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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 180-187

Utilisation of evidence-based practice and its associated factors among nurses


1 Lecturer, Department of Surgical Nursing, School of Nursing, University of Gondar College of Medicine and Health Sciences, Ethiopia
2 Assistant Professor, Department of Medical Surgical Nursing, KLES Centenary Institute of Nursing Sciences, Belagavi, Karnataka, India

Date of Submission26-Sep-2020
Date of Decision07-Jun-2021
Date of Acceptance17-Jun-2021
Date of Web Publication11-Nov-2021

Correspondence Address:
Mr. Abebaw Alemayehu
University of Gondar, Gondar
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcn.ijcn_101_20

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  Abstract 


Evidence-based practice (EBP) is a problem-solving approach to clinical practice where, nurses integrate current best research evidence with their clinical skill and knowledge to make decisions for a specific client by considering his/her values. Despite the positive effects on patient care, nurses do not consistently utilise EBP in the clinical areas. The present study was aimed to assess the utilisation and associated factors of EBP among Nurses working in South Nations Nationalities and Peoples of Ethiopia Region Referral Hospitals, South Ethiopia. An institution-based cross-sectional study was conducted from July to September 2019; 684 respondents were selected using the simple random sampling technique, and out of them, 671 had completed the questionnaire making it 98% of response rate. Good EBP utilisation was found among 369 (55%) (95% confidence interval: 51.2, 58.9) participants. Marital status, knowledge, communication skill, training, Internet access, guideline availability and staff culture were the significant predictors for utilising evidence in practice. Although more than half of the respondents had utilised EBP, it was found to be not adequate. Availing EBP guidelines, Internet access and building nurse's EBP competencies, either by giving separate training or incorporating EBP as part of nursing curriculum would improve its utilisation.

Keywords: Ethiopia, evidence-based practice, nurse, referral hospital, utilisation


How to cite this article:
Alemayehu A, Jevoor PC. Utilisation of evidence-based practice and its associated factors among nurses. Indian J Cont Nsg Edn 2021;22:180-7

How to cite this URL:
Alemayehu A, Jevoor PC. Utilisation of evidence-based practice and its associated factors among nurses. Indian J Cont Nsg Edn [serial online] 2021 [cited 2022 May 28];22:180-7. Available from: https://www.ijcne.org/text.asp?2021/22/2/180/330335




  Introduction Top


Evidence-based practice (EBP) is a problem-solving approach to clinical practice whereby nurses integrate current best evidence with their clinical expertise to make decisions for a specific client by considering his or her preferences and values.[1] Nurses have knowledge and skill that are developed from their academic education and clinical experiences. Nurses also have skill on how to communicate with patients and how to elicit their feelings. Hence, nurses have to integrate this knowledge and skill while providing care.[2]

The patient may raise doubts about treatment options available in regard to their religious, spiritual, sociocultural values including economical issues. Hence, it is about listening to them and using these as an input during their health-care decision-making.[3] Globally, nursing is the buil ding block of most health-care systems and nursing staff accounts for more than 50% of health professional groups in all health facilities.[4] The nursing profession remains central to utilise EBP. EBP positively influences the practice of nurses and enables them to shift from intuition and tradition to scientifically-based practices.[5],[6]

Utilising evidence in clinical practice results in reduced costs, improved patient outcomes and serves as a standard for quality patient care.[7],[8] It results not only in high job satisfaction but also increases work efficiency and fills the gap between research, theory and practice.[9] Despite the positive effect of EBP on patient outcomes, nurses do not regularly utilise it.[7] Evidence shows that EBP is a new health-care approach that has been shown to be effective and could reduce the burden of tuberculosis, HIV/AIDS, malaria and other infectious diseases in Africa by guiding preventive and curative aspects; however, it has not yet widely implemented.[10],[11] Based on the World Health Organisation, most African research activities are connected to academic organisations and how much nursing-related research evidence is being utilised is not exactly known.[12]

In Ethiopia, the Federal Ministry of Health lacks skilled health professionals who could use evidence for policy-making. In addition, at all levels of the health systems, the culture of using evidence[13] is minimal. Therefore, this study was conducted with the aim of determining EBP and identifying factors that affect EBP among nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals (SNNPERRHs), Ethiopia.

Justification of the study

There is limited evidence on EBP and there is no study that concludes nurses' utilizing the EBP region wise.[14] Those studies were done among all health-care professionals not specifically among nurses and the results were not reported specific to each professional group. Therefore, the aim of this study was to determine the extent of evidence use in practice in the nursing sector and to provide sound recommendations, so it can aid to improve their EBP during patient care. Thus, the results of this study would help Referral Hospitals to recognise factors related to EBP utilisation and help them to take corrective measures to give the most up-to-dated, research tested and high-quality patient care.

The objectives of the study were to

  • Assess evidence use in practice among nurses
  • Determine the factors that affect nurses' EBP (utilisation).



  Methods Top


Study design, setting and sampling

An institution-based cross-sectional study was conducted in SNNPERRHs, South Ethiopia. The region is from the southern part of Ethiopia. Currently, the region has 69 public hospitals five of which; Dila, Soddo, Nigit Eleni, Arba Minch and Mizan, are referral Hospitals. Each Referral Hospital serves 3.5–5 million people.[15] There are about 1465 nurses working in those hospitals. There were a total of 140, 223, 390, 458 and 254 nurses who were assigned in the different units of the above-mentioned Referral Hospitals, respectively. All nurses who were working in SNNPERRHs during the data collection time with work experience of 6 months and above were included in the study. The minimum required sample size was calculated using the single population proportion formula by considering the proportion of nurses utilising evidence as 61.5%,[16] with 95% confidence interval (CI) and a 5% margin of error. This yielded a sample size of 401 nurses, after adjusting for a 10% non-response rate. The sample size for the second objective was also calculated by taking three predictor variables from previous study.[17]

The largest sample size from the study variables was 684, which was higher than the sample size calculated from the single population proportion formula. Thus, the minimum adequate sample size for this study was 684. To reach individual nurses; first, we had allocated nurses in the five hospitals proportionally using the following formula:



Where; n = total sample size to be selected, N = total population, Ni = total population in each hospital and ni = sample size from each hospital. Finally, nurses as the samples were selected by the simple random sampling technique, and sampling procedure is explained explicitly in [Figure 1].
Figure 1: Schematic presentation of sampling procedure on utilisation and associated factors of evidence-based practice in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospital, Ethiopia, 2019

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Data collection tools

Data were collected using a pre-tested, semistructured, anonymous and self-administered questionnaire, which are adapted from different literature developed by various authors for the same purpose.[18],[19],[20],[21] The questionnaire was prepared in English and organised into six main sections: sociodemographic, knowledge, attitude toward EBP, communication skill, utilisation and associated factors for EBP. Previous studies with the scale proved that the utilization subscale is valid and reliable. In two studies, its Cronbach's alpha was documented as 0.93[19] and 0.847.[20] However, for the sake of contextualisation, the reliability of the tool was checked through Cronbach's alpha value using the data obtained from the pre-test and found to be 0.916, 0.845, 0.898 and 0.953 for knowledge, attitude, utilisation and communication subscale, respectively. The questionnaire measured the following:

Knowledge about evidence-based practice

A total of 17 questions were asked to measure nurses' knowledge about EBP, with each of them having a three level response (1 = no, 2 = somewhat and 3 = yes). 'No' response was coded as '1', 'somewhat' responses as '2' and 'yes' responses as '3'. Each respondent's total EBP knowledge scores with a possible minimum score of 17 to a maximum 51 were calculated. The median of knowledge score about EBP was 34 (interquartile range = 13). Respondents having knowledge score equal and above the median score were considered as having 'good knowledge' and those below as having 'poor knowledge'.

Attitude towards evidence-based practice

Eleven questions were asked to measure nurses' attitude towards EBP. Each attitude question had a five-point rating scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree). Each respondent had a possible total attitude score ranging from 11 to 55. The median of attitude score towards EBP was 43 (interquartile range = 9). Nurses who scored equal and above the median were labelled as having 'favourable attitude' if not as 'unfavourable attitude'.

Evidence-based practice utilization

Six questions were adapted from previous studies[19],[20] to measure nurses' EBP utilisation. Each item had a 5-point Likert scale (1 = never, 2 = sometimes, 3 = usually, 4 = often and 5 = always) with a minimum score of 6 and a maximum score of 30. The median utilisation score was 16 (inter-quartile range = 9). Nurses who scored equal and above the median score were categorized as having 'good EBP utilisation' while those below the cutoff point as having 'poor EBP utilisation'.

Nurse to patient communication

Sixteen questions were adapted from a previous study[22] to measure the effectiveness of nurses' communication with the patient. Each item had a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree) with a minimum score of 16 and a maximum score of 80. Respondents who scored equal and above the median, 59 were classified as having 'effective communication' otherwise 'ineffective communication'. The Shapiro–Wilk test is used to check the median scores for above-mentioned descriptors of the tool.

Pilot study for data quality control

A pilot study was conducted under the supervision of Principal Investigator along with co-investigator with the sample size among 68 (10%) nurses working in Woleta Wondo Specialised Hospital, which was not included in the study. It was employed 2 weeks before the actual data collection time to check the reliability and validity of the tool and to modify the questionnaire accordingly.

Data collection procedure

First, permission was obtained from each hospital administrative body. List of all nurses who had a work experience of 6 months and above by excluding nurses who are on maternity or annual leave was created. Participant nurses then were selected randomly using given identification numbers. Five data collectors and five supervisors, at B.Sc Nursing level were recruited. They got a half day training to familiarise them with the aim of the study, confidentiality, participant rights and verbal consent. After a warm greeting, description of the purpose of the study and assurance of confidentiality and willingness to participate, the questionnaire was distributed to each eligible nurse during the two or three different shift programs (morning, afternoon and night duties). Finally, by thanking their honest cooperation, the filled questionnaire was collected back from the participants.

Data processing and analysis

The collected data were cleaned, checked for its completeness, categorised, coded and entered to Epi Info version 7.2.1.0 software. Then, it was exported to IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp for analysis. The result was interpreted and presented using appropriate tables, graphs and charts. Descriptive parameters, such as medians and interquartile for non-normally distributed continuous data, frequencies and percentages for categorical data were calculated. Model fitness was checked by using a Hosmer-Lemeshow goodness-of-fit test and found 8.799 Chi-square and 0.360 P values. Binary logistic regression model was used. Variables with P < 0.2 in the bi-variable logistic regression model were further entered into multivariable logistic regression model using backward likelihood ratio method to control confounders. The statistical significance was declared at the P < 0.05 with 95% of CI.

Ethical consideration

Ethical clearance was obtained from School of Nursing Ethical Review Committee on behalf of University of Gondar, Ethiopia. Before beginning data collection, permission letter was obtained from School of Nursing and was submitted for each referral hospital. From each participant, a verbal informed consent was obtained after clearly describing purpose, benefit and risk of the study. Again, study participants were informed of their full right to skip or ignore any questions or terminate their participation at any stage. Confidentiality was maintained by using anonymous questionnaires.


  Results Top


Out of 684 proposed nurses, 671 of them completed the questionnaire, which makes a response rate of 98.1%. Almost half of nurses 342 (51%) were male. Majority of the respondents were married 447 (66.6%) and Bachelor's degree holders were 571 (85.1%). With regard to education completion; the vast majority, 598 (89.1%) of them completed their education from Government institutions. Majority of the respondents were from surgical and medical units each accounted 27.1% and the least 6.1%, of them were from critical care unit [Table 1].
Table 1: Sociodemographic characteristics of nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals, Ethiopia, 2019 (n=671)

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Evidence-based practice (utilising evidence in practice)

In this study, the proportion of nurses who had good EBP was found to be 55% (95% CI: 51.2, 58.9) [Figure 2]. The median and inter-quartile range of respondents' utilisation score was 16 and ± 9, respectively. About 131 (19.5%) nurses frequently formulated clinical questions. In addition, 177 (26.4%) of them usually integrated evidence that they got with patient preference and values and their clinical decision-making skills. However, only 7.3% of them appraise the literature always and 22.7% and 19.5% of them usually evaluate the outcome of their practice and share information, respectively [Table 2].
Figure 2: Overall evidence-based practice utilisation by nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospital, Ethiopia, 2019

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Table 2: Frequency of evidence-based practice utilisation among nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals, South Ethiopia, 2019

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Factors related to evidence utilization

Organisational-related factors

Among the participants, 409 (61%) reported that standard guidelines were available at the work place, but nearly half (47.2%) of them reported that there was no internet access to utilize evidence or computers for use (54.2%). Similarly, 409 (61%) of the respondents reported that there was not enough time and 367 (54.7%) of them expressed that a nurse manager who leads and facilitates EBP utilization was not available at work area [Table 3].
Table 3: Organisational-related factors for evidence-based practice among nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals, Ethiopia, 2019 (n=671)

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Individual-related factors

From the total respondents, 517 (77%) of them did not take EBP training either as part of their curriculum or separately, 42.3% of them had no research experience and 49.5% of them had difficulty in interpreting research findings. About 53.9%, 51.1% and 50.4% of them had good EBP knowledge, favourable attitude towards EBP and effective communication skill respectively [Table 4].
Table 4: Individual-related factors for evidence-based practice utilisation among nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals, Ethiopia, 2019 (n=671)

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Factors affecting evidence-based practice utilisation

From the number of variables that were entered in to the bi-variable model; marital status, work experience, knowledge about EBP, attitude towards EBP, nurse-patient communication, training about EBP, computer skill, research experience, willingness to utilise EBP, availability of standard guideline at the work area, internet access, computer availability at the workplace, presence of enough time at workplace, staff culture, were significantly associated with EBP utilisation. These factors then were entered into multi-variable logistic regression model using the backward method to control confounders. In the multivariable analysis; marital status, work experience, knowledge about EBP, communication skill, training about EBP, standard guideline availability, internet access and staff culture had significant association with EBP utilisation.

The finding from the multivariate analysis showed that marital status had significant association with utilisation of EBP. Nurses who were single in marital status were 66.2% more likely to utilise EBP compared to ever-married nurses. Nurses who had worked for <5 years were about 1.8 times more likely to utilise EBP compared to those who had worked more than 10 years. The odds of having good EBP utilisation among nurses who had good knowledge about EBP was found to be two times more likely compared to those who had poor knowledge about EBP. Nurses who had internet access and availability of standard guidelines at work were 1.7 times and 1.8 times more likely to utilise EBP as compared to their counterparts, respectively. In addition, the finding from the multivariable analysis showed that staff culture towards EBP was one determinant factor for its utilization. It indicates that those nurses who had interest to utilise EBP were 1.8 times more likely to utilise EBP compared to those who resist EBP utilisation at work. The odds of using evidence in practice was 3.2 times more if training on EBP course was taken and 2.5 times higher in effective nurse-patient communication situations [Table 5].
Table 5: Logistic regression analyses for individual and organisational factors to utilisation of evidence-based practice, among nurses working in South Nations, Nationalities and Peoples of Ethiopia Region Referral Hospitals, Ethiopia, 2019

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  Discussion Top


In this study, 55% (95% CI: 51.2, 58.9) of nurses had good EBP utilisation. This finding is comparable with the study done in Kenya,[12] Zambia[23] and Addis Ababa, Ethiopia[14],[24] where 53.6%, 54%, 57.6% and 51.8% of nurses, respectively, had utilised EBP during their clinical practice. However, this finding is lower when compared to the study conducted in southern Ethiopia and South-west Ethiopia, where 61.5%[25] and 81.1%[26] of nurses utilised EBP during their patient care. This difference could be from knowledge and sample size difference. In this study, the sample size is somewhat higher than the study done in Southern Ethiopia (n = 208) and South-west Ethiopia (n = 333). Again, from those studies, it was reported that most of the participants had better knowledge about EBP as a majority, 81.2%[16] and 62.9%[26] of their respondents were familiar with the concept of EBP than the present study (34.6%). Hence, knowledgeable nurses are confident and eager to integrate evidences in their practice as compared to their counterparts.

This finding is higher than the study done in Australia, Iran and two African countries of Ghana and Uganda, where only one-third,[27] 41%,[28] 25.3%[29] and 19%[30] of nurses had utilised EBP, respectively. This could be due to the difference in knowledge, attitude, training and operational definition from study to study. In addition, it could associate that the majority of health workers, including nurses in Africa did not learn about EBP at schools.[31] After adjusting for possible confounding factors, it was found that the factors that were significantly associated with EBP utilisation were age, knowledge, communication skill, access to internet, training about EBP, standard guideline availability and staff culture.

This study showed that, marital status had significant association with EBP utilisation. It was found that nurses who were single in marital status were 66.2% more likely (adjusted odds ratio [AOR] =1.662, 95% CI: [1.089, 2.536]) to utilise EBP than married nurses. This is contrast with the study of Kenya[32] in which marital status had no relationship with utilization of EBP but analogous with other studies.[16],[33] The reason could be due to the fact that married nurses have added duties at home which put them to extra workload.

In the present study, work experience was significantly associated with utilisation of EBP (AOR = 1.849 [1.049, 3.257]). Nurses who had worked for <5 years were about 1.8 times more likely to utilise EBP compared to those who had worked more than 10 years. This finding is consistent with the study from Iran[19] but, reverse to the study from Norway[34] and Ethiopia,[14] that stated having fewer work experience had preventive association or work experience had no association to EBP, respectively. This discrepancy may be due to differences in the study period and sample size. It could be also that those nurses who have ten or more years working experience may not have had the opportunity of learning EBP at nursing school since EBP is a recently introduced new approach. Updating scientific knowledge needs high motivation. In addition, younger nurses are better in valuing EBP and elders were tending to use self-experience.[34]

This study finding shows that having good knowledge about EBP was two times (AOR = 2.044: 95% CI: [1.406–2.972]) more likely to have a good EBP utilisation compared to having poor knowledge about EBP. This finding is in line with results from other studies[20],[21],[30],[35],[36],[37] whereby nurses who knew about EBP were more likely to utilise research findings in clinical practice than those who did not know.

This study adds a new variable, communication skill and has a significant association with EBP utilization. Those nurses who had effective communication with the patient were 2.5 times (AOR = 2.537: 95% CI: [1.744–3.689]) more likely to utilise EBP as compared to those who had ineffective communication skill. The reason for this finding might be due to the fact that having effective communication with the patient prevents missing or wrong interpretation of patient's important information and creates a trustworthy environment between the two. This may have contributed in integrating patient's values and preferences in evidence. Another reason is to effectively communicate with the patients, recent evidence of practice and management modalities becomes necessary and therefore the communication aspect could have had an input in EBP. In addition, this might be due to the notion that nurses' communication skill is the key to quality of patient care.[22]

Similar to studies conducted in Iran[28] and North-west Ethiopia,[17] this study also found out that training on EBP was significantly associated with utilisation of EBP. It was observed that nurses who attended EBP training either as part of their curriculum or separately are 3.2 times (AOR = 3.224 95% CI: [1.957–5.311]) more likely to use EBP compared to those who did not attend it. The reason could be that training may help nurses to be clearer about the steps of EBP.[38]

Internet access which was another significant predictor is in agreement with studies done in different countries.[17],[29],[34],[35],[39],[40],[41] This could be due to the fact that EBP utilisation needs some prerequisites like searching over the internet and easy access to online EBP resources which simplifies the use of EBP. Studies done in the USA and Ethiopia that states lack of updated guidelines and organisational factors such as absence of resources to be accessed in the work area is the hindering factor for utilising EBP.[24],[42]

Furthermore, staff culture towards EBP was one determinant factor for its utilisation. This notion is supported by the studies conducted in two countries: USA[7] and South Africa.[43] The study done in Australia puts the reason why majority of nurses become resistant towards EBP utilisation is because that they are locked in their comfort zones (care based on experience, tradition and common sense).[36]

Limitation and strengths

We believe this study to be the first regionally representative investigation in context with utilisation of EBP and its associated factors among nurses in Ethiopia, Africa. The study employed a multilevel analysis to obtain precise estimates after adjusting for clustering effects. Thus, the study has power to generalise findings to the country and can be applied in low- and middle-income countries to develop customised patient care keeping his/her values intact, which in turn could cause holistic benefits to the clients in long run. However, the use of self-administered questionnaire may provide overestimated result.


  Conclusion Top


Even though more than half (55%) of the respondents had good utilisation, EBP in this study was found to be low as compared to studies conducted in other parts of Ethiopia. Marital status of the respondent, work experience, knowledge about EBP, communication skill, EBP training, Internet access, availability of standard guideline and staff culture were significantly associated with utilisation of EBP. Interventions aiming towards evidence use if patient care tailored according to the associated and predictor variables need to be planned and executed to improve evidence utilisation leading to EBP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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