HOW DO CLINICIANS OBTAIN, USE AND EMBED RESEARCH EVIDENCE

WITHIN PRACTICE? SURVEY METHOD

Abstract

Background

The demand for quality care requires the translation of research evidence. However, little is

known how evidence is used, obtained or embedded in practice settings. A better

understanding of this phenomenon may provide insight into the factors that affect the

translation of research into practice.

Objectives

The aim is to explore how evidence-based knowledge and evidence-based practice is obtained,

used and enacted within the clinical setting.

Design

The study was a descriptive exploratory study using survey method. The setting was one local

health district in metropolitan Sydney, Australia.

Methods

All senior nurses and midwives working across six hospitals and primary and community care,

with access to an email account, were invited to participate in the study. Inclusion criteria

included: all nurses and midwives were eligible for enrollment. A survey was developed,

piloted and distributed to explore how evidence is obtained, used and enacted within the

clinical setting.

Results

There were 204 survey respondents. The findings identified that the majority (n = 157;

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76.96%) of respondents obtained evidence for practice, primarily from clinical practice

guidelines. Respondents perceived the best evidence for the use of evidence-based practice was

peer review journals (n = 64; 31.37%), followed by research studies (n = 57; 27.94%),

randomised controlled trials (n = 26; 12.75%) and evidence databases from the internet (n =

14; 6.86%). The majority (n = 168; 82.35%) of respondents had positive attitudes and beliefs

about the use of evidence-based practice to improve the quality of patient care. Most

respondent (n = 138; 67.65%) were confident in their ability to change practice based on

research evidence. However, there were reported four key themes of barriers to evidence-based

practice implementation emerged from qualitative data. Four key themes included the need for

time, the need for management and organisational support, the need for educational

opportunities, and challenges to accessing evidence.

Conclusions

The study provided an understanding of the relationship between evidence-based practice,

evidence-based knowledge and patient care processes. Positive attitudes and beliefs towards

evidence-based practice can influence clinicians to change behaviour, practice and procedures.

To facilitate the closure of the research-practice gap, collaboration between clinicians and

organisations needs to improve to provide better support and embed evidence-based

knowledge and evidence-based practice across different clinical settings.

What is already known about the topic?

Evidence-based practice promotes quality and consistency with care practices.

Evidence-based knowledge and Evidence-based practice are not dynamic concepts.

Barriers to knowledge translation can affect the use of evidence in practice.

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What this paper adds

This study demonstrates that evidence based knowledge and evidence based practice are

deeply embedded in everyday practice

Building research capacity and implementing local education strategies are needed to better

support the translation of research within organisations.

The importance of forums and opportunities, within clinical settings, to share knowledge

assists to bridge the research-practice gap.

This study highlights that clinical leaders are pivotal for role modeling evidence-based

practice implementation.

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HOW DO CLINICIANS OBTAIN, USE AND EMBED RESEARCH EVIDENCE

WITHIN PRACTICE? SURVEY METHOD

BACKGROUND

Today, the sophistication of the health care system requires clinicians to integrate research

evidence into practice. Research evidence must underpin best practice to better ensure

consistent, appropriate and meaningful care (Stevens, 2013, Youngblut and Brooten, 2001)

Therefore, the quality of care must be embedded in a practice that is based on available

evidence. This today has become known as Evidence-Based Practice (EBP). The term EBP is

relatively new and according to Justice (2008), the term EBP evolved from evidenced-based

medicine. Evidenced-Based Medicine was first introduced by Guyatt et al (1992) and he

argued that clinicians need to move away from intuition and unsystematic decision-making

towards research informed clinical decision-making. Subsequently, the notion of evidenced-

based medicine has been widely adopted and today is fundamental to all health professionals

worldwide aiming to optimise the quality of care (Claridge and Fabian, 2005, Sackett et al.,

1996).

To promote a culture of EBP in the clinical setting, researchers (Eizenberg, 2011, Stevens,

2013, Yost et al., 2015) suggest that clinicians should be updating their knowledge, based on

research evidence in order to support, improve and/or enhance clinical decision-making and

practice. Masic, Miokovic & Muhamedagic (2008) also argue that clinicians need to strive to

ensure that their knowledge and behavior are informed by the latest evidence-based knowledge

(EBK) relevant to their field, patient preferences, context and care.

Nonetheless, the consequence of failing to use research evidence has been widely discussed in

the literature (Green and Seifert, 2005, National Center of the Dissemination of Disability

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Research, 2005, Vanderstoep and Seifert, 1993). Grimshaw (2003) identified that 30% to 40%

of patients did not receive care based on research. Indeed, over 20% of the care activities were

not needed and/or potentially harmful to patients. The failure to shape practice using research

can bring about inconsistent and suboptimal care (Ketelaar et al., 2008).

The inability to use research has been attributable to an inability to translate research evidence

into practice (Pravikoff et al., 2005). Indeed, Morris, Wooding & Grant (2011) found that

translation of research evidence can take up to an average of 17 years. The process of moving

research from testing an intervention through to dissemination and into clinical practice is

termed Knowledge Translation (KT) (Kon, 2008, Morris et al., 2011, Sudsawad, 2007). While

the process of KT has been well articulated there is little evidence of ‘how’ clinicians translate

research evidence into everyday practice and clinical settings. Therefore, the aim of the study

was to explore how clinicians obtain, use and embed evidence in the clinical setting.

METHODS

Setting

This study was a multi-site study conducted within one metropolitan Local Health District

(LHD) in Sydney Australia. The setting contained one tertiary referral centre, five district

metropolitan hospitals and primary and community care.

Sample

A convenience sample of nurses and midwives working across the LHD were invited to

participate in a survey. Inclusion criteria included: nurses and midwives who had access to a

LHD email account were eligible for enrollment within the study. The study exclusion criteria

included agency and casual nurses.

Survey tool

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The survey, developed for the study, comprised 25 questions, which included close-ended and

open-ended comment questions. The survey explored four key areas: participant

demographics; use of evidence in everyday practice; perception of evidence-based practice;

and facilitators or barriers to the use of evidence. Pilot testing of the survey was undertaken

with four nursing and midwifery clinicians. During the pilot testing phase only minor editorial

changes were required and the order of four questions were rearranged.

Content, construct and criterion validity aspects strengthen the appropriateness of the survey.

Content validity was strengthened by the researchers completing a comprehensive review of

the literature relevant to the study aims and pilot testing of the tool. Construct validity was

strengthened by the identification of relevant items for inclusion and the iterative process of

data analysis and interpretation by two expert researchers. Criterion validity was also

strengthened as the survey was based on the work of Areskoug, Kammerlind & Sund-Levander

(2012), Funk et al. (1991), Jette et al. (2003), and Upton & Upton (2006).

SurveyMonkeyTM was used to distribute the survey. The survey was distributed across the LHD

between March and June 2014. For the purposes of this study, one survey reminder was

distributed four weeks after the original email was sent out.

DATA ANALYSIS

The reporting of this study was guided by STROBE Observational studies and COREQ

guidelines (Tong et al., 2007, von Elm et al., 2007). Survey data was directly downloaded in

EXCELTM from SurveyMonkey and analysed using IBBM SPSS v.22 software. Prior to the

survey, a decision was made to exclude surveys missing more than 25% of data fields.

Qualitative survey data were downloaded and stored in an NVivoTM v10. The qualitative data

analysis involved the systematic search for patterns and trends and involved an iterative

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process. Data analysis began with a ‘line-by-line’ analysis and coding was applied. The coding

of data enabled the researcher to identify patterns which coalesce into major themes (Wolcott,

2008). Open comments were (re)-analysed until ‘thematic saturation’ was reached, meaning

that no new themes emerged (de Laine, 2000). Gibbs’s (2007) framework was used to guide

analyses.

ETHICAL APPROVAL

Ethical approval was obtained from a Human Research Ethics Committee (HREC:

LNR/13/HAWKE/280). All participant data were anonymous with no personal identify

characteristics collected.

RESULTS

Total survey response was 222 with 18 (8.0%) missing more than 25% of data, which were

subsequently excluded from analysis. The analysis was undertaken on a response of 204

(92.0%) surveys. Of the 204 respondents the majority were female (n = 183; 89.71%) and

registered nurses (n = 199; 97.55%). The mean age of respondents was 46.6 (SD 9.9). The

mean experience working in the health care setting was 23.6 years (SD11.2 years). The

majority (n = 159; 77.94%) of respondents held a Master Degree (Table 1).

Of the 204 respondents the majority (n = 166; 81.37%) held a position of leadership including

clinical nurse/midwife consultants (CNC/CMC) (n = 61; 29.90%). Twenty-seven (13.24%)

respondents held a registered nurse position, with three (1.47%) holding enrolled nurses

position. The majority (n = 85; 41.67%) of respondents were from the district hospitals.

Seventy-nine (38.73%) respondents were from a tertiary hospital and thirty-five (17.15%) were

from a primary healthcare and community setting (PHC) (Table 1).

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Respondents reported that they obtained evidence for clinical practice primarily from clinical

practice guidelines (n = 157; 76.96%) and followed by research articles (n = 153; 75.00%).

Respondents ranked clinical practice guidelines (n = 63; 30.88%), literature databases (n =26;

12.75%) and research articles (n = 22; 10.79%) as the three most commonly used evidence

sources for everyday clinical practice (Table 2).

The majority (n = 167; 81.86%) of respondents reported that they used the internet to obtain

evidence and/or to gain access to journals for supporting their EBP. Many (n = 159; 77.94%)

of the respondents reported that they had the ability to access relevant online databases on

work computers. Of these respondents, 144 (70.59%) reported that they frequently used home

computers or personal devices to access online databases.

Respondents (n = 128; 62.75%) reported that they had opportunity to look for evidence to

support their clinical practice almost every shift. Some respondents (n = 55; 26.96%) reported

that they had time during work activities to look for evidence to support their clinical practice.

There was a statistical difference (X2 = 17.069; df = 8; p = 0.029) when comparing CNC/CMC

and other registered practitioner groups in the frequency of searching for evidence.

The majority (n = 149; 73.04%) of respondents reportedly searched evidence related to general

clinical practice, followed by focused searching to address a specific patient care (n = 143;

70.10%) issue and guideline and/or treatment (n = 137; 67.16%) options.

Most respondents reported discussing EBK and EBP among their own discipline specific

groups (n = 176; 86.27%), medical groups (n = 129; 63.24%), and with clinical managers (n =

121; 59.31). Over half of the respondents (n = 115; 56.37%) reported using self-reflection

when considering the value of EBK and EBP. Ninety-three (45.59%) respondents reported

discussing EBK and EBP with patients.

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Respondents reportedly shared information about EBK and EBP during in-services education

(n = 66; 32.35%) and sessions and ward meetings (n = 62; 30.39%). Respondents also reported

EBK and EBP was shared in everyday workplace communications. Examples were given such

as emails (n = 13; 6.37%), general ward discussions (n = 10; 4.90%), clinical handover (n = 6;

2.94%), conferences (n = 5; 2.45%), university education courses (n = 4; 1.96%) and journal

clubs (n = 3; 1.47%).

Respondents perceived the best evidence was peer review journals (n = 64; 31.37%), followed

by research studies (n = 57; 27.94%), randomized controlled trials (n = 26; 12.75%) and

evidence information from the internet (n = 14; 6.86%). Of the respondents ten (4.90%)

reported on the importance of systematic reviews and meta-analysis. Nine (4.11%) respondents

reported relying more on ward based forums and or in-service education sessions to inform

EBP.

The majority (n = 168; 82.35%) of respondents perceived that EBP assisted to improve the

quality of patient care. Many respondents (n = 138; 67.65%) were confident in their ability to

change practice by using evidence, while thirty-five respondents (17.16%) were not confident

to initiate practice change.

Qualitative data

The thematic findings from the open-ended quesitons within the survey identified four key

themes. The four key themes identified were: 1) The need for time; 2) The need for

management and organisational support; 3) The need for educational opportunities; and 4)

Challenges to accessing evidence.

Theme 1: The need for time

The theme ‘The need for time’ identified that nurses and midwives encountered time barriers

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when seeking to implement evidence and/or reading research to update their knowledge and

better inform practice activities. Respondents recognised the need to underpin their knowledge

and skills with appropriate evidence but felt the work environment failed to provide

opportunity to facilitate this process. Instead many believed that they needed to undertake this

activity outside of work hours. The respondent highlights.

“If I had more time to give to research, I could use that time to implement evidence-based practice.” (Survey ID 102)

“I do pretty much all my research and investigations in my own time as I don't have anywhere near enough time to do all that my job entails just to keep our service running. I know my staff feel much the same.” (Survey ID 197)

Theme 2: The need for management and organisational support

The second theme that surfaced from the open-ended survey questions was ‘The need for

management and organisational support’. Many respondents reported management and the

organisation should provide support and infrastructure to facilitate EBP and innovation

implementation. Respondents commented that they perceived insufficient support from

management and organisation, which at times led to unsuccessful implementation of

innovation and evidence into clinical practice. The following quotes illustrate this view.

“Managers need to listen as currently several initiatives that improve clinical practice have been forwarded but have been ignored [them] for a long period of time - very disheartening for clinical staff.” (Survey ID 48)

“It's important to start the change at management level, I had experience of having clinical project/ research stopped by previous manager who regarded clinical research as something very luxurious or extra.” (Survey ID 50)

Theme 3: The need for educational opportunities

The third theme identified from open-ended questions was ‘The need for educational

opportunities’. This theme describes how important educational opportunities were to

supporting and facilitating EBK and the implementation of EBP. Respondents described that

greater access to ward in-service education, educational training and and/or workshops could

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increase their knowledge and update evidence informed practice. The following exemplars

highlight:

“Regular in-services, involve nursing and medical [staff] to teach to gain a greater understanding of EBP.” (Survey ID 129)

“Research workshops have been extremely useful, informative and demystifying.” (Survey ID 143)

“Nurses should be taught how to use EBP as it is essential for the delivery of high-quality nursing care.” (Survey ID 204).

Theme 4: Challenges to accessing evidence

The final theme that arose from the open-ended survey questions was ‘Challenges to accessing

evidence’. This theme explored the importance of having access to research evidence. Many

nurses and midwives reported that they had limited access to computers and software to gain

access to evidence to inform their everyday practice. Respondents reported that they had

limited access to databases and this was perceived as a barrier to EBP and EBK. The following

quotes illustrate.

“Ability to access databases and online journals from home would be helpful.” (Survey ID 25)

“It would be very helpful if we could access literature online at work, and further more to print information requested by patients, instead we have to use our own devices. Does a Midwife pulling out her iPhone to read evidence-based practice to then explain to the patient look very professional to the public? I think not.” (Survey ID 128)

Respondents also wanted greater access to nursing and midwifery experts such clinical nurse

educators (CNEs) and CNCs. The following exemplar highlights:

“Having access to a CNE, CNC would be helpful.” (Survey ID 105)

The qualitative analysis identified four key themes, which were perceived as a barrier to EBK

and EBP implementation in everyday practice. The perceived lack of time to search for

evidence; insufficient support from management and organisation; and inability to access

educational services and EBP information potentially limited opportunity for evidence driven

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practice and clinical behavioural change.

DISCUSSION

The study findings highlight that EBK and EBP are embedded in everyday practice. The

survey findings identify that the translation of evidence is an interactive process (praxis) with

personal knowledge. Further the findings of this study suggest that clinicians are heavily

engaged in searching for evidence, although attitudes and beliefs can influence and drive the

acquisition and/or support of evidence. Clinical leadership and organisational support were

identified as key elements to supporting the translation of research evidence into practice.

However, a number of barriers were identified that remain consistent within the literature.

The findings showed that EBK and EBP are not static concepts for clinicians and that the

constructs of EBK and EBP are deeply embedded within clinical practice. The survey findings

highlighted the interactive nature (praxis) between EBK and EBP and how it can influence

clinician judgment, decision making and behaviour within clinical settings. In this way,

clinicians are able to better deliver safe, consistent and evidence informed patient care.

In this study, the engagement with research was initiated by clinicians when searching for

evidence to update knowledge and better inform practice. Searching for research is recognised

by the International Council of Nurses (2012) as a critical first step to assist clinicians in better

understanding available evidence. While a study conducted by Haynes (1993) identified that

clinicians often searched for research from textbooks and colleagues. Straus & Haynes (2009)

argued that such information may be out dated and/or inaccurate. This study identified that

textbooks and colleagues’ were only a minor information source and instead, clinicians were

more likely to use credible information source including electronic databases, research journals

and validated clinical practice guidelines.

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However, the study findings identified that very few clinicians searched for or used systematic

reviews. Few respondents perceived the importance of systematic reviews to inform EBK and

EBP. However, systematic reviews are considered one of the most valuable sources of

evidence (Kiesler and Auerbach, 2006, Medina and Pailaquilen, 2010, Straus and Haynes,

2009). Indeed, Medina & Pailaquilen (2010) claim that systematic reviews represent the gold

standard of research summaries as they use strategies that limit bias and random error. Thus,

clinicians need to learn about the importance of systematic reviews in terms of EBK and EBP.

Technology and the internet were identified as important platforms for evidence searching. In

this study most clinicians relied on electronic databases, arguing that this was quicker than

traditional manual library searches. Electronic databases allowed clinicians to access and

evaluate evidence for a range of patient care issues. However, researchers (Rodrigues, 2000,

Wells, 2006) have raised concerned about the widespread use of interactive web-based

technologies and the volume of non-validated, misleading and potentially harmful health

information available which could undermine EBK and EBP. Hence, it is imperative that

clinicians not only understand how to search for evidence but the different levels of research

evidence prior to implementation or adoption.

The majority of clinicians held positive attitudes and beliefs towards EBP and felt confident to

initiate practice change based on research. Many researchers (Campbell, 2010, Masic et al.,

2008, Stevens, 2013, Yost et al., 2015) support that positive attitudes and beliefs towards EBP

play an important role in underpinning the drive for EBP in clinical settings. Indeed, attitudes

and beliefs can influence the uptake and internalisation of evidence. Positive attitudes and

beliefs towards the value and importance of evidence can lead to improved engagement and

translation of research evidence into practice (Fineout-Overholt et al., 2005, Heiwe et al., 2011,

Stokke et al., 2014). Similarly, Bridges, Bierema & Valentine (2007) argued that positive

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attitudes and beliefs towards EBP are a positive predictor of whether clinicians will adopt EBP.

Although clinicians felt positive and confident to implement evidence in practice the study

identified that clinician leadership was needed to support understanding, obtaining and use of

evidence within practice. Leadership roles are important in driving the implementation of EBK

and EBP within the healthcare system (Commonwealth of Australia, 2009, Daly et al., 2014).

This study discovered that the majority of respondents that held a leadership position within

their organisation ranked EBK and EBP more highly when compared to other clinical roles.

The results are not surprising given that within New South Wales, Australia these senior

clinical leadership roles are recognised as knowledge brokers and are specifically positioned to

lead EBP (Hirschkorn and Geelan, 2008, Miers, 2016, Stetler et al., 2014). Therefore, roles

equivalent to a nurse consultant or educator are invaluable positions that can target, role model

and champion EBK and EBP in healthcare settings (Aarons et al., 2014, Dawson and Benson,

1997, Vaughan et al., 2000).

However, some clinicians reported that they had infrequent opportunities to meet and discuss

issues with clinical experts. The survey identified that consultant or educator roles were pivotal

in this function. Hence, organisations need to value the importance of clinical leadership

positions and understand that their absence may impede or inhibit the development of EBK

and the implementation of EBP. Consequently, clinical leadership roles, which are focused on

championing EBK and EBP should be a priority and resourced within health services.

The findings of the study identified that sharing knowledge with the health care team and

patient assisted to bridge the research-practice gap. Clinicians reported that they usually shared

EBK through their everyday practice. The act of sharing knowledge in the clinical setting

contributed towards knowledge translation (KT), which can deepen a clinician’s understanding

of evidence informed practice. Through this process evidence can be translated into new

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behaviours, procedures and models of care (Dopson and Fitzgerald, 2005, Gagliardi et al.,

2016, Solomon, 2015). Dopson & Fitzgerald (2005) and Fincham (1994) argued that sharing

knowledge becomes ‘actionable knowledge’ in which research evidence is converted into

actions and leads to evidence-based transformation in clinical areas. Based on our findings and

others (Bate and Robert, 2002, Hommel et al., 2015), sharing evidence could model positive

behaviours towards EBK and EBP and help move forward ‘knowledge’ into ‘action’

The majority of clinicians reported on the importance of organisational support in obtaining,

using and enacting EBP. Clinicians’ reported that there were a lack of organisational support in

terms of time and authority to pursue, implement and change new ideas into practice; The

literature provides extensive evidence that a lack of organisational support can limit, impede or

inhibit EBP cultural change (Lipscomb, 2016, Solomon, 2015). Importantly, many studies

(Dalkir, 2005, Hockenberry et al., 2006, Majid et al., 2011, Schoonover, 2006, Wallis, 2012,

Young and Ward, 2001) argue that organisational management support is essential to foster

and facilitate clinicians obtaining, using and enacting evidence in practice. Driving a culture of

EBP and translation of evidence requires managerial support and commitment.

The importance of educational programs to increase a clinician’s knowledge and understanding

of EBP was reported in this study. Clinicians reported the need for further educational support

to improve understanding and research skills in searching evidence for EBP. Clinicians need to

understand how to assess the quality of evidence specific to their clinical field. The provision

of research educational programs within health settings could be an initial step for

organisations to close the gap between research and practice.

LIMITATIONS

There are a number of limitations to be considered for this study. Firstly, the survey required

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that nurses and midwives have access to a hospital email account, which may have limited

those who could respond to the survey and hence, sampling bias may be presented. Secondly,

the majority of survey respondents were female; therefore, the findings may not be applicable

to male nurses or midwives. Thirdly, the majority of survey respondents were registered nurses

and so the view of midwives may be different. Lastly, as the study was conducted using the

survey method, it details only what nurses or midwives report they do, which may not reflect

everyday practice.

CONCLUSION

This study has provided insight into and understanding of how clinicians search for, use and

obtain evidence for everyday practice. More importantly, EBK emerges from the searching of

research evidence to confirm and/or support clinical decision-making in practice. In searching

for evidence clinicians need to understand how to judge the quality of research specific to their

clinical field. However, having EBK in and of itself does not translate into or build an EBP

culture in the clinical setting. Therefore, sharing research knowledge during every day working

interactions can assist in the co-creation of new knowledge and inspire practice change.

Transforming knowledge into clinical action and behaviour can only succeed with

collaboration between clinicians and their organisation. It is important that both clinicians and

organisations have a positive attitude towards EBP and establish processes to better support the

integration of new knowledge and EBP. Investment in educational programs can provide

clinicians with the skills and capabilities to better search for, use and obtain evidence. Through

this process, clinicians will be better able to translate research knowledge into practice.

ACKNOWLEDGEMENTS

N/A

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