According to the Institute of Medicine, as many as 98,000 patient deaths occur each year in U.S. health facilities. One primary limitation of current research of nurses' use of research-based knowledge in practice is that the vast majority of studies, which have described barriers and facilitators of evidence-based practice have been qualitative or quasi-experimental designs. There is a paucity of research related to studies about the acquisition and implementation of research-based knowledge in nursing practice in the context of real-time problems that must be solved with on the spot reflective practice. This study examined the effect of a 3-part evidence-based-practice exercise on capability beliefs of RNs to access and implement research-based knowledge into practice. Bandura's Social Cognitive Theory guided the study. Confidence levels were measured using the Evidence-Based Practice Capability Belief Scale post-intervention. For inferential findings, data was analyzed using Independent T-tests, and Mann-Whitley U. Descriptive statistics and p-values compared the two randomly assigned groups on the demographic variables. Chi-square statistics were used to report these findings.
Purpose. The purpose of this study is to promote evidence-based practice behaviors in RNs who provide direct patient care in an Emergency Department setting on a number of important indicators. Also, this study will aim to redirect incorrect self-beliefs and habits of thinking that EBP behaviors cannot be regularly used in nursing practice.
Background. There is a need to understand nurses thought processes in situations that require them to acquire new knowledge. Despite efforts to move research knowledge into regular nursing practice, the scholarship of research remains primarily in academia. Many problems nurses face must be solved by on the spot reflection and actions must be undertaken with time constraints that further add to the complexity of patient care. It is not reasonable to expect nurses to take time to form research questions and perform statistical designs while caring for patients. Furthermore, it is not reasonable to expect nurses to possess all knowledge available to solve every problem they may face on a typical day. Nurses should be confident that they can access and implement research-based knowledge into their practice and there should be user-friendly ways to do so.
Evidence suggests that research knowledge integrated into nursing practice makes patient care safer, more economical and increases patient satisfaction (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). However, nurses do not routinely participate in the acquisition and implementation of current research (Brown et al., 2009; Fink et al., 2005; &Kaplan et al., 2014). Although nurses agree that implementation of research knowledge would improve patient care, nurses do not see the relevance of research in their own practice (Aboshaiqah, Qasim, Abashaireth, & Patalagsa, 2014; Estabrooks, 1998), nor do they consider it part of their professional responsibility (Majid et al., 2011; Wallen, et al., 2010). Researchers have attempted to bridge the gap between research and practice. Numerous studies identify personal and environmental barriers as well as facilitators to implementation of research knowledge into practice. In one such study, researchers aimed to link scientific evidence to nursing practice, by providing a cadre of research mentors, who were knowledgeable in research implementation and made the mentors available to staff nurses. The mentors assisted nurses in formulating answerable clinical questions supported by sound research evidence. Other researchers aiming to stimulate scientific curiosity in nurses introduced research concepts in easily understood terms, such as whether sugar-free chocolate chip cookies taste better than regular ones (Walden, Cephus, Gordon, & Johnson-Hagan, 2015), or whether healthy potato chips taste as good as less healthy ones (Wolf, Paoletti, & Hongyan, 2012). While there have been research interventions that claim statistical success, these interventions are expensive and emphasize the learning of research jargon and statistical designs. Furthermore, no evidence was found that these efforts have resulted in the sustainable long-term use of research knowledge translation into regular nursing practice, or how nurses translate research knowledge into practice. In order for behavior change to take place, nurses must acknowledge that (a) the standard of care for patient care changes as new information becomes available, (b) it is the responsibility of nurses to seek sound research knowledge to guide their practice, © there must be nurse buy-in to the concept of lifelong learning. This does not necessitate that nurses master statistical design. There has been little or no research that incorporates practice friendly strategies, such as smart-phone apps, whereby nurses can access sound clinical information, and apply it to their practice. This study has the potential to change the concept of research knowledge implementation into regular practice, in alignment with the vision of the IOM Future of Nursing by assessing capability beliefs of nurses to implement research evidence into regular practice. Emergency nurses will be used for this study. Emergency nurses are well suited to innovative approaches because of the variety and complexity of their clinical experiences. Also, emergency nurses have a multitude of problems that span all disciplines of nursing practice. Furthermore, emergency nurses are often the first point of contact into the health care system for at-risk populations (Hawk, 2013).
This study proposes to introduce novel approaches to bridge the research knowledge gap using hand-held and computer technology to develop nurse confidence in the acquisition and implementation of research-based knowledge in practice friendly ways that can be used at the point of care. Handheld technology is an effective clinical tool that can be used to access research knowledge and support evidence- based practice and the complex thinking required to approach clinical problems (Hudson & Buell, 2011.)
Research Question. Do Emergency Department (ED) nurses who provide direct patient care and participate in a 3-part Social Cognitive Theory (SCT) evidence-based practice video report higher beliefs in capability levels as measured by the belief capabilities scale, than comparable ED nurses who receive an attention control video about healthy lifestyles?
Bandura's self-efficacy theory conceptualizes personal efficacy beliefs as "beliefs in one's capabilities to organize, and execute the courses of action required to produce given attainments" (Bandura, 1997). Bandura, (1986) proposed a sociocognitive perspective of human functioning that recognized individuals as pro-active and self- regulating. Bandura (1986) emphasizes that a critical element of human behavior is self-belief. Bandura viewed people as self-organizing, proactive, self-reflecting and self-regulating rather than only reactive individuals, which are shaped only by their environment (Pajeres, 2006). According to SCT, human performance results from a dynamic relationship of personal, behavioral, and environmental influences (Glanz, Rimer, & Viswaneth,2008). For example, how people interpret the consequences or benefits of their behavior informs and may change subsequent behavior. This is the foundation of Bandura's (1986) conception of reciprocal determinism, the view that (a) personal factors (b) behavior, and © environmental influences create interactions that result in a triadic reciprocality.
Research Design . A pilot study was conducted in the fall of 2017. A randomized two-group experimental design was implemented using a sample of 45 nurses. Research procedures are described in detail in Appendix A.
Setting. The setting was an anonymous, secure, online survey delivered via PsychDataÂ®. This method enabled the respondents to complete the questionnaire at their convenience, in their preferred environment. The questionnaire could be completed via any device with Internet access, such as a computer, tablet, or cell phone.
Sample. The sample was drawn from a population of nurses, who were at least Registered Nurses that are employed in the emergency care setting and provide direct care to patients. The participants were licensed nurses employed in the U.S.; males and females; had the ability to read and understand English, and were 18 years of age or older. The participants for the study were recruited via placement of the recruitment letter with embedded link onto discussion boards in hospitals. Snowball sampling was utilized by encouraging participants to forward the recruitment letter with an embedded link to other potential participants.
A power analysis was conducted using a literature search. Because of the scarcity of experimental studies that closely correlate with my study, in terms of acquisition and implementation of research-based knowledge directed at the place where patient care occurs, characteristics of my study variables, such as self-management and self-efficacy were used. Three experimental studies were found that had enough information to calculate an effect size. The effect sizes of the studies reviewed were .3, .56, and .37. The effect size closest to my study is Borycki et al., so that effect (.3) was used for the study (See Table 1).
A minimum number of participants for the pilot study was 30. For a full study, a sample size of 240 was determined via power analysis using a power of .8 and an alpha of .05 based on a literature-based effect size of .35. An anticipated attrition rate of 10% added 24 participants for a total sample of 264. Therefore, 30 (more than 10%) was deemed adequate for the pilot study.
Instrument. The Evidence-Based Practice Capability Beliefs Scale (EBPCBS), developed by Wallin (2009) was used for data collection (Appendix B). The instrument has six items that measure the latent variables of capability beliefs; personal factors, environmental factors, and behavior. EBPCBS is a one-dimensional scale that specifically evaluates capability beliefs. The instrument adds to the construct of the study because it measures capability beliefs, which aligns with Bandura Social Cognitive Theory that measures self-efficacy, not intent. The answer choices for the six items on the scale were designed to assess nurses' capability beliefs to access and incorporate EBP behaviors into practice. It is criterion based because it was designed specifically to address capability beliefs. using a four-point response format (1 = to a very low extent, 2 = to a low extent, 3 = to a high extent, 4 = to a very high extent). The Likert-scale questionnaire was validated in a 2012 study conducted by Wallin, Bostrom, & Gustavsson. The reliability coefficient was established by Cronbach's alpha.
Data Collection Procedures. Following approval from the Texas Woman's University Institutional Review Board, data collection began. The survey was uploaded into the secure electronic platform, PsychDataÂ®. Participants remained anonymous to the researcher and consent to participate in the study was implied by completion of the online survey. The survey was open until adequate sample size was achieved. The participants accessed the survey by clicking on the link in the recruitment letter or by copy-and-pasting the link into their browser. The participants were recruited via the recruitment letter with embedded link, which was posted in 3 hospital breakrooms. Snowball sampling was encouraged in the recruitment letter.
Demographic information was obtained following completion of the survey. Information gathered included information about personal practice, including length of time in practice, whether the participant provides direct care to patients, employment status, and number of patient ED visits annually. Personal information was collected that included age, gender, educational level, and race. Demographic questions are listed in Appendix C.
Data Analytic Techniques. The completed surveys were exported into the Statistical Package for the Social Sciences (SPSS), Version 25 for analysis. Parametric and nonparametric tests were employed to answer the research question. For the data analysis, a statistician was consulted to determine the best analytical method based on the data collected. The choice of analytical methods would allow for appropriate conclusions to be drawn.
Sample Description. 56 participants accessed the link. Of the 56, 48 answered the questionnaire/posttest in full. Of the 54, 28 were randomized to the control group and 28 to the intervention group. 3 participants answered that they did not provide direct patient care, so those surveys were eliminated. There were 45 useable surveys. Of these, 20 were randomized to the intervention group and 25 were randomized to the attention control group. The principal investigator was unable to obtain information on the number of participants who copied the posted link. In addition, snowball sampling was encouraged in the recruitment letter. Therefore, the response rate for the survey was unable to be determined. (See Table 2 for sample description).
Instrument Reliability and Validity. Content validity was examined for the CBS with Item-Content Validity indices between 0.8 and 1 (Bostrom et al., 2009). Construct validity was examined by Wallin et al., (2012). The internal structure of the CBS was performed by using two groups for exploratory and confirmatory analysis. Factor analysis of item correlations between the two groups was performed and confirmed the fit of the scale was invariant and could be replicated. Forsman et al., (2012), reported construct validity, with factor loadings between 0.78 and 0.84. Reliability for the CBS has been examined using with Cronbach alphas reported between 0.75 and 0.90., (Forsman et al.,2012; Rudman et al., 2012).
Research Question. The completed surveys were exported into the Statistical Package for the Social Sciences (SPSS) Version 25 for analysis. First, Likert type items were checked for normality using skewness and kurtosis statistics. Despite the small sample size, none of the skewness or kurtosis statistics are above an absolute value of 2.0, therefore it can be assumed that each distribution is normal. Next, the statistical assumption of homogeneity of variance was tested. The two groups were compared using independent samples t-tests. There was a non-significant difference between the groups for Likert item 4, p = .16. However, it was violated for Likert items 1, 2, 3, 5, and 6. Therefore, Mann-Whitley U tests were done for questions 1,2,3,5 and 6.
The statistical assumption of homogeneity of variance was checked using independent samples t-test. Homogeneity of variance is the assumption that the samples are obtained from populations of equal variance (Pallant, 2013). The independent samples t-test is a parametric technique that requires one categorical independent variable with two groups (intervention and control), and one continuous dependent variable (confidence levels) (Pallant, 2013). The independent samples t-test compares the mean scores of 2 different groups of people (Pallant, 2013). Homogeneity of variance was violated for Likert items 1, 2, 3, 5, and 6 because, for these items, the significant values are less than .05. Therefore, Mann-Whitley U was used for analyses for those comparisons. An independent-samples t-test was conducted to compare the confidence levels for group 1 (control) and group 2 (intervention). There was a non-significant difference between the groups for Likert item 4, p = .16. Because homogeneity of variance was violated for question 1,2,3,5, and 6, Mann-Whitney U tests were used for analysis of those questions. The Mann-Whitney U test is a non-parametric test that corresponds to the parametric independent samples test (Pallant, 2013). The Mann-Whitney U test compares medians of the two groups, converts the scores on the continuous variable to ranks across the two groups, and then evaluates whether the ranks for the two groups differ significantly (Pallant, 2013).
There was significant difference between the groups for Likert item 1, p = .025. There were non-significant differences for Likert item 2, p = .08, item 3, p = .12, item 5, p = .09, and item 6, p = .08. Descriptive statistics and p-values were used to compare the two randomly assigned groups on demographic variables. Chi-square statistics were used to report these findings. There was a non-significant difference between the groups for all characteristics. The results are summarized in table 4.
Relationship of findings to Literature and Theoretical Framework. Bandura Social Cognitive Theory (SCT) is concerned with people's beliefs in their capabilities to produce given achievements (Bandura, 1997). Bandura emphasized that human behavior and motivation are driven by beliefs that people have about their capabilities (Pajeres, 2006). The theoretical basis for the dependent variable in my study, capability beliefs to access and incorporate research-based evidence into practice, aligns with Bandura's ideas about self- efficacy. Self-efficacy is one's beliefs about how his or her actions produce future attainments. Modification of self-efficacy is directed by self-efficacy theory (Bandura, 1997). According to Bandura (1997), how people behave can be better predicted by their capability beliefs, then by what they are actually capable of doing. Table 3 shows how the proposed study connects with the SCT.
Evidence-based practice behaviors are described in this study as accessing and implementing research-based knowledge in practice. The study is designed to reflect strategies that can be used to reflect development of EBP behaviors in practice, identify strengths, and highlight areas for potential growth, using examples of clinical situations. In order to ensure a well-rounded perspective, feedback from interdisciplinary colleagues is essential. Use of research knowledge in nursing practice has never been more important because changing paradigms in healthcare demand quality more than ever before (Perez-Campos, Sanchez-Garcia, & Pancorbo-Hidalgo, 2014; Institute of Medicine (IOM), 2001; 2003; 2010). Development of research knowledge is a part of contemporary nursing education, and nurses are expected to contribute (International Council of Nurses, 2013). However, acquisition and implementation of current research in practice is not widely implemented after graduation. In fact, nurses persist in reliance on peer opinions and what was learned in school to guide their practice (Aboshaiqah, Qasim, Abashaireth, & Patalagsa, 2014; Estabrooks, Chong, Brigidear, & Profetto-McGrath, 2005; Pravikoff, Tanner, & Pierce, 2005; Shaflei et al., 2013). The average age of today's nurse is greater than 40 and most nurses graduated before 1998 when research was not routinely included in nursing curricula (Estabrooks, et al., 2005; Fink et al., 2005; Pravikoff et al., 2005). Patient care guided by habit and peer opinion becomes outmoded and has the potential to be dangerous.
Evaluation. A major aim of the study is to redirect incorrect self-beliefs and habits of thinking that EBP behaviors cannot be regularly used in nursing practice. From the six questions in the instrument that describe confidence to use EBP behaviors, only question 1 showed a significant difference between groups. However, the remaining p values come close to a significant value. It is, therefore, possible that concluding that the other questions are not statistically significant could represent a type II error, whereby we fail to reject a false null hypothesis. A larger sample may produce significant results.
The small sample size was a limitation of the pilot study; however, 84% of the participants who began the survey completed it, indicating that the use of the survey would be a reasonable method to collect data regarding the knowledge, attitudes, and self-efficacy of nurses working in emergency care.
Recommendations for Revisions for Full Study
For the full study, additional methods to access the ED nurse population were warranted and considered. The recruitment methods for the full study were amended to include accessing several Facebook discussion boards of groups of ED nurses, such as "Show Me Your Stethoscope". A reminder letter will be posted on the same member discussion boards two weeks after the study begins. Furthermore, incentives for participation will be considered.
Aboshaiqah, A. E., Qasim, A., Abashaireth, A., & Patalagsa, J. G. (2014). Nurses' perception of barriers to research utilization in a public hospital in Saudi Arabia. Saudi Medicine Journal, 35(9), 1136-1139. https://www.ncbi.nlm.nih.gov/pubmed/25228191
Bandura, A. (1991). Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes, 50(2), 248-287. https://www.sciencedirect.com/science/article/pii/074959789190022L
Brown, C. E., Wickline, M. A., Ecoff, L., & Glaser, D. (2009). Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing, 65(2), 371-381. https://www.ncbi.nlm.nih.gov/pubmed/19040688
Bandura, A. (2006). Guide for constructing self-efficacy scales. In F. Pajares & T. Urdan (Eds.). Self-efficacy beliefs of adolescents, (Vol. 5., pp. 307-337). Greenwich, CT: Information Age Publishing.
Estabrooks, C. A., Chong, H., Brigidear, K., & Profetto-McGrath, J. (2005). Profiling Canadian nurses' preferred sources for clinical practice. Canadian Journal of Nursing Research, 37(2), 118-141. https://www.ncbi.nlm.nih.gov/pubmed/16092784
Fink, R., Thompson, C. J., & Bonnes, D. (2005). Overcoming Barriers and Promoting the Use of Research in Practice. JONA: The Journal of Nursing Administration, 35(3). https://www.ncbi.nlm.nih.gov/pubmed/15761309
Glanz, K., Rimer, B. K., Viswanath, K., & Orleans, C. T. (2008). Health behavior and health education: Theory, research and practice. San Francisco: Jossey-Bass.
Hawk, M. (2013). The Girlfriends Project: Results of a Pilot Study Assessing Feasibility of an HIV Testing and Risk Reduction Intervention Developed, Implemented, and Evaluated in Community Settings. AIDS Education and Prevention, 25(6), 519-534. https://www.ncbi.nlm.nih.gov/pubmed/24245598
Hudson, K., & Buell, V. (2011). Empowering a safer practice: PDAs are integral tools for nursing and health care. Journal of Nursing Management, 19(3), 400-406. https://www.ncbi.nlm.nih.gov/pubmed/21507112
Institute of Medicine. (2001). Retrieved from Crossing the Quality Chasm: A New Health System for the 21st Century : Health and Medicine Division
Institute of Medicine. (2003). Fostering rapid advances in health care: Learning from system demonstrations. Retrieved from http://iom.nationalacademies.org/Reports/2002/Fostering-Rapid-Advances-in-Health-Care-Learning-from-System-Demonstrations.aspx
Institute of Medicine; Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2010.). The Future of Nursing: Leading Change, Advancing Health. Retrieved from The Future of Nursing: Leading Change, Advancing Health | The National Academies Press
International Council of Nurses (2013). Scope of Nursing Practice. 404 Not Found
Kaplan, L., Zeller, E., Damitio, D., Culbert, S., & Bayley, K. B. (2014). Improving the Culture of Evidence-Based Practice at a Magnet® Hospital. Journal for Nurses in Professional Development, 30(6), 274-280. https://www.nursingcenter.com/cearticle?an=01709760-201411000-00002&Journal_ID=54029&Issue_ID=2651313
Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses' perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99(3), 229-236. https://www.researchgate.net/publication/51489842_Adopting_evidence-based_practice_in_clinical_decision_making_Nurses'_perceptions_knowledge_and_barriers
Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The State of Evidence-Based Practice in US Nurses. JONA: The Journal of Nursing Administration, 42(9), 410-417. https://www.ncbi.nlm.nih.gov/pubmed/22922750
Pallant, J. (2013). SPSS Survival Manual (5th ed.). Berkshire, England: Open University Press.
Perez-Campos, M. A., Sanchez-Garcia, I., & Pancorbo-Hidalgo, P. L. (2014). Knowledge, attitude and use of evidence-based practice among nurses active on the Internet. Investigation and Education Enferma, 32(3), 451-460. https://www.ncbi.nlm.nih.gov/pubmed/25504411
Pravikoff, D. S., Tanner, A. B., & Pierce, S. T. (2005). Readiness of U.S. Nurses for Evidence-Based Practice. American Journal of Nursing, 105(9), 40-51. https://www.ncbi.nlm.nih.gov/pubmed/16138038
Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine:How to practice and teach EBM. Second edition. Edinburgh:Churchill Livingstone, 2000.
Shafiel, E., Baratimarnani, A., Goharinezhad, S., Kallhor, R., & Azmal, M. (2014). Nurses' perceptions of evidence- based practice: A qualitative study at a teaching hospital in Iran. Medical Journal F the Islamic Republic of Iran, 28(135), 2-8. https://www.semanticscholar.org/paper/Nurses’-perceptions-of-evidence-based-practice%3A-a-a-Shafiei-Baratimarnani/261084af5f4e65ad93971b10b2fa1c01b72170b2
Titler M.G. (2008). The Evidence for Evidence-Based Practice Implementation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US) ;Apr. Chapter 7. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2659/
Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. Journal of Advanced Nursing, 66(12), 2761-2771. https://www.ncbi.nlm.nih.gov/pubmed/20825512
Wallin, L., Bostrom, A., & Gustavsson, J.P. (2012). Capability beliefs regarding evidence- based practice are associated with application of EBP and research: Validation of a new measure. Worldviews on Evidence- Based Nursing, 9 (3), 139- 148. https://www.ncbi.nlm.nih.gov/pubmed/22458331
Walden, M., Cephus, C. E., Gordon, M. D., & Hagan, J. (2015). The Great American Cookie Experiment: Engaging Staff Nurses in Research. Journal of Pediatric Nursing, 30(3), 508-515.. https://www.sciencedirect.com/science/article/pii/S0882596314003273
Wolf, I. S., Paoletti, C., & Du, H. (2012). Nursing Research Across a Large Health Care System. Nursing Administration Quarterly, 36(4), 332-339. https://journals.lww.com/naqjournal/Pages/toc.aspx?year=2012&issue=10000