Promoting Evidence-Based Practice: A Study of Perceptions and Practices of Nursing Council Members in a Magnet® Organization

Background: Despite the increasing availability of and access to the research literature, and the Institute of Medicine’s goal for 2020 that 90% of clinical decisions be supported by accurate, timely and up-to-date clinical information, implementation of evidence-based practice (EBP) remains inconsistent (McClellan et al., 2007). Factors at the individual and organizational level influence the use of EBP. These factors include beliefs that EBP improves patient care and outcomes, extent of EBP knowledge and skills, access to EBP mentors and supportiveness of the organization (Melnyk et al., 2012).Organizations applying for or those that have achieved Magnet® status, a designation awarded by the American Nurses Credentialing Center (ANCC) for excellence in nursing, must demonstrate the use of EBP (ANCC, 2014).

In a recent study by Melnyk and colleagues (2012), a national survey was conducted with a random sample of 1015 RNs who were members of the American Nurses Association (ANA) to assess the state of EBP and the needs of nurses related to EBP, and to determine if these factors differ between master’s prepared and non-master’s prepared nurses and Magnet® versus non-Magnet organizations. Survey respondents were asked to rate their EBP beliefs, skills and use in practice. A significant majority of respondents believed some form of education and mentoring was needed. More non–master’s degree prepared nurses indicated that they needed more knowledge and skills and would participate in EBP education programs. Nurses in Magnet® organizations reported higher levels of knowledge, resources and implementation of evidence-based care. The study results indicated that although the nurses believe in evidence-based care, and the majority reported EBP implementation in their organization, barriers to implementation persisted and included lack of time, non-supportive organizational culture, lack of EBP knowledge and skills, lack of access to information and often lack of support from colleagues, nurse leaders and managers (Melnyk et al.).

Aim: The first aim of this study was to assess the evidence-based practices, perceptions and EBP competencies of nursing council members in our Magnet® organization compared to the state of EBP as reported in the national ANA study by Melnyk et al. in 2012. The second aim was to identify opportunities to assist nursing staff to achieve competence in EBP by identification of specific barriers including education, resources, and support.

Methods: The setting for this descriptive, exploratory study was a large, urban medical center in Northeastern U.S. The study facility achieved its second Magnet® designation in 2012 and has successfully demonstrated the use of EBP to improve patient care outcomes. EBP education and skills training has been provided for the past ten years through the Clinical Scholar Program. This program is designed to teach EBP skills, provide tools, and reduce some of the common barriers to EBP implementation through the use of mentors (Strout et al. 2009). At the study organization there is also a shared governance approach to decision making through a council structure that includes Nursing Practice, Research, Quality, Magnet, Clinical Advancement and Informatics councils. Many practice and policy decisions are made by these councils that require the use of EBP skills. Although there is an expectation that nurses will engage in EBP, and an organizational culture that supports EBP, the extent to which nurses have the basic competencies and knowledge of available resources to engage in EBP remained unknown.

Survey invitations were emailed to 235 council members using the Research Electronic Data Capture (RedCAP) secure web-based platform for managing online surveys and databases. The survey instrument was developed with questions taken directly from the ANA survey used by Melnyk and colleagues (2012). Responses to these 18 Likert-scale items ranged from 1 (strongly disagree) to 5 (strongly agree) and were designed to illicit the respondent’s perspective, current needs and competencies related to EBP. Melnyk et al. reported good internal consistency (Cronbach’s alpha = .88) for the 18-item questionnaire. Permission to use the tool was obtained from the primary author. The final survey was composed of 10 demographic questions, the 18 item ANA questions and 12 additional items. Five items using the same 5-point Likert scale were added that surveyed nurses’ perceptions of performing EBP.  Seven items using a 5-point Likert response (1= least needed, 5= greatest need) were added to assess the respondent’s needs regarding EBP, including education and resources. The data were collected between December 4, 2014 and January 5, 2015 with email invitations and reminders sent every two weeks.

Results: Eighty (34.5%) council members responded to the survey invitations. Data were analyzed with descriptive statistics and one-way ANOVA using SPSS version 17.0. The 18-item EBP Survey showed very good internal consistency (Cronbach’s alpha = .81). There were no significant differences (p=.77) found for total EBP score among education levels or between staff RNs and other positions (p=.39). Staff RNs were significantly less clear about EBP steps (M=3.59) compared to other positions (M=4.10) (t=-2.04, df=77, p=.045) and were significantly more likely to agree that their leaders/managers consistently made evidence-based decisions (M=4.03) compared to those in other positions (M=3.58) (t=2.16, df=76, p=.036). When data were compared between respondents who were on the Research council versus those on other councils, Research council members were significantly more likely be clear about EBP steps (M=4.38) compared to those respondents on other councils (M=3.65) (t=1.99, df=77, p=.05). Research council nurses also agreed more often that barriers were existing in the clinical setting that made implementing EBP challenging (M=3.50) compared to other council members (M=2.67) (t=2.36, df=76, p=.021). The five additional items that evaluated the nurses’ perceptions about their ability to perform evidence-based practice steps showed that staff RNs compared to those in other positions were significantly less likely to agree that they were able to perform a critical appraisal of the literature (M=3.19 vs. 3.98, p=.012) or evaluate outcome data to determine best practice (M=3.26 vs. 3.85, p=.017).

The top three identified needs were on-site education and skills building sessions (M=4.09), tools that can help them implement EBP with their patients (M=4.00) and consistent access to EBP mentors in the clinical setting (M=3.87). The three least needed resources were regular seminars with EBP experts (M=3.77), a virtual on-line resource center where best practices are housed and experts are available for consultation (M=3.71) and an online education program with expert EBP mentors (M=3.62). When staff RNs were compared to other positions, bedside nurses were significantly less likely to perceive a need for the virtual on-line resource center than those in other positions (M=3.47 vs. 4.05, p=.034) respectively.

The data from our study were also compared with Magnet® and non-Magnet results published by Melnyk et al. (2012). There was a significant difference between the three groups based on the 18 EBP survey items (F=4.61, df=2, p=.014). Post hoc Tukey comparisons showed that nurses at the study organization had higher mean scores (M=3.87, CI=3.67, 4.06) compared to non-Magnet respondents (M=3.46, CI=3.27, 3.67). There were no significant differences with comparisons with the Magnet® published results. Comparisons of the individual EBP survey items among the three groups showed that study nurses were significantly more likely to agree that they believed that EBP results in the best clinical care for patients (M=4.61 vs. M=4.46 Magnet® vs. M=5.36 non-Magnet facilities); and non-Magnet hospitals were significantly more likely to report that there are many barriers to EBP that exist in their clinical environment (M=3.06 vs. M=2.79 Magnet® vs. M=2.76 study facility).

Limitations:One limitation of this study is its low response rate (34.5%), which may not have captured the entire view of the council members of the study facility. It also is not possible to know how the characteristics of the responders compared with those of the nonresponders or how the characteristics of the council members compare with the RNs in general who are not members of any of our councils.

Conclusions and Implications for Practice: The results of this study confirmed that there is a need to continue educational strategies such as the Clinical Scholar Program and to inform the staff about the EBP tools that are available electronically. The results confirmed as well that there is a continuous and growing need to develop a pool of EBP mentors for consistent access to the staff. As Melnyk et al. (2012) have pointed out, a key factor in sustaining and establishing EBP is the availability of mentors who typically have not only excellent knowledge and skills in EBP, but also skills in individual and organizational behavior change strategies. However, EBP mentors need support and their own mentoring as well. Therefore there is a need to provide feedback and to organize education and retreats for these EBP mentors. The comparison of the results from this study with the national level survey (Melnyk et al. 2012) has been valuable. The results confirmed that our council members' responses regarding EBP were similar to those reported from other Magnet® facilities and higher compared to non-Magnet facilities.