FAHC studying nursing knowledge of evidence-based practice.

Submitted by The Evidence-Based Practice Team, FAHC 

Two years ago, nurses on the Quality and Research Council at Fletcher Allen Health Care (FAHC) voiced their observations that nurses at the bedside did not really know the meaning of evidence-based practice. These observations triggered the creation of a new committee: The Evidence Based Practice (EBP) Team. The EBP Team's mission is to create a culture of clinical inquiry, develop a process and resource network to apply evidence or conduct research at the bedside, and educate nurses to become skilled and competent in the use of EBP, thus enriching nursing practice and enhancing patient outcomes at FAHC.

To model the clinical inquiry concept, the team conducted an actual research study. The team developed a survey to assess nurses' knowledge, attitudes, and ultimately determine nurses' learning needs related to EBP. The 56 item survey was adapted from a national survey and distributed to 1200 registered nurses across all practice areas at Fletcher Allen the Spring of 2006 (Phase I) and again in the Winter of 2007 (Phase II). Phase II helped evaluate the change in knowledge and attitudes after an education intervention.

The survey respondents from Phase I (n=333, a 28% response rate) and Phase II (n=300, a 25% response rate) had similar demographics as seen below but there were a few critical characteristics that were significantly different. One demographic difference observed in the two survey samples concerns the year respondents graduated from nursing school. More nurses who graduated between the years 2000 and 2007 responded to the Phase II survey compared to the Phase I survey (29% vs 18%) and furthermore, fewer nurses who graduated in or before 1975 completed the survey in Phase II compared to the Phase I (20% vs 28%). In addition, more nurses with a bachelors or masters degree responded to the Phase II survey compared to the Phase I (60% vs 36%), while at the same time fewer associate or diploma nurses responded to the Phase II survey compared to the Phase I survey (39% vs 54%). So an important demographic difference to keep in mind when interpreting the results is that Phase II nurses were on average newer graduates and more educated than respondents in the Phase I survey. Thus, nurses who participated in the Phase II survey were:

* 94% Female

* 69% Age 40-59

* 78% Staff RNs vs nursing leadership, educators & advanced practice nurses

* Work experience at FAHC

** 29% 5 years or less

** 18% 6-10 years

** 10% 11-15 years

** 15% 16-20 years

** 28% 21 years or more

* 68% worked in acute inpatient setting

An educational intervention with three components was provided between Phase 1 and Phase II. The first component of the educational intervention included a presentation to nursing leadership and the nursing shared governance councils on the process leading up to the study and the results of the Phase I survey. A Nursing Grand Rounds presentation in November 2006 shared mostly the same content with the general nursing staff audience. The main educational component was a colorful pictorial powerpoint presentation created as a flip chart binder for every inpatient and outpatient nursing unit. The binder presentation described how EBP fits in FAHC's philosophy of nursing, our adopted definition of EBP, rationale for EBP, examples of evidence and multiple examples of EBP at work at FAHC.

Responses on a number of survey items were significantly different between Phase I and Phase II. One of the key outcomes that we had hoped to see was for nurses to know that EBP was imbedded in our philosophy of nursing here at FAHC. The nurses' awareness that EBP was in the nursing philosophy did improve after the educational intervention (45% vs 69%). In addition, the incidence of nurses reporting no awareness about EBP in the nursing philosophy dropped from 52% to 34% in Phase II after the intervention (p>0.0001). Most survey items were assessed using a 5-point Likert scale:

* 0 = I don't know 

* 1 = Never

* 2 = Rarely

* 3 = Sometimes

* 4 = Frequently

* 5 = Always

One item measured on the survey was whether nurses could identify an expert in the use of EBP. This outcome showed a statistically significant difference (p>0.0001) between Phase I and Phase II; in Phase I, only 38% of nurses responded that they "always" or "frequently" knew an expert in EBP versus 54% after the educational intervention.

Another survey question addressing organizational structures--such as whether or not policy committees examine and search for evidence of best practice--was also assessed by having nurses choose a response from the above-mentioned Likert scale. When the responses of 4s (Frequently) and 5s (Always) were lumped together and compared to the remaining responses of sometimes, rarely, never and I don't know, we again found a statistically significant difference (p=0.004) between Phase I and Phase II. After the educational intervention, more nurses agreed that FAHC's hospital-wide policy committees searched for best practice evidence.

Another question asked on the survey was, "When you need nursing information, how do you find it?" Responses to this question are shown below, ranked in order of the greatest responses to always and frequently:

1. Colleagues and peers (71% Phase I vs 69% Phase II)

2. Internet/WWW (49% vs 57%)

3. Journals and Books (46% vs 48%)

4. Conferences/inservices (32% vs 36%)

5. Databases (CINAHL, OVID) (14% vs 21%)

6. Assistance from Librarian (3% vs 5%).

The rank order was the same for Phase I and II and only one item was statistically significant between Phase I and II and that was: "I search the databases." The differences in how this question was ranked may be related to the fact that the sample in Phase II included more new graduates as well as nurses with bachelors and masters degrees.

When asked, "How often do you need to access nursing information to support your role?," there was no difference between the Phase I & II responses and the four response choices were roughly even; 22% said they often (several times a week) access information, 27% said regularly (weekly), 29% occasionally (once or twice a month) and 22% seldom (less than once a month). How does this compare nationally? A 2005 AJN article, using the same survey, reported 28% often, 33% regularly, 27% occasionally and 12% seldom, a statistically significant difference (p>0.0001). In addition, Sigma Theta Tau asked the same question of its membership in 2006 and reported 30% often, 34% regularly, 26% occasionally and 10% seldom or never, again a statistically significant difference between FAHC results (p>0.0001). See the sidebar graphs depicting the AJN, Sigma Theta Tau, and FAHC data for comparison.

[GRAPHIC OMITTED]

How Often Do You Need Info to
Support Your Role?

AJN Sept 2005 N=749

Often (several times per week)      28.4% (n=212)
Regularly (weekly)                  32.8% (n=246)
Occassionally (1-2 times/month)     26.7% (n=200)
Seldom (less than once per month)   12.1% (n=91)

Note: Table made from pie chart.

Nationally Perceived Need for
Info/Research

Regularly (weekly)                  34%
Occassionally (1-2 times/month)     26%
Seldom (less than once per month)    8%
Never                                2%
Often (several times per week)      30%

Note: Table made from pie chart.

How Often Do You Need to Access
Nrs Info to Support Your Role?

[GRAPHIC OMITTED]

Nurses were also asked to respond yes or no to a list of potential
individual barriers to nurses' use of research in practice (other
than time which we know is number one based on the literature).
Only the first three items (from the list of barriers below) were
statistically different between Phase I and Phase II; nurses picked
items 1, 2 and 3 as barriers more frequently in Phase I than they did
in Phase II, which might again be related to the demographic
differences in the two groups. Below is the rank order based on the
total number of yes responses.

Individual Barriers          # Respondents   # Respondents   P value
                             selecting       selecting
                             item in         item in
                             Phase I         Phase II

1.  Lack of understanding    62                   50         (p=0.001)
    of electronic
    databases
2.  Difficulty accessing     43                   33         (p=0.012)
    research materials
3.  Lack of literature       35                   23         (p=0.001)
    search skills
4.  Lack of skills to        26                   24
    critique and/or
    synthesize
5.  Lack of knowledge of     25                   22
    the research process
6.  Difficulty               22                   18
    understanding research
    article
7.  Lack of computer         20                   20
    skills
8.  Lack of access to        18                   14
    library
9.  Lack of access to        5                     6
    computer
10. Lack of value for        2                     3
    research in practice

The last question on the survey asked nurses to respond yes or no to
a list of potential institutional barriers to nurses' use of research
in practice. Only two items were statistically different between
Phase I & II populations. Below is the rank order based on the total
number of yes responses.

Institutional Barriers       # Respondents   # Respondents   P value
                             selecting       selecting
                             item in         item in
                             Phase I         Phase II

Inadequate budget for
educating nurses in the
use of information
resources                    79                   72

FAHC goals with a higher     72                   74
 priority

Inadequate budget for
acquisition of
information resources        71                   61         (p=0.029)

FAHC perceives that
nursing staff is not
eager or prepared to         45                   40
incorporate or pursue EBP

FAHC perceives EBP or
research as not achievable
in the "Real World"          35                   26         (p=0.006)

Overall, the EBP committee was very excited about these results
because it validated that our educational intervention had an impact
on the knowledge and attitudes of nurses around EBP at FAHC. More
nurses could identify that EBP was part of our philosophy, identify
an expert to help, felt rewarded for innovations in practice, felt
colleagues and other professionals support EBP, and felt satisfied
with the work environment's support of EBP. Findings suggest that
nurses need to access and provide care based on nursing information
and that nearly half indicate that the need arises at least weekly
and 70% say it happens at least 1-2 times per month. In addition,
nurses typically access more than one source of nursing information
and are most likely to consult with peers or use the internet than
journals/books. At least 75 % of nurses indicate they understand
newly published EBP.

Learning needs identified from the survey reaffirm that it is the
"fine motor" skills of EBP/research that are the biggest barrier.
Thus, future projects will focus on building nurses' understanding
of electronic databases, accessing research materials and literature
search skills for EBP at the bedside to assure the best patient
outcomes.