Nurses’ readiness for evidence-based practice : implementing the paradigm shift of transforming evidence for clinical practice

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DISSERTATIONS | HANNELE SAUNDERS | NURSES’ READINESS FOR EVIDENCE-BASED PRACTICE... | No 359

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THE UNIVERSITY OF EASTERN FINLAND Dissertations in Health Sciences

ISBN 978-952-61-2166-6 ISSN 1798-5706

Dissertations in Health Sciences

THE UNIVERSITY OF EASTERN FINLAND

HANNELE SAUNDERS

NURSES’ READINESS FOR EVIDENCE-BASED PRACTICE:

IMPLEMENTING THE PARADIGM SHIFT OF TRANSFORMING EVIDENCE FOR CLINICAL PRACTICE

Systematic implementation of evidence- based practice (EBP) has become a high priority and a global movement for healthcare

organizations worldwide, because it yields better patient outcomes and higher quality and

consistency of care at a lower cost. However, due to reasons including lack of readiness for EBP, nurses do not consistently implement EBP

in daily practice. This study explored nurses’

readiness for EBP implementation through an integrative review, an RN national survey at Finnish university hospitals, and a randomized

controlled trial at one university hospital.

HANNELE SAUNDERS

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Nurses’ Readiness for Evidence-Based Practice:

Implementing the Paradigm Shift of

Transforming Evidence for Clinical Practice

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HANNELE SAUNDERS

Nurses’ Readiness for Evidence-Based Practice:

Implementing the Paradigm Shift of

Transforming Evidence for Clinical Practice

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Canthia CA100, Kuopio, on Monday, July 4^th 2016, at 12 noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

Number 359

Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland

Kuopio 2016

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Grano Oy Jyväskylä, 2016

Series Editors:

Professor Veli-Matti Kosma, M.D., Ph.D.

Institute of Clinical Medicine, Pathology Faculty of Health Sciences Professor Hannele Turunen, Ph.D.

Department of Nursing Science Faculty of Health Sciences Professor Olli Gröhn, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Professor Kai Kaarniranta, M.D., Ph.D.

Institute of Clinical Medicine, Ophthalmology Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D. (pharmacy) School of Pharmacy

Faculty of Health Sciences Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto ISBN (print): 978-952-61-2166-6

ISBN (pdf): 978-952-61-2167-3 ISSN (print): 1798-5706

ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Supervisors: Professor Katri Vehviläinen-Julkunen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO

FINLAND

Professor Kathleen R. Stevens, Ed.D.

Department of Nursing Science

University of Texas Health Sciences Center SAN ANTONIO, TEXAS

USA

Reviewers: Professor Ellen Fineout-Overholt, Ph.D.

Department of Nursing Science University of Texas at Tyler TYLER, TEXAS

USA

Adjunct Associate Professor Kristiina Hyrkas, Ph.D.

Department of Nursing Science University of Southern Maine PORTLAND, MAINE USA

Opponent: Clinical Associate Professor Lynn Gallagher-Ford, Ph.D.

College of Nursing Ohio State University COLUMBUS, OHIO USA

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Saunders, Hannele

Nurses’ Readiness for Evidence-Based Practice: Implementing the Paradigm Shift of Transforming Evidence for Clinical Practice

University of Eastern Finland, Faculty of Health Sciences

Publications of the University of Eastern Finland. Dissertations in Health Sciences 359. 2016. 106 p.

ISBN (print): 978-952-61-2166-6 ISBN (pdf): 978-952-61-2167-3 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

ABSTRACT:

Integration of evidence-based practice (EBP) into clinical care delivery has become an international movement and a priority for healthcare organizations globally, because it has been shown to yield better patient outcomes as well as higher quality and consistency of care at a lower cost. Accordingly, systematic implementation of EBP has internationally been recognized as an excellent way to reduce unwanted variations in care quality and improve the effectiveness and cost-efficiency of healthcare delivery. However, although EBP implementation should be the norm in clinical nursing practice, nurses do not consistently engage in EBP in daily practice, primarily due to lack of readiness for EBP.

Thus, strengthening nurses’ EBP competencies is of critical importance in order to achieve and sustain the highest quality and consistency of clinical care as well as best patient outcomes in nursing care delivery.

The primary purpose of this study was to explore nurses’ readiness for EBP nationally and internationally. The aims of this study were to: 1) investigate the state of the science on practicing nurses’ readiness for EBP internationally; 2) determine and describe the state of readiness for EBP of Registered Nurses (RNs); 3) compare the impact of the Magnet®

journey status of Finnish university hospitals on RNs’ EBP competencies and nurse workforce; and 4) test and evaluate the effectiveness of an EBP educational intervention designed to strengthen RNs’ readiness for EBP, i.e., improve their EBP competencies. The study consisted of three sub-studies: an integrative review (n=37); a national survey of RNs at Finnish university hospitals (n=943), and a randomized controlled trial at one university hospital (n=77).

The study revealed that internationally and nationally, although nurses were familiar with, had positive attitudes toward, and believed in the value of EBP in improving care quality and patient outcomes, they lacked the EBP competencies required for integrating best evidence into clinical care delivery, and did not use EBP in practice.However, Finnish Advanced Practice Nurses (APNs) as EBP mentors are in a key role for strengthening RNs’

readiness for EBP implementation and for creating an EBP-infused professional nursing practice environment and organizational culture. APN-led EBP and research utilization education interventions strengthened practicing RNs’ EBP competencies. The study provides a benchmark from Finland for international evaluations and comparisons of nurses’ readiness for EBP. Advancing practicing RNs’ EBP competencies may ultimately benefit patients as well as nurses via improving patient and nurse outcomes while increasing the quality and efficiency of clinical care delivery at healthcare organizations.

National Library of Medicine Classification: WY 100.7; WB 102.5

Medical Subject Headings: Evidence-Based Practice; Clinical Competence; Nurses; Advanced Practice Nursing; Surveys and Questionnaires; Randomized Controlled Trials as Topic

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Saunders, Hannele

Sairaanhoitajien näyttöön perustuvan toiminnan valmiudet: Paradigman muutoksen implementointi näytön tiivistämiseksi kliiniseen hoitotyöhön soveltuvaan muotoon.

Itä-Suomen yliopisto, terveystieteiden tiedekunta

Publications of the University of Eastern Finland. Dissertations in Health Sciences 359. 2016. 106 s.

ISBN (print): 978-952-61-2166-6 ISBN (pdf): 978-952-61-2167-3 ISSN (print): 1798-5706 ISSN (pdf): 1798-5714 ISSN-L: 1798-5706

TIIVISTELMÄ:

Näyttöön perustuvan toiminnan (NPT) integrointi päivittäiseen potilashoitoon on tärkeää terveydenhuolto-organisaatioille ympäri maailmaa, koska NPT:n perustuvan hoidon on osoitettu johtavan parempiin potilaiden hoitotuloksiin sekä tasalaatuisempaan potilashoitoon alhaisemmilla kustannuksilla. NPT:n järjestelmällisen implementoinnin onkin kansainvälisesti tunnistettu olevan erinomainen keino parantaa hoidon laatua, vaikuttavuutta ja kustannustehokkuutta. Vaikka potilaat ja terveydenhuollon johtajat odottavat NPT:n implementoinnin olevan normaali toimintatapa terveydenhuollossa, suurimmalla osalla sairaanhoitajista ei ole riittäviä NPT:n implementoinnin valmiuksia työskennelläkseen parhaaseen saatavilla olevaan tiivistettyyn tietoon perustuvasti. Tästä syystä sairaanhoitajien NPT:n implementoinnin valmiuksien vahvistaminen on ensiarvoisen tärkeää korkealaatuisimman potilashoidon ja parhaiden potilaiden hoitotulosten saavuttamiseksi ja varmistamiseksi terveydenhuollossa.

Tämän tutkimuksen tarkoituksena oli selvittää sairaanhoitajen NPT:n implementoinnin valmiuksia kansallisesti ja kansainvälisesti. Tutkimuksen tavoitteina oli selvittää, millainen on sairaanhoitajien NPT:n implementoinnin valmiuksien taso kansainvälisesti; kuvata sairaanhoitajien NPT:n implementoinnin valmiuksien tasoa Suomen yliopistollisissa sairaaloissa; vertailla, miten erot yliopistollisten sairaaloiden Magneettisairaalamallin käyttämisessä potilashoidon kehittämiseen vaikuttavat sairaanhoitajien NPT:n kompetensseihin ja muihin heidän työhönsä liittyviin tekijöihin; sekä arvioida sairaanhoitajien NPT:n implementoinnin valmiuksia kehittävien interventioiden vaikuttavuutta. Tutkimuskokonaisuus koostui kolmesta osatutkimuksesta: integroivasta kirjallisuuskatsauksesta (n=37), kansallisesta kyselytutkimuksesta Suomen yliopistollisissa sairaaloissa (n=943) ja randomoidusta kontrolloidusta kokeellisesta tutkimuksesta yhdessä yliopistollisessa sairaalassa (n=77).

Kansainvälisesti sekä kansallisesti tämä tutkimus osoitti, että vaikka sairaanhoitajat tunsivat NPT-käsitteen, suhtautuivat NPT:n positiivisesti, ja uskoivat sen hyödyllisyyteen hoidon laadun ja potilaiden hoitotulosten parantamisessa, he katsoivat että heidän oma NPT-osaamisensa ei ollut riittävää parhaan näytön käyttöönottoon kliinisessä päätöksenteossa, eikä NPT:tä käytetty hoitotyössä. Advanced Practice Nurse (APN) ammattirooleissa toimivat ovat NPT-mentoreina avainasemassa sairaanhoitajien NPT:n implementoinnin valmiuksien vahvistamisessa. Tutkimuksen tulokset mahdollistavat suomalaisten sairaanhoitajien NPT:n implementoinnin valmiuksien kansainvälisen arvioinnin ja vertailun, mikä auttaa parantamaan potilashoidon laatua, sen tasalaatuisuutta ja vaikuttavuutta, ja tulee siten hyödyttämään ennen kaikkea potilaita.

Luokitus: WY 100.7; WB 102.5

Yleinen suomalainen asiasanasto: näyttöön perustuva hoitotyö; sairaanhoitajat; hoitotyö; kliininen hoitotiede;

kompetenssi; osaaminen; asiantuntijuus; kvantitatiivinen tutkimus

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”All that I am, or hope to be, I owe to my angel mother.”

Abraham Lincoln

(Josiah G. Holland, The Life of Abraham Lincoln (1866))

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Acknowledgements

This study has grown out of the synergistic efforts and support from many different parties. It was completed in collaboration between the University of Eastern Finland and all five university hospitals in Finland: Helsinki University Hospital, Kuopio University Hospital, Turku University Central Hospital, Oulu University Hospital, and Tampere University Hospital. I wish to express my warmest thanks to all those who have made this study possible but whom I am unable to personally acknowledge here.

My greatest gratitude goes to my principal supervisor, Professor Katri Vehviläinen- Julkunen PhD, for her constructive advice and thoughtful guidance during this process. I have often stood in awe of your prompt responses and insightful comments which have been invaluable to me during this process. You gave so generously of your time and knowledge, always challenging me to think independently and guiding my learning with a spirit of appreciation, yet supporting my freedom to develop my individual abilities and academic scholarship. I could not have achieved all this without your tireless encouragement and enduring support. I also owe a debt of deep gratitude to my other supervisor, Professor Kathleen R. Stevens EdD. Your thoughtful guidance and shared insights have been invaluable during this process, particularly during the data analysis and reporting –phases of the study. Both of my supervisors deserve the highest honor from this process, you believed in me and kept me going with your encouragement and support even during my occasional moments of self-doubt, giving me hope and contributing greatly to the study and the preparation of this PhD dissertation.

I would like to express my sincere thanks to the pre-examiners of my PhD thesis, Professor Ellen Fineout-Overholt PhD and Adjunct Associate Professor Kristiina Hyrkas PhD, for their useful and constructive comments on how to improve this summary. I would also like to extend my most appreciative thanks to Clinical Associate Professor Lynn Gallagher-Ford PhD, for accepting the request to act as my esteemed opponent. I would like to thank University of Eastern Finland Docent Ari Voutilainen PhD and Marja-Leena Lamidi for their helpful discussions on the statistical analyses of the study with me, they enabled me to complete the analyses without too much despair while at the same time, learn a great deal about statistics. Special thanks go to University of Texas San Antonio Health Sciences Center School of Nursing statistician Bruce Paper, without whose endless patience, quiet kindness, and a great sense of humor, as well as invaluable expertise on the statistical analyses of the ERI data, I might still be lumbering away at analyzing the data today.

Ever since I first became a nurse, I remember myself always wondering, what evidence were clinical decisions based on? Over the years, my desire to understand the facts behind clinical decisions steadily grew with my nursing experience. Later on as a practicing APRN, patient advocacy most definitely included respectfully explaining to the patients the reasons - the rationale - behind the clinical decisions made in their treatment, always aspiring to ascertain that those reasons were based on best available evidence. I wish to warmly thank Professor Bernadette Mazurek Melnyk PhD, whose impressive yet pragmatic life’s work on the implementation of evidence-based practice (EBP) in nursing first awakened me to realize the vital importance of all nurses’ engaging in the systematic integration of best evidence into the daily care decisions of every patient. Without best available evidence as the basis for nurses’ clinical decision-making, there will not be excellence in nursing practice, best patient outcomes, or highest quality of care, issues which ought to be close at heart for every nurse aspiring to practice to the best of their knowledge and for the best of their patients. Provision of best possible care is our duty as healthcare professionals; to attain it, implementation of EBP is our responsibility which we simply cannot put off any longer, delegate to others, or claim it does not apply to us – for

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EBP concerns every nurse in every care setting during every shift and with every patient – no more excuses.

I would like to express my sincere thanks to many colleagues at Helsinki University Hospital for their understanding and support. I warmly thank Nina Fagerholm PhD, a colleague and a friend whom I regard as partially responsible for my becoming a PhD student in nursing science at the University of Eastern Finland. Your sunny enthusiasm, enduring support, and practical advice from the seasoned PhD graduate to the novice PhD candidate, have made this entire process and in particular, tackling some of the interesting peculiarities in the academic traditions along this journey much easier. Sincere thanks also go to Leena Timonen MNSc, with whom I spent many moments wondering about the hidden secrets of electronic survey programs. Special thanks go to the nurse administrators at Helsinki University Hospital for providing me with the helpful opportunity to work part-time and take study leave so that I could dedicate more time for research during the past few months. My deepest thanks go to all the nurse participants of the original studies who willingly gave of their time and shared their expertise so that all this could become possible. All of your contributions are greatly appreciated.

This study was financially supported by the University of Eastern Finland, the Finnish Work Environment Fund, the Finnish Nurses’ Educational Foundation, the Saastamoinen Foundation, and the Finnish Nurses’ Association. I am deeply grateful and greatly appreciative for their support.

Finally, I want to thank from the bottom of my heart all my longtime friends and relatives both in the USA and in Finland, without your constant cheering me on, your unending support and your steadfast belief in my abilities, I might not have been able to keep my eye on the ball through the last couple of years. I simply cannot put in words how much it meant to me how recently, you cared enough not to allow me to get cooped up and wallow alone in my sorrow but instead, pulled me right back to life, whether I liked it or not. I will remain forever indebted to you. Please know I will never forget what you did for me. You are all very dear to me and always in my thoughts, wherever I happen to be in the world.

However, my deepest and most enduring gratitude goes to the people closest to me, first and foremost to my loving mother, who recently passed away. Dear Mama, not long ago you told me that your greatest wish was to live to see the day of my dissertation defense.

Although it was not meant to be, I know that you are here with me today, smiling at me from heaven and blessing me with your love. I could not have achieved this without your unconditional love, your endless support, and your steadfast faith in me even when during those moments when I had none myself. I hope you are proud of me today. I also owe a debt of gratitude to my deceased dad, who taught me the meaning of hard work, perseverance, and the importance of lifelong learning. Dad, I can still hear your voice telling me never to give up, and although we did not always see eye to eye, you saw my potential (or perhaps it was my pigheadness), allowed me to try my own wings early on and travel my own path in life, and for that I am forever grateful. In the words of a classic poem by Maya Angelou, I truly stand on the shoulders of my parents, without whose lifelong love, encouragement, and endless support this dissertation would not exist today.

Mount Rushmore, SD, at the dawn of a New Year full of possibilities, December 31^st, 2015 Hannele Saunders

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List of the original publications

This dissertation is based on the following original publications:

I Saunders H. and Vehviläinen-Julkunen K. 2015. The state of readiness for evidence-based practice among nurses: An integrative review. International Journal of Nursing Studies, doi: 10.1016/j.ijnurstu.2015.10.018

II Saunders H., Stevens K. R. and Vehviläinen-Julkunen K. 2016. Nurses’ readiness for evidence-based practice at Finnish university hospitals: A national survey.

Journal of Advanced Nursing, doi: 10.1111/jan.12963

III Saunders H. and Vehviläinen-Julkunen K. 2016. Nurses’ EBP beliefs, perceived EBP knowledge, and nurse workforce outcomes in Magnet-aspiring, Magnet- conforming, and non-Magnet university hospitals in Finland: A comparison study. Journal of Nursing Administration, accepted.

IV Saunders H. and Vehviläinen-Julkunen K. 2016. Nurses’ evidence-based practice beliefs and role of evidence-based practice mentors at university hospitals in Finland. Worldviews on Evidence-Based Nursing, accepted.

V Saunders H., Vehviläinen-Julkunen K. and Stevens K. R. 2016. The effectiveness of an educational intervention to advance RNs’ readiness for EBP: A single-blind randomized controlled trial. Applied Nursing Research, doi:

10.1016/j.apnr.2016.03.004

The publications were adapted with the permission of the copyright owners.

The summary also includes previously unpublished material.

The Turnitin OriginalityCheck service has been employed in verifying the originality of this PhD thesis.

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implemented to strengthen RNs’ readiness for EBP ... 65 6.1.5 Summary of discussion ... 68 6.2 Discussion of limitations and strengths of the study ... 73 6.2.1 Nurses' readiness for EBP internationally ... 73 6.2.2 RNs' readiness for EBP at university hospitals in Finland ... 74 6.2.3 Effectiveness of an education intervention designed and

implemented to strengthen RNs' readiness for EBP ... 75 7 SUMMARY AND CONCLUSIONS ... 79 8 RECOMMENDATIONS ... 83 8.1 Recommendations for future research ... 83 8.2 Recommendations for clinical practice ... 84 8.3 Recommendations for nursing education ... 86 8.4 Recommendations for leadership and policy level ... 87 9 REFERENCES ... 89 APPENDICES

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Abbreviations

AACN American Association of Colleges of Nursing ACE Academic Center of

Excellence

AME Action Model of Expertise ANA American Nurses Association ANCC American Nurses

Credentialing Center ANOVA Analysis of Variance APN Advanced Practice Nurse APRN Advanced Practice Registered

Nurse

ARCC Advancing Research and Clinical practice through close Collaboration

CINAHL Cumulative Index to Nursing and Allied Health Literature CNA Canadian Nurses Association CNS Clinical Nurse Specialist CPG Clinical Practice Guideline CVI Content Validity Index ECTS European Credit Transfer and

Accumulation System EBN Evidence-based nursing EBP Evidence-based practice ERI Evidence-based Practice

Readiness Inventory

HOTUS Nursing Research Foundation (in Finland)

ICN International Council of Nurses

IOM Institute of Medicine JBI Joanna Briggs Institute MIXED Linear Mixed Models

procedure (in SPSS)

MSAH Ministry of Social Affairs and Health (in Finland)

MNSc Master of Science degree in Nursing Science

MHC Master of Health Care degree NACNS National Association of

Clinical Nurse Specialists (in the USA)

NIHW National Institute for Health and Welfare (in Finland) PUBMED United States National

Library of Medicine

RCT Randomized Controlled Trial RN Registered Nurse

RU Research utilization SPSS Statistical Package for the

Social Sciences

USA United States of America WHO World Health Organization WMA World Medical Association

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Implementation of evidence-based practice (EBP) has emerged as an international movement among health care organizations worldwide. Increasing demand for chronic and more complex healthcare services due to rapidly aging populations, shortages of nurses and other healthcare professionals, challenges in employing compatible new information technologies in healthcare, and need for major structural reforms of healthcare delivery systems to improve productivity, are common trends in today’s society, emphasizing the need for improving the quality, consistency, and safety of patient care through systematic integration of best evidence into healthcare delivery(Clancy et al. 2008, Amalberti 2013).

Consistent implementation of EBP has internationally been recognized as an excellent means for improving effectiveness and cost-efficiency of healthcare delivery(Wallen et al.

2010, Melnyk et al. 2016). In healthcare organizations dedicated to promoting best practices, EBP is associated with higher quality care and better patient outcomes at lower expenditures than care steeped in tradition and customs (Fielding & Briss 2006, McGinty &

Anderson 2008, Wallen et al. 2010). The Magnet Recognition Program®, in which excellence in nursing practice grounded in EBP is a basic tenet of effective healthcare services delivery, has clearly demonstrated this trend, resulting in superior patient outcomes and care quality in hospitals that have earned the Magnet hospital designation (Turkel et al. 2005, Wolf et al.

2008, Drenkard 2010, Salmond et al. 2010, Luzinski 2011, Kutney-Lee et al. 2015). As the largest group of healthcare professionals working in hospital care (sometimes also called specialized healthcare in Finland), nurses must find ways to work more smartly, efficiently, and cost-effectively with limited adequately trained personnel and other limited resources in a climate of regular spending cuts and economic austerity, in order to maintain care quality and respond to the multifaceted challenges facing healthcare delivery systems today. Nurses provide care to hospitalized patients 24/7; thus implementation of EBP in patient care delivery is largely a nursing responsibility, as integrating best evidence into daily clinical care by adhering to evidence-based best practices, such as clinical practice guidelines (CPGs) and clinical care bundles adapted to the local context, typically involves implementing many nursing-intensive tasks in practice. Therefore, improving nurses’ EBP implementation by strengthening their readiness for EBP, i.e., advancing their EBP competencies, is of critical importance in order to achieve and sustain the highest quality and consistency of clinical care and best patient outcomes in clinical care delivery.

As many studies have demonstrated that evidence-based nursing care positively impacts care quality as well as nurse and patient outcomes (Aiken et al. 2003, Salmond et al. 2010, Wallen et al. 2010, Levin et al. 2011, Melnyk et al. 2012, Kutney-Lee et al. 2015, Wilson et al.

2015), aiming to help nurses consistently implement EBP through the systematic use of effective clinical interventions based on evidence-based CPGs and clinical care bundles is essential to creating excellence in clinical care delivery and moving EBP implementation forward in clinical nursing practice. Although the paradigm shift from research utilization (RU) to EBP has begun to occur globally in the nursing profession, it has been extremely slow, primarily because the transformation of new research evidence into real-world applications in clinical practice presents many multidimensional challenges (Wallen et al.

2010, Harrison & Graham 2012). These challenges include the complex nature of the EBP implementation process, lack of availability and access to translated best evidence in a format that is relevant, practical, and usable in clinical practice, lack of APNs to mentor the EBP implementation of frontline nurses and lead the translation of best evidence into a pragmatic, usable and actionable format for clinical nursing practice, lack of nurses’

individual and organizational readiness for EBP implementation, lack of organizational expectations to implement EBP, lack of organizational cultures and professional practice

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environments supportive of EBP, and insufficient allocation of organizational resources to EBP implementation, such as dedicated time, funds, and active support from EBP mentors, champions, and healthcare leaders (Upton & Upton 2005, Pravikoff et al. 2005, Nagykaldi et al. 2006, Ploeg et al. 2007, Sherriff et al. 2007, Brown et al. 2008, Melnyk et al. 2008a, Thiel &

Ghosh 2008,Van Patter Gale & Schaeffer 2009, Wallen et al. 2010, Levin et al. 2011, Harrison

& Graham 2012, Melnyk et al. 2012, Harding et al. 2014, Saunders 2015, Wilson 2015, Melnyk et al. 2016).

Following an influential Institute of Medicine (IOM) report about the flaws in healthcare delivery in the USA (IOM 2001), experts recommended a major overhaul for all health professions to prepare them to respond to the challenges with new skills, including EBP implementation (IOM 2003). As part of the implementation of a national strategy to overcome the challenges, the IOM (2010) set the national goal in the USA for 2020 that 90%

of all clinical decisions be evidence-based. In Finland, the National Health Care Act (1326/2010) clearly demands that all care delivered to patients must be safe, timely, and evidence-based. In the European Union (EU), Directive 2011/24/EU on patient rights in cross-border healthcare provided EU citizens with the freedom to select the healthcare delivery system of any EU or European Economic Area (EEA) country as their designated provider of healthcare services reimbursable by national health insurances, a reform which opened up international competition in the provision of healthcare services within the EU/EEA countries, thus placing higher demands for all healthcare organizations for better quality and cost-efficiency of healthcare services. However, despite these new legislative, care quality, and cost-efficiency requirements, and despite the expectations of patients and declarations of healthcare leaders, governmental agencies, and professional organizations that implementation of EBP in healthcare delivery should be the norm, the majority of clinicians in healthcare organizations do not consistently implement EBP (IOM 2010, ICN 2012). Furthermore, despite many international and national EBP initiatives to improve integration of EBP into patient care delivery, the chasm between research and clinical practice at the bedside still remains substantial.

The purpose of this study was to explore nurses’ individual readiness for EBP both internationally and nationally at university hospitals in Finland via three different methods:

An integrative literature review on the state of science related to nurses’ readiness for EBP internationally; a national survey of RNs’ readiness for EBP at university hospitals in Finland; and a randomized controlled trial (RCT) to test and evaluate the effectiveness of an APN-led intervention designed and implemented to strengthen RNs’ readiness for EBP.

Conducting RCTs to investigate the effectiveness of clinical interventions is relatively new in nursing science in Finland. Internationally, the body of knowledge on nurses’ readiness for EBP has been steadily growing in the English-speaking countries with a relatively long tradition for conducting EBP research (Pravikoff et al. 2005, Gerrish et al. 2008, Thiel &

Ghosh 2008, Waters et al. 2009, Ross 2010, Melnyk et al. 2012, Warren et al. 2016). However, less is known about nurses’ EBP readiness in the non-English-speaking countries that have joined the global EBP movement more recently. Cross-cultural findings from studies conducted in different countries enlarge and enrich the growing international body of literature on nurses’ EBP readiness, and thus contribute to building a more comprehensive, global understanding of the type of competences that nurses need to effectively integrate EBP into daily healthcare delivery. The results of this study provide a review on the state of the science on nurses’ readiness for EBP internationally, a baseline measurement of the state of Finnish nurses’ EBP readiness at university hospitals, a benchmark for international comparisons of nurses’ EBP readiness, and an evaluation of the effectiveness of an intervention designed and implemented to advance nurses’ EBP competencies at a university hospital in Finland. Most of the results reported in this study have not been identified in previous nursing research studies internationally, and none have previously been identified in Finland. Therefore, this study adds new knowledge to the international and national bodies of EBP evidence.

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2 Conceptual and Theoretical Aspects of Evidence-Based Practice in Nursing

2.1 EVIDENCE-BASED PRACTICE IN NURSING 2.1.1 Definitions

The classic definition of evidence-based practice (EBP) in healthcare, i.e., integration of best research evidence with clinical expertise and patient preferences, was originally formulated by Sackett et al. (1996, 2000). Also early on, DiCenso et al. (1998) defined EBP in nursing as a process in which nurses make clinical decisions using the best available evidence, their clinical expertise, and patient preferences, in the context of available resources. Based on Sackett et al.’s definition, Melnyk et al. (2005, 2012, p.410) defined EBP as a “Evidence- based practice (EBP) is a problem-solving approach to clinical decision making in healthcare that integrates the best evidence from well-designed studies with a clinician’s expertise, which includes internal evidence from patient assessments and practice data, and a patient’s preferences and values.”This definition was selected to define the EBP of nurses in this study.

Thus EBP is a way to standardize clinical practice according to the best available evidence (Kring 2008), in contrast to nursing’s traditional manner of knowledge acquisition solely through custom, routines, social interactions, intuition, and experience (Shiley 2006). In other words, successfully crossing the quality chasm from opinion-based to evidence-based practice requires the critical appraisal of both sources and methods of knowledge acquisition, as well as consistency in its application to clinical practice. Standardization of clinical practice through EBP is essential because it minimizes unwanted variations in practice, which may lead to unpredictable and suboptimal clinical outcomes, which in turn may diminish confidence in nursing’s ability to provide high-quality, safe care, thus undermining the credibility of the entire profession (Stevens 2009, Profetto-McGrath et al.

2010). Furthermore, previous research studies have indicated that EBP is associated with higher quality care and superior patient outcomes at lower expenditures than care that is steeped in tradition and customs (Wallen et al. 2010, Melnyk 2012). EBP has also been shown to improve clinicians’ skills, optimize care delivery, improve consistency of care, and increase patient satisfaction (Melnyk et al. 2012, 2016). It is therefore no wonder that EBP has emerged as a major priority for healthcare organizations worldwide.

2.1.2 The EBP implementation and knowledge transformation processes

Prior to EBP, what has been called the ’old’ paradigm of research utilization (RU), or the retrieval, critique, and use of research results in practice from a single primary study (Melnyk & Fineout-Overholt 2011), used to be the focus of nursing research. In what has been described a paradigm shift from RU to EBP, the ’new’ paradigm of EBP is commonly considered to be a much broader concept which also includes research utilization, as well as the integration of summarized and translated best evidence from several well-defined studies into clinical practice (Melnyk et al. 2004, Melnyk & Fineout-Overholt 2011; Stevens et al. 2012, Stevens 2013). Similarly to Melnyk & Fineout-Overholt’s (2011) definition, research utilization was described as a process of critiquing, implementing, and evaluating research findings by Taylor (2007), while on the other hand, Stevens (2012) emphasized the importance of integrating the critically appraised, summarized and translated best evidence into clinical decision-making, instead of each practicing nurse having to personally critically appraise, summarize, and translate best evidence into a usable and actionable format for clinical care delivery. In other words, Melnyk & Fineout-Overholt (2011) described research

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utilization as one part of EBP, whereas Polit and Beck (2010) asserted that research utilization differs from EBP essentially as to their starting points: research utilization begins with research itself, whereas EBP begins with identifying a clinical issue or problem for which there is a need to find an evidence-based answer. By contrast, Leung et al. (2014) contended that research utilization equals to one step, i.e., the Apply-step, out of the five A’s or steps of implementing EBP (Ask, Access, Appraise, Apply, and Assess) described by Straus et al. (2011). However, based on the previous works of nurse scientists (Gortner et al.

1976, Roper 1977, Hunt 1981), DiCenso et al. asserted as early as 1998 (p.38) that advocating the idea of EBP, i.e., that nursing practice should be based on best available information, “is not new,” but instead, nurse scientists in EBP research had for the past 20 years primarily been focusing on identifying barriers to EBP and on strategies to overcome them, rather than on what should be at the core of nursing practice, i.e., implementing EBP in daily clinical care delivery, and how to actually make it happen.

It is important to keep in mind that the process of EBP implementation consists of more than integrating the best available evidence, clinician’s own expertise, and patient preferences into daily clinical decision-making, it also involves completion of several clearly defined steps (Table 1): 1) identifying a relevant or important clinical issue or problem, for which there is a need to find an evidence-based answer; 2) defining a researchable clinical question; 3) searching for, retrieving, and selecting the most relevant, best evidence available; 4) critically appraising the best evidence; 5) integrating best evidence with the clinician’s expertise and patient preferences and values, into clinical decision-making in daily practice; 6) evaluating the impact of the practice decision or change; and 7) disseminating the outcomes of the practice change. However, implementing this process of EBP in clinical practice has been shown to be challenging (Wallen et al. 2010, Harrison & Graham 2012, Matthew-Maich et al. 2013), due to the rather complex and multifaceted nature of the process itself, as well as several factors influencing the process that are internal and external to nurses. However, the process of EBP implementation, albeit crucially important in daily care delivery, is nevertheless a means to an end, i.e., to achieve the main anticipated outcomes of improving care quality and patient outcomes through systematic, evidence-based quality improvement (Shojania & Grimshaw 2005, Stevens 2010). For the process of EBP implementation to function in clinical practice, the best evidence to be integrated into clinical decision-making needs first to be translated into a practical and relevant format that is actually usable in clinical care delivery. In addition, factors that are internal and external to nurses, i.e., nurses’ lack of individual and organizational readiness for EBP, need to be strengthened prior to the EBP implementation process to enable it to function properly. Nurses’ individual readiness for EBP includes such factors as nurses’ attitudes toward, beliefs about, and knowledge and skills related to EBP, as well as nurses’ self-efficacy (i.e., confidence) in their own abilities to employ EBP (Stevens et al. 2012, Stevens 2009, 2013.) Organizational readiness for EBP in turn includes such factors as an organizational culture and leaders actively supportive of EBP, an EBP- infused professional nursing practice environment, and availability of EBP mentors within the organization (Melnyk et al. 2004, Wallen et al. 2010, Melnyk & Fineout-Overholt 2011, Melnyk et al. 2012, Melnyk et al 2016). This study explored nurses’ individual readiness for EBP at university hospitals in Finland.

For an organization to be successful in attaining integration of translated best evidence into nurses’ clinical decision-making in patient care delivery, i.e., implementation of the

’new’ paradigm of EBP, knowledge transformation (KT) is also required, in addition to a functioning EBP implementation process, as well as adequate levels of readiness for EBP implementation among individual nurses and the organization. KT is a process by which best available evidence from high-quality primary research studies is transformed through a series of stages and forms into into rigorous evidence summaries and further into CPGs and clinical care bundles to to support clinical decision-making and impact on health outcomes via implementation in daily care delivery.

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CPGs, also known as best practice guidelines (BPGs), are intended to offer concise, evidence-based recommendations for patient care delivery that are usable in clinical practice (Grol & Grimshaw 2003).KT literature seeks to explain the processes involved in increasing the availability of translated best evidence, such as evidence-based CPGs and clinical care bundles, as well as facilitating their uptake and guiding their consistent implementation in clinical practice (Eccles et al. 2005, Grimshaw et al. 2006, Bick & Rycroft- Malone 2010). Although there are widely recognized underlining assumptions in the KT process, including: 1) EBP implementation, which is clinical care delivery based on best evidence, occurs with the translation of high-quality summarized and synthesized best evidence into CPGs and clinical care bundles and the adoption, uptake, and implementation of CPGs and clinical care bundles in practice; and 2) as long as the translated best evidence is embedded in a CPG or clinical care bundle, it will be fairly straightforward to move it into practice (Harrison & Graham 2012), these assumptions may not always be reliable. In reality, translating best evidence into a relevant, usable and actionable format for clinical practice via the KT process is neither simple nor straightforward, but instead a complex, multifaceted, contextual and challenging process that is often difficult to understand (Grimshaw et al. 2004, Rycroft-Malone 2007, Matthew- Maich et al. 2013) and overwhelming for both the individual nurses and the healthcare organizations where they work at (Harrison & Graham 2012). Table 1 compares the steps of the EBP and KT processes for integration of translated best evidence into clinical decision- making, i.e., decision-making related to clinical care delivery to patients.

Table 1. Comparison of the steps of the EBP process and the knowledge transformation process (Saunders et al. 2016). Reprinted with the kind permission of John Wiley & Sons.

EBP process Knowledge transformation (KT) process

1. Recognizing evidence needs and defining a

researchable clinical question 1. Discovering evidence 2. Searching for, retrieving, and selecting

evidence 2. Summarizing evidence

3. Critically appraising evidence 3. Translating evidence into clinically relevant and usable form in the local setting

4. Integrating best evidence with clinician’s expertise, patient preferences and values in clinical decision-making

4. Integrating evidence into practice

5. Evaluating the outcomes of practice decision or change

6. Disseminating the outcomes

5. Evaluating the impact of evidence integration

When the EBP implementation and the KT processes are compared, it is important to note that in the KT process, the focus is on summarizing best evidence from several well- designed, robust primary research studies into evidence summaries, such as systematic reviews, meta-analyses (from quantitative best evidence), and metasyntheses (from qualitative best evidence), which are subsequently synthesized into CPGs, and further translated into clinical care bundles (quantitative) and lines of actions (LOAs) (qualitative).

In the clinical care bundle and LOA format, the summarized best evidence has been translated via the KT process into practical core clinical interventions grounded in the local circumstances (i.e., adapted to the local practice context), and thus relevant, actionable, and thus more readily integrated into the local practice settings. Therefore, the benefits of clinical care bundles and LOAs include their succinct format, because in the clinical care bundles and LOAs the translated best evidence from sometimes quite lengthy CPGs with complex sentence structures and copious sub-points, has been synthesized into 3 to 5 practical, clearly stated clinical core interventions that have been adapted to the local practice context. Precisely the succinct, clear format of clinical care bundles and LOAs adapted to the local practice setting, is regarded as a usable and pragmatic form of

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translated best evidence by many clinicians and thus, more readily actionable and implementable in daily clinical practice. This, in turn, can help improve frontline nurses’

and other clinical practitioners’adherence to the clinical care bundles and LOAs, and thus improve the potential for quality, consistency, efficiency, and equity of clinical care delivery to patients. In other words, the primary purpose of knowledge translation is to summarize, transform, and adapt best evidence into a pragmatic and practice –friendly format that is more relevant, usable, and actionable in the local clinical practice setting. This enables frontline nurses to integrate the translated best evidence easier into their own practice, thus providing opportunity to improve the degree and consistency of EBP uptake, adoption, and implementation at healthcare organizations.

Finally, it is important to note that knowledge translation requires expert-level EBP competencies. This has direct implications for all nurse leaders at healthcare organizations in terms of staffing and scheduling at clinical patient care settings. It is crucially important for nurse leaders to ensure that APNs and other nurses with expert-level EBP competencies are employed and easily accessible to frontline nurses at the direct clinical care settings, to ensure the availability of translated best evidence in a pragmatic, usable, and readily actionable format for frontline nurses in daily clinical care delivery. In addition, it is essential that APNs’ core practice domains are prioritized: The central core domains of APNs should include EBP mentorship of frontline nurses, in addition to advanced-level direct clinical practice. This means that clinical mentorship of frontline nurses in evidence- based care delivery in direct clinical care settings is a critically important core practice domain of APNs in order to strengthen frontline nurses’ readiness for EBP implementation, to ensure frontline nurses’ use of their newly-strengthened EBP competencies in daily clinical decision-making, and to improve the consistency of frontline nurses’

implementation of EBP, which will help the organization attain higher quality of care and better patient outcomes. Furthermore, application of a more pragmatic, collaborative approach to EBP implementation is required to accomplish EBP integration into the daily practice of frontline nurses in the clinical care settings. The collaborative approach requires 1) dividing the tasks related to the steps of the EBP implementation process between APNs with expert-level EBP competencies serving as EBP mentors and frontline nurses; and 2) closer collaboration between the APN-EBP mentors and frontline nurses in implementing the steps of the EBP process in direct patient care practice settings. The collaborative approach is essential to actually achieving consistent integration of translated best evidence among frontline nurses into daily clinical practice, and it requires that nurse leaders focus on ensuring the required ‘role-mix’ for EBP implementation in their local clinical practice settings so that those steps of the collaborative EBP implementation process requiring knowledge translation and technical research skills can be performed by APNs and other nurses with expert-level EBP competencies. It is also crucial that nurse leaders, including clinical leaders such as APNs, ensure frontline nurses’ unencumbered access to translated best evidence in a format that is relevant, practical, readily actionable, and adapted to the local clinical practice setting, such as clinical care bundles and LOAs. This is necessary to afford frontline nurses a realistic opportunity to be successful in consistently integrating best evidence into their own clinical practice with patients within today’s intense practice settings, to move forward with the attainment of the organizational goals of improving quality of care and patient outcomes (Saunders 2015.)

2.1.3 Readiness for EBP in nursing

In clinically oriented fields of practice, it is crucially important to specify the required knowledge, attitudes, beliefs, skills, and abilities (i.e., competencies) for successful performance of critical work functions, which will guide the preparation of clinicians in their work and educational settings (Stevens 2009, Melnyk et al. 2014). Competence has previously been defined in nursing as the “ability to perform the task with desirable outcomes under the varied circumstances of the real world” (Benner 1984, p. 304), and as

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the ability to do something well (Merriam Webster Dictionary 2012). In this study,

‘readiness’ conveys adequate preparedness for successful performance of a work function that, in turn, demonstrates ‘competency.’ Based on Bandura’s self-efficacy theory (1986, 1997), two constructs of readiness were measured in this study: Self-efficacy and subject- matter knowledge, reflecting competency. In the Transtheoretical Model, Prochaska &

Velicer (1997) defined self-efficacy as consisting of two constructs: 1) Confidence that one can engage in healthy behavior across different challenging situations; and 2) Temptation to engage in the unhealthy behavior across different challenging situations. In aligment with Prochaska & Velicer’s (1997) use of confidence as the primary construct of self-efficacy, nurses’ confidence in their ability to perform the competency was used as the primary construct of readiness in this study. Readiness for EBP in this study refers to the nurses’

self-efficacy, i.e., confidence in engaging in EBP behaviors, and more broadly, also encompasses the factors related to nurses’ capabilities to engage in EBP behaviors in order to integrate best evidence into clinical decision-making, such as nurses’ familiarity with, attitudes toward, and beliefs about EBP, as well as their EBP knowledge and skills.

It is important to note that although the assessment of nurses’ competencies related to various patient care -related tasks and activities has been a standard practice for years in many healthcare organizations worldwide, the development and assessment of nurses’ EBP competencies, which are critically important abilities for attaining high-quality care and patient outcomes through achieving excellence in nursing practice, has been limited (Melnyk & Fineout-Overholt 2014). However, there are two notable exceptions to this in the international literature, both of which originate from the USA: First, the national consensus competencies for employing EBP in nursing (Stevens 2009), developed in the USA by a national expert panel, systematically generated, validated, and endorsed EBP competency statements for nurses through multiple iterations. As a result of this process, the essential EBP competencies, consisting of 10 to 32 items, depending on the level of nursing educational preparation (i.e., Associate, Baccalaureate, Masters, or Doctoral level), are used to evaluate nurses’ abilities to employ EBP as well as guide EBP professional development programs in nursing (Stevens 2009). In addition, the Evidence-Based Practice Readiness Inventory (ERI) instrument was developed based on the essential EBP competencies for nursing (Stevens 2009), using the Stevens Star Model of Knowledge Transformation© as its framework (Stevens 2004). More recently, Melnyk et al. (2014) have also developed a set of 13 EBP competencies for practicing RNs and 11 additional EBP competencies for APNs using a Delphi survey technique for consensus-building among EBP mentors from across the USA. Melnyk et al.’s (2014) EBP competencies take a pragmatic perspective to the EBP knowledge and skills required of practicing RNs and APNs primarily in clinical practice as well as how to assess these competencies, while Stevens’ (2009) essential EBP competencies also guide nurses’ professional and educational development in EBP.

2.2 THEORETICAL BASIS FOR THE STUDY 2.2.1 Background

The outlook of this study is firmly grounded in pragmatism (Hannes & Lockwood 2011), instead of the positivist or constructivist perspectives that traditionally have influenced the approaches to EBP implementation in medicine or in nursing, respectively. Part of the alignment with pragmatism for this study is a particular focus on the utility of the summarized, synthesized and translated best evidence to end-user groups in practice, e.g., nurse clinicians and other clinical practitioners. Pragmatism particularly emphasizes the practical value of the summarized, synthesized and translated best evidence (Hannes &

Lockwood 2011, Saunders 2015), with which the clinical practice-oriented topic of this study is strongly aligned. Accordingly, this study focuses on how the processes of EBP implementation and KT can be utilized to produce and implement translated best evidence in the most relevant and usable form for clinical practice, e.g., in the form of clinical care

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bundles or LOAs that directly inform and support clinical decision-making in patient care, and provide practical interventions for clinical nurses to use in their care delivery to patients (Korhonen et al. 2012, Saunders 2015).

In order to be able to internalize implementation of EBP so that it becomes a part of their daily practice, it is important for nurse clinicians to understand the origins of evidence- based knowledge. This includes comprehending how quantitative and qualitative evidence syntheses can be sources for evidence-based, pragmatic clinical interventions usable in daily care delivery, after translation into e.g. clinical care bundles or LOAs through the KT process. Although systematic reviews of quantitative evidence, e.g. meta-analyses, provide information on the effectiveness of an intervention, frontline nurses and other clinical practitioners may realize that quantitative study designs alone do not capture many practice-related problems or issues of interest for clinical care delivery, as these issues are frequently multifaceted in nature. Therefore, it is important to keep in mind that metasyntheses, i.e., systematic reviews of qualitative evidence, can be another significant source of pragmatic interventions for clinical practice which complement quantitative reviews, as they can help understand and explain a clinical problem or issue of interest more comprehensively (Pearson et al. 2005, Walsh et al. 2005) than quantitative reviews alone. Essential to EBP implementation is also understanding the KT process, during which the best evidence is translated through successive stages into formats that are more readily usable in clinical practice, such as evidence summaries, e.g., systematic reviews of quantitative and qualitative evidence (Stevens et al. 2012). In this discussion, meta-analysis is used as an example of a systematic review of quantitative best evidence, and meta- aggregative metasynthesis is used as an example of a systematic review of qualitative best evidence. Meta-analyses and metasyntheses are thus examples of evidence summaries that complement each other and together, can help nurse clinicians understand the clinical problem or issue of interest more comprehensively (Hannes & Harden 2012, Hannes &

Macaltis 2012, Korhonen et al. 2012, Saunders 2015). Moreover, meta-analyses help answer the question “What works?” while metasyntheses help explain“How or Why it works?”

When synthesized into a systematic mixed studies review (SMSR, Polit & Beck 2012),they provide nurse clinicians with the most pragmatic, yet comprehensive understanding of the clinical problem or issue of interest, helping answer the question “What works under which circumstances?” (Borglin 2013). The SMSRs, based on the synthesis of e.g. meta-aggregative metasyntheses and meta-analyses, may therefore comprise sources of practical interventions based on translated best evidence that is more readily implementable in clinical practice, due to the more comprehensive synthesis of quantitative and qualitative best evidence summaries grounded in pragmatism (Hannes & Lockwood 2011, Korhonen et al. 2012, Saunders 2015). On the other hand, nurse clinicians and other clinical practitioners that engage in clinical decision-making on a daily basis may be particularly interested in the KT process of further translating evidence summaries, such as meta- aggregative metasyntheses and meta-analyses, into synthesized statements (called CPGs when based on quantitative best evidence), which directly support clinical practice (Hannes

& Lockwood 2011). As the CPGs and synthesized statements are further translated via the KT process into even more concise, pragmatic, and readily actionable formats as clinical care bundles (quantitative) and LOAs (qualitative), they provide nurse clinicians with practical interventions in the most relevant and usable form for integration into daily care delivery. The similarities and complementary features of syntheses of quantitative and qualitative evidence summaries as sources of practical and usable interventions for addressing clinical problems in daily practice, are illustrated in Figure 1.

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Figure 1. Process of knowledge translation, i.e., summarizing and synthesizing quantitative and qualitative best evidence from primary research studies into pragmatic interventions for clinical practice, using meta-aggregative metasynthesis and meta-analysis as examples of summarized qualitative and quantitative evidence, respectively (Saunders 2015). Reprinted with the kind permission of Wiley-Blackwell.

Figure 1 displays meta-aggregative meta-aggregation and meta-analysis as examples of approaches to conducting systematic reviews of qualitative and quantitative evidence, respectively, which are further translated into synthesized statements and CPGs via the KT process, and eventually further translated into LOAs and clinical care bundles for integration into clinical practice. The LOAs and clinical care bundles are in effect pragmatic clinical interventions based on summarized, synthesized, and translated best evidence, actionable and readily implementable in daily practice by nurse clinicians delivering care to patients. The LOAs are thus the qualitative analogue for clinical care bundles, as both contain practical core interventions that complement each other and together, provide more comprehensive answers and pragmatic actions which enable nurse clinicians to address the clinical problem or issue of interest in a more complete manner. In summary, nurse clinicians’ understanding of summarized quantitative and qualitative best evidence as sources for pragmatic clinical interventions that are actionable and readily usable in daily practice is important because it may provide frontline nurses with a rationale for internalizing implementation of EBP and thus, may help facilitate their uptake, adoption, and implementation of EBP in daily care delivery.

2.2.1.1 Levels of knowledge usability in evidence-based clinical practice

As part of their efforts to more systematically implement EBP, healthcare organizations worldwide aim at boosting the use of CPGs in order to standardize clinical practices and to move best evidence that has been summarized and translated into recommendation form into daily practice, to achieve more consistent care delivery. The primary underlying assumption for these efforts is that improved clinical care processes, quality of care, and

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patient outcomes occur when care is based on summarized and translated best evidence, i.e., when CPGs are integrated into daily practice (Grimshaw et al. 2006, Thomas et al. 2009, Harrison & Graham 2012). However, even though healthcare organizations have invested a lot of resources, particularly over the last couple of decades, to implement CPGs in patient care, a considerable chasm still exists between what we know and what we actually do in clinical care delivery regarding consistent integration of best evidence into practice (IOM 2001, Wallen et al. 2010, Matthew-Maich et al. 2013, Stevens 2013).

Evidence-based CPGs, which have been developed through using the KT process to translate evidence summaries into practice recommendation form, represent a significant step forward in transforming best evidence into more practical and usable formats to assist with the integration of research-based evidence into clinical decision-making at the point- of-care (Edwards et al. 2005). However, findings from previous studies indicate that evidence-based CPGs are nevertheless not systematically implemented in clinical practice (Bennett et al. 2003, Meline & Paradiso 2003, Fink et al. 2008, Wallen et al. 2010, Melnyk et al. 2012), partially due to nurse clinicians’ lack a sufficient understanding on how to consistently adopt and integrate CPGs into daily care delivery (Eccles et al. 2005, Grimshaw et al. 2006, Bick & Rycroft-Malone 2010). In addition, complicating CPG adoption is the wide variation in their quality, particularly in relation to how the guidelines were developed and to the group or body that developed them (Graham & Harrison 2005).

However, publication of high-quality, evidence-based CPGs from credible international and national bodies, such as the Agency for Health Care Research and Quality (AHRQ), the Royal College of Nursing (RCN), as well as the Finnish national Käypä hoito (Duodecim)- and nursing CPGs (Hotus), along with the development of several coherent EBP models to guide their implementation, have helped facilitate the efforts of many healthcare organizations globally in using evidence-based CPGs to improve the quality and consistency of care delivery as well as patient outcomes (Harrison and Graham 2012, Matthew-Maich et al. 2013).

Another reason why nurse clinicians do not consistently implement evidence-based

CPGs in clinical practice is because CPGs frequently are not in a readily usable format for clinical practice, which prevents them to be easily integrated into daily care delivery.

Although many CPGs comprise robust evidence summaries in recommendation form, at several pages long, they often are far too lengthy, contain far too complex a structure or language, and fail to incorporate local evidence or circumstances, to be readily integrated into daily clinical decision-making (Harrison & Graham 2012, Korhonen et al. 2012, Saunders 2015). In order to implement EBP in daily clinical care delivery, the translated best evidence should be packaged into a concise and user-friendly format that is readily accessible and relevant in the local context, such as clinical care bundles and LOAs, which consist of 3-5 practical and actionable core clinical interventions that have been adapted to the local circumstances (IHI 2012a, b, c, d, Resar et al. 2012). This will enable nurse clinicians to integrate the translated best evidence in these formats into their daily practice much more easily than most CPGs. The KT process for translating best evidence from evidence summaries to these formats is illustrated by the levels of knowledge usability in evidence-based clinical practice (Figure 2). Usability refers to the format of the translated best evidence that from the clinical practitioner’s viewpoint is pragmatic, concise, relevant, and actionable in daily practice in the local setting as basis for clinical decision-making related to patient care.

An important aspect improving usability of translated best evidence is the integration of local knowledge, including data from local studies and about the local population (e.g., needs and environmental assessments, and prevalence studies of the clinical problem or issue of interest), as well as patient assessment data, outcomes management data, and quality improvement data (i.e., internal evidence) (Melnyk et al. 2014). It is essential to also evaluate the local circumstances and context, including how they affect CPG implementation e.g., the local care delivery model and any local gaps or variations in

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practice related to the clinical problem or issue of interest, because it is usually not possible to adopt a CPG ‘as is’ in daily practice but instead, the CPGs need to be tailored to the local circumstances to allow their integration into daily practice (Harrison & Graham 2012, Singer & Vogus 2013). Thus, the levels of knowledge usability in clinical practice outlined in Figure 2 provide a summary of the different formats of translated best evidence related to their usability in clinical practice, which may help frontline nurses integrate EBP into daily care delivery.

Figure 2.Levels of knowledge usability in evidence-based clinical practice (Saunders 2015).

Reprinted with the kind permission of Wiley-Blackwell.

2.2.2 EBP implementation models in this study

In the last few years, many EBP models and frameworks have been published in the literature to understand various aspects of EBP implementation and to guide integration of best evidence into clinical practice, some of which have been summarized by Ciliska et al.

(2010) and by Rycroft-Malone & Bucknell (2010). However, one of the earlier EBP implementation models, the Stevens Star Model of Knowledge Transformation© (Stevens 2004), also known as the ACE Star Model of Knowledge Transformation©, the origins and premises of which have previously been described by Mitchell et al. (2010), was selected as one of the relevant frameworks to be used as theoretical basis for this study. The Star Model was selected because it not only helps identify the specific EBP knowledge, skills, attitudes, beliefs and abilities, i.e., EBP competencies, requisite to frontline nurses’ employment of EBP in clinical decision-making, it also emphasizes the importance of using knowledge translation to transform the best available evidence into forms of knowledge that are more relevant, practical, and usable for frontline nurses in daily care delivery.

The knowledge transformation (KT) process, defined as the conversion of best available evidence from primary research studies through a series of stages and forms, into formats that are more readily usable in practice to support clinical decision-making and thus better

Nurses’ readiness for evidence-based practice : implementing the paradigm shift of transforming evidence for clinical practice

uef.fi

Dissertations in Health Sciences

HANNELE SAUNDERS

NURSES’ READINESS FOR EVIDENCE-BASED PRACTICE:

IMPLEMENTING THE PARADIGM SHIFT OF TRANSFORMING EVIDENCE FOR CLINICAL PRACTICE

HANNELE SAUNDERS

Nurses’ Readiness for Evidence-Based Practice:

Implementing the Paradigm Shift of

Transforming Evidence for Clinical Practice

Nurses’ Readiness for Evidence-Based Practice:

Implementing the Paradigm Shift of

Transforming Evidence for Clinical Practice

Acknowledgements

List of the original publications

Contents

Abbreviations

2 Conceptual and Theoretical Aspects of Evidence-Based Practice in Nursing