Barriers to evidence based practice in primary care: a review of the literature

Patient and healthcare professionals' perceived barriers and facilitators to the implementation of psychosocial screening in cardiac practice: A Delphi study

BACKGROUND

Psychosocial risk factors contribute to the incidence and progression of coronary heart disease (CHD). Psychosocial screening may identify individuals who are at risk and aid them with getting appropriate care. To successfully implement psychosocial screening in the cardiology practice, the current study aims to identify key barriers and facilitators to its implementation and evaluate their perceived importance among health care professionals (HCPs) and patients.

METHODS

We took a modified 3-round Delphi study approach to gain insight into key determinants that could either impede or ease implementation. Round 1 gathered data from HCPs (n = 9; cardiologists, medical psychologists, cardiac nurses) and CHD patients (n = 21), which we transcribed verbatim, coded, and processed into unique determinants. In rounds 2 and 3, participants were asked to select the most relevant determinants and rank them based on importance. Subsequently, determinants were classified by implementation level.

RESULTS

Patients were generally more positive towards screening. HCP barriers included time-constraints, disruption of primary activities, and limited knowledge on psychosocial risk and screening, while patient barriers were commonly related to accessibility and patient characteristics (e.g., health literacy, motivation). Facilitators of both groups mainly pertained to the use of the screener and follow-up care, such as increasing the accessibility and the benefits of the screener.

CONCLUSION

Barriers may be targeted by enhancing the effects of the facilitators. Increasing the accessibility to the screener and interventions, improving information provision, and appointing a contact person to oversee the screening process may ease the screening and care process for both patients and HCPs.

Prospective application of theoretical implementation frameworks to improve health care in hospitals - a systematic review

BACKGROUND

Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes.

METHOD

We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1^st January 1995 to 15^th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category.

RESULTS

Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results.

CONCLUSIONS

Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base.

TRIAL REGISTRATION

CRD42019119429.

Self-reported attitudes, skills and use of evidence-based practice among Swiss chiropractors: a national survey

STUDY OBJECTIVES

The high burden of disease associated with musculoskeletal disorders severely impacts patients' well-being. As primary care providers, Swiss chiropractors ought to contribute towards identifying and using effective treatment strategies. An established approach is the full integration of evidence-based practice (EBP). This study aimed to investigate the attitudes, skills and use of EBP among Swiss chiropractors, as well as investigating potential facilitators and barriers for its adoption.

METHODS AND MATERIAL

All 329 members of the Swiss Association of Chiropractic (ChiroSuisse) were invited in March 2021 to participate in this cross-sectional survey. Data were acquired anonymously online, using the Evidence-Based practice Attitude and utilization SurvEy (EBASE). The survey encompassed 55 questions measuring attitudes (n = 8, response range 1-5; total score range of 8-40), skills (n = 13, response range 1-5; total score range of range of 13-65) and use of EBP (n = 6, response range 0-4; total score range of 0-24).

RESULTS

228 (69.3%) chiropractors returned complete EBASE questionnaires. This sample was representative of all ChiroSuisse members with respect to gender, age groups and proportion of chiropractic residents. Respondents generally held positive attitudes towards EBP, as indicated by the high mean (31.2) and median (31) attitude sub-score (range 11-40). Self-reported skills had a mean sub-score of 40.2 and median of 40 (range 13-65). Knowledge about EBP-based clinical practice had been primarily obtained in chiropractic under- or postgraduate education (33.8% and 26.3%, respectively). Use of EBP achieved a lower sub-score, with mean and median values of 7.4 and 6, respectively (range 0-24). The most commonly identified barriers preventing EBP uptake were lack of time (67.9%) and lack of clinical evidence in chiropractic/manual therapy-related health fields (45.1%).

CONCLUSION

Swiss chiropractors held favourable attitudes and reported moderate to moderate-high skill levels in EBP. Nevertheless, similar to chiropractors in other countries, the self-reported use of EBP was relatively low, with lack of time and lack of clinical evidence being the most named barriers.

Barriers and facilitators to the implementation of interventions for medically unexplained symptoms in primary care: A modified Delphi study

OBJECTIVE

Medically Unexplained Symptoms (MUS) are physical symptoms that last for longer than several weeks and for which no (sufficient) somatic explanation can be found. Interventions for treating MUS in primary care are available, but their implementation in daily practice appears difficult. In the current study we aim to explore key barriers and facilitators to the implementation of MUS-interventions in primary care.

METHODS

A three-round modified Delphi study was performed, using the input of 58 experts that are (in)directly involved in the care for patients with MUS (e.g. general practitioners (GPs), GP mental health workers, policy advisors). In the first online questionnaire, we generated ideas about relevant barriers and facilitators on different implementation levels. These ideas were independently coded by two researchers, and reformulated into unique barriers and facilitators. In round two, participants selected the ten most relevant barriers and facilitators from round one, which were ranked on importance in round three.

RESULTS

We identified 42 unique barriers and 57 unique facilitators to the implementation of MUS-interventions. The three highest ranked barriers were all related to time, i.e. too little time for treating complex MUS-patients. The most important facilitator was a positive attitude towards MUS-patients. Results varied somewhat per profession.

CONCLUSION

Key barriers and facilitators to the implementation of MUS-interventions seem to exist on the level of the patient, intervention, professional, organization, and external context. All of these levels should be taken into account in order to increase implementation success of MUS-interventions in primary care.

Validation of the Implementation Climate Scale in Nursing

BACKGROUND

One critical factor in effective implementation of evidence-based practices (EBPs) in nursing is an organizational context that facilitates and supports implementation efforts. Measuring implementation climate can add useful insights on the extent to which the organizational context supports EBP implementation.

AIMS

This study cross-validates and examines the psychometric properties of the Implementation Climate Scale (ICS), which measures nurses' perceptions of their unit's climate for EBP implementation.

METHODS

This study analyzed ICS data from two cross-sectional studies, including 203 nurses from California and 301 nurses from Florida. Analyses included evaluation of internal consistency, multilevel aggregation statistics, and confirmatory factor analyses.

RESULTS

The 18-item ICS demonstrated comparable psychometric properties to the original measure development paper in both samples. Confirmatory factor analyses provided support for the scale's factor structure in both samples.

LINKING EVIDENCE TO PRACTICE

The ICS is a pragmatic measure that can be used to assess unit implementation climate in nursing contexts. Results from the ICS from nurses and nurse leaders can provide insights into implementation-specific barriers and facilitators within the organizational context.

Reducing the use of physical restraints in home care: development and feasibility testing of a multicomponent program to support the implementation of a guideline

BACKGROUND

A validated evidence-based guideline was developed to reduce physical restraint use in home care. However, the implementation of guidelines in home care is challenging. Therefore, this study aims to systematically develop and evaluate a multicomponent program for the implementation of the guideline for reducing the use of physical restraints in home care.

METHODS

Intervention Mapping was used to develop a multicomponent program. This method contains six steps. Each step comprises several tasks towards the design, implementation and evaluation of an intervention; which is theory and evidence informed, as well as practical. To ensure that the multicomponent program would support the implementation of the guideline in home care, a feasibility study of 8 months was organized in one primary care district in Flanders, Belgium. A concurrent triangulation mixed methods design was used to evaluate the multicomponent program consisting of a knowledge test, focus groups and an online survey.

RESULTS

The Social Cognitive Theory and the Theory of Planned Behavior are the foundations of the multicomponent program. Based on modeling, active learning, guided practice, belief selection and resistance to social pressure, eight practical applications were developed to operationalize these methods. The key components of the program are: the ambassadors for restraint-free home care (n = 15), the tutorials, the physical restraint checklist and the flyer. The results of the feasibility study show the necessity to select uniform terminology and definition for physical restraints, to involve all stakeholders from the beginning of the process, to take time for the implementation process, to select competent ambassadors and to collaborate with other home care providers.

CONCLUSIONS

The multicomponent program shows promising results. Prior to future use, further research needs to focus on the last two steps of Intervention Mapping (program implementation plan and developing an evaluation plan), to guide implementation on a larger scale and to formally evaluate the effectiveness of the multicomponent program.

Evidence-based practice: Knowledge, attitudes, implementation, facilitators, and barriers among community nurses-systematic review

BACKGROUND

This study is to summarize the status of knowledge, attitudes, implementation, facilitators, and barriers of evidence-based practice (EBP) in community nurses (CNs). EBP has been widely adopted but the knowledge, attitudes, and implementation of EBP among CNs, and the facilitators and barriers they perceived have not been clearly confirmed.

METHODS

A literature search was conducted using combined keywords in 3 English databases and 3 Chinese databases of peer-reviewed publications covering the dates of publication from 1996 to July, 2018. Twenty articles were included. The information of the knowledge, attitudes, implementation, and the perceived facilitators and barriers of EBP in CNs was extracted and summarized.

RESULTS

CNs had positive attitudes toward EBP, but insufficient knowledge and unprepared implementation. The most cited facilitators were academic training, management functions, and younger age. Inadequate time and resources were recognized as main barriers hindering the transforming from knowledge and attitudes to implementation. Developed interventions mainly focused on knowledge facilitation rather than the elimination of objective barriers.

CONCLUSIONS

Findings demonstrate a compelling need for improvement in knowledge and implementation of EBP in CNs, compared with the better attitudes. Except education, knowledge translating into implementation needs more coordination with authorities to magnify the facilitators and overcome the barriers. Further studies need to concentrate on deficient knowledge and implementation of EBP among CNs. Policy makers can use the facilitators and barriers found by this review to modify nursing education, current scientific resources supplement, practice supports for care improving.

Making the Most of Continuing Medical Education: Evidence of Transformative Learning During a Course in Evidence-Based Medicine and Decision Making

INTRODUCTION

Continuing medical information courses have been criticized for not promoting behavior change among their participants. For behavior change to occur, participants often need to consciously reject previous ideas and transform their way of thinking. Transformational learning is a process that cultivates deep emotional responses and can lead to cognitive and behavioral change in learners, potentially facilitating rich learning experiences and expediting knowledge translation. We explored participants' experiences at a 2-day conference designed to support transformative learning as they encounter new concepts within Information Mastery, which challenge their previous frameworks around the topic of medical decision making. Using the lens of transformative learning theory, we asked: how does Information Mastery qualitatively promote perspective transformation and hence behavior change?

METHODS

We used a hermeneutic phenomenologic approach to capture the lived experience of 12 current and nine previous attendees of the "Information Mastery" course through individual interviews, focus groups, and observation. Data were thematically analyzed.

RESULTS

Both prevoius and current conference attendees described how the delivery of new concepts about medical decision making evoked strong emotional responses, facilitated personal transformation, and propelled expedited behavior change around epistemological, moral, and information management themes, resulting in a newfound sense of self-efficacy, confidence, and ownership in their ability to make medical decisions.

DISCUSSION

When the topic area holds the potential to foster a qualitative reframing of learners' guiding paradigms and worldviews, attention should be paid to supporting learners' personalized meaning-making process through transformative learning opportunities to promote translation into practice.

Translating research findings to clinical nursing practice

AIMS AND OBJECTIVES

To describe the importance of, and methods for, successfully conducting and translating research into clinical practice.

BACKGROUND

There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse-led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well-established barriers to the conduct and translation of research evidence into practice.

DESIGN

This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice.

METHODS

This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence-informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse-led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence.

CONCLUSIONS

Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this.

RELEVANCE TO PRACTICE

Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central.

Evidence-Based Practice and School Nursing

School nurses need to demonstrate that their practice is based on the best evidence available, which is usually data obtained from research. Evidence-based practice involves combining the best evidence available with nursing expertise and patient and family preferences to determine optimum care. Evidence-based practice guidelines are developed by carefully reviewing the available evidence on a topic and synthesizing this information into recommendations for practice. This article defines evidence-based practice and best evidence, describes the development of evidence-based practice guidelines, discusses factors that affect the use of research and evidence-based practice guidelines in school nursing, and reviews current sources of evidence-based practice guidelines for school nurses. Strategies that school nurses can use to incorporate evidence into their practice are discussed. One recommendation is that school nurses partner with nurse leaders and nurse researchers to develop evidence-based practice guidelines relevant to school nurse practice.

Translation, adaptation and psychometric testing of a tool for measuring nurses' attitudes towards research in Indonesian primary health care

AIM

The purpose of this study was to translate, adapt and psychometrically test the Nurses' attitudes towards and awareness of research and development within nursing (ATRAD-N) version II for measuring nursing research and research utilization in Indonesian primary health care nurses.

DESIGN

Cross-sectional survey.

METHOD

The translation process was conducted by applying the forward and back-translation method. Adaptation and content validity was assessed by six experts in Indonesia. The psychometric testing was performed using factor analysis and Cronbach's alpha coefficient on a sample of 92 primary health care nurses in South Kalimantan, Indonesia in 2013.

RESULTS

The translated instrument showed acceptable content validity with index of .97. The factor analysis (Principal Component Analysis with Direct Oblimin rotation) obtained a five-factor structure that differed from those identified in previous studies. The cumulative percentage of variance was 56.5%. The Cronbach's alpha coefficient for individual factors ranged from .719 - .884. The resulting form of the Indonesian ATRAD-N was found to have acceptable content validity and homogeneity reliability but not construct valid in Indonesian settings.

The impact of research education on student nurse attitude, skill and uptake of evidence-based practice: a descriptive longitudinal survey

AIMS AND OBJECTIVES

To measure the impact of an undergraduate research education program on the attitude, skill and uptake of evidence-based practice among undergraduate student nurses.

BACKGROUND

The contribution of evidence-based practice to clinical decision-making, quality of care and patient outcomes is well-documented. One approach to improving evidence-based practice uptake in clinical practice is through the provision of undergraduate research education; notwithstanding, the impact of research training on nursing practice is poorly established.

DESIGN

Descriptive longitudinal survey.

METHODS

Three hundred and fifty four third-year nursing students enrolled in a Bachelor of Nursing program of a large Australian University were invited. Pre- (Phase 1) and post-completion (Phase 2) of a 16-week research education program, participants were asked to complete the Evidence-Based Practice Attitude and Utilization Survey; an 82-item online questionnaire measuring attitudes, skills and use of evidence-based practice, and barriers and facilitators of evidence-based practice uptake.

RESULTS

The survey was completed by 84 (24%) participants in Phase 1 and 33 (39% of Phase 1) participants in Phase 2. Program exposure resulted in a significant improvement in median skill and use subscores, but not median attitude subscore. Participants perceived inadequate skills in the interpretation, appraisal and application of research findings to clinical practice as being less of a barrier to evidence-based practice uptake posteducation, and access to online critical appraisal tools as being significantly more useful in facilitating evidence-based practice uptake posteducation.

CONCLUSIONS

The findings suggest that undergraduate research education may have a significant effect on nursing students' research skills and use of evidence-based practice, and minimise barriers to evidence-based practice uptake posteducation.

RELEVANCE TO CLINICAL PRACTICE

Undergraduate research education may play an important role in improving student nurse uptake of evidence-based practice; whether these changes can be sustained when transitioning from student nurse to registered nurse is a question for further research.

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews

Background

This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.

Design

This study is a systematic review of reviews.

Methods

MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.

Results

Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.

Conclusions

This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.

Systematic review registration

PROSPERO CRD42014009410

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0396-4) contains supplementary material, which is available to authorized users.

Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews

OBJECTIVE

To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care.

DESIGN

Systematic review of reviews.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion.

DATA SYNTHESIS

Extracted data were synthesised using a narrative approach.

RESULTS

91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality.

CONCLUSIONS

There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies.

PROSPERO REGISTRATION NUMBER

CRD42014009410.

What are the factors of organisational culture in health care settings that act as barriers to the implementation of evidence-based practice? A scoping review

BACKGROUND

The responsibility to implement evidence-based practice (EBP) in a health care workplace does not fall solely on the individual health care professional. Organisational barriers relate to the workplace setting, administrational support, infrastructure, and facilities available for the retrieval, critique, summation, utilisation, and integration of research findings in health care practices and settings.

OBJECTIVE

Using a scoping review approach, the organisational barriers to the implementation of EBP in health care settings were sought.

METHOD

This scoping review used the first five of the six stage methodology developed by Levac et al. (2010). The five stages used are: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The following databases were searched from January 2004 until February 2014: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL.

RESULTS

Of the 49 articles included in this study, there were 29 cross-sectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. The articles were analysed and five broad organisational barriers were identified.

CONCLUSIONS

This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. Even for a health care professional who is motivated and competent in the use of EBP; all of these barriers will impact on their ability to increase and maintain their use of EBP in the workplace.

Medical students' attitudes on and experiences with evidence-based medicine: a qualitative study

RATIONALE, AIMS AND OBJECTIVES

This qualitative study was designed to determine the attitudes towards and experiences of medical students on evidence-based medicine (EBM).

METHODS

The study was conducted using the phenomenological method. Medical students' attitudes about and experiences with evidence-based medicine were determined through semi-structured interviews. Forty senior medical students were chosen by purposive sampling from medical sciences students of Tabriz University and Shahid Beheshti University. The context of interviews was analysed using the content analysis method.

RESULTS

Medical students' attitudes and experiences were ascertained through four main questions, and their answers were divided in to 12 categories and 31 subcategories. According to the subjects of the study, two basic concepts that they understood about EBM were its being up to date and requiring research skills. To the question what is necessary for EBM, the students' answers were summarized as follows: access to information, teamwork and faculty members who could provide modeling and organizational support. Students reported having used EBM for problem solving, thinking and self-confidence. On the other hand, lack of equipment and facilities, human factors and organizational factors were considered the main barriers to EBM use.

CONCLUSION

According to the results of this study, providing suitable conditions and appropriate planning to address identified barriers and encouraging students can promote EBM practice. Also, more extensive EBM integration in medical curricula and clinical settings by leading faculty members would prompt medical students to use EBM in their daily practice.

Barriers to evidence-based medicine: a systematic review

INTRODUCTION

Evidence-based medicine (EBM) has emerged as an effective strategy to improve health care quality. The aim of this study was to systematically review and carry out an analysis on the barriers to EBM.

METHODS

Different database searching methods and also manual search were employed in this study using the search words ('evidence-based' or 'evidence-based medicine' or 'evidence-based practice' or 'evidence-based guidelines' or 'research utilization') and (barrier* or challenge or hinder) in the following databases: PubMed, Scopus, Web of Knowledge, Cochrane library, Pro Quest, Magiran, SID.

RESULTS

Out of 2592 articles, 106 articles were finally identified for study. Research barriers, lack of resources, lack of time, inadequate skills, and inadequate access, lack of knowledge and financial barriers were found to be the most common barriers to EBM. Examples of these barriers were found in primary care, hospital/specialist care, rehabilitation care, medical education, management and decision making. The most common barriers to research utilization were research barriers, cooperation barriers and changing barriers. Lack of resources was the most common barrier to implementation of guidelines.

CONCLUSION

The result of this study shows that there are many barriers to the implementation and use of EBM. Identifying barriers is just the first step to removing barriers to the use of EBM. Extra resources will be needed if these barriers are to be tackled.

Improving treatment of depression in primary health care: a case study of obstacles to perform a clinical trial designed to implement practice guidelines

AIM

The aim of this study is to investigate factors contributing to the failure of a randomized clinical trial designed to implement and test clinical practice guidelines for the treatment of depression in primary health care (PHC).

BACKGROUND

Although the occurrence of depression is increasing globally, many patients with depression do not receive optimal treatment. Clinical practice guidelines for the treatment of depression, which aim to establish evidence-based clinical practice in health care, are often underused and in need of operationalization in and adaptation to clinical praxis. This study explores a failed clinical trial designed to implement and test treatment of depression in PHC in Sweden.

METHOD

Qualitative case study methodology was used. Semi-structured interviews were conducted with eight participants from the clinical trial researcher group and 11 health care professionals at five PHC units. Additionally, archival data (ie, documents, email correspondence, reports on the clinical trial) from the years 2007-2010 were analysed.

FINDINGS

The study identified barriers to the implementation of the clinical trial in the project characteristics, the medical professionals, the patients, and the social network, as well as in the organizational, economic and political context. The project increased staff workload and created tension as the PHC culture and the research activities clashed (eg, because of the systematic use of questionnaires and changes in scheduling and planning of patient visits). Furthermore, there was a perception that the PHC units' management did not sufficiently support the project and that the project lacked basic incentives for reaching a sustainable resolution. Despite efforts by the project managers to enhance and support implementation of the innovation, they were unable to overcome these barriers. The study illustrates the complexity and barriers of performing clinical trials in the PHC.

A literature review of end-stage renal disease and cachexia: understanding experience to inform evidence-based healthcare

INTRODUCTION

Cachexia is a major cause of morbidity and mortality in people who have end-stage renal disease (ESRD). The majority of research into cachexia in ESRD has focused on the biological aspects of the syndrome and potential treatment modalities. While this research is necessary, it predominately focuses on the physical impact of cachexia in ESRD. The multi-dimensional psychosocial ramifications of this syndrome have been highlighted in other end-stage illness trajectories, but have not been systematically explored in persons who have ESRD.

AIM

This paper discusses why this research is necessary, alongside further studies to help define the pathophysiology of this syndrome.

CONCLUSION

The rich insightful data gained from understanding the patients' illness experience will positively contribute to the limited knowledge base available and inform future holistic patient-centred care delivery which recognises and responds to not only the biological but also the psychosocial impact of cachexia.

A survey of Australian chiropractors' attitudes and beliefs about evidence-based practice and their use of research literature and clinical practice guidelines

Background

Research into chiropractors’ use of evidence in clinical practice appears limited to a single small qualitative study. The paucity of research in this area suggests that it is timely to undertake a more extensive study to build a more detailed understanding of the factors that influence chiropractors’ adoption of evidence-based practice (EBP) principles. This study aimed to identify Australian chiropractors’ attitudes and beliefs towards EBP in clinical practice, and also examine their use of research literature and clinical practice guidelines.

Methods

We used an online questionnaire about attitudes, beliefs and behaviours towards the use of EBP in clinical practice that had been developed to survey physiotherapists and modified it to ensure that it was relevant to chiropractic practice. We endeavoured to survey all registered Australian chiropractors (n = 4378) via email invitation distributed by Australian chiropractic professional organisations and the Chiropractic Board of Australia. Logistic regression analyses were conducted to examine univariate associations between responses to items measuring attitudes and beliefs with items measuring: age; years since registration; attention to literature; and use of clinical practice guidelines.

Results

Questionnaires were returned by 584 respondents (response rate approximately 13%). The respondents’ perceptions of EBP were generally positive: most agreed that the application of EBP is necessary (77.9%), literature and research findings are useful (80.2%), EBP helps them make decisions about patient care (66.5%), and expressed an interest in learning or improving EBP skills (74.9%). Almost half of the respondents (45.1%) read between two to five articles a month. Close to half of the respondents (44.7%) used literature in the process of clinical decision making two to five times each month. About half of the respondents (52.4%) agreed that they used clinical practice guidelines, and around half (54.4%) agreed that they were able to incorporate patient preferences with clinical practice guidelines. The most common factor associated with increased research uptake was the perception that EBP helps make decisions about patient care.

Conclusions

Most Australian chiropractors hold positive attitudes towards EBP, thought EBP was useful, and were interested in improving EBP skills. However, despite the favourable inclination towards EBP, many Australian chiropractors did not use clinical practice guidelines. Our findings should be interpreted cautiously due to the low response rate.

The challenges of communicating research evidence in practice: perspectives from UK health visitors and practice nurses

BACKGROUND

Health practitioners play a pivotal role in providing patients with up-to-date evidence and health information. Evidence-based practice and patient-centred care are transforming the delivery of healthcare in the UK. Health practitioners are increasingly balancing the need to provide evidence-based information against that of facilitating patient choice, which may not always concur with the evidence base. There is limited research exploring how health practitioners working in the UK, and particularly those more autonomous practitioners such as health visitors and practice nurses working in community practice settings, negotiate this challenge. This research provides a descriptive account of how health visitors and practice nurses negotiate the challenges of communicating health information and research evidence in practice.

METHODS

A total of eighteen in-depth telephone interviews were conducted in the UK between September 2008 and May 2009. The participants comprised nine health visitors and nine practice nurses, recruited via adverts on a nursing website, posters at a practitioner conference and through recommendation. Thematic analysis, with a focus on constant comparative method, was used to analyse the data.

RESULTS

The data were grouped into three main themes: communicating evidence to the critically-minded patient; confidence in communicating evidence; and maintaining the integrity of the patient-practitioner relationship. These findings highlight some of the daily challenges that health visitors and practice nurses face with regard to the complex and dynamic nature of evidence and the changing attitudes and expectations of patients. The findings also highlight the tensions that exist between differing philosophies of evidence-based practice and patient-centred care, which can make communicating about evidence a daunting task.

CONCLUSIONS

If health practitioners are to be effective at communicating research evidence, we suggest that more research and resources need to be focused on contextual factors, such as how research evidence is negotiated, appraised and communicated within the dynamic patient-practitioner relationship.

Beliefs and expectations of paramedics towards evidence-based practice and research

OBJECTIVE

The objective of this cross-sectional online survey was to better understand the beliefs of paramedics towards research and evidence-based practice and their expectations regarding its impact on their ability to provide patient care.

METHODS

An online survey of frontline paramedical staff in New South Wales, Australia, was conducted in March, 2010. Paramedics were asked to respond to five questions relating to their beliefs and expectations relating to prehospital research and evidence-based practice, using a four-point Likert scale for each. Descriptive statistics are used to describe responses to survey questions. Tests for trend between nominal and ordinal explanatory variables and ordinal survey responses were performed using χ(2) statistics.

RESULTS

There were 892 responses to the survey throughout the 1-month study period. The vast majority of paramedics believed prehospital research and paramedic participation in research were very important. Ninety per cent believed prehospital research would improve patient care, while 92% reported being likely to change clinical practice as a result of prehospital evidence. Paramedics with shorter lengths of service and those with tertiary education were significantly more supportive of, and had higher expectations of, research and evidence-based practice.

CONCLUSIONS

Paramedics who responded to this online survey appear to have generally positive expectations of and perceptions towards evidence-based practice and research and their impact on prehospital care. Tertiary education and shorter length of service were associated with more positive expectations of, and higher level of support for, evidence-based practice.

Barriers to, and facilitators of, research utilisation: a survey of Hong Kong registered nurses

Aim  Despite increasing efforts to promote the utilisation of research in daily nursing practice it is apparent that there are a number of obstacles to address. This paper reports a study to examine the barriers to, and facilitators of, research utilisation among registered nurses in Hong Kong. Methods  A survey design and a random sampling method was used. The final sample consisted of 1487 registered nurses working in private and public health-care sectors in Hong Kong. A bilingual version of the Research Utilisation Questionnaire, comprising a 31-item barriers scale, and an 8-item facilitators scale was used. The instrument was mailed to participants who were asked to return the completed questionnaire by mail. Results  The highest ranking barriers to research utilisation reported by respondents were related mainly to organisational factors with regards to inadequate facilities, no authority to change procedures, and time constraints. Hong Kong nurses, however, did not appear to see any problem with regards to items related to characteristics of research, such as conclusions drawn from research being justified, research articles not being published fast enough, and literature reporting conflicting results. This indicates that nurses are aware of research developments in nursing and can critically analyse research reports. With regards to facilitators of research utilisation, respondents agreed that managerial and peer support are the greatest facilitators. Conclusions  The results indicate that factors influencing research utilisation are multidimensional and should be taken into account by all involved in the research enterprise: researchers, practitioners, educators, managers and policy-makers. The results of this study provide directions on how to assist nurses in Hong Kong in their efforts to utilise research.

Implementation and spread of interventions into the multilevel context of routine practice and policy: implications for the cancer care continuum

The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability.

Validation of the theoretical domains framework for use in behaviour change and implementation research

BACKGROUND

An integrative theoretical framework, developed for cross-disciplinary implementation and other behaviour change research, has been applied across a wide range of clinical situations. This study tests the validity of this framework.

METHODS

Validity was investigated by behavioural experts sorting 112 unique theoretical constructs using closed and open sort tasks. The extent of replication was tested by Discriminant Content Validation and Fuzzy Cluster Analysis.

RESULTS

There was good support for a refinement of the framework comprising 14 domains of theoretical constructs (average silhouette value 0.29): 'Knowledge', 'Skills', 'Social/Professional Role and Identity', 'Beliefs about Capabilities', 'Optimism', 'Beliefs about Consequences', 'Reinforcement', 'Intentions', 'Goals', 'Memory, Attention and Decision Processes', 'Environmental Context and Resources', 'Social Influences', 'Emotions', and 'Behavioural Regulation'.

CONCLUSIONS

The refined Theoretical Domains Framework has a strengthened empirical base and provides a method for theoretically assessing implementation problems, as well as professional and other health-related behaviours as a basis for intervention development.

Attitude towards Evidence-Based Nursing Questionnaire: development and psychometric testing in Spanish community nurses

BACKGROUND

A readiness assessment for identifying and measuring variables that can facilitate evidence-based nursing (EBN) is important. Attitude towards EBN is one of its components. However, questionnaires that exclusively measure attitude to EBN do not exist in Spanish-speaking contexts.

AIM

This paper is a report of the development and psychometric testing of a Spanish-language assessment tool: the Evidence-Based Nursing Attitude Questionnaire (EBNAQ).

METHODS

The questionnaire was developed in three phases: item generation through a review of scientific literature and focus groups; item selection through an expert review; content and construct validity testing, and internal consistency reliability testing. The instrument was validated in terms of construct validity by a factorial analysis and content validity by grouping the items into the three categories of attitude: cognitive, affective and behavioural. Data were collected from May to November of 2008.

RESULTS

The questionnaire was validated in a sample of 219 Spanish community nurses, who had a mean age of 43.21 (SD 10.3) years, and 64.5% (141) were women. A total of 54.3% (121) had been working in the community for more than 10 years. The questionnaire consisted of 15 items grouped into the three factors that make up the concept of attitude. Cronbach's alpha was 0.853 for the entire questionnaire. The factor solution explained 54.70% of the variance.

CONCLUSIONS

The EBNAQ is brief, making it a user-friendly tool. It is the first Spanish-language questionnaire that exclusively measures attitude towards EBN in nurses who work in the community. The EBNAQ can be used efficiently in research and practice settings to better understand nurses' attitudes towards evidence-based practice.

Psychometric testing of the Spanish version of the practice environment scale of the nursing work index in a primary healthcare context

AIM

This paper is a report of psychometric testing of the Spanish version of the Practice Environment Scale of the Nursing Work Index for use in a primary health care.

BACKGROUND

The Practice Environment Scale of the Nursing Work Index has been widely used in different studies and contexts. However, there is no validated version for primary care nursing staff in Spain.

METHODS

A descriptive, multicentre, cross-sectional study for transcultural adaptation and psychometric validation purposes. Data were collected from October 2009 to January 2010. To test the reliability of the factors in the measurement model, Cronbach's alpha was used. To study the measurement model, different structural models were tested, using exploratory and confirmatory factor analyses. 377 completed questionnaires were obtained from a total of 553 nurses working for the Public Health Service in the Balearic Islands (Spain). This represents a response rate of 68·2%.

RESULTS

For overall reliability, a Cronbach alpha of 0·91 was obtained. The confirmatory analysis upholds the original five-factor structure.

CONCLUSION

The excellent goodness of fit of the confirmatory analysis corroborates the validity of this adapted version in primary healthcare contexts.

Are complementary medicine practitioners implementing evidence based practice?

BACKGROUND

Over the past few decades the health professions have witnessed increasing pressure to shift from a culture of delivering care based on tradition and intuition, to a situation where decisions are guided and justified by the best available evidence. While there are concerns that many complementary and alternative medicine (CAM) practitioners may be cautious about embracing such an approach, no studies to date have effectively tested this assumption.

OBJECTIVE

To identify the skills, attitude, training and use of evidence-based practice (EBP) amongst CAM practitioners.

DESIGN

Descriptive survey, using the evidence-based practice attitude and utilisation survey (EBASE).

SUBJECTS

Randomly selected nationwide sample of system-based, non-medically qualified CAM practitioners practicing in a clinical capacity within Australia.

MAIN OUTCOME MEASURES

Practitioner skill, attitude, training and use of EBP.

RESULTS

Of the 351 questionnaires successfully dispatched, 126 were returned (36%). Most practitioners believed EBP was useful (92%) and necessary (73%) in CAM practice. While the majority of clinicians (>74%) reported participation in EBP activities, albeit infrequently, only a small to moderate proportion of decisions were based on evidence from clinical trials, with most practitioners relying on traditional knowledge, textbooks and clinical practice guidelines. Lack of available evidence, time, industry support and skills were perceived as barriers to EBP uptake.

CONCLUSIONS

While the small response rate limits the generalisability of these findings, the sample was considered representative of Australian CAM practitioners. What this study shows is that even though CAM practitioners may be supportive of EBP, education and training is needed to further improve clinician understanding and application of evidence-based practice.

The research-practice relationship in ergonomics and human factors--surveying and bridging the gap

Significant discord has been aired regarding the widening research-practice gap in several disciplines (e.g. psychology, healthcare), especially with reference to research published in academic journals. The research-practice gap has profound and wide-ranging implications for the adequacy of ergonomics and human factors (E/HF) research and the implementation of research findings into practice. However, no substantive research on this issue has been identified in E/HF. Using an online questionnaire, practitioners were asked about their application of scientific research findings published in peer-reviewed journals and to suggest ways to improve research application in practice. A total of 587 usable responses were collected, spanning 46 countries. This article describes some of the key differences and correlations concerning reading, usefulness and barriers to application among respondents, who varied in terms of organisational type, percentage of work time devoted to application vs. research, society membership and experience. Various solutions proposed by the survey respondents on ways to bridge the research-practice gap are discussed. STATEMENT OF RELEVANCE: The relationship between research and practice in E/HF has long been a subject of discussion, with commentators pointing to tension and possible implications for the adequacy of the discipline. Findings from a cross-sectional survey provide ergonomics practitioners' views on research, leading to discussion of strategies for achieving better integration.

Critical care: does profusion of evidence lead to confusion in practice?

There have been a plethora of articles on evidence-based practice or its many derivative terms (evidence-based nursing, evidence-based medicine, evidence-based health care, etc.). However, the word 'based' implies an almost unquestioning belief in evidence. I will argue that the term 'Evidence Informed Practice' is probably more accurate. This argument will be underpinned by Archie Cochrane's 'road to Damascus' questioning of the value of soft over hard interventions and challenge what is held up as gold-standard evidence. The differences in definitions of evidence-based practice will also be discussed. Carper's identification of ethical, aesthetic and personal knowing will be used to debunk the myth that empirical evidence is always the gold standard for care and treatment. It will be argued that empirical evidence can be ignored when it clashes with other types of evidence. Finally, the tension between certainty and agreement with evidence will be explored.

Virtual Communities of Practice: Bridging Research and Practice Using Web 2.0

A significant dilemma for the health and human service professions continues to be the question of how best to bridge the divide between academic research and practice. Communities of practice have traditionally been a vehicle for collaborative research and for information exchange (Moore, 2008). Through collaboration, communities of practice have the ability to disseminate knowledge and transmit best practices in these disciplines (Barry, 2007). However, organizational constraints on time can impose barriers to professional partnerships (i.e., Le May, Mulhall, & Alexander, 1998). Increasingly restrictive research agendas of faculty pose an additional barrier (Colbeck, 2000). Web 2.0 technologies may offer a solution to this challenge. According to Boulos and Wheeler (2007), Web 2.0 technologies “represent a quite revolutionary way of managing and repurposing/remixing online information and knowledge repositories, including clinical and research information, in comparison with the traditional Web 1.0 model” (p. 2). Also, a greater repository of information among communities of practice can be generated via new technology (Kok, 2006). This article describes a virtual community of practice developed through a partnership between the University at Buffalo School of Social Work and the University at Buffalo Teaching and Learning Center. A participatory process that included stakeholder input through use of surveys and focus groups was employed. A definition of community of practice is presented, and the five stages of development of communities of practice as outlined by Wenger, McDermott, and Snyder (2002) is applied to the current example. The utility of an online social networking tool for creating professional partnerships and for knowledge dissemination is explored. Barriers to implementation are expounded.

The place and barriers of evidence based practice: knowledge and perceptions of medical, nursing and allied health practitioners in malaysia

Background

Despite a recent increase in activities to promote evidence-based practice (EBP), it was unclear how Malaysian hospital practitioners received this new approach in medicine. This study examines their confidence and perceptions on EBP.

Findings

We conducted cross-sectional surveys using a self-administered questionnaire during two EBP training courses in two Malaysian hospitals in January and June 2007. Our subjects (n = 144) were doctors and nursing and allied health staff (NAH) participating in the EBP courses. Our questionnaire covered three domains: confidence and understanding (six items), attitude (five items) and barriers to practice (four items). We presented simple descriptive statistics, including the sum ratings and the proportions with different responses for each item, and compared different groups using Mann-Whitney U test for scaled ratings and Chi-square test for dichotomous responses.

Ninety-two doctors and 52 NAH staff completed the surveys. Overall, doctors expressed slightly higher confidence on EBP compared to NAH staff. Out of a maximum sum rating of 27 over six items, doctors reported an average of 18.3 (SD 3.2) and NAH staff reported an average of 16.0 (SD 3.4), p = 0.002. Doctors were also more positive in their views on EBP. For example, 67.4% of doctors disagreed, but 61% of NAH staff agreed that "the importance of EBP in patient care is exaggerated", and 79.3% of doctors disagreed, but 46.2% of NAH staff agreed that "EBP is too tedious and impractical". Similar responses were observed for other items in the domain.

Doctors and NAH staff shared similar concerns on barriers to evidence-based practice. The highest proportions considered poor facilities to access evidence a barrier (76% of doctors and 90% of NAH), followed by poor awareness of evidence (62% of doctors and 70% of NAH) and time constraints (63% of doctors and 68% of NAH), p = 0.09 for the combined rating of four items in the domain.

Conclusions

The findings of our survey suggest a need for greater efforts in promoting EBP among Malaysian hospital practitioners especially for NAH staff. From the responses based on the barriers to EBP, improving facilities for accessing evidence and promoting more user-friendly resources to address time constraints appear to be the priorities.

Exploring decision making in intellectual disability nursing practice: a qualitative study

Due to the dearth of relevant research, intellectual disability nurses may have difficulty identifying sources of evidence on which they can base their clinical decisions. The aim of the present research was to explore how intellectual disability nurses make decisions and how their decisions are influenced by evidence. The method was guided by interpretative phenomenology and the analysis adopted an idiographic approach. Twelve National Health Service intellectual disability nurses in Wales participated in semi-structured interviews. Four key themes were identified: getting to know the person; working as a team; evidence to support decision making; and understanding of evidence-based practice. In the context of the myriad of other professionals involved in caregiving, the nurses conveyed a commitment towards ensuring that the person with intellectual disability is at the centre of decision making. Although using empirical evidence to support practice was acknowledged, these nurses considered person centred decision making to be paramount.

Healthcare professionals' intentions to use clinical guidelines: a survey using the theory of planned behaviour

Background

Finnish clinical guidelines are evolving toward integration of knowledge modules into the electronic health record in the Evidence-Based Medicine electronic Decision Support project. It therefore became important to study which factors affect professionals' intention to use clinical guidelines generally in their decision-making on patient care. A theory-based approach is a possible solution to explore determinants of professionals' behaviour. The study's aim was to produce baseline information for developers and implementers by using the theory of planned behaviour.

Methods

A cross-sectional internet-based survey was carried out in Finnish healthcare organisations within three hospital districts. The target population (n = 2,252) included physicians, nurses, and other professionals, of whom 806 participated. Indicators of the intention to use clinical guidelines were observed by using a theory-based questionnaire. The main data analysis was done by means of multiple linear regressions.

Results

The results indicated that all theory-based variables--the attitude toward the behaviour, the subjective norm, and the perceived behaviour control--were important factors associated with the professionals' intention to use clinical practice guidelines for their area of specialisation in the decisions they would make on the care of patients in the next three months. In addition, both the nurse and the physician factors had positive (p < 0.01) effects on this intention in comparison to other professionals. In the similar models for all professions, the strongest factor for the physicians was the perceived behaviour control, while the key factor for the nurses and the other professionals was the subjective norm. This means that context- and guideline-based factors either facilitate or hinder the intention to use clinical guidelines among physicians and, correspondingly, normative beliefs related to social pressures do so for nurses and other healthcare professionals.

Conclusions

The results confirm suggestions that the theory of planned behaviour is a suitable theoretical basis for implementing clinical guidelines in healthcare practices. Our new finding was that, in general, profession had an effect on intention to use clinical guidelines in patient care. Therefore, the study reaffirms the general contention that different strategies need to be in place when clinical guidelines are targeted at different professional groups.

Why isn't more injury prevention evidence-based?

The focus on evidence-based practice is critical to addressing the issue of injuries, yet advances in the science of injury prevention have not always led to advances in practice. Effective approaches are not always adopted, or when adopted and transferred from one setting to another, they do not always achieve expected results. These challenges were the basis of two breakout sessions at the second European Injury Control and Safety Promotion Conference in Paris, France (October 2008). In summarising the key issues raised during those sessions, this article describes what is meant by evidence-based practice, discusses why evidence-based practice tends not to occur and considers approaches that may facilitate the adoption and implementation of evidence-based strategies. To address the challenge, specific action is required, both on the part of the research community and those responsible for developing and implementing injury prevention policies and programmes.

Nurses' perceptions of the barriers to and the facilitators of research utilization in Turkey

The aim of this study was to determine nurses' perceptions of the barriers to and facilitators of research utilization in Turkey. Barriers Scale was utilized in the research, and the population was 631 nurses. According to the research results, the first three important barriers were inadequate authority (63.6%), lack of time (54.0%), and insufficient facilities (52.8%). Nurses have perceived the organizational management support as the most important easing factor in their applications (n = 156). It is highly recommended that nurses be trained in research methods and evidence-based practice, that research articles be written more clearly, and that Research and Development centers where nurses could get consultation services be established.

The evidence-based practice ideologies

This paper puts forward the argument that there are various, competing, and antithetical evidence-based practice (EBP) definitions and acknowledges that the different EBP definitions are based on different epistemological perspectives. However, this is not enough to understand the way in which nurse professionals choose between the various EBP formations and consequently facilitate them in choosing the most appropriate for their needs. Therefore, the current article goes beyond and behind the various EBP epistemologies to identify how individuals choose an epistemology, which consequently will assist our understanding as to how an individual chooses a specific EBP formation. Individuals choose an epistemology on the mere belief that the specific epistemology offers the ideals or ideas of best explaining or interpreting daily reality. These ideals or ideas are termed by science, history, and politics as ideology. Similarly, individual practitioners choose or should choose between the different EBP formations based on their own personal ideology. Consequently, this article proceeds to analyse the various ideologies behind different EBP definitions as to conclude that there are two broad ideologies that inform the various EBP formations, namely the ideology of truth and the ideology of individual emancipation. These two ideologies are analysed and their connections to the various EBP formations are depicted. Eventually, the article concludes that the in-depth, critical, and intentional analysis by individual nurses of their own ideology will allow them to choose the EBP formation that is most appropriate and fitting for them, and their specific situation. Hence, the conscious analysis of individual ideology becomes the criterion for choosing between competing EBP formations and allows for best evidence to be implemented in practice. Therefore, the best way to teach EBP courses is by facilitating students to analyse their own ideology.

Nursing students learning to utilize nursing research in clinical practice

The purpose of the study was to examine the significance of a learning assignment in relation to research skills and learning of nursing students in clinical practice. The learning assignment included an oral presentation of a nursing research article, which the students gave to their fellow students and ward nurses. The students also chaired the discussion after the presentation. The target group for the study was nursing students of a Finnish polytechnic who had been studying for 2-2 1/2 years and had accomplished a minimum of 120 ECTS credits of the total of 210 ECTS credits. When participating in the study, the students were completing a six-week clinical practice of optional studies. The data were collected with a questionnaire designed for the study. It consisted of six open-ended questions. Three of the questions were related to learning of research skills. Two questions were concerned with learning during the ongoing clinical practice. The final question inquired the students' views on the development of the learning assignment. The students received the questionnaire before the commencement of their clinical practice, and they returned it to the other researcher after their clinical practice. The questionnaire was given to 80 students, of which 50 returned it; the response rate was 63%. The data were analysed by content analysis question by question. According to the results, the learning assignment advanced the understanding of research concepts for the majority of the students. In particular, the students reported that the oral presentation clarified the research concepts, and the structure of a scientific article was also elucidated. The students stated that the assignment generated ideas concerning the development of nursing care. In relation to the ongoing clinical practice, the assignment advanced patient encounters and interaction, and bearing responsibility the most. Proposals for the further development of the learning assignment were expressed by more than half of the nursing students. Half of them suggested ensuring the interest in the topic from the ward.

Clinical Nurse Specialists' Use of Evidence in Practice: A Pilot Study

BACKGROUND

The interest in finding ways to bridge the gap between nursing research and implementation of findings into practice has been increasing. Clinical nurse specialists (CNSs) may be a bridge between frontline nurses and current developments in practice. While several researchers have studied the use of evidence by nurses in general, no known studies have been focused specifically on the use of evidence by CNSs.

PURPOSE

The purpose of this pilot study was to develop an understanding of the sources, nature, and application of evidence used by CNSs in practice and to investigate the feasibility of conducting a qualitative study focused on the CNS role in relation to evidence use in practice.

METHODS

This pilot study is a descriptive exploratory design in the qualitative paradigm. Seven CNSs from a large Western Canadian health region were interviewed. Interview transcripts were reviewed for recurrent themes about sources of evidence, evidence use, and barriers and facilitators to evidence use.

FINDINGS

CNSs access and use evidence from a variety of sources. All CNSs indicated that research literature was a primary source of evidence and research was used in decision-making. Peers and experience were also important sources of evidence. CNSs used the Internet extensively to consult research databases, online sources of evidence, and to contact peers about current practice. CNSs also gathered evidence from frontline nurses, healthcare team members, and families before decision-making. The choice of evidence often depended upon the type of question they were attempting to answer. Barriers cited by CNSs support previous research and included lack of time, resources, and receptivity at clinical and organizational levels. Facilitators included peers, organizational support, and advanced education.

DISCUSSION

CNSs in Canada have advanced education and clinical expertise and many are employed in roles that permeate organizational management and clinical nursing care. It is suggested that qualitative research in naturalized settings that investigates the role of CNSs in relation to the dissemination of evidence in nursing practice needs attention.

A review of evidence-based practice, nursing research and reflection: levelling the hierarchy

AIM

This paper examines the evidence-based practice movement, the hierarchy of evidence and the relationship between evidence-based practice and reflective practice.

BACKGROUND

Evidence-based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice.

METHOD

A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence-based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence-based practice, reflection and research. Only material written in English was included.

FINDINGS

The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence-based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence-based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence.

CONCLUSION

Evidence-based practice is necessary for nursing, but its' effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence-based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence-based practice movement.

RELEVANCE TO CLINICAL PRACTICE

Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.