|Year : 2021 | Volume
| Issue : 3 | Page : 40-45
The effect of advanced professional programs on nurses' beliefs and implementation of evidence based practice in prince Sultan Military Medical City, Saudi Arabia
Thamer Mohammed Alduraywish, Faisal Alenezi, Nawaf Alshammari
Centre for Health Studies, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
|Date of Submission||25-Feb-2021|
|Date of Decision||17-Mar-2021|
|Date of Acceptance||18-Mar-2021|
|Date of Web Publication||10-Aug-2021|
Thamer Mohammed Alduraywish
Centre for health studies, Prince Sultan Military Medical City, P.O Box 7879, Riyadh 11159
Source of Support: None, Conflict of Interest: None
Context: Health-care systems move rapidly toward evidence-based practice (EBP); however, it is still challenging to determine if nurses who have received professional education have adopted EBP into their daily practice. Aim: This study aimed to investigate the effect of advanced professional programs in EBP beliefs and EBP implementation in Prince Sultan Military Medical City. Setting and Design: A cross-sectional study was conducted including 166 nurses who work at Prince Sultan Military Medical City. Subjects and Methods: Data were obtained using an adopted two questionnaires for the EBP-Beliefs and EBP-Implementation Scales. Statistical Analysis Used: Data were analyzed using SPSS version 23. Descriptive analysis was used to determine statistical significance and correlation between variables. Results: The mean score for EBP beliefs was 57.5 and the average score of EBP implementation was 45. A significant correlation was found between professional programs and EBP beliefs, and there were mean score differences between diploma and the other two groups (graduate and postgraduate). Conclusions: Professional programs showed a relationship with EBP beliefs; however, an increase of EBP beliefs does not always imply an increment on EBP implementation. Despite some obstacle factors such as lack of mentorship and training programs, EBP can benefit from advanced professional nursing programs, as believing of EBP importance increase with higher nurses' education level which can affect positively on patients' outcomes.
Keywords: Critical care nursing, evidence-based practice, evidence-based practice beliefs, evidence-based practice implementation, Saudi Arabia
|How to cite this article:|
Alduraywish TM, Alenezi F, Alshammari N. The effect of advanced professional programs on nurses' beliefs and implementation of evidence based practice in prince Sultan Military Medical City, Saudi Arabia. Saudi Crit Care J 2021;5:40-5
|How to cite this URL:|
Alduraywish TM, Alenezi F, Alshammari N. The effect of advanced professional programs on nurses' beliefs and implementation of evidence based practice in prince Sultan Military Medical City, Saudi Arabia. Saudi Crit Care J [serial online] 2021 [cited 2021 Nov 30];5:40-5. Available from: https://www.sccj-sa.org/text.asp?2021/5/3/40/323610
| Introduction|| |
Nursing staff comprises the largest health professional population, and the majority of them work directly with patients, evaluating their needs and making decisions. Evidence-based practice (EBP) has been defined as a problem-solving approach to decision-making that integrates the best evidence from well-designed, robust, and current studies, including internal evidence from practice data and patients' assessments, preferences, and values. It is a priority for health-care organizations globally to integrate EBP to improve patient outcomes, quality, and care consistency., However, contrary to the expectation of EBP implementation, the majority of nurses do not consistently engage in EBP and still rely primarily on established knowledge for patient care rather than any other source.,
Previous research has suggested that the implementation of EBP by nurses is influenced by knowledge, attitude, beliefs, and barriers. The transtheoretical model of health behavior change used by Melnyk et al. showed that there are processes that help introduce a change in the actual behavior, including three cognitive beliefs: (1) appreciating that the change is important to one's success, (2) believing that a change can be productive, hence committing to it, and (3) appreciating the positive effect on the work that is brought by the change.
Multiple findings indicated that nurses consistently reported favorable attitudes toward and beliefs about EBP for improving quality care and outcomes, and this was positively associated with knowledge of EBP, higher educational level, and EBP experience. However, it should not be assumed that because nurses have positive attitudes and beliefs in EBP they automatically possess the skills or know how to use EBP. Part of the key strategy to close the gap theory–practice is to encourage nurses to pursue higher levels of education and training that enable them to examine research, critique it, and decide what is best for their patients.
Aims of the study
This study was conducted for two main objectives: first, to investigate the effects of advanced professional nursing programs (education level) on EBP beliefs and EBP implementation. The second objective is to determine the correlation between nurses' EBP beliefs and implementation at Prince Sultan Military Medical City.
| Subjects and Methods|| |
This is a cross-sectional, descriptive, and correlational study in which survey responses of 166 nurses in the critical care setting were collected.
Nonprobability sampling including 166 registered nurses divided into three groups of different educational levels (diploma, graduate, and postgraduate) working at Prince Sultan Military Medical City. The inclusion criteria included full-time nurses working for at least 1 year in the critical care setting. After attaining the required approvals from the hospital, nurses were recruited to the study during January and February 2019. Participants were asked to complete the questionnaires in a web-based data entry program (Google Forms). A document with all the study-related information (e.g., the importance of the study) was given to each participant, along with an informed consent form to be completed and signed. The researcher explained the objective of the study and answered any questions of recruited nurses. Confidentiality was assured at all stages of the study, and there was no risk during participating in the study.
The protocol was reviewed and approved by the Research Ethics Committee of the Scientific Research Canter, Prince Sultan Military Medical City. The respondents were also informed that they had the right to withdraw from the study at any point, and they could gain access to the study results. To ensure confidentiality, personally identifying information was not collected.
The “EBP Belief Scale” and the “EBP Implementation Scale” were used. Demographic variables were gathered in the first part of the survey. The EBP Belief Scale is a 16-item scale that allows measurement of a person's beliefs about EBP and the ability to implement it. It consists of a 5-point Likert scale that ranges from 1 (strongly disagree) to 5 (strongly agree). Scoring of the instrument involves a total number of responses to the 16 items for a final score that ranges between 16 and 80 points. Thus, scores below 64 indicate that there is less than agreement with their knowledge of, and confidence and belief in, their ability to implement EBP; scores above 48 (but <64) indicate that there is not a full commitment at this point to EBP; and scores lower than 48 indicate there is no commitment to EBP. The EBP Implementation Scale allows measurement of the extent to which EBP is implemented. Participants are asked to respond to each question on a 5-point frequency scale indicating how often in the past 8 weeks they performed the item. The scale ranges from 0 times to >8 times, with scores consisting of a summary of the responses to the 18 items for a total score between 18 and 90 points. A response of 0–17 indicates that in the past 8 weeks, respondents have implemented EBP <1 time; a score of 18–35 would indicate between one and three times; a score of 36–53 would indicate between four and five times; a score of 54–71 would indicate between six and seven times; and a score of 72 would indicate respondents had implemented EBP eight times or more. The Cronbach's alpha statistic for each scale was >0.90.
Data were collected via Google Forms and coded using Microsoft Excel, and then, it was exported to SPSS v23 (Statistical Package for the Social Science (Riyadh, Saudi Arabia)) to conduct descriptive and inferential statistics. Descriptive analysis included distributions and frequencies, and inferential analysis included Kendall's tau-b (τb) correlation coefficient and a one-way analysis of variance (ANOVA) with Tukey's post hoc test to determine statistical significance.
| Results|| |
In total, 166 nurses returned the questionnaires. More than half of the participants (60%) were female, the majority of them in the age range of 30–39 years old (47%), followed by 33% between 20 and 29 (33%), and 20% over 40. In other words, 80.5% of the participants were under 40 years old. With respect to the highest education level obtained, the sample was divided into three groups: diploma (14%), graduate degree (46%), and postgraduate degree (40%). There was an average of 8 years of experience (standard deviation [SD] = 6 years) [Table 1].
Regarding the EBP Beliefs Scale, the average total score was 57.5 (min 24; max 74) with a SD equal to 9. The item with the highest score was “I am sure that implementing EBP will improve the care that I deliver to my patients” with 80% agreeing or strongly agreeing with the statement. Following that was “I believe that EBP results in the best clinical care for patients” (77.8%) and “I believe that critically appraising evidence is an important step in the EBP process” (74%). Worth noting is that those three answers are related to the value given to EBP. On the other hand, the questions with lower percentages that strongly agreed or agreed were statements about having access to the best resources to implement EBP (59.7%), overcoming barriers in implementing EBP (61.5%), and believing that EBP takes too much time (49.4%). These three statements are all related to perceived obstacles to EBP implementation [Table 2].
|Table 2: Percentages of the items in the evidence-based practice beliefs scale|
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The average total score on the EBP Implementation Scale was 45 (min 18; max 90), with an SD equal to 15. The majority of nurses (75%) reported collecting data related to a patient's problem at least one time in the last 8 weeks, and 16% of them did it more than eight times. Almost 86% of the participants had critically appraised evidence from a research study at least one time in the last 8 weeks, including 35% between one and three times, and 32% between four and six times. On the other hand, 36% reported never accessing the National Guidelines Clearinghouse and 24% had done it just one to three times. Interestingly, 27% had never generated a population intervention comparison outcomes (PICO) question about their clinical practice and 33% had only done it one to three times in the last 8 weeks. Promotion of EBP and sharing an EBP guideline with colleagues were reported to be more than 4–6 times in 8 weeks (49% and 47%, respectively) [Figure 1].
|Figure 1: Evidence-based practice implementation scale answers (N = 166)|
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Professional programs on evidence-based practice beliefs and evidence-based practice implementation
Kendall's tau-b (τb) correlation coefficient for nonparametric samples was run to determine the relationship between EBP beliefs and EBP implementation. There was a positive correlation between both variables, which was statistically significant (τb = 0.108, P ≤ 0.05). The test was also carried out to analyze the relationship between professional programs (educational level) and EBP beliefs and EBP implementation. It was found that EBP beliefs and education level had a moderate, significant correlation (τb = 0.122, P ≤ 0.05). However, EBP implementation and education level did not have a significant correlation.
The difference between variance of the EBP beliefs scores and EBP implementation scores within the three different professional programs (diploma, graduate degree, and postgraduate degree) was also analyzed. There was a statistically significant difference between groups for the EBP beliefs scores, as determined by a one-way ANOVA (F = 9.511, P = < 0.001). However, the ANOVA showed nonsignificant variance means for the EBP implementation scores across education groups (P =0.529).
A Tukey post hoc test for EBP beliefs revealed that educational level “Diploma” was statistically significantly lower than “Graduate Degree” (−9.017 ± 2.1, P = 0.000) and “Postgraduate Degree” (−8.019 ± 2.14, P = 0.001). However, there was no statistically significant difference between the “Graduate Degree” and “Postgraduate Degree” groups (P = 0.998).
| Discussion|| |
The sample was comprised 166 nurses working in the critical care setting at Prince Sultan Military Medical City. The majority of them (80.5%) were under 40 years old, with moderate–high education level (postgraduate: 40%, graduate: 46%, and diploma: 14%), and an average of 8 years of experience. The mean score for EBP Beliefs was 57.5, suggesting that EBP approach is not integrated into critical care nursing daily practice. The average total score of EBP implementation was 45, meaning between four and five times in the last 8 weeks, which is lower than expected (nurses should be implementing EBP at a minimum of 6–7 times in this timeframe). A significant correlation was found between education level and EBP beliefs; however, education level and EBP implementation did not have a significant correlation. The ANOVA for EBP beliefs showed differences in the mean scores between diploma and the other two groups (graduate and postgraduate).
In the context of the Kingdom of Saudi Arabia, measurement of EBP beliefs and EBP implementation among graduate nursing students showed a very low overall mean score in the implementation of EBP, suggesting an association between EBP beliefs and attendance to EBP training and age. These results are similar to the findings and also correspond with studies made in the Turkey clinical care setting where it was found that nurses' knowledge, skills, and practice levels regarding EBP were relatively low, although they held positive attitudes and beliefs toward EBP.,,, Verloo (2017) et al. . investigated the EBP beliefs and EBP implementation using the same instruments in the Swiss clinical setting. They reported EBP beliefs' mean is 56 points (1.5 points lower than the present study), and an EBP implementation's mean is only 13 points reflecting a lower level of implementation in comparison with the current study (mean of 45 points). The researchers explained a large variance of means due to the participants' heterogeneity in regard to education level and age, which differs from this study, as this sample was more homogeneous (80% had graduate or postgraduate degree and 80% were under 40 years old). Similar to this study's findings, the Swiss study reported higher scores in items related to the value of EBP, while the lowest score came from the statement, “I am sure that I can access the best resources to implement EBP.”
In the Saudi settings, nurses identified their own experiences as the most frequently used sources of knowledge for practice. The least frequent were external sources of research evidence. In this study, it was found that 60% of the sample had accessed the National Guidelines Clearinghouse up to three times in the past 8 weeks, and only 23% had read and appraised a clinical research study more than six times in the last 8 weeks. Kilicli et al. reported that nursing experience and information acquired through nursing school were the most frequently used sources of knowledge for their clinical practice, rather than research results. A recent integrative review found that although nurses were familiar with, had positive attitudes toward, and believed in the value of EBP, they perceived their own EBP practice knowledge and skills as insufficient for employing them. In addition, nurses reported that the most important barriers perceived by cardiovascular nurses were lack of time, collaboration, and self-authority to utilize research.
Regarding advanced professional programs, several studies had concluded that education is a significant factor in nurses' perception of EBP,,,, and that perceived barriers decrease with the increase in one's educational level. Interestingly, in the present study, a statistically significant difference (ANOVA) was found in EBP beliefs among the group diploma and the other two groups (graduate and postgraduate); however, no difference was found between graduate and postgraduate. Middlebrooks et al. conducted an integrative review regarding EBP training, although there was a great variation among EBP programs, the majority of participants reported increased awareness, value, beliefs, knowledge, and skills. However, implementation was not reported. In this review, it was also found that mentorship is a key factor for improving EBP, and six of the included studies referred to the importance of having a librarian with expertise to help facilitate online database searching.
In the present study, no correlation was found between EBP implementation and advanced professional programs, nor was there a difference of EBP implementation mean scores between degree groups, i.e., diploma, bachelor, and master's degree holders. One of the reasons behind these findings is the lack of training culture and provision which is not readily available nor adequate enough as well as lack of nurses' researching skills and relevant tools alongside with insufficient knowledge about using and integrating EBP into daily practice played important roles contributing to these findings. However, Verloo et al. (2017) found a significantly higher level of EBP implementation by those who were formally trained (graduate) in comparison to those with undergraduate education. Similarly, the study conducted by Singleton among doctor of nursing practice students reported a significant outcome in EBP beliefs and EBP implementation during the Ph D program (pretest vs. posttest), highlighting that in-practice mentorship is as critically important as teaching is to the academic setting. They also concluded that EBP does not occur in isolation, but rather a social or cultural change is required to harvest early adaptations and teamwork.
The limitations of the present study are related to the frequently questioned accuracy and reliability of self-report questionnaires, which may be susceptible to recall social desirability biases. Furthermore, nurses who have not participated in EBP training programs may overestimate or subestimate the amount of evidence-based care they provided on a daily basis. When comparing the results of the present study with others, the demographic characteristics of the sample must be considered, as a large portion of the participants (80%) were younger than 40 years, and 80% had a graduate or postgraduate degree.
| Conclusions|| |
The present study reports the level of EBP beliefs and EBP implementation in critical care at Prince Sultan Military Medical City, and how it is correlated with advanced professional programs. Accordingly, with the EBP belief scores, nurses reported a moderate level of commitment with EBP. EBP implementation indicated a higher score mean than other studies; however, it is still low among several items related to the use of research resources such as databases, clinical research articles, and guidelines. A correlation was found between professional programs and EBP beliefs but was not the same for EBP implementation. Furthermore, the mean difference on EBP beliefs was significant only when comparing diploma to graduate or postgraduate. Hence, it can be concluded that professional programs showed a relationship with EBP beliefs; however, an increase of EBP beliefs does not always imply an increment on EBP implementation. EBP could benefit from advanced professional programs, but there are other factors involved in the clinical practice, as other authors suggest. Training together with mentorship and resources available at the workplace could help EBP implementation on a larger scale. Furthermore, there is a need for studies with higher levels of evidence and randomized samples to eliminate bias associated with convenience samples.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Melnyk BM, Fineout-Overholt E, Gallagher-Ford L, Kaplan L. The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. J Nurs Adm 2012;42:410-7.
Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011.
Saunders H, Vehviläinen-Julkunen K. The state of readiness for evidence-based practice among nurses: An integrative review. Int J Nurs Stud 2016;56:128-40.
Melnyk BM, Gallagher-Ford L, Zellefrow C, Tucker S, Van Dromme L, Thomas BK. Outcomes from the first Helene fuld health trust national institute for evidence-based practice in nursing and healthcare invitational expert forum. Worldviews Evid Based Nurs 2018;15:5-15.
Wallen GR, Mitchell SA, Melnyk B, Fineout-Overholt E, Miller-Davis C, Yates J, et al
. Implementing evidence-based practice: Effectiveness of a structured multifaceted mentorship programme. J Adv Nurs 2010;66:2761-71.
Hadgu G, Almez S, Tsehay S. Assessment of nurses' perceptions and barriers on evidence based practice in Tikur Anbessa Specialized Hospital Addis Ababa Ethiopia. Am J Nurs Sci 2015;4:73-83.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.
Thiel L, Ghosh Y. Determining registered nurses' readiness for evidence-based practice. Worldviews Evid Based Nurs 2008;5:182-92.
Koehn ML, Lehman K. Nurses' perceptions of evidence-based nursing practice. J Adv Nurs 2008;62:209-15.
Alanen S, Kaila M, Välimäki M; ECCE Study Group. Attitudes toward guidelines in Finnish primary care nursing: A questionnaire survey. Worldviews Evid Based Nurs 2009;6:229-36.
Fitzpatrick JJ. The future of nursing (our future): Leading change, advancing health. Nurs Educ Perspect 2010;31:346.
Melnyk BM, Fineout-Overholt E, Mays MZ. The evidence-based practice beliefs and implementation scales: Psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5:208-16.
Cruz JP, Colet PC, Alquwez N, Alqubeilat H, Bashtawi MA, Ahmed EA, et al
. Evidence-based practice beliefs and implementation among the nursing bridge program students of a Saudi university. Int J Health Sci (Qassim) 2016;10:405-14.
Kilicli AB, Kelber ST, Akyar I, Litwack K. Attitude, source of knowledge, and supporting factors on evidence-based nursing among cardiovascular nurses: A cross-sectional descriptive study in Turkey. J Eval Clin Pract 2019;25:498-506.
AbuRuz ME, Hayeah HA, Al-Dweik G, Al-Akash HY. Knowledge, attitudes, and practice about evidence-based practice: A Jordanian study. Health Sci J 2017;11:1.
Ammouri AA, Raddaha AA, Dsouza P, Geethakrishnan R, Noronha JA, Obeidat AA, et al
. Evidence-Based practice: Knowledge, attitudes, practice and perceived barriers among nurses in Oman. Sultan Qaboos Univ Med J 2014;14:e537-45.
Heydari A, Mazlom SR, Ranjbar H, Scurlock-Evans L. A study of Iranian nurses' and midwives' knowledge, attitudes, and implementation of evidence-based practice: The time for change has arrived. Worldviews Evid Based Nurs 2014;11:325-31.
Verloo H, Desmedt M, Morin D. Beliefs and implementation of evidence-based practice among nurses and allied healthcare providers in the Valais hospital, Switzerland. J Eval Clin Pract 2017;23:139-48.
Hamaideh SH. Sources of knowledge and barriers of implementing evidence-based practice among mental health nurses in Saudi Arabia. Perspect Psychiatr Care 2017;53:190-8.
McCloskey DJ. Nurses' perceptions of research utilization in a corporate health care system. J Nurs Scholarsh 2008;40:39-45.
Middlebrooks R Jr., Carter-Templeton H, Mund AR. Effect of evidence-based practice programs on individual barriers of workforce nurses: An integrative review. J Contin Educ Nurs 2016;47:398-406.
Kajermo KN, Undén M, Gardulf A, Eriksson LE, Orton ML, Arnetz BB, et al
. Predictors of nurses' perceptions of barriers to research utilization. J Nurs Manag 2008;16:305-14.
Singleton JK. Evidence-based practice beliefs and implementation in doctor of nursing practice students. Worldviews Evid Based Nurs 2017;14:412-8.
[Table 1], [Table 2]