The Reach, Transferability, and Impact of the Evidence-Based Practice Questionnaire: A Methodological and Narrative Literature Review

Evidence Review

The Reach, Transferability, and Impact of theEvidence-Based Practice Questionnaire: AMethodological and Narrative LiteratureReviewDominic Upton, PhD, FBPsS, C. Psychol • Penney Upton, PhD, AFBPsS, C. Psychol •Laura Scurlock-Evans, PGD PRM, BSc (Hons), MBPsS

Keywords

nursing,evidence-based

practice,methodological and

narrative literaturereview,

staff development,psychometric

analysis,Evidence-Based

PracticeQuestionnaire

ABSTRACTBackground: Since the 1990s, evidence-based practice (EBP) has been increasingly emphasizedin nursing, but its implementation is still sometimes met with confusion and resistance. Therefore,identifying factors affecting its implementation is crucial. The Evidence-Based Practice Question-naire (EBPQ) was published in 2006, addressing a need for a robust measure of nurses’ practiceof, attitudes toward, and knowledge of EBP. The growing body of professionals using the ques-tionnaire means that a review of its reach, transferability, and impact is timely.

Aims: The aims of this review were threefold: (a) identify the situations in which the EBPQ hasbeen used in both published and unpublished research internationally (Reach); (b) collate thepsychometric properties of the EBPQ from the research reviewed (Transferability); and (c) discussthe study’s findings to shed new light on issues facing professionals in implementing EBP, andpossible future directions for research (Impact).

Methods: Literature searches on studies reported between 2006 and July 2012 inclusive wereconducted using the terms “Evidence-Based Practice Questionnaire” and “EBPQ.” Green, John-son and Adams’s guidelines for completing narrative literature reviews and Terwee et al.’s frame-work for reporting questionnaires’ psychometric properties were adopted to ensure rigor.

Findings: Twenty-seven studies were reviewed in which the EBPQ had been translated into fivedifferent languages and used with a variety of professional groups. The questionnaire demon-strated convergent and discriminant validity and good internal reliability. Research adopting thequestionnaire identified a range of variables related to EBP implementation, including qualifica-tion route and job role.

Linking Evidence to Action: Assessment of organizational culture and workforce training needsprior to developing educational interventions is crucial. The EBPQ has the potential to providefurther understanding of these and other issues faced by professionals when implementing EBP.

BACKGROUNDEvidence-based practice (EBP) represents the “integration ofthe best research evidence with patients’ values and clinicalcircumstances in decision making” (Shaneyfelt et al., 2006,p. 1116). At its core, this approach aims to ensure that peopleconsistently receive the best care possible, based on the appli-cation of the most up-to-date research available, rather thanmere tradition (Brown, Wickline, Ecoff, & Glaser, 2009).

Since the 1990s, the EBP approach has been increasinglyadopted within health care, both within the United Kingdom(Upton & Upton, 2006) and internationally (Brown et al.,2009). There are a number of reasons for this drive towardEBP, including the need for quality assured, dependable health-

care services (Upton & Upton, 2006) and the increasing ac-countability of healthcare workers (Prior, Wilkinson, & Neville,2010). However, despite EBP being identified as a key methodby which to reduce the costs associated with ineffective meth-ods of diagnosis and treatment (Upton, 1999), its uptake hasbeen problematic. Although there have been dramatic shiftsin professional education and policy over the last 20 yearswithin nursing practice, research still identifies inconsisten-cies in EBP adoption and implementation (Rolfe, Segrott, &Jordan, 2008; Sandstrom, Borglin, Nilsson, & Willman, 2011).Therefore, further research is required into the barriers pre-venting EBP implementation to enable targeted interventionsto be developed and evaluated. For this reason, there is also a

46 Worldviews on Evidence-Based Nursing, 2014; 11:1, 46–54.C© 2014 Sigma Theta Tau International

Evidence Reviewneed for a psychometrically validated and robust measure ofEBP.

Measures of EBPAlthough a number of tools are available to assess EBP, manyonly measure evidence acquiring or appraising skills generally(Shaneyfelt et al., 2006); assess competency of clinical deci-sion making through the use of vignettes and case histories;or assess only one aspect of EBP (e.g., attitudes). Only a hand-ful of frequently used tools exist that measure more diverseself-reported facets of EBP simultaneously, which includes (a)Jette et al.’s (2003) EBP survey tool, (b) the BARRIERS scale(Funk, Champagne, Wiese, & Tornquist, 1991), and (c) the EBPBeliefs and Implementation Scales (Melnyk, Fineout-Overholt,& Mays, 2008). This review examined another such measure,the Evidence-Based Practice Questionnaire (EBPQ; Upton &Upton, 2006).

The EBPQThe EBPQ was developed to measure factors influencing EBPuptake and implementation, initially within nursing practice(Upton & Upton, 2006). It is a 24-item self-report measure,comprising three subscales: practice (use), attitude (attitudetoward EBP), and knowledge (knowledge and skill in EBP).See Table S1 online for details of the items comprising thequestionnaire.

The questionnaire was developed through the generationof a pool of items, which were rated by a random sample of751 nurses from NHS Wales and subjected to a principal com-ponent analysis (PCA). The PCA revealed three factors, whichform the basis of the subscales.

The EBPQ has been found to be quick and easy to adminis-ter, and to have good internal reliability as measured by Cron-bach’s alpha; the alpha for the overall questionnaire is .87 andthe three subscales have alphas of .85 (practice), .79 (attitude),and .91 (knowledge; Upton & Upton, 2006).

Evidence of the EBPQ’s construct validity was providedthrough moderate correlations between knowledge of a localEBP initiative and questionnaire scores (suggesting the ques-tionnaire was measuring EBP-related attitudes) and a statis-tically significant difference between individuals, who wereaware of the local initiative and those who were not (indicatingdiscriminant validity).

AIMSThis review reports the use of the EBPQ since its pub-lication in 2006, paying particular attention to its usein international research, interventions, and training inthe workplace. Specifically, the aims of the review werethreefold:

1. Identify the situations in which the EBPQ has beenused in both published and unpublished researchinternationally (Reach).

2. Collate the psychometric properties of the EBPQfrom the research reviewed, paying particular atten-tion to translated versions (Transferability).

3. Discuss the studies’ findings to shed new light onissues facing professionals in implementing EBP,and possible future directions for research (Impact).

METHODSThe review followed the reporting standards identified byGreen, Johnson, and Adams (2006) for writing narrativeliterature reviews and Terwee et al.’s (2007) frameworkfor reviewing research instruments’ psychometric properties.Terwee et al. (2007) proposed eight criteria to assess themeasurement properties of questionnaires: content validity,internal consistency, criterion validity, construct validity,reproducibility (encompassing ability and reliability), longitu-dinal validity, responsiveness, floor and ceiling effects, andinterpretability. A narrative and methodological review frame-work was adopted as it provides the facility to present a broadperspective on the EBPQ and its development while allowingfor a systematic critique of the research presented.

Search MethodsThe review was carried out upon research reported between2006 and July 2012 (inclusive), using the terms “EvidenceBased Practice Questionnaire” and “EBPQ.” The databasessearched were: Academic Search Complete, Cumulative Indexof Nursing and Allied Health Literature (CINAHL) Plus, Amer-ican Psychological Association databases (PsycARTICLES),Medline, Journal Storage (JSTOR), and Science Direct (searchone). Google Scholar also was searched using identical terms(search two). Finally, a database maintained by the authors ofall professionals working in different healthcare and social caredomains, who had requested permission to use the EBPQ forresearch, training, or educational purposes, was used to iden-tify further studies (search three). This included unpublishedresearch and articles published in languages other than En-glish. A flowchart of study retrieval and selection is presentedin Figure 1.

Search OutcomeSearch one identified 10 potentially eligible studies, search twoidentified 12 more, and search three identified a further 11.Three ongoing research projects also were included.

Studies were initially assessed to ascertain their suitabilityfor inclusion in the review (see Table S2 online for criteria).To be included, all three subscales or the entire questionnairemust have been used and sufficient detail regarding study de-sign, sample, and results provided. Applying these criteria ex-cluded eight studies from the review (see Table S3 online forcharacteristics of excluded studies). The results of two articleswere combined because they reported the results of the sameresearch study (Pfenning, 2009, 2010).

Worldviews on Evidence-Based Nursing, 2014; 11:1, 46–54. 47C© 2014 Sigma Theta Tau International

EBPQ Literature Review

Figure 1. Flowchart of the study retrieval and selection process.

Quality AppraisalStudies included in the review were quality appraised (see TableS2 online for criteria). Fifteen articles were awarded a goodrating and five articles an average rating. No poor ratings wereawarded. Eight further studies included in the review werenot quality appraised, because they represented either ongoingprojects or evaluation and training projects. See Table S4 onlinefor characteristics of the studies included in the review andcitations.

Data AbstractionFocus was placed on modifications to the questionnaire, psy-chometric properties reported, research purpose and design,and factors affecting EBP (i.e., barriers and facilitators). Oneauthor undertook all data extraction to ensure consistency and,where appropriate, was reviewed by the remaining authorsto ensure rigor. If information was missing, contact was at-tempted with the study’s primary author.

SYNTHESISThis review followed a textual approach to data synthesis. Con-tent analysis was used to deductively and inductively categorize

recorded text using predetermined concepts (Norwood, 2000)and provided a framework for organizing the data for synthe-sis. Content categories were based on theoretical knowledgeabout the reach and impact of the EBPQ, and the psychometricqualities of questionnaires identified by Terwee et al. (2007).The inclusion of gray literature and unpublished research helpto avoid publication bias (Song et al. 2010). The synthesis ofdata under categories was undertaken by one author (to en-sure consistency) and reviewed by the other authors (to ensurerigor).

FINDINGSAim 1: ReachThe EBPQ is becoming increasingly popular with researchersworking outside the United Kingdom. Of the 22 research stud-ies and 5 educational and training purpose studies included,44% were conducted in the United States, 33% in Europe (only2 in the United Kingdom), and 22% in other countries (SaudiArabia, New Zealand, Australia, South Korea, and China).

The majority of the studies were conducted with nurses(70%); the remaining studies were conducted with al-lied health professionals (AHPs; 11%), social workers (4%),


Evidence Reviewcomplementary and alternative medicine practitioners (4%),and mixed samples of health professionals (4%). One ongoingstudy’s sample composition was unavailable.

The aims of the research reviewed included identifying bar-riers and facilitators of EBP (38%), translating the EBPQ (25%),evaluating educational interventions (17%), assessing organi-zational culture (13%), and psychometric validation (8%).

Aim 2: TransferabilityMany studies reviewed reported psychometric properties ofthe original and modified version of the EBPQ (see Table S5online for details), allowing the questionnaires’ performanceto be assessed.

Psychometric properties of the original EBPQ: Internal con-sistency. Terwee et al. (2007) suggest internal consistency canbe established through exploratory factor analysis (EFA) andconfirmatory factor analysis (CFA), and through Cronbach’salpha (where values of .70–.95 demonstrate adequate internalreliability).

The original EBPQ exhibited strong internal consistency forthe entire questionnaire, and practice and knowledge subscales(Brown et al., 2009, 2010; Gorelick, 2010; Kim et al., 2012;Koehn & Lehman, 2008; Lehman, 2007; Pfenning, 2009,2010; Prior et al., 2010; Stichler, Faan, Fields, Kim, & Brown,2011; Upton, Scurlock-Evans, Stephens, & Upton, 2012). How-ever, the attitude subscale was consistently associated with alower Cronbach’s alpha, suggesting further refinement may berequired.

Reproducibility: Agreement. Although none of the studiesassessed agreement directly, Pfenning (2009, 2010) found theCronbach’s alpha of the entire questionnaire remained veryhigh before and after an intervention, suggesting a strong de-gree of consistency.

Reproducibility: Responsiveness. Pfenning (2009, 2010),Kim et al. (2012), and Toole, Stichler, Ecoff, and Kath (2012)identified statistically significant improvements on some or allof the EBPQ subscales following participation in educationalinterventions. These findings suggest the EBPQ is sensitive tochange, particularly in the practice of EBP. However, specificstatistical results were not reported, and attempts to contact theauthors for further information were unsuccessful.

Reproducibility: Reliability, and floor and ceiling effects.Koehn and Lehman (2008), Lehman (2007), and Upton et al.(2012) identified low standard deviations for the three subscalesand total scale; suggesting small variation between individuals’scores. This may explain why both studies failed to find signif-icant results for the Practice and Knowledge subscales (whichhad the lowest SDs) in their analyses, indicating further workmay be required to explore the EBPQ’s sensitivity to individ-ual differences. Alternatively, only small differences betweenparticipants may have actually existed.

Construct validity. The EBPQ demonstrated significant cor-relations (in predicted directions) with other relevant measures

(or their subscales or items), such as the BARRIERS subscale(Brown et al., 2009, 2010; Kim et al., 2012) and the EBASEscale (Leach & Gillham, 2008). No further information on thepsychometric properties outlined by Terwee et al. (2007) wasprovided by the studies.

Translation studies. Mosci and Chiari (2009) developed threeindependent Italian translations of the EBPQ. These were rec-onciled into a single translation, back translated into English,and then reconciled with the original EBPQ. The translatedEBPQ was piloted with a group of 18 nurses and physiothera-pists to establish content validity. To explore the structure andconstruct validity of the questionnaire, it was administered to192 healthcare professionals (response rate = 65.7%), who hadattended EBP training at an Italian hospital, and 128 staff (noresponse rate reported), who had never attended EBP training.A PCA with oblique rotation revealed three factors, althoughitem 1 of the attitude subscale was excluded as it did not reachthe factor-loading threshold of .4. The Cronbach’s alpha forthe three subscales all suggested strong internal consistency.Construct validity was supported through the finding that par-ticipants, who had completed EBP training, scored significantlyhigher on each of the subscales than participants who had not.

Another Italian translation of the EBPQ was developed byRomani and Forni (2010); this version was reviewed by anexpert nurse to ensure comparability with the original itemsand content validity. The authors modified the Likert scale fromthe original 7- to 4-points, to further simplify the EBPQ. Thismade comparisons with the original difficult, and no reliabilityor validity information was reported.

Using a similar method to Mosci and Chiari (2009), DePedro-Gomez et al. (2009) translated the EBPQ into Spanish.This questionnaire was administered to primary healthcare andhospital nurses (N = 246, response rate = 88.9%) recruitedthrough a training program aimed at improving clinical prac-tice effectiveness (for individuals with no prior EBP training).

The internal consistency of the translated EBPQ was as-sessed using EFA; although three factors were revealed, prob-lems were identified with items 7, 22, 23, and 24 (loadinghighly onto more than one factor) and item 16 (loading poorlyonto all three factors). These items were, therefore, droppedfrom the Spanish EBPQ. CFA suggested the 19-item tri-factormodel provided an improved fit of the data: better than theuni-factor or 24-item tri-factor models. Cronbach’s alpha forthe final subscales were strong.

The EBPQ was recently translated into Korean by Lim (sub-mitted). A back translation was performed, to ensure compa-rability with the original questionnaire, and administered to aconvenience sample of 453 registered nurses (response rate =95.7%) working in 44 large medical centers in the Republicof Korea. Cronbach’s alpha for the entire EBPQ, practice andknowledge subscales were excellent. However, the alpha for theattitude subscale was below Terwee et al.’s (2007) suggestedcutoff.



Two further studies were ongoing at the time of writ-ing; a Norwegian translation project with nurse anesthetists(Svarthaug & Hall-Lord, Gjovik University College) and a Man-darin Chinese translation project with 1,600 healthcare profes-sionals in China (Yang, Central South University).

Other professional groups. The utility of the EBPQ for non-healthcare professionals has also been explored; Rice et al.(2010) administered the EBPQ to a random sample of 180 so-cial workers (response rate = 10.8%) to assess its structure andvalidity with this group.

The Cronbach’s alpha for the entire questionnaire, and prac-tice and knowledge subscales were high, but the attitude’s sub-scale alpha was below Terwee at al.’s (2007) suggested cutoff.CFA was performed and the removal of item 1 of the attitudessubscale resulted in a better model fit and was dropped fromsubsequent analyses.

Differences between the structure of the EBPQ in Riceet al.’s and the original study may reflect underlying differ-ences in the two populations; for example, the use of EBP insocial work in the United States is not as widespread as it is inthe nursing field (Rice, Hwang, Abrefa-Gyan, & Powell, 2010).

Although many of the translation studies provided reliabilityand validity information, none provided information on thefull range of criteria specified by Terwee et al. (2007). Furtherresearch is required to fully establish the quality of the adaptedmeasures.

Aim 3: ImpactEducational background. Higher education (tertiary) qualifi-cations have been associated with greater ability to use researchtools (Romani & Forni, 2010), more positive attitudes (Brownet al. 2010; Mosci & Chiari 2009), greater knowledge (Mosci &Chiari, 2009; Prior, Wilkinson, & Neville, 2010), and uptake(Mosci & Chiari, 2009; Thomas & Falan, 2011) of EBP. For ex-ample, Mosci and Chiari (2009) found that 92.7% of all nurseswith a master’s level qualification (compared to only 48.8% ofnurses with diploma level qualifications) had heard of EBP andBrown et al. (2010) identified small significant positive corre-lations between master’s level education and the three EBPQsubscales. Koehn and Lehman (2008) found that nurses withassociate degree and diploma level qualifications scored signif-icantly less positively on attitudes toward EBP than did nurseswith bachelor’s and master’s qualifications (with a large effect).However, although Stichler et al. (2011) identified a statisticallysignificant positive correlation between master’s level educa-tion and attitude toward EBP for nursing faculty (teachers),they identified a statistically significant negative correlationbetween doctoral degree education and EBP attitudes. The au-thors suggest this may be confounded by the different settingsfaculty members worked in (those with master’s level qualifi-cations tended to teach in clinical contexts, whereas those withdoctoral degrees tended to work in academic contexts). Fur-thermore, although Kim et al. (2012) also found statisticallysignificant negative correlations between baccalaureate quali-

fications and each EBPQ subscale, and a positive correlationbetween master’s level qualifications and the knowledge sub-scale, these differences disappeared after controlling for othervariables.

Work experience. Inconsistencies in the relationship betweenlength of work experience and EBP were identified. For exam-ple, research with newly qualified AHPs failed to identify anysignificant differences in length of work experience for thosewith high-, medium-, or low-EBP use or skill profiles (Uptonet al., 2012). However, Prior et al. (2010) found length of timepracticing as a registered nurse was negatively correlated withthe EBPQ practice subscale and length of time practicing in pri-mary health care was negatively correlated with the knowledgesubscale. De Pedro-Gomez et al. (2011) found that profession-als with fewer years of experience were more likely to havemore positive attitudes toward and greater skill in EBP, andUpton et al. (2012) found indications that younger profession-als (29 years and under) were more likely to have greater skill inEBP implementation than older professionals—although thesedid not achieve statistical significance. However, Romani andForni’s (2010) research suggests that newly graduated staffmay also experience difficulty with elements of EBP; new pro-fessional graduates have foundations in EBP from their train-ing, but have not yet had the opportunity to practice EBP, whilenurses, who are more experienced in their role, may potentiallyneed greater support with computer and research skills.

Inconsistent results have also been reported concerningEBP and job role. Research suggests that as nurses’ grade-levelincreases, so too does their practice of EBP (Brown et al., 2010).Grade level has also been identified as a significant predictor ofscores on the EBPQ attitude subscale, with junior grade-levelstaff demonstrating lower scores than senior grade-level staff(Gorelick, 2010).

The staff nurse role has been significantly negatively corre-lated with all three EBPQ subscales (Brown et al., 2010; Kimet al., 2012), whereas the nurse manager role has been signif-icantly positively correlated with the practice and knowledgesubscales (Brown et al., 2010). Indeed, De Pedro-Gomez et al.(2011) and Gonzales-Torrente et al. (2012) found that nursesin managerial roles scored significantly higher on all EBPQsubscales than nurses in nonmanagerial roles. However, otherresearch has failed to identify this pattern (Kim et al., 2012).

The nurse educator role has been significantly positively cor-related with the practice and knowledge subscales (Kim et al.,2012), and the attitude subscale (Brown et al. 2010, Kim et al.,2012). However, Stichler et al. (2011) suggested nurses in teach-ing roles should be provided with ongoing educational supportto ensure that their knowledge and skills remain current, toincrease the likelihood of their implementation in teachingactivities. Ultimately, variation in EBPQ scores may reflect dif-fering emphasis placed on EBP by the roles.

Technology. Technology plays a key role in EBP, such as whensearching for information online. Thomas and Falan (2011)found confidence in using computers was a facilitator of


Evidence ReviewEBP implementation. However, Gorelick (2010) found thatincreased Internet use with a clinical agency computer was as-sociated with a decrease in practice of EBP, which may reflecta function of confidence in using such equipment.

Gorelick (2010) also examined whether personal digital as-sistant (PDA) use facilitated clinical decision making or uptakeof EBP. Although no significant differences were identifiedon decision making, nurses, who occasionally used PDAs, re-ported higher EBPQ Practice subscale scores than those whodid not.

Educational interventions. Kim et al. (2012) identified sta-tistically significant improvements in EBP practice and knowl-edge following a 9-month collaborative and interactive regionalEBP fellowship program. No significant improvements in at-titude toward EBP were identified, although this may simplyreflect highly positive attitudes prior to the intervention. Pfen-ning (2009, 2010) identified significant increases in nurses’EBP attitudes, knowledge, and practice following involvementin a professional journal club, suggesting this may be a cost-effective intervention.

Toole et al. (2012) examined the impact of two teaching de-livery methods on EBP implementation: computer and classbased. They found statistically significant improvements inpractice of EBP following both interventions, but no statisticallysignificant differences between the interventions, suggestingcomputer-based learning may provide a cost-effective alterna-tive to traditional methods. A further research project exploringthe effectiveness of different educational interventions in SirRun Run Shaw Hospital is ongoing (Tang & Hu; ZhejiangUniversity, China).

The EBPQ as an evaluation tool. In an unpublished study,the EBPQ was used to evaluate two Saudi Arabian hospitals’ or-ganizational cultures (identifying significant differences), theKing Khalid Eye Specialist Hospital and the King Faisal Spe-cialist Hospital Research Centre (Salem, unpublished study).

In the United Kingdom, the EBPQ has been used as an ed-ucational tool to facilitate awareness and use of EBP with aTrafford Primary Care Trust speech and language therapydepartment. The EBPQ has also been adopted at AuburnMontgomery School of Nursing (Alabama, USA) as an evalu-ation tool for baccalaureate nursing students’ junior-level EBPcourse, in relation to student attainment, course content, andpresentation methods.

The relationship between EBP and its barriers and facili-tators is complex; exploring profiles of EBP may provide aneffective means of examining these issues. For example, Ven-tura et al. (unpublished study) used the EBPQ to explore thecharacteristics of 58 physiotherapists and speech therapists,who fell into medium- and high-attitude groups. The profilesrevealed significant differences on a range of variables includ-ing: participants’ age (younger participants were more likelyto be located in the medium-attitude group) and training at-tendance. Those in the high-attitude group are more likely

to attend EBP-specific training or conferences, whereas themedium group attend non-EBP-specific training.

DISCUSSIONLimitations of the ReviewNarrative literature reviews may encounter greater risk ofconfirmation bias (Baumeister & Leary, 1997). However, thequality appraisal and methodological review frameworks wereselected to mitigate this issue. The inclusion of unpublishedand gray literature provides a means of identifying the use ofthe EBPQ in practice and helps to avoid publication bias, butalso means that some articles have not been through the rigorof the peer-review process.

Three studies written in languages other than English weresent to the authors by contacts from their database. Althoughfurther non-English studies were identified in searches oneand two, no other non-English journal sources were searched,indicating a potential source of bias.

Strengths and limitations of the research reviewed. Re-search using the EBPQ is in its infancy; the literature baseavailable to review is growing, but is not yet large enough for aquantitative systematic review or meta-analysis. The nature ofthe literature base also means that some articles lacked detailand the psychometric properties of the EBPQ have not beenexamined in full. However, the available information supportsthe adequacy of the questionnaire’s performance under a rangeof circumstances.

A large proportion of the studies reviewed used convenienceor purposive sampling, bringing into question the representa-tiveness of some of the research findings. Also, some of thestudies’ samples were small and female-dominated. Althoughthis may reflect the demographics of the population, further re-search is required to explore these issues and generalizationsof these findings should be tentative at this stage.

Strengths and potential limitations of the EBPQ. The EBPQhas been used in a range of circumstances. In the cases wherethe questionnaire was modified, many researchers suggestedthe EBPQ was chosen because no appropriate measures wereavailable in the preferred language (Svarthaug & Hall-Lord,in progress; Tang & Hu, in progress), or for the professionalgroup of interest (Rice et al., 2010). The EBPQ also was chosenbecause it was quick and simple to administer and measuredall three constructs simultaneously, thereby reducing burdenon participants (Rice et al., 2010).

Psychometric properties of the original EBPQ. The originalEBPQ exhibited strong internal reliability across the studiesfor the entire questionnaire, including practice and knowledgesubscales. However, further research is required to examinethe internal consistency of the attitude subscale.

There may be a number of reasons why this subscale isassociated with lower Cronbach’s alpha levels. For example, intwo of the modified versions of the EBPQ, the first item of theattitude subscale was excluded because it did not appear to fit



well with the remaining subscale items. This may reflect thefact that this item refers to the impact of workload on incor-porating evidence into practice in general, whereas the otheritems are more specific to clinical practice. Alternatively, it mayreflect greater confusion in participants’ responses, owing tothe different response scale provided (i.e., paired statements asopposed to ratings from poor to best).

Although the research reviewed provides some informa-tion on the EBPQ’s construct validity, reproducibility, internalconsistency, and floor and ceiling effects, further research is re-quired to explore content validity, criterion validity, agreement,and interpretability.

The modified versions of the EBPQ reported slightly dif-ferent underlying factor structures to the original, although allwere ultimately tri-factorial in nature. The removal of itemsfrom the EBPQ, for example, item 1 of the attitude subscalefrom Mosci and Chiari’s (2009) Italian EBPQ and Rice et al.’s(2010) social worker EBPQ version, and the Spanish EBPQ-19,mean that the different versions are not directly comparablewith the original. However, these appeared to be necessarymodifications to ensure reliability.

Implications for Practice and PolicyThe data from this review show many individuals recog-nize the importance of EBP, but numerous barriers preventits implementation. These barriers are not uniform: theyare different across subgroups of the workforce and acrossdifferent organizations. For example, it appears that some edu-cational qualifications may better prepare nurses to implementEBP than others. As Koehn and Lehman (2008) highlight intheir article, some educational programs do not require course-work in statistics and research processes to be completed.Individuals from these educational pathways may need sup-port through mentoring schemes or targeted skills workshopspostregistration.

Educational background is by no means the only factoraffecting attitudes toward and implementation of EBP. Theresearch suggests that providing ongoing support for experi-enced, as well as newly qualified, staff members is needed toincrease confidence in EBP.

A consistent finding was the role technology played inadopting EBP; specifically, greater confidence facilitates EBP.Targeted skills workshops could be developed to address theparticular needs of a workforce to help overcome this issue, asthis may reduce the burden (both time and resource) on nurses.This highlights the need to assess organizational culture andstaff learning needs prior to the development of educationalinterventions, to ensure effectiveness.

The EBPQ can be used as a tool to identify EBP barriers,both within nursing and potentially across different profes-sional groups. Disseminating information about “what works”in other professions may also help to develop innovative edu-cational programs and inform postregistration nurse trainingprograms (and vice versa).

Research is required to identify the most effective educa-tional interventions currently being adopted. The studies re-viewed in this paper, such as those conducted by Pfenning(2009, 2010), were assessed immediately after the interven-tions’ completion, and therefore little is known about whetherthese improvements have longevity. However, this researchhighlights that the EBPQ is sensitive to change and suggests itis an appropriate tool for evaluation research.

Although this review has identified some important themesconcerning the barriers and facilitators of EBP, the relation-ships are far from clear: further research is required to under-stand the contradictions identified.

CONCLUSIONSThe factors identified as important to EBP implementationprovide a starting point to review training, policy, and practice.The review and supporting literature also indicates the need fora robust measure of EBP that can be used to assess EBP uptake,organizational culture, training needs, and the effectivenessof educational interventions. The EBPQ provides a means toachieve these goals and has demonstrated good performanceon a number of quality assessment criteria.

Despite the growing interest in the tool, this review hasidentified gaps in knowledge. Further systematic inquiry willhelp to increase the versatility of the EBPQ—a measure whichalready appears to have both research and educational value,and which may be a useful tool in efforts to reduce the research–practice gap. WVN

LINKING EVIDENCE TO ACTION

• Many individuals recognize the importance ofEBP, but numerous barriers prevent its imple-mentation. These barriers are not uniform; theyare different across subgroups of the workforceand across different organizations.

• The EBPQ is a 24-item valid and reliable instru-ment that can be used to measure practice (use),attitude (attitude toward EBP), and knowledge ofEBP.

• The EBPQ can be used as a tool to identifyEBP barriers and EBP uptake, both within nurs-ing and potentially across different professionalgroups.

• Further research is needed to explore contentvalidity, criterion validity, agreement, and inter-pretability of the EBPQ as well as effectivenessof interventions to enhance implementation ofEBP.


Evidence ReviewAuthor information

Dominic Upton, Professor of Health Psychology, Institute ofHealth and Society, University of Worcester, Henwick Grove,Worcester, UK; Penney Upton, Head of Psychological Sci-ences, Institute of Health and Society, University of Worcester,Henwick Grove, Worcester, UK; Laura Scurlock-Evans, Psy-chology Assistant, Psychological Sciences, Institute of Healthand Society, University of Worcester, Henwick Grove, Worces-ter, UK.Address correspondence to Professor Dominic Upton, Insti-tute of Health and Society, University of Worcester, HenwickGrove, Worcester, WR2 6AJ, UK; [email protected]

Accepted 23 September 2013Copyright C© 2014, Sigma Theta Tau International

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doi 10.1111/wvn.12019WVN 2014;11:46–54

SUPPORTING INFORMATIONAdditional supporting information may be found in the online version of this article at the publisher’s web site:

Table S1. Items Comprising the EBPQ.Table S2. Inclusion Criteria and Quality Assessment Tool.Table S3. Reasons for Exclusion and Characteristics of the Eight Excluded Studies.Table S4. Characteristics of Studies Included in the Review.Table S5. Summary of the Psychometric Properties of the Original EBPQ and Its Translated Versions.


Documents

The Reach, Transferability, and Impact of the Evidence-Based Practice Questionnaire: A Methodological and Narrative Literature Review