Nurses are better at using their professional knowledge andapplying research in their work following postgraduate study inevidence-based practice (EBP). Their belief in the value of suchwork also increases.

Sykepleien Forskning 2018 13(69520)(e-69520)DOI: https://doi.org/10.4220/Sykepleienf.2018.69520

PEER-REVIEWED RESEARCH

Nurses are betterequipped for evidence-based practice followingpostgraduate study

KeywordsNurses Attitudes Behaviour Evidence-based practice Pretest-posttest design

ABSTRACT

Cecilie Katrine Utheim GrønvikSpesialsykepleier i geriatri og førstelektorAvdeling for helse- og sosialfag, Høgskolen i Molde

Ingeborg UlvundJordmor og førstelektorAvdeling for helse- og sosialfag, Høgskolen i Molde

Stål BjørklyProfessorAvdeling for helse- og sosialfag, Høgskolen i Molde og Oslo universitetssykehus

Authors

Background: Norwegian health authorities expect the health service to be evidence-based. Inorder to meet this expectation, Molde University College established a postgraduate studyprogramme in EBP in 2009.

Objective: To examine whether postgraduate study in EBP helped nurses to change theirattitudes and behaviour in relation to EBP. 

Method: A cross-sectional study with a pretest-posttest design. Nurses (n = 62) answered theNorwegian versions of the Evidence-Based Practice Beliefs Scale and Evidence-BasedPractice Implementation Scale at the start (n = 56) and end (n = 55) of a postgraduate studyprogramme in EBP. 

Results: The response rate was 90.3 at pretesting and 88.7 at posttesting. The distribution ofresponses to both scales showed good internal consistency. That is, the nurses did not usethe scales in a random or unreliable way. The change between pretest and posttest wasstatistically signi�cant for 5 of 16 items in the EBP Beliefs Scale and for 10 of 18 items in theEBP Implementation Scale.

Conclusion: The results indicate that postgraduate study strengthened nurses’ positiveattitude towards EBP. In conclusion, the nurses reported increased activity in connection withthe �rst four steps in EBP. However, it was beyond the scope of this investigation to assesswhether this change actually resulted in more and improved evidence-based practice.

The authorities expect the health service to basedecisions concerning treatment, prevention and care onreliable knowledge about the outcome of interventions(1). In the Health&Care21 strategy (2) and the follow-up action plan (3), evidence-based practice (EBP) isdescribed as an instrument for promoting quality,greater patient safety and effectiveness in health andsocial services.

EBP entails basing decisions on the patient’s wishesand needs in the given situation as well asrecommendations from the best research-based andexperience-based knowledge available. EBP ispresented as a six-step process:

Step one is about reflecting on own practice and steptwo concerns the framing of a good clinical question.Step three relates to finding research-based knowledgeand step four entails the critical appraisal of researchliterature. Step five is about integrating valid andapplicable research-based knowledge with experience-based knowledge and the user’s preferences. Step sixinvolves evaluating own practice (4).

Melnyk et al. (5) point out that nurses’ EBP-relatedknowledge, skills and attitudes impact on how researchis applied in practice. Despite the increasing focus onevidence-based health services, many Norwegiannurses report that they seldom read research findingsor apply them to their own practice (5–7).

One reason for this may be that not all nurses have theknowledge or skills to search for, read, criticallyunderstand or apply research (7, 8). In order to achievethe goal of an evidence-based health service, Sandvik,Stokke and Nortvedt (7) suggest that nurses need to betrained in EBP.

Systematic reviews (9, 10) suggest that training inEBP is most effective when it is based on principlesfor how adults learn. Good information, clear learninggoals and specific work tasks with the opportunity toexercise practical skills are indicated as having apositive effect. This also applies to variation in the useof lectures and interactive methods, as well asinteraction between participants in the form of smallgroup discussions and group work.

In addition, Khan and Coomarasamy (9) and Young etal. (10) emphasise that the EBP training is mosteffective when it is based on real issues from practice.This is also the case when students receive training incritical assessment and when they are given regularfeedback.

EBP in practice

«Many Norwegian nurses report that theyseldom read research findings or apply themto their own practice.»

EBP in education

Several studies have shown that EBP training makesnurses more positive towards EBP (7, 11, 12).However, we do not know of any Norwegian surveysthat chart nurses’ EBP-related attitudes and behaviourat the start and end of postgraduate study in EBP. Thepurpose of this study was to map whether postgraduatestudy in EBP helped change nurses’ attitudes andbehaviour with regard to EBP.

We conducted a survey of nurses from the specialisthealth service and primary health service who hadcompleted a postgraduate study programme in EBP atMolde University College in the period 2009–2012 (n= 62, distributed in three cohorts). At the start (pretest)and end (posttest) of the postgraduate study, academicadministrators distributed two questionnaires thatrespondents answered anonymously within 15minutes.

The postgraduate study programme consists of sevenseminars over two semesters. The content and teachingmethods are based on the recommendations in thebook Jobb kunnskapsbasert (4) about evidence-basedpractice, and the recommendations by Khan andCoomarasamy (9) and Young et al. (10). Thesystematic reviews indicate that training in EBP ismost effective when the participants find it useful fortheir own practice.

MethodSample and data collection

Postgraduate study

The students therefore use a problem from their ownpractice as a basis for acquiring knowledge and skillsabout the first four steps in EBP. At the seminars, theteaching methods alternate between lectures, smallgroup discussions, skills training and the use ofinteractive methods such as the online course atkunnskapsbasertpraksis.no. devised by WesternNorway University of Applied Sciences and theNorwegian Knowledge Centre for the Health Services.The purpose is to teach healthcare personnel to searchfor, critically appraise and use research-basedknowledge in practice.

Between the seminars, the students work on specificcourse requirements linked to the steps. Theserequirements are solved in groups of three to fivestudents and are assessed by the teacher. At the finalseminar, each group presents a summary of completedcourse requirements. The groups receive feedbackfrom fellow students and teachers. They then bringtogether the course requirements in a writtenassignment, which is the home exam.

Fifteen ECTS credits are awarded to students who passthe exam. Students are encouraged to present the examassignment at their workplace. The postgraduate studyprogramme does not have a stated goal of trainingstudents to implement EBP, but the intention is thatstudent-based methods contribute to the knowledgeand skills that are considered to be transferable topractice after completion of the programme.

We used the Norwegian translations of the Evidence-Based Practice Beliefs Scale (13) and Evidence-BasedPractice Implementation Scale (13) to measure self-reported changes in attitudes and behaviour withregard to EBP. The scales were translated toNorwegian in 2008 by a research group at the Centrefor Evidence-Based Practice, Western NorwayUniversity of Applied Sciences in collaboration withthe original US authors.

Measuring instruments

The translation was in line with the World HealthOrganization’s (14) principle for forward and backtranslations. In the Norwegian translation, theEvidence-Based Practice Beliefs Scale was called KBPholdningsskala and the Evidence-Based PracticeImplementation Scale became KPBimplementeringsskala. We were given permission touse the scales by Nina Rydland Olsen at the Centre forEvidence-Based Practice.

The EBP Beliefs Scale consists of 16 items thatmeasure self-reported attitudes and confidence in therespondents’ own knowledge and skills in connectionwith EBP (Table 1). The responses were scored on afive-point Likert scale, ranging from 1 (stronglydisagree), 2 (disagree), 3 (neither agree nor disagree),4 (agree) to 5 (strongly agree). The total score for thescale varies from 16 to 80. A high total score indicatespositive attitudes towards EBP.

The EBP Implementation Scale consists of 18 itemsthat measure self-reported activity related to EBP(Table 2). The response alternatives are 0 = 0 times, 1 = 1–3 times, 2 = 4–5 times, 3 = 6–8 times and 4 = > 8times. The total score for the survey varies from 0 to72. A high total score indicates increased self-reportedpractice of EBP. National and international reliabilityanalyses show that the scales have good internalconsistency (12, 15, 16).

The Dean of the Faculty of Health Sciences and SocialCare granted permission to conduct the survey. Atstart-up, the nurses received written and oralinformation about the survey. Participation wasvoluntary, and those who agreed to participate signed aletter of consent. In order to ensure the confidentialityand anonymity of participants, we did not collect anydemographic data.

Research ethics considerations

Statistical analyses

In line with recommendations by Melnyk et al. (15),the values for the two negatively formulated items inthe EBP Beliefs Scale were recoded into reversedcontent (items 11 and 13 in Table 1) before weconducted the statistical analyses.

The element of missing data for the entire sample was< 3 per cent for all questions. Questions that aparticipant had omitted to score were given a valuethat corresponded to the participant’s mean score onthe other questions. Mean scores were used as ameasure of central tendency in each section of the EBPBeliefs Scale.

In the EBP Implementation Scale, median values wereused as a measure of the mean value in each section,since all the score steps above 0 (= 0 times) had morethan one specific value (1 = 1–3 times, 2 = 4–5 times,3 = 6–8 times and 4 = > 8 times). The one-sampleKolmogorov-Smirnov test (17) was used to establishwhether the distribution of the scores in the EBPBeliefs Scale and the EBP Implementation Scale wereapproximately normal.

Since none of the score distributions were normal, weused non-parametric tests in further analyses.Anonymisation prevented us from making a direct(matched) comparison of the individual participant’sscores at pretesting and posttesting. These comparisonswere therefore done with statistical tests for dependentsamples.

We used the Wilcoxon signed-rank test (17) to testdifferences between pretesting and posttesting for eachsection of both scales, and to test differences in thesample’s total scores at pretesting and posttesting. Wemeasured the internal consistency reliability in theEBP Beliefs Scale and the EBP Implementation Scaleusing Cronbach’s alpha. The study was based on aconventional significance level of p < 0.05.

Since repeated tests in the same sample can givemeasurement errors, whereby differences that are notreal are shown to be statistically significant (type 2errors), we used the Bonferroni procedure. TheBonferroni procedure involves the use of a morestringent criterion: p < 0.001, for significant findings.We analysed the data using the Statistical Package forSocial Sciences (SPSS) version 22.

At pretesting, 56 of 62 nurses (90.3 per cent)completed both scales. At posttesting, 55 of 62 nurses(88.7 per cent) completed both scales. Gender was theonly demographic variable available, but since therewas only one man in the sample, it was not possible toanalyse any gender disparities. The internalconsistency of the distribution of responses wemeasured using Cronbach’s alpha was 0.80 in the EBPBeliefs Scale and 0.89 in the EBP ImplementationScale.

Table 1 shows that the average total score in the EBPBeliefs Scale at pretesting was 52.84, standarddeviation (SD) = 5.75 with a range from 41 to 65. Atposttesting, the mean total score was 60.80, standarddeviation (SD) = 5.41 with a range from 51 to 73. Thechange in mean total score from pretesting toposttesting for the EBP Beliefs Scale was statisticallysignificant, p < 0.001.

Results

Attitudes towards evidence-based practice

https://sykepleien.no/sites/default/files/gronvik_tabell1_0.png

The results in Table 1 show that the change betweenpretesting and posttesting for items 2, 3, 10, 14 and 15in the EBP Beliefs Scale was statistically significant (p< 0.001). The pretest results show that nurses wereunsure about their own EBP-related knowledge andskills at the start of the postgraduate study (items 2, 10,14 and 15 in Table 1). A higher mean score atposttesting may indicate increased confidence in theirown EBP-related knowledge and skills at the end ofthe postgraduate study.

At pretesting, the nurses reported that they did notknow the steps in EBP (item 2 in Table 1), while atposttesting they reported that they were familiar withthese. The nurses also reported that they were surethey could implement EBP both at the start and the endof their postgraduate studies (item 3, Table 1). Inconnection with knowledge about how they couldmeasure the effect of clinical practice (item 10, Table1), the results show that they did not know this atpretesting and were unsure about it at posttesting.

With regard to their skills in using EBP, it was found atpretesting that the nurses were not confident in theirown ability to implement EBP (item 15 in Table 1) orhow EBP could be used to bring about changes inpractice (item 14). A higher mean score at posttestingmay indicate that a change has taken place.

«[At pretesting] the nurses were notconfident in their own ability to implementEBP or how EBP could be used to bringabout changes in practice.»

A high mean score for items 1, 5, and 9 (Table 1)shows that nurses were confident that EBP couldimprove their work when they started theirpostgraduate studies. The posttest results suggest thattheir studies reinforced their positive attitudes. It wasalso found that the nurses were confident that criticalappraisal of research-based knowledge is an importantstep in EBP (item 4 in Table 1) at both measurementtimes.

With regard to items concerning whether their practiceis evidence-based (item 16, Table 1), the nurses reportthat they were unsure about this at both measurementtimes.

At pretesting, median values < 1 indicate that theresponse alternative ‘0 times’ is the response that thenurses give when answering how many times theyhave performed various activities related to EBPduring the last eight weeks (Table 2). Only for the itemabout whether they have collected clinical informationabout a patient problem in the last eight weeks (item 5,Table 2) does the median value indicate that they havedone so one to three times (median value > 1).

Behaviour in relation to EBP

Table 2 shows that the mean total score in the EBPImplementation Scale at pretesting was 4 (SD = 5.79),with a range from 0 to 25. At posttesting, the meantotal score was 20 (SD = 8.92), with a range from 6 to43. The change in mean scores in the EBPImplementation Scale from pretesting to posttesting isstatistically significant, at < 0.001.

The results show that the nurses report increasedactivity from pretesting to posttesting for all itemsexcept item 7. In addition, the change is statisticallysignificant in 10 out of 18 items, at p < 0.001 (Table2).

This relates to items about increased activity due to,within the last eight weeks, applying knowledge fromdifferent sources, critically appraising a research study,framing a clinical question in a standardised mannerand discussing a research study informally with acolleague, presenting research-based knowledge in areport or to a colleague, telling a colleague aboutclinical guidelines based on research, disseminatingknowledge from a research study to aninterdisciplinary group, reading and criticallyappraising a clinical research study, using theCochrane database and promoting the use of EBPamong colleagues.

To the best of our knowledge, this study is the first toevaluate whether Norwegian nurses’ EBP-relatedattitudes and behaviour change between the start andend of postgraduate study in EBP. The main findingsin the study show that the nurses gained moreconfidence in their knowledge of the steps in EBP andin the importance of EBP in the health service. Thestudy also showed that the nurses reported undertakingevidence-based activities to a greater extent after theyhad completed their postgraduate studies.

Discussion

A high mean total score on the EBP Beliefs Scale atboth pretesting and posttesting may indicate that thenurses have a positive attitude towards EBP and agreethat clinical practice based on research improves thequality of the health service. The change in total scoresfrom pretesting to posttesting is significant. Variationsin education programmes, differing measurementtimes and analytical methods make it difficult to drawdirect comparisons with results in previous Norwegianstudies, but overall the studies reinforce the belief thatEBP produces the best treatment outcome for patients(5, 7, 11, 12, 18).

A review article (19) examining how individual factorsimpact the use of research in clinical practice suggeststhat a positive attitude is crucial to whether nurses readand use research in their practice. In our study, weobserved that the nurses’ attitudes and assessments oftheir own ability to use an evidence-based approach intheir work were more positive at the end of theirpostgraduate studies than at the start.

The biggest change was in item 2 (Table 2), where thenurses went from disagreeing that they had knowledgeof the steps in EBP, to reporting that they were familiarwith the steps at posttesting. The result suggests thatthe nurses learned more about the steps in EBP in theirpostgraduate studies. This result concurs with aNorwegian (12) and an international study (19). Thesestudies reinforce the assumption that training in EBP iscrucial to meeting the health authorities’ expectationsfor an evidence-based health service (20).

A low mean total score at pretesting of the EBPImplementation Scale shows that the nurses reportedlow EBP-related activity before starting theirpostgraduate studies, which may suggest that they hadlittle focus on evidence-based activities in practice.

Attitudes, abilities and knowledge changed 

Barriers to implementing EBP

The increase in mean total scores from 4 at pretestingto 20 at posttesting indicates that the nurses reportedmore EBP-related activity after they had completedtheir postgraduate studies. The result is still low, but issomewhat higher than that found in, for example, thestudy by Snibsøer et al. (12). According to Snibsøer etal. (12), a low mean total score on the EBPImplementation Scale may be associated with barrierssuch as lack of allocated time, resources, knowledgeand authority to change practice.

In order to successfully implement EBP, it is thereforeimportant to map barriers in the specific context (21).Dahlheim et al. (22) indicate that skills and knowledgein EBP can help reduce such barriers. They found thatnurses with evidence-based skills more often readresearch than those who do not have such skills (22).Increasing research-related activity can lead to betterpatient safety and job satisfaction (23).

In post-testing, the results showed a statisticallysignificant change in the nurses’ EBP-related activitylevel in 10 out of 18 items after the Bonferronicorrection. The nurses reported that they had usedknowledge from different sources, critically appraiseda research study and framed clinical questions in astandardised manner to a greater extent at posttestingthan at pretesting. They had also discussed researchwith colleagues and disseminated and presented it tothem, used Cochrane Library’s database and promotedthe use of EBP among colleagues.

Although the plan was for the nurses to work with thesteps in EBP based on a clinical problem from theirown practice (9), it may be that the education only hadan ‘academic’ effect. The nurses’ uncertainty aboutwhether their practice was evidence-based both at thestart and end of their postgraduate studies may indeedindicate this.

Evidence-based activities in practice

Comparable studies (11, 12, 18) show that nursesreport limited evidence-based activity in practicedespite their EBP training. Further research on what isneeded to ensure greater implementation of EBP inpractice is therefore necessary.

A surprising result in the study was statisticallysignificant changes in items about EBP that were notthematised in the postgraduate study, e.g. items 6, 8and 10 (Table 2), which deal with presenting researchto colleagues. Greater understanding and discussion ofresearch results in practice can help more nurses torecognise the value of using research-based knowledgein practice.

According to a literature review by Sandvik et al. (7),healthcare personnel’s ability to read and understandresearch is crucial to being able to implement researchin practice. Researchers must therefore takeresponsibility for presenting research results in a waythat healthcare personnel understand. Anothersurprising result showed that, during their postgraduatestudies, the nurses indicated that they had becomemore sure about how to measure the impact of clinicalpractice. The postgraduate study programme did notfocus on impact assessment, but emphasised learningactivities aimed at increasing the nurses’ criticalappraisal abilities.

The understanding of research needs toimprove

Reading and critically appraising moreresearch

At both measurement times, the nurses agreed thatcritically appraising research-based knowledge (item4, table 1) is an important step in EBP. The changebetween pretesting and posttesting showed asignificantly greater emphasis on this (p < 0.005).Because repeated significance tests within the samesample can give unreliable findings, we usedBonferroni-corrected p-values. In order to identify asignificant difference, the p-value would have to be atleast 0.001.

Despite this, the finding suggests that there was astatistical tendency for the postgraduate study tocontribute to the greater emphasis on criticallyappraising research. The change between pretestingand posttesting in items 2 and 11 in the EBPImplementation Scale (Table 2) shows that reading andcritically appraising research were two of the activitiesthat had increased most. This partly explains thegrowth in support for EBP.

Other Norwegian studies (6, 24) show that Norwegiannurses think that critically appraising research is achallenge. It is therefore positive that the nurses in ourstudy report obtaining more knowledge and skills inthis area. The ability to think critically is found to becrucial to being able to use research in practice (24,25).

Whether nurses should learn EBP in undergraduate orpostgraduate studies is open to discussion. Today’snursing students learn about the steps in EBP in theirundergraduate education, but not all nurses whograduated in past years received such training. Nurseswith many years of experience often have an informalauthority to set the standard in practice.

«The postgraduate study [contributed] to thegreater emphasis on critically appraisingresearch.»

Everyone should have competence in EBP

Efforts to ensure that everyone has competence in EBPare therefore necessary to safeguard the quality in thefuture health service. Health policy makers aretherefore proposing the mandatory training ofhealthcare personnel in EBP as one of severalinstruments for improving the quality in the healthservice (2). Nurses are the largest healthcareprofession in the health service, and their ability toapply EBP therefore impacts on the quality of theentire health service.

More knowledge about the steps in EBP can makenurses more likely to search for and discuss researchwith colleagues and nursing students. We believe thatestablishing a culture in which it is natural to read anddiscuss research can make a positive contribution toimplementing EBP in practice.

Some of the items in the study also showed nosignificant change between pretesting and posttesting.These results can reflect themes where thepostgraduate study programme has potential forimprovement. Results from the EBP Beliefs Scalesuggest that more emphasis should be placed on thepositive effects of EBP on clinical practice.

Results from the EBP Implementation Scale indicatethat postgraduate study should have a greater focus onmeasures that can reduce barriers to implementingEBP in practice. Postgraduate study programmesshould also focus on the patient’s right to research-based information. According to Snibsøer et al. (12),the results of training in evidence-based practice candiffer depending on whether it takes place in anacademic institution or in a clinical nursing context.

Strengths and limitations of the study

Although the results are in keeping with national andinternational studies, the sample size in the studylimits our ability to generalise the results. On the otherhand, generalisation is aided by the high response ratesat both measurement times and the participation ofrespondents from different parts of the specialist healthservice and the primary health service.

The reliability of the survey is also strengthened sincethe internal consistency reliability was good for bothscales. A high internal consistency in the scores of atool means that the respondents have understood thedifferent elements of the tool in the same way and thatthe difference between the participants’ scores is notdue to systematic measurement errors. With aconventional p-value of 0.05, there would have been 8significant differences in the EBP Beliefs Scale and 14in the EBP Implementation Scale.

Using a more stringent significance level (p < 0.001)gave fewer significant differences, but increased theprobability of the differences found between pretestingand posttesting being real. We believe that theincreased reliability in the study’s result strengthensthe study’s internal validity.

A methodical limitation of the study was that theacademic administrator for the postgraduate studyprogramme carried out the study. Since the scales arebased on self-reporting, this may have contributed tosystematic errors in scores if the respondents adaptedthe answers to what they thought the researchersexpected to find. That participants’ responses do notnecessarily reflect reality will always be a weakness insuch surveys (26). However, the fact that thequestionnaires were answered anonymously mayreduce this source of error.

Ideally, the students should have been randomised intoa group that had studied EBP and a control group thatreceived the corresponding amount of teaching in otherthematic content. However, such a randomised designwas not feasible given the eight-month survey period.The choice of a naturalistic pre- and post-design meanswe can steadfastly assert that only postgraduate studyin EBP contributed to the result.

Another limitation is that the anonymous nature of thestudy meant we were unable to collect demographicinformation about the respondents and analyse thepossible impact of such factors. However, the resultsfrom two systematic literature reviews (27, 28) showedno significant correlation between socio-demographicvariables and attitudes and behaviour in connectionwith EBP among nurses.

The danger of using the same scale at pretesting andposttesting is that the respondents learn somethingfrom the first measurement that affects the result of thesubsequent measurement. Since pretesting andposttesting were more than eight months apart, it isunlikely that the respondents remembered exactly howthey responded in the pretest. Another limitation maybe that some respondents answered the EBPImplementation Scale at pretesting based on learningactivities in the postgraduate study programme and noton their own practice.

Since the scales were developed in and for a UScontext, the applicability of the scales needs to bestudied in the Norwegian health service context.Furthermore, that our study could have given differentresults if it had been carried out today cannot be ruledout.

Implications for further research

There is a great need for studies that use methods otherthan self-reporting of attitudes, knowledge and skills inorder to evaluate training in EBP. Future researchshould instead focus on process outcome metrics thatmeasure whether practices change as a result oftraining in EBP.

Postgraduate study strengthened the nurses’ positiveattitudes towards EBP and their belief in the value ofusing evidence-based knowledge in practice. Inaddition, the nurses reported an increase in evidence-based activities. Since we lack empirical evidence onwhether nurses actually changed their own practices,we cannot conclude that postgraduate study leads togreater implementation of EBP in practice.

Self-reporting of attitudes and practices is important,but it is the actual implementation of EBP and theimpact this has on patients that is most crucial for thequality in the nursing profession.

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Conclusion

«Postgraduate study strengthened thenurses’ positive attitudes towards EBP andtheir belief in the value of using evidence-based knowledge in practice.»

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