|Nurses' Skill Level and Access to Evidence-Based Practice
|Edna Cadmus PhD, RN, NEA-BC
Elizabeth A. Van Wynen EdD, RN, NE-BC
Barbara Chamberlain DNSc, APN,C, CCRN, WCC
Patricia Steingall MS, RN, NE-BC
Mary Ellen Kilgallen RN, MEd, NE-BC
Cheryl Holly EdD, RN
Lynn Gallagher-Ford MSN, RN, NE-BC
|JONA: Journal of Nursing Administration
Volume 38 Number 11
Pages 494 - 503
Integrating evidence-based practice into the culture of an acute care hospital requires assessment, planning, and intervention by nursing leadership. The authors discuss a statewide study that assessed the skill level of nurses in obtaining evidence for their nursing practice, using computers and databases, as well as evaluating the perceived availability of resources in their hospitals to access evidence.
Evidence-based practice (EBP) is "a problem-solving approach to clinical decision making within a healthcare organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence."1 Porter-O'Grady 2 explains to us that "EBP is not a cookbook or cookie-cutter approach to developing or managing clinical practice. It requires a degree of flexibility and fluidity based on firm scientific and clinical evidence validating appropriate and sustainable clinical practice." The Institute of Medicine identified the need for patients to receive care based on this approach.3 Yet, many organizations are still grappling with how to accomplish this goal. The question to ask is why?
Certain characteristics are needed by organizations and individuals to accomplish a consistent approach to incorporating EBP into patient care. Some of these characteristics are described in the literature. Levin and Feldman 4 described Titler's Iowa Model of EBP as a widely recognized model that focuses on the team approach to seek out the evidence and solutions-a commitment from both the individual nurse and the organization is necessary to create a culture of EBP that allows patients to receive care based on evidence. It is important to understand that "a key element of evidence-based clinical decision making is personalizing the evidence to fit a specific patient's circumstances," comments DiCenso et al.5 This requires individual judgment. Polit and Beck 6 stress that " EBP provides an important framework for self-directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion." This requires commitment by the individual practitioner.
Over the past several years, much research has focused on identification of barriers to implementation of EBP. A significant study by Pravikoff et al 7 showed that most US nurses did not value research, were not able to conduct database searches, and received little or no training in the use of evidence-based tools. According to Klem and Weiss,8 nurses struggle with using EBP because they lack the ability to identify, access, and evaluate information. Additional barriers include lack of access to resources (Pierce 9), ability to conduct a clinical database search (Tanner 10), education (Pravikoff 7), availability of mentors/experts, and organizational support (Gerrish and Clayton 11).
Recently, reports in the literature have focused on moving beyond barriers and toward identification of successful implementation strategies. These works often reflect aspect of context and support for nurses in their daily work experience such as information at the bedside (Fineout-Overholt and Johnson 12), dialogue between administration and staff (Fink et al 13), time to review and implement research findings, colleague support (Hutchinson and Johnson 14), creation of a culture where EBP is valued and expected (Melnyk and Fineout-Overholt 15), and relevance of the evidence to the organization and practice.
It Starts With a Question
With a goal in mind to advance EBP in the state of New Jersey, the Organization of Nurse Executives of New Jersey (ONE/NJ) research committee conducted a review of the literature that showed that there are skill deficits, roadblocks, and a lack of support from leaders regarding EBP in many practice settings. As a result, the research committee decided that the Pravikoff et al 7 national study, Readiness of U.S. Nurses for Evidence-Based Practice, was worth replicating to determine if a sample of NJ registered nurses (RNs) were different from the national sample of RNs.
Pravikoff et al used a geographic-stratified random sample of 3,000 RNs with a return of 987 respondents for a return rate of 37%. Their published results focused on 760 clinical RNs to whom they administered the 93-item questionnaire entitled Information Literacy for Evidence-Based Nursing Practice. Based on the results of their study, they concluded that RNs in the United States were not ready for EBP as there were gaps in both their information literacy and computer skills. In addition, they concluded that due to limited access to high-quality information resources and personal attitudes toward the conduct of research, nurses did not engage in any activities related to EBP or research.7
The research committee's operating assumption was that there would be differences in skill level and access to EBP resources within the state of New Jersey compared with the national data. It was felt that because New Jersey has the highest concentration in the nation of magnet-designated hospitals in 1 state, the RN knowledge and access to EBP would be higher than at a nonmagnet hospital. In addition, the research committee wanted to (1) determine if regional differences existed in New Jersey as to skill level and resource availability and (2) determine if magnet and nonmagnet differences existed as to skill level and resource availability so it could better meet its goal of advancing EBP.
Organization of Nurse Executives of New Jersey Study
A descriptive, exploratory survey was undertaken to assess NJ nurses' perceptions of their skills in obtaining evidence and access to information as well as to identify any barriers to practicing in an evidence-based manner. Institutional review board (IRB) approval was obtained through the principal investigator's institution (Englewood Hospital and Medical Center). All site coordinators also requested IRB committee approval from their individual hospitals. Once the individual hospital approvals were received, they were enrolled in the study.
The ONE/NJ research committee posed 5 questions:
* Do NJ nurses perceive that they are significantly different than the rest of the nation based on the Pravikoff et al study result?
* Is there a significant difference between magnet and nonmagnet hospitals in New Jersey as it relates to EBP?
* Are there significant differences among the northern, central, and southern region hospitals of New Jersey in reference to the individual practitioner skills and resources available for using EBP?
* Are the resources needed for nurses to practice in an evidence-based manner available?
* Is there something that the ONE/NJ can do as a professional organization to help create 1 standard for EBP across the state?
To assess this area of concern, a request for permission was granted directly from Pravikoff to use the Information Literacy for Evidence-Based Nursing Practice instrument. Some modifications were needed to align the job titles to those currently used in New Jersey versus nationally. The content validity, according to Pravikoff et al, for the Information Literacy for Evidence-Based Nursing Practice instrument was established by experts in the fields of nursing, nursing informatics, and information science.7 Reliability and validity of this instrument had not been established at the time of this study.
The Information Literacy for Evidence-Based Nursing Practice survey used for this study was originally a 93-item questionnaire. The Pierce 9 and Tanner 10 works focused on RN faculty, graduate nursing students, and clinical staff in Louisiana. Their questionnaire was further modified for use in the pilot study of nursing administrators in Louisiana and New York. Teleform technology, a high-volume, high-accuracy, automated character-recognition and capture technology that supports batch processing of data forms, was used in the development of this instrument.
Various design formats for responding to questions were incorporated. Pravikoff et al 7 asked respondents answer "yes," or "no," or "do not know" to questions about the existence of resources (such as print indexes, electronic databases, current journals, and online resources) and access to them. Ranking of terms was also used in the response format, for example, "the top 3 individual barriers to using research in practice (from a list of 10) or the top 3 organizational barriers (from a list of 6). Because the lack of time is generally recognized as a major problem, it was not included in the list of choices (respondents were instructed "Besides time, rank the 3 primary barriers…").7
For the purposes of our replication study, the Information Literacy for Evidence-Based Nursing Practice instrument's quantitative item count was decreased from 93 to 56. Our first modification concerned asking the respondent to enter his/her hospital code in the space provided. Each hospital was assigned a code number to facilitate data sorting. It is important to note that another of our modifications involved eliminating each question's choice of answer with its own number. The only questions that ONE/NJ research committee did not replicate were Pravikoff et al questions numbers 87 to 92. These questions did not apply to acute care hospitals. Question 85's choices were changed to reflect acute care hospitals. In addition, an open-ended qualitative question was included for respondents' to add their personal comments about EBP and the survey. Two graduate nursing informatics students from the University of Medicine and Dentistry of New Jersey, School of Nursing, reformatted the tool for administration for both the paper and electronic method. Each hospital received a supply of paper surveys with instructions as well as directions to access SurveyMonkey.com for the electronic version.
The chief nursing officers from each acute care hospital in the state of New Jersey (n = 112) listed on the New Jersey Hospital Association's list of NJ hospitals were offered the opportunity to have their hospital RNs participate in this study. Participation was solicited via mail by the ONE/NJ's chair of the research committee and/or at ONE/NJ meetings of nurse executives. The hospital list included acute care and specialty care hospitals. Thirty-two hospital leaders accepted (29%) and 80 hospital leaders (71%) did not accept the invitation to participate and/or opted out because they did not match the criteria for inclusion (eg, acute care hospital). If they chose to participate, they needed to (1) identify a hospital champion, "site coordinator," who was responsible for educating their hospital RNs about the survey's purpose, distribute flyers, and collect the paper surveys if they were used; (2) obtain IRB approval or a letter of approval to participate in the study; and (3) provide the research committee with demographic information about their institution. In return, leaders in participating institutions would receive their hospital data back in raw-score format, allowing them to analyze and compare their individual data to the state of New Jersey and national data.
The anonymous survey was distributed exclusively to acute care hospital nurses as either a paper or electronic version between December 1, 2006, and January 5, 2007. The online version was administered through SurveyMonkey.com, an online survey company that allows one to purchase space on which to place surveys so others can respond to questionnaires and/or surveys via the Internet. Each hospital coordinator was provided with a PowerPoint presentation, letters for distribution to the RNs, and flyers for posting. The 32 site coordinators contacted more than 12,000 RNs to participate in this study. A total of 3,411 RNs completed the survey, yielding a response rate of 28.4%. Because only a hospital code was used for identification, the confidentiality of each respondent was assured. It is also worth noting that, similar to the Pravikoff et al 7 study, the number of respondents varied by question because some respondents chose to skip questions. The results are presented in the aggregate.
The electronic results (n = 2,911) were aggregated through the Survey Monkey.com site directly. The handwritten surveys (approximately n = 500) were entered by members of the research committee and the New Jersey Hospital Association staff into SurveyMonkey.com, yielding a total sample of 3,411. Quantitative data were analyzed using SPSS software (SPSS, Chicago, IL). The level of significance was set at P < .05. Qualitative data were sorted according to categories and analyzed collectively by members of the ONE/NJ research committee.
Most respondents were 40 to 59 years old (55.5%) and were women (73.6%). Table 1 presents the characteristics of NJ nurses. The sample of NJ nurses (n = 3,411) defined their primary professional role as clinical (64.4%), administrators (11.96%), education (6.95%), "no responses" (4.56%), and "other" (12.49%). Nurses were asked if they were familiar with the term evidence-based practice. Eighty-two percent of the nurses responded that they were familiar with the term (18% were not). They were asked if the policies and procedures in their institution reflected EBP: 78% responded yes, 9% said no, and 13% did not know.
|Table 1. Characteristics of New Jersey Nurses (n = 3,411)
Ability With Computers
Respondents were asked to identify their comfort in using computers, MS Windows, MS Word, and databases, with computers being the least skill and databases being the most complex skill. They needed to rate their ability in all 4 categories as to whether they considered themselves novice, familiar, competent, skilled, or expert. Eighty-five (n = 2,301) percent of the respondents rated themselves between "competent" and "expert" in their ability to use a computer and 15% (n = 387) as "novice" or "familiar." The ability to use MS Windows showed that 78% (n = 2,108) ranked themselves between "competent" and "expert" and 22% (n = 582) as "novice" or "familiar." The ability of using a word-processing program revealed that 70% (n = 2,284) rated themselves between "competent" and "expert," whereas 30% (n = 801) were "novice" or "familiar." Statewide, 51% (n = 1,327) of the respondents perceived that they were "competent" to "expert" in databases, which was the most complex skill.
Frequency of Seeking Information and Sources of Information
Registered nurses were asked to identify "how often do you need information to support your nursing role?" Table 2 shows those ONE/NJ responses with comparison to the Pravikoff et al results. The NJ respondents (42.6%, n = 1,140) indicated they sought information to support their nursing role "several times a week" as compared with only 28.3% nationally. The "less than once monthly" yielded 7.3% for NJ RNs as compared with 12.1% nationally. Age and educational levels were also analyzed for this question. In general, as age of the respondents increased, the perceived skill level using databases decreased. In addition, as educational preparation of the respondents increased, skill in using databases increased. Peers and the Internet were the top 2 sources for seeking data either "daily" or "many times daily."
|Table 2. Information-Seeking Frequency and Sources of Information
Nurses were also asked how often they sought nursing information from their peers and from the librarians (Table 2). The most frequent source identified for accessing information was from peers (never [1.8%], rarely [6.2%], sometimes [30.3%], frequently [41.8%], and always [19.9%]) as compared with librarians who were the least used source of information (never [37.5%], rarely [25.7%]) sometimes [22.8%], frequently [9.3%], and always [4.7%]).
Frequency of Engagement in Research Activities
Respondents were also asked, "In the last year, how frequently have you personally participated in the following activities: (1) identified researchable problems, (2) participated in research, and (3) evaluated research reports." Statewide results compared with the results of Pravikoff et al demonstrated that less than 50% participated in any of the above activities (Table 3). Further analysis was conducted on engagement in research activities according to "professional role." The results demonstrated that greater than 50% of the RN staff never identified, participated, or evaluated research reports, and 43.7% of the NJ nurses never used research.
|Table 3. Registered Nurses' Involvement in Identifying a Researchable Problem, Participating in Research, and Evaluating Research Reports
Resource Quality and Availability
New Jersey nurse respondents were asked, "Overall, how would you rate the following information resources in your workplace?" The information resources cited on the Information Literacy for Evidence-Based Nursing Practice instrument were print materials, online resources, or other information resources. Statewide results showed print materials (70.1%), online resources (68.6%), and other information resources (63%) rated as either "adequate" or "more than adequate," respectively (Table 4).
|Table 4. Registered Nurses' Rating of Adequacy of Information Resources in the Workplace
Barriers to Evidence-Based Practice
New Jersey nurse respondents were asked to identify institutional and individual barriers to nurses' use of research in practice, other than time. "Individual" barriers identified statewide, however, were different from those of Pravikoff et al results. The top 3 "individual" barriers identified by the respondents in NJ were (1) lack of skills to critique or synthesize, (2) lack of understanding pertaining to databases, and (3) difficulty accessing research materials. According to Pravikoff et al study, the lack of value for research was the No. 1 barrier as compared with it being number 8 for the NJ RNs (Table 5). Similar to the national results of Pravikoff et al, the top 3 institutional barriers for NJ hospitals were (1) lack of organizational budget for training in resource utilization, (2) presence of other goals with higher priorities, and (3) lack of organizational budget for acquisition of information resources. Statewide results are compared with the national results of Pravikoff et al (Table 5).
|Table 5. Personal and Institutional Barriers to Nurses' Use of Research in Practice (Other Than Time)
Magnet Versus Nonmagnet Results
To determine if there were any differences in results between NJ acute care hospitals that were "magnet" designated or "nonmagnet designated," data were analyzed using the Levine test for homogeneity of variances, Welsh test of equality of means for unequal variances, and a 1-way analysis of variance. Of the 32 NJ hospitals participating, there were 11 magnet- and 21 nonmagnet-designated hospitals participating in this study.
Results showed that participants at magnet hospitals (n = 11) experienced significant differences from participants at nonmagnet hospitals (n = 21) in the following areas: using computers, MS Windows, MS Word, and databases (P < 0.01); seeking information more often from a librarian (P < 0.01), the Internet (P < 0.01), conferences or workshop (P = 0.36), CINAHL (P < 0.01), and MEDLINE (P < 0.01); engaging in research activities in all 4 aspects: identifying (P = .02), evaluating (P = 0.02), utilizing (P < 0.01), and participating in research (P < 0.01); rating the quality and availability of print, online, and other resources as being adequate or more than adequate than in nonmagnet facilities (P < 0.01). However, there were no significant differences between the 2 groups in seeking information from peers, bibliography, and journals/books.
The study was designed to provide quantitative data, but to ensure that maximum information was elicited from the participants, a qualitative response section was included. The committee analyzed the comments submitted by the respondents and organized them into categories. These categories reflected the various sections of the Information Literacy for Evidence-Based Nursing Practice instrument. The categories by rank order included (1) survey design, (2) access, (3) management support, (4) knowledge, (5) time, (6) resources, (7)competing priorities, (8) resistance, and (9) interest. A total of 222 qualitative responses were submitted, which is a small response rate; however, valuable information was provided by those participants. A sample of the comments can be found in Figure 1.
|Figure 1. Sample of NJ RNs comments.
Survey design elicited 65 responses, and most of the comments were that the survey was too lengthy and had repetitive questions. Several respondents stated that they had to rank their choices when they felt only 1 choice applied. Comments relating to access (n = 46) were the next most common response. The theme in these comments was that either computer access to the databases was not readily available or that there were no resources to assist them to access the databases, particularly on the night shift. Respondents also stated that Internet access was blocked as per the institutions' policy. Many institutions do not allow RNs access to the Internet while at work for a multitude of reasons, especially misuse. The lack of Internet access to reputable Web sites can impede the output of RNs conducting database searches and reviews of the literature for clinical issues.
Management support was third in the number of comments (n = 39). Responses were both positive and negative, although negative comments outnumbered positive comments. Many of the negative comments related back to the access issue, and respondents stated that access and appropriate needed resources were not supported by their management. Positive comments included support of research/evidence-based practice committees and a commitment by institutions to provide evidence-based policies and procedures.
Thirty comments were grouped in the knowledge category. The need for additional training to search databases was the common theme of respondents in this area. Other respondents indicated that continuing education, as a whole, has suffered as a result of budget cuts. Lack of time was also a frequent comment and received 25 responses. The survey tool acknowledged that time was the major barrier and asked respondents to identify barriers, other than time. In the qualitative section, however, lack of time and competing priorities were a major theme.
In both the Pravikoff et al study and the ONE/NJ study, the age ranges of the respondents were similar. Estabrooks 16 identified that nurses practice based on what they learned in nursing school as well as their experiences in practice. If nurses with limited knowledge on how to use databases are relying on their peers for information and the Internet, they may not be using the best evidence to achieve the best outcomes. Van Wynen 17 addresses this issue by writing, "It is clearly important that nurses and nurse researchers alike possess the competencies that are necessary to access, retrieve, and analyze research evidence for their practice throughout their career. Information literacy is important for nurses to acquire because they will use these skills to decipher the vast expanse of knowledge that is generated through healthcare research."17 Budget and resources cannot always be labeled as barriers to EBP; national nurse executives today must explore their staff nurses' personal and professional attitudes of lack of motivation and desire to improve their professional nursing practice.
The results demonstrated that the library was rarely used by the participants; in fact, 50% of the respondents said they never used the hospital library, with some indicating that they did not know where the library was or that nurses were not allowed in the library. This may be explained by the increased pace of activity in the hospital which limits the feasibility of seeking information from the library. If this is the case, how do we ensure that evidence is accessible and that they have the skills to easily retrieve it? It raises the question of how the librarian can enhance the nurses' ability to retrieve evidence.
The clinical nurses' ability to engage in any research activity was limited. This is concerning in that nurses are expected to practice using an evidence-based approach and understand which patient care management protocols produce better outcomes.
Barriers to research other than time showed interesting results. Two of the 3 top institutional barriers focused on the allocation and acquisition of resources. The other barrier was the presence of other goals with higher priorities. This was not surprising to the committee because of the well-publicized financial difficulties of hospitals in New Jersey, and therefore as a result, the first priority was going to be improving the bottom line. However, perhaps some funding resources could be reallocated.
Individual barriers included lack of skills to critique or synthesize research, lack of understanding pertaining to databases, and difficulty accessing research materials. The individual barriers focus toward the need for education. This was markedly different than the results of Pravikoff et al, which identified the No. 1 individual barrier as the lack of value for research. The committee perceived these results as positive as changing values are difficult or impossible to achieve, whereas education is an achievable action.
Dissemination of Findings
Organization of Nurse Executives of New Jersey and their nursing research committee's goal for the dissemination of their study's findings included an action plan that included (1) a full-day nursing research conference that focused on the replication of the Pravikoff et al study's findings, (2) the submission of a article based on the study's findings, and (3) increase the knowledge base of the RNs from staff nurse to nurse executive in the area of EBP. The national, state of New Jersey, and ONE/NJ hospital's results were presented at the ONE/NJ Research Conference in June 2007, where Diane Pravikoff gave the keynote address. In addition, the ONE/NJ partnered with the University of Medicine and Dentistry and the Health Sciences Library Association of New Jersey's librarians across the state to assist us in the development of an action plan for New Jersey.
During the research conference, an open forum was held with those participating in the conference. After reviewing the survey's results, the audience was divided into work groups and asked to answer the following questions:
* What is needed to practice in an evidence-based way?
* Who needs to know about EBP and why?
* Does teaching EBP strategies change anything?
* Can institutions afford to educate every bedside RN about EBP? If not, then who?
* Based on the organization and individual barriers, what recommendations do you have?
* What strategies do you have to improve the use of EBP? Administration, clinical, educators, librarians, schools of nursing?
* What 3 priorities would you like ONE/NJ's research committee to address?
Based on the responses from the audience to the above, there was an overwhelming request for ONE/NJ to develop an EBP tool kit that each interested hospital in the state of New Jersey could incorporate. The participants also strategized with each other to formulate ideas to move EBP forward in their organizations.
Implications for Nurse Executives
The survey identified that as the age of the RN increased, the computer skill level decreased. This fact has implications for nurse executives whose RN workforce is aging. Clearly, nurse executives need to assist the older staff RN in attaining the computer skills needed for current practice. The results also showed that educators have a much higher perceived competency in computer and database usage. Nurse executives may have the opportunity to partner with nurse educators to educate their older nurse. The younger nurses could also assist their older colleagues, given the right framework for education. Could this be a way to bridge the gap between older and younger nurses?
The survey results showed that nurses most often access information from their peers and secondly access the Internet to obtain information. The opportunity for nurse leaders is to ensure that access to the databases (such as CINAHL and Cochrane) would be most beneficial when RNs are seeking evidence-based resources. Because the RNs are stating that they use the computer to access information, having the best information readily available could entice the RNs to use the preferred sites. The more RNs are educated about accessing databases, making it user-friendly for the nurse, the less likely they are to use their peers for information.
The survey results highlight that the library is not the place where the RN gets his/her information. The implication for nurse executives is that he or she may need to collaborate with the hospital librarian to reach the nurse in a different way. The librarian may be able to bring the "library" to the staff by going to the nursing units and educating the RNs on how to access information on the computer, by offering his/her expertise when an RN is conducting his/her first search, and by providing "tips" on an ongoing basis to the RNs to keep their interest.
The results indicated that clinical RNs rarely if ever identify, participate, or evaluate research. The implication for nurse executives is that the nurses need more education on how to access and use the evidence from research in practice. The good news for the nurse executive is that the study participants value research, even if they do not know how to use it. The inference here is that if the RNs are given the education, they will use the research to incorporate into their EBP. The nurse leaders need to capitalize on this finding as the RNs are ready for the education.
The study participants identified budgetary and resource allocation as institutional barriers. Nurse executives live with the paradox of the importance of allocating resources for EBP and research education with the ever increasing fiscal constraints placed on them. Nurse executives must be creative in addressing both sides of the dilemma.
In summary, the nurse executive needs to find creative ways to support EBP, both in resources and education for the clinicians. Nurse executives must support the use of including EBP into the development, review, and revision of all nursing and administrative policies and procedures. From an organizational prospective, EBP should be a goal incorporated into the information technology plan for the hospital.
Although all acute care hospitals in the state were asked to participate in the study, only 32 hospitals representatives responded to the call for participation. Because this was a self-selection process, which resulted in a convenience sample, the generalizability of the findings may not be representative of the entire pool of hospitals. Because each hospital provided the survey to their nurses, some nurses may not have participated because they were concerned with confidentiality and anonymity. The instrument was repetitious, and based on feedback from the participants, it forced choices where some participants would have responded differently had they had more choices.
Based on the results of this replication study, ONE/NJ concludes the following:
* Gaps still exist in RNs' computer and searching skills and availability to access EBP information and "best practices." Unlike Pravikoff et al national study, NJ RNs across the state value nursing research and EBP and know that it is important for tomorrow's nursing practice and patient outcomes;
* Administrators, educators, clinicians, librarians, and schools of nursing faculty could all benefit from the results of this study; and
* It is suggested that nurse executives evaluate their individual hospitals and implement change as it relates to EBP. Putting together an action plan for your organization can help ensure that there is 1 standard of care for patients and that the next Institute of Medicine report will show a significant difference in all organizations across the United States.
The authors thank ONE/NJ research committee 2006-2007 and 2007-2008; University of Medicine and Dentistry of New Jersey Graduate Nursing Informatics students: Jim Hollingsworth and Hedy Tellerman; Susan Salmond, EdD, RN, NEA-BC, Interim Dean, UMDNJ for her guidance; Pat Daley, RN, MA, NE-BC, Executive Director, ONE/NJ; Deborah A Jasovsky, PhD, RN, NEA-BC; Ruthann Kelman, MSN, RN, NE-BC; Rosalie Grantoza, RN, MSN, MBA, BC, CCRN; Louise M. Baca, RN, MSN, CCRP; Kathleen Mariak Cummins, MS, RN, APN-C; New Jersey Hospital Association staff and librarians; Marylee Demeter, statistician; Diane Pravikoff; and AONE Institute of Research for their seed grant sponsored by Cerner 2006. This grant assisted in duplication of the survey, mailing costs, and statistical analysis of the data.
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