8

Finding organisational information 22.6 41.4 36

Using organisational information (policies / guidelines, etc) to change practice

24.6 41.7 33.7

Reviewing organisational information 27.2 42.5 30.3

Reviewing research ‘evidence’ 34 35.8 30.2

Using research evidence to change practice 35 35.9 29.1

Finding research ‘evidence’ 40.7 33.8 25.5 Department of Health/Public Health Nursing (2013) Care in Local Communities: a new vision and model for district nursing. DH, London

Gerrish K, Ashworth P, Lacey A, et al (2007) Factors influencing the development of evidence-based practice: a research tool. J Adv Nurs 57: 328–38

Gerrish K, Ashworth P, Lacey A, Bailey J (2008) Developing evidence-based practice: experiences of senior and junior clinical nurses. J Adv Nurs 62: 62–73

Gerrish K (2010) Evidence-based practice. In: K Gerrish, A Lacey, eds. The Research Process in Nursing. Wiley Blackwell, Chichester: 488–500

Gerrish K, Guillaume L, Kirshbaum M, McDonnell A, Tod A, Nolan M (2011a) Factors influencing the contribution of advanced practice nurses to promoting evidence-based practice among front-line nurses: findings from a cross-sectional survey. J Adv Nurs 67: 1079–90

Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M, Tod A (2011b) The role of advanced practice nurses in knowledge brokering as a means of promoting evidence-based practice among clinical nurses. J Adv Nurs 67: 2004–14

McCaughan D, Thompson, C, Cullum, N, Sheldon T, Thompson D (2002) Acute care nurses’ perceptions of barriers to using research information in clinical decision making. J Adv Nurs 39: 46–60

McKenna H, Ashton S, Keeney S (2004) Barriers to evidence based practice in primary care: a review of the literature. Int J Nurs Stud 41: 369–78

Spenceley S, O’Leary K, Chizawsky L, Ross A, Estabrooks C (2008) Sources of information used by nurses to inform practice: an integrative review. Int J Nurs Stud 45: 954–70

Thompson C, McCaughan D, Cullum N, Sheldon T, Raynor P (2005) Barriers to evidence-based practice in primary care nursing: why viewing decision-making as context is helpful. J Adv Nurs 52: 432–44

KEY POINTS It is increasingly important that

community nurses can deliver evidence-based practice.

A pragmatic approach is needed, whereby those nurses working in the community are enabled to access research-based guidance.

Due to the multiple locations of community nurses, the internet is a useful source of information.

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