2015 The State of Readiness For Evidence-Based Practice A
2015 The State of Readiness For Evidence-Based Practice A
Review
Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, POB 1627, 70211 Kuopio, Finland
Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland and Kuopio University Hospital, POB 1627,
70211 Kuopio, Finland
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 24 August 2015
Received in revised form 23 October 2015
Accepted 23 October 2015
Keywords:
Evidence-based practice
Nursing
Knowledge
Clinical competence
Review literature
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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1. Introduction
Improving patient outcomes and quality and consistency of care through integration of evidence-based
practice (EBP) into daily care delivery is a priority for
healthcare organizations globally (McGinty and Anderson,
2008; Melnyk et al., 2010; Wallen et al., 2010). Systematic
implementation of EBP is essential to improving the
effectiveness and cost-efciency of care (Grol and Grimshaw, 2003; Hart et al., 2008; Melnyk et al., 2012; Pravikoff
et al., 2005). However, it is hampered by a multitude of
reasons (Gifford et al., 2007; Wallen et al., 2010; Wilkinson
et al., 2011), particularly lack of nurses individual and
organizational readiness for EBP, which is further complicated by lack of best evidence in a form that is useful for
and easily translated and integrated into practice (Hallberg, 2006; Harrison and Graham, 2012). As a result,
contrary to the expectation that implementation of EBP
should be the norm in daily practice, the majority of nurses
and other clinicians do not consistently engage in EBP
(Bennett et al., 2003; Fink et al., 2005; Meline and Paradiso,
2003; Melnyk et al., 2012; Wallen et al., 2010).
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Nursing role
The clinical/
frontline nurse
The EBP mentora
The EBP mentora
The EBP mentora
The clinical/
frontline nurse
a
The EBP mentor = an Advanced Practice Nurse (APN) or other nurse
with expert-level EBP competencies.
2. Aim
The aim of this integrative review was to summarize
and synthesize the current research literature examining
the individual or personal factors related to nurses
readiness for EBP, i.e., the EBP knowledge, skills, attitudes,
and beliefs of RNs needed to employ EBP in clinical
practice. It addresses the following research question:
What is the state of the science on practicing nurses
readiness for EBP implementation at healthcare organizations?
3. Design
An integrative review of published research on nurses
readiness for EBP, i.e., nurses EBP knowledge, skills,
attitudes, and beliefs needed for nurses to integrate best
evidence into in clinical practice was conducted. The
approach used to summarize and synthesize the current
research literature in this review was previously described
by Thomas and Harden (2008). The review process is
presented according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) statement or guideline for reporting study methods and results
(Moher et al., 2009). Synthesis of the results focused on
evaluating the methodological quality of the studies using
the quality appraisal instruments developed by the Joanna
Briggs Institute (JBI) for descriptive, experimental, and
qualitative research studies.
4. Methods
4.1. Literature search
Literature search methods (Torraco, 2005) were used to
conduct searches from May through July 2014 which were
further updated through additional searches during
JanuaryFebruary 2015. The electronic databases
PubMed/MEDLINE (Ovid), CINAHL, Scopus, ProQuest Dissertations and Theses, and the Electronic Theses and
Dissertations System were searched for primary empirical
studies published between the beginning of January 2004
January 31, 2015 without any language restrictions. The
following keywords and terms were used: evidencebased, nurs*, readiness, preparedness, implement*,
experienc*, role*, attitud*, belief*, skill*, view*, and
perception*. With the expert assistance of a university
librarian, these terms were rst searched independently
and then in combination. The search term research
utilization was not used in this review as the aim was
to focus on nurses EBP knowledge, skills, attitudes, and
beliefs. In addition to the searched databases, reference
chasing of the primary research studies included in the
integrative review and hand-searching the lists of contents
of the following peer-reviewed journals was conducted
between the years of 20042014: Worldviews on Evidence-Based Nursing, Journal of Advanced Nursing, BMC
Health Services Research, Journal of Nursing Management,
and Journal of Nursing Administration. These journals
were selected for hand-searching because they had
published the majority of the primary studies focusing
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Table 2
Study inclusion and exclusion criteria for the integrative review (N = 37).
Study inclusion criteria
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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60 records excluded
44 full-text articles
assessed for eligibility
40 full-text articles
appraised critically for
methodological quality
37 studies included in
the integrative review
Fig. 1. Flowchart presenting an overview of the systematic search and review process.
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Table 3
Characteristics of the primary studies included in the integrative review
(N = 37).
Characteristics
Country
USA
Europe
Australia
Israel
Iran
Singapore
Number of participants
<100
100499
500999
>1000
Study design
Descriptive cross-sectional survey
Quasi-experimental (pre-post)
Experimental (RCTa)
Qualitative
Response rate
50%
51%
Not reported
Unable to calculate
Sampling method
Probability
Non-probability
Both
Outcomes measuredb
Familiarity with EBP
Attitudes toward EBP
Beliefs about EBP
EBP knowledge and skills
EBP implementation or use of research in practice
Practice settingsc
Hospital care
Primary care
Schools/colleges/universities
Community care
Other
EBP conferences or workshops
National meetings of Prof. organizations
Unspecied
N (%)
18
13
3
1
1
1
(49)
(35)
(8)
(3)
(3)
(3)
6
20
8
3
(16)
(54)
(22)
(8)
30
5
1
1
(81)
(13)
(3)
(3)
13
14
8
2
(35)
(38)
(22)
(5)
5 (13)
31 (84)
1 (3)
12
18
22
28
25
27
7
4
3
3
1
1
1
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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summarize evidence for use in daily practice (BekeHarrigan et al., 2008; Bostrom et al., 2009; Brown et al.,
2008; Cadmus et al., 2008; Dalheim et al., 2012; Gerrish
et al., 2008; Hart et al., 2008; Koehn and Lehman, 2008;
Pravikoff et al., 2005; Ross, 2010; Sherriff et al., 2007;
Thorsteinsson and Sveinsdottir, 2014; Thorsteinsson,
2012; Veeramah, 2004; Waters et al., 2009).
The greatest gaps in technical skills related to EBP
were associated with nurses primary role: Clinical nurses
perceived having most learning needs related to the EBP
skills of identifying research needs and formulating a
researchable question (Bostrom et al., 2009; Brown et al.,
2008; Cadmus et al., 2008; Koehn and Lehman, 2008;
Majid et al., 2011; Ross, 2010; Thorsteinsson, 2012),
searching for and retrieving research reports (BekeHarrigan et al., 2008; Bostrom et al., 2009; Brown et al.,
2008; Dalheim et al., 2012; Hart et al., 2008; Ross, 2010;
Thorsteinsson and Sveinsdottir, 2014; Thorsteinsson,
2012) critically appraising research reports (Bostrom
et al., 2009; Brown et al., 2008; Cadmus et al., 2008;
Dalheim et al., 2012; Gerrish et al., 2008; Koehn and
Lehman, 2008; Mollon et al., 2012; Ross, 2010; Sherriff
et al., 2007; Thorsteinsson, 2012; Veeramah, 2004; Waters
et al., 2009), synthesizing evidence (Mollon et al., 2012;
Ross, 2010; Thorsteinsson, 2012), integrating best evidence into practice (Cadmus et al., 2008; Hart et al., 2008;
Ross, 2010; Thorsteinsson, 2012; Veeramah, 2004) and
evaluating the effect of EBP on clinical care (Adams and
Barron, 2009; Bostrom et al., 2009), while APNs had
learning needs in the EBP skills of undertaking research
and clinical benchmarking (Gerrish et al., 2011). Also
notable was the low participation of nurses in research
(Bonner and Sando, 2007; Cadmus et al., 2008; Ross, 2010;
Thorsteinsson, 2012), as it is an important avenue for
learning the technical research skills related to the steps
of the EBP process. In addition, willingness to undertake
research was linked to increased use of research in practice
(Bonner and Sando, 2007). In addition, several included
studies found that nurses participation in changing
practice based on best evidence was an even greater
learning need than the technical research skills related to
the EBP process, as the studies showed that nurses not only
lacked condence in their ability to change practice, they
also perceived themselves as lacking the autonomy,
authority and support from their managers, peers, and
other colleagues to change practice (Dalheim et al., 2012;
Gerrish et al., 2008; Melnyk et al., 2010; Veeramah, 2004).
6.3.5. Nurses EBP implementation and use of research in
practice
Simply because nurses have positive attitudes toward
and believe in EBP improving clinical practice and patient
outcomes, however, it should not be assumed that they
automatically possess the skills or know how to use
evidence in practice (Cadmus et al., 2008; Waters et al.,
2009), especially when skills only tend to develop through
repeated practice of EBP (Mollon et al., 2012). In fact, the
ndings indicated that irrespective of nationality, nurses
implementation of EBP, i.e., integration of best evidence
into daily care delivery, remained largely undeveloped
(Waters et al., 2009), low (Cadmus et al., 2008; Filippini
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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11
Acknowledgments
This research was supported by grants from Finnish
Nurses Education Foundation, Finnish Nurses Association,
Saastamoinen Foundation, and the Finnish Work Environment Fund awarded to Ms. Saunders, all of which are
gratefully acknowledged. In addition, Ms. Saunders is
supported by a grant for an Early Stage Researcher at the
University of Eastern Finland, Faculty of Health Sciences,
Dept. of Nursing Science, for 20142016.
Conict of interest: None declared.
10. Conclusions
The ndings of this review suggest that irrespective of
primary role, practice setting, or nationality, most nurses
are not ready for EBP. Although nurses are familiar with the
concept of EBP, have positive attitudes toward EBP, and
believe in the value of EBP in improving care quality and
patient outcomes, nurses perceive their own EBP knowledge and skills to be insufcient for employing EBP, i.e., for
using best available evidence as the basis for clinical
decision-making in daily practice. The ndings also
indicate that irrespective of nationality, large proportions
of nurses do not use research or integrate best evidence
into their daily practice. As nurses are the largest group of
healthcare professionals working in healthcare organizations globally, it is likely that the anticipated outcome of
EBP to provide best possible care at the lowest possible
cost in an environment of limited resources (Closs and
Cheater, 1999) is seldom realized in nursing care. This is
likely to have serious implications on the quality of care,
patient outcomes, and patient safety at healthcare organizations worldwide.
Given the IOMs (2011) goal that by 2020, 90% of all
clinical decisions should be evidence-based, there is an
urgent need for healthcare leaders to collaborate in
designing and implementing effective strategies that
promote the integration of best evidence into daily care
delivery of the nursing workforce. In particular, all
efforts should be focused on systematically using
strategies that have been shown effective in rigorous
studies, to translate best evidence into practice-friendly
forms that nurses actually can use in daily care delivery,
i.e., forms that are relevant in the local context and
readily usable in clinical practice, such as evidencebased CPGs and care bundles. Lastly, the selected
strategies need to include using effective interventions
to strengthen nurses readiness for EBP, in order to
progress from opinion-based toward evidence-based
practice in patient care.
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practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
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Melnyk, B.M., Fineout-Overholt, E., Giggleman, M., Cruz, R., 2010. Correlates among cognitive beliefs, EBP implementation, organizational
culture, cohesion and job satisfaction in evidence-based practice
mentors from a community hospital system. Nurs. Outlook 58,
301308.
Melnyk, B.M., Fineout-Overholt, E., Feinstein, N.F., Sadler, L.S., GreenHernandez, C., 2008. Nurse practitioner educators perceived knowledge, beliefs, and teaching strategies regarding evidence-based practice: implications for accelerating the integration of evidence-based
practice into graduate programs. J. Prof. Nurs. 24 (1), 713.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., The PRISMA Group, 2009.
Preferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. PLoS Med 6 (6), e1000097, http://dx.doi.org/
10.1371/journal.pmed1000097.
Mollon, D., Fields, W., Gallo, A.-M., Wagener, R., Soucy, J., Gustafson, B.,
Kim, S.C., 2012. Staff practice, attitudes and knowledge/skills regarding evidence-based practice before and after an educational intervention. J. Contin. Educ. Nurs. 43, 411419.
Munten, G., Van den Bogaard, J., Cox, K., Garretsen, H., Bongers, I., 2010.
Implementation of evidence-based practice using action research: a
review. Worldviews Evid.-Based Nurs. 7 (3), 135157.
Polit, D.F., Beck, C.T., 2004. Nursing Research: Principles and Methods, 7th
edn. Lippincott, Williams & Wilkins, Philadelphia, PA.
Pravikoff, D., Tanner, A., Pierce, S., 2005. Readiness of U.S. nurses for
evidence-based practice. Am. J. Nurs. 105 (9), 4051.
Rolfe, G., Segrott, J., Jordan, S., 2008. Tensions and contradictions in
nurses perspectives of evidence-based practice. J. Nurs. Manag. 16,
440451.
Ross, J., 2010. Information literacy for evidence-based practice in perianesthesia nurses: Readiness for evidence-based practice. J. Perianesth. Nurs. 25 (2), 6470.
Sandstrom, B., Borglin, G., Nilsson, R., Willman, A., 2011. Promoting the
implementation of evidence-based practice: a literature review focusing on the role of nursing leadership. Worldviews Evid.-Based
Nurs. 4, 212223.
Saunders, H., 2015. Translating knowledge into best practice care bundles: a pragmatic strategy for EBP implementation via moving postprocedural pain management nursing guidelines into clinical
practice. J. Clin. Nurs. 24 (1314), 20352051.
Shaneyfelt, T., Baum, K.D., Bell, D., Feldstein, D., Houston, T.K., Kaatz, S.,
Whelan, C., Green, M., 2006. Instruments for evaluating education in
evidence-based practice: a systematic review. J. Am. Med. Assoc. 296
(9), 11161127.
Sherriff, K., Wallis, M., Chaboyer, W., 2007. Nurses attitudes to and
perceptions of knowledge and skills regarding evidence-based practice. Int. J. Nurs. Pract. 13, 363369.
Stevens, K.R., Puga, F., Low, V., 2012. The ACE-ERI: an instrument to
measure EBP readiness in student and clinical populations. Retrieved
from
http://www.acestar.uthscsa.edu/su12/documents/ace/
8%20The%20ACE-ERI%20%20Instrument%20to%20Benchmark.pdf
(accessed 05.06.15).
Straus, S.E., Glasziou, P., Richardson, W.S., Haynes, R.B., 2011. EvidenceBased Medicine: How to Practice and Teach It. Church Livingstone
Elsevier, Edinburgh, UK.
Taylor, M.C., 2007. Evidence-Based Practice for the Occupational Therapist. Blackwell Publishing, Oxford, UK.
Thiel, L., Ghosh, Y., 2008. Determining Registered Nurses readiness
for evidence-based practice. Worldviews Evid.-Based Nurs. 5 (4),
182192.
Thomas, J., Harden, A., 2008. Methods for the thematic synthesis of
qualitative research in systematic reviews. BMC Med. Res. Methodol.
8, 45, http://dx.doi.org/10.1186/1471-2288-8-45.
Thorsteinsson, H.S., 2012. Icelandic nurses beliefs, skills, and resources
associated with evidence-based practice and related factors: a national survey. Worldviews Evid.-Based Nurs. 10 (2), 116126.
Thorsteinsson, H.S., Sveinsdottir, H., 2014. Readiness for and predictors of
evidence-based practice of acute care nurses: a cross-sectional postal
survey. Scand. J. Caring Sci. 28, 572581.
Torraco, J., 2005. Writing integrative literature reviews: guidelines and
examples. Hum. Resour. Dev. Rev. 4, 356367.
Upton, D., Upton, P., 2005. Nurses attitudes to evidence-based practice:
impact of a national policy. Br. J. Nurs. 14 (5), 284288.
Varnell, G., Haas, B., Duke, G., Hudson, K., 2008. Effect of an educational intervention on attitudes toward and implementation of
evidence-based practice. Worldviews Evid.-Based Nurs. 5 (4),
172181.
Veeramah, V., 2004. Utilization of research ndings by graduate nurses
and midwives. J. Adv. Nurs. 47 (2), 183191.
Wallen, G., Mitchell, S., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C.,
Yates, J., Hastings, C., 2010. Implementing evidence-based practice:
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018
G Model
13
Waters, D., Crisp, J., Rychetnik, L., Barratt, A., 2009. The Australian experience of nurses preparedness for evidence-based practice. J. Nurs.
Manag. 17, 510518.
Wilkinson, J., Nutley, S., Davies, H., 2011. An exploration of the roles of
nurse managers in evidence-based practice implementation. Worldviews Evid.-Based Nurs. 8 (4), 236246.
Please cite this article in press as: Saunders, H., Vehvilainen-Julkunen, K., The state of readiness for evidence-based
practice among nurses: An integrative review. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.10.018