Nursing Center - Journal Article

Originating from Florence Nightingale's work, using evidence to determine the best patient care has been the ethos for nursing practice.1 Evidence-based practice (EBP) requires structures and processes "to evaluate existing nursing practice" and "translate new knowledge into nursing practice" for positive patient outcomes.2 This reflects Donabedian's quality improvement framework of structure, process, and outcomes.3 One essential structure for promoting effective EBP use by nurses is strong leadership.4,5 Positive beliefs and attitudes about EBP's value are an integral part of the nurse leaders skill set for advancing evidence-based care at the bedside.6-8

The nurse executive team at a Midwestern 350-bed community hospital conducted a gap analysis to determine EBP application in the nursing department and found a glaring deficit. Further investigation revealed that nurses at the bedside received little or no support from their nurse leader(s). Nurses expressed frustration about their efforts to use EBP, and many current nurse leaders had little or no experience using EBP. Nurse leaders cited time constraints as a barrier for learning EBP concepts and suggested using a flexible online educational program. The results of the gap analysis made online education the first priority toward incorporating EBP to improve patient outcomes.

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Do you know the way?

Many nurses lack proficiency in using EBP for clinical decision making and consider inadequate nurse leader support a significant barrier impeding their ability to use EBP effectively.1 For these nurses, completing assigned patient-care tasks usually takes precedence over initiating practice changes.9,10 Nurses often rely on "senior and/or experienced nurse colleagues for information" rather than searching for evidence-based solutions.11 The majority of nurse leaders express positive attitudes about EBP, but many don't incorporate it into daily practice or teach it to direct care nurses.12 Many nurse leaders have been in their roles for years, but lack advanced academic degrees.6,12 This means that their own EBP skills may be weak, so they focus on routine practice in a busy, stressful work environment.13

In a large nationwide EBP study, nurses (N = 1,097) reported they lacked literacy skills to search and interpret research.1 This illustrates that leaders' verbal support alone is insufficient.14 Nurse leaders must have solid skills in utilizing EBP to be role models for direct care nurses.15 EBP education programs for nurse leaders must include current research findings, the EBP process, literacy skills, protocol development, a budget outline, and an implementation plan.7

A literature search from 2008 to 2011 using the key words "online EBP education for nurse leaders" yielded few relevant results. The majority of articles focused on online EBP education in general, not specifically for nurse leaders. After discussions with hospital nurse leaders and the literature review, an online program was developed as a pilot to improve nurse leaders' use of EBP. The pilot study's aim was to answer the following question: Can an online program improve nurse leaders' attitudes, beliefs, and implementation of EBP? To measure attitudes, beliefs, and implementation, we used the EBP Beliefs (EBPB) and EBP Implementation (EBPI) scales developed by Melnyk and Fineout-Overholt.9 Implementation was also measured by increased EBP practice change in the nursing department.

The road map

Five online modules were designed to strengthen nurse leaders' expertise in EBP by practicing what they were learning in the modules and developing application skills using real-time (work) situations. Each module included a prerecorded audio and slide presentation to be reviewed during off-duty time. After each module, participants submitted an assignment by e-mail to the investigators and received feedback within 48 hours. Participants could view each module in 10 to 15 minutes, and the assignment took approximately 30 minutes to 1 hour to complete. A scaffolding approach was used in which early exercises developed EBP knowledge for use in subsequent modules.

The introductory module addressed beliefs and attitudes toward EBP. Module one addressed developing clinical questions. Module two addressed finding evidence, using key words, and searching for available research. Module three taught ways to evaluate and rate research articles. Module four focused on developing a protocol (or policy), implementation plan, and budget for an EBP project. (See Table 1.) The study researchers and a skilled librarian were available for additional support. Participants had 6 months for program completion.

Table 1: Modules for... - Click to enlarge in new window

Table 1: Modules for the online EBP program

Journey preparation

No EBP projects were in production by nurse leaders before the program, creating an opportunity to promote design and completion of evidence-based protocols. After approval by both hospital and university Institutional Review Boards as an exempt study, the investigators invited the hospital's nurse leaders (N = 61) to participate in the study via e-mail. Leaders included RN nurse managers, directors, educators, clinical nurse specialists, and NPs. Forty-four nurse leaders consented to participate in the program and received a link to online modules and instruments.

A simple pretest, intervention, and posttest research design was employed. The study instruments were the EBPB and EBPI scales, as well as a demographic data form developed by the researchers.9 The EBPB measures attitudes and beliefs about EBP; the EBPI measures actual EBP implementation. These instruments were created to evaluate programs for improved use of evidence in clinical settings.9 The EBPB has 16 items about attitudes and beliefs related to EBP rated on a 5-point Likert scale. Scores on two negatively worded items are reversed and responses to each item are summed for a score between 16 and 80. The EBPI asks participants to rate how frequently they perform aspects of EBP, such as reviewing an article or sharing knowledge with a colleague. Each ranking is assigned a number 0 to 4 and then summed for a score between 0 and 72.

Demographic data indicated 74% of leaders reported 16 or more years' nursing experience, and all had some exposure to EBP. (See Table 2.) Only 30% of these nurse leaders had completed an EBP course, and the majority held a bachelor's of science in nursing degree or a master's of science in nursing degree. Two diploma-prepared nurses completed surveys. All data were deidentified to protect participants' confidentiality, with only aggregate data reported. Data collection occurred before the program's initiation and 3 months following program closure, when participants received a link to repeat the EBPB and EBPI scales.

Table 2: Demographic... - Click to enlarge in new window

Table 2: Demographic data

Of 44 original participants, 34 completed the demographic survey, 41 completed the first EBPB scale, and 33 completed the EBPI scale. After the online program, 27 completed the second EBPB scale and 24 completed the second EBPI scale. The EBPB and EBPI mean scores were higher on both the initial and second surveys than the original instrument testing study. (See supplemental content on the Nursing Management iPad app.) Most items didn't show statistical significance. A power analysis indicated that at least 40 subjects were required for an effect and sample size to achieve significance.

The EBPB scale had an internal consistency of Cronbach's alpha = 0.85 in the preintervention and 0.79 in the postintervention group. The EBPI scale had an internal consistency of Cronbach's alpha = 0.95 in the preintervention and 0.93 in the postintervention group. Both were consistent with other findings.9,16 Further analysis revealed that two EBPB items reached statistical significance (P < 0.05): (1) participants' clarity about the EBP process and (2) knowledge about implementing EBP. (See supplemental content on the Nursing Management iPad app.) No EBPI items reached statistical significance (P < 0.005). (See supplemental content on the Nursing Management iPad app.) These findings suggest improvement in some aspects of EBP beliefs. Three months after the study, six participants had implemented practice changes compared with no EBP projects before the program.

Arriving at the destination

This pilot study illustrates the use of an online program for nurse leaders to increase their skills for implementing EBP. The instruments had acceptable reliability, and findings were similar to mean scores and ranges of the instruments in previous studies.16,17 Although leaders were able to easily identify clinical problems, their follow-through by module completion was weak. Six EBP projects were in various stages of completion when the second data collection occurred. Three months later, all six projects were implemented, resulting in these significant improvements in patient care:

* direct care nurse/physician/patient rounding

* blog site for new employee preceptors

* improving sepsis detection and protocol implementation

* improving EBP-based teamwork

* reducing medication errors in home health

* developing an EBP-based palliative care program.

An interesting pattern emerged as the program progressed. Initially, there was great enthusiasm. The majority of participants completed the first assignment and submitted their EBP question (n = 38). There was a sharp decline in the number of returned assignments after release of modules three and four. These modules required a literature search about participants' EBP questions, including reviewing and rating applicable research articles. Most participants didn't use the resources available to assist with this process. Only five participants sought assistance from the librarian or study investigators. Three participants, who successfully completed the program, were graduate nursing students who had additional support. The majority of nurse leaders had been in their positions for many years and never completed an EBP course. The online program alone may not have sufficiently increased research knowledge and literacy skills to guide them through difficult parts of the process.18

Roadblocks

Lack of time and priority setting were issues for this group. Multiple distractions and role demands made the program less of a priority.19 Current knowledge indicates time is a significant barrier, preventing nurses from searching and reading literature, analyzing research, and developing clinical protocols.20,21 Only six nurse leaders actually implemented their projects, and our sample size is too small to demonstrate significant differences in attitudes, beliefs, and implementation of the overall group.22 The low completion rate began after the third module when participants started the literature search and review. Only 24 of the original 44 participants completed the initial and second surveys.

Although it isn't clear why there was such low participation at this point, several factors should be considered. One factor may be the time demand on these leaders imposed by organizational priorities, including significant responsibilities in designing a new hospital. Another consideration is that an online education program alone may result in higher attrition rates due to participants' sense of isolation during the course.23 It's unknown which participants completed a previous course; the six participants who finished the program had completed a college-level EBP course before the online program.

Future travels

Traditional nursing practices no longer ensure quality care. Although nurses express positive attitudes about EBP, they don't routinely integrate it into care delivery.16 In today's fast-paced, technologic healthcare environment, nurse leader support is essential for direct care nurses to use EBP to benefit patients. Nurse leaders must enhance their own EBP proficiency to become role models for direct care nurses.

Despite the impact of this pilot study's limitations on its results, an online format may be an innovative approach to improve nurse leaders' EBP use in community hospitals. Successful projects in this study addressed organizational priorities that may have been the major impetus for their success.

For busy nurse leaders, an online EBP program with more intense monitoring, mentoring, collegial support, and focus on organizational priorities may augment learning and meet needs for flexibility. Initial assessment of nurse leaders' research knowledge and literacy skills is recommended. Mentoring by nurse scientists is essential for leaders to gain confidence in their own EBP skills and to mentor direct care nurses in the delivery of evidence-based care.