Obstacles in employing evidence-based practice by nurses in their clinical settings: a descriptive study

EBP is a central element of quality patient care, lessening practice dissimilarity and improving nursing self-governance.15 It also enhances healthcare value and cultivates nurses’ dynamic commitment to their practices. Nurses who utilize an EBP, advance to care and practice in the environment that encourages EBP are more authorized as they are capable of creating diversity in the care of their patients.16 In addition, utilization of EBP is reflected on the finest technique for developing nurses’ talent to discover and solve clinical problems. This implies that nurses have developed the skills and knowledge to search for, appraise and employ research evidence for clinical decision construction and to help techniques to convey high-quality care.17

While the optimistic force of EBP has been established throughout various studies, foremost obstacles subsist that hinder EBP from becoming the standard of care all over the world. These obstacles include insufficient EBP knowledge and skills of nurses, misperceptions that EBP needs excessive time, organizational culture and policies, as well as inadequate support from nurse leaders and managers, in addition to lack of resources and investment in EBP. The level to which nurses implicated in EBP and were able to utilize it in the study’s hospital was unidentified.18 Therefore, the purpose of this study was to identify obstacles in employing EBP by nurses in their clinical settings.

This study aimed to identify the obstacles in employing EBP by nurses in their clinical settings.

This descriptive design utilized to conduct the current study was carried out at Benha University Hospital in medical and surgical units as well as outpatient clinics located at Benha City, Al Qalyubia Governorate. A convenient sample of 154 nurses working at Benha University Hospital in medical and surgical departments, operating theatre, critical care units, and outpatient clinics were willing to participate in the study.

Two tools were utilized to carry out this study.

An official permission was obtained from hospital medical directors of Benha University Hospital and nursing directors to accomplish the current study. Then, the study’s possible participants congregated and a clarification of the study nature, purpose, and procedure were provided to them. They informed that participation is voluntary, that their responses will be confidential and that any information gained from their responses will be presented in a cumulative format and nothing will be exposed to their personal identity.

The fieldwork of this research occurred on November 2017 until February 2018. An oral consent was obtained from nurses to participate in the current study, and they provided with an explanation about the aim of the study before participation. After that, the study tools were handed to them to fill.

A pilot study was accomplished in 10% of the study sample to test the clarity and validity of the study tool contents, and subjects involved in the pilot study were excluded from the study sample.

The calculated data were analyzed and tabulated using number and percentage distribution for qualitative data and mean and standard deviation for quantitative data, and correlation coefficient (r) was calculated using SPSS, version 20, to determine if there were statistically significant relations.

Moreover, the obstacle of organizational limitations were deemed as the greatest obstacle in Benha University Hospital. The majority of the study nurses agreed that there are inadequate facilities, which may be because the setting in the current study has restricted economic and human resources. The restraint of the fiscal resources leads to an intricacy in implementing the research EBP findings, which may need additional equipment and supplies and also inadequate organizational infrastructures that are deliberated to endorse EBP. These findings were consistent with many of previous studies.24,26,28 The majority of the studied nurses stated that there is no library in the hospital and they face troubles in attainment of the research evidence. In addition, there is absence of full-text nursing articles or up-to-date textbooks. This is because the restricted Internet access in the hospital does not supply them contact to those databases that contain the massive body of research. Lack of authority to change patient care, which was ranked as the second obstacle for our studied nurses, was inconsistent with previous studies, which ranked it in the top five barriers.29,30,31

Among organization-related obstacles that come at top ranking by the study subjects were the nurses do not have time to read researches, nurses do not feel they have enough authority to change patient care procedures, and the nurses feel results are not generalizable to own setting. These obstacles have often been reported in prior obstacles studies.26,32 These results may be attributed to the scarcity of the staff members, intense tasks and workload offered to them, and neither time nor power to read and utilize research findings in their practice. Likewise, a study revealed that head nurses do not have the time to revise research articles, it was rare for head nurses to discuss article findings with nurses, and staff nurses do not have the time to search article reports.33 This was supported by another study, which reported that inadequate time and deficiency of EBP education were recognized as the most significant factors hampering applying EBP.34 Additionally, other studies reported deficient time to accomplish the entire EBP process as a famous organizational obstacle, while employing EBP is a time-overwhelming process principally concerned with contacting, finding, comprehending, and evaluating research findings as well applying reasonable changes as explained by other studies.35,36 This finding is in line with another study, which justified that this result may be related to grave workloads and shortage in staffing that hinder the application of EBP. In addition, the subjects in his study viewed nursing care as task orientated. Moreover, nurses in this study supposed that they did not have the authority to implement EBP. Nurses reported that physician’s orders were not consistent with nursing research-directed clinical practice.37

The findings of the current study showed that another identified organizational obstacle is inadequate support from administration and other staff. From the researchers’ view, utilizing research findings in clinical settings needs association among managers, academics, and practitioners. This was consistent with previous studies that noted the same results and found that lack of authority and management support was perceived to resist in opposition to changing the usual practice in the favor of EBP.25,38.39

Regarding the quality of research-related obstacles, nurses agreed that the publishing takes a long time, the language of the research, the research conclusions are not reasonable, and the research has conflicting results are the greatest obstacles. This may be due to deficiency in efficient communication between researchers and nursing practitioners as a result of disparate beliefs and education and lack of experience, awareness, skills, and motivation in use of research. Another study confirmed that bachelor degree nurses do not learn research-related courses after their graduation, excluding those who schedule postgraduate studies. Deficiency in research-related knowledge makes nurses unable to comprehend methodology and findings of the researches, even if these researches are written in an excellent eminence.40

The results of our study showed that the use of English as a dominant language of journals was another apparent obstacle for the nurses, which is concordant with the results of similar studies in other non-English language countries. This is supported by studies conducted in Taiwan presenting that nurses favored evidence-based resources to be obtainable in Chinese.3,40 For the most part of the high-quality nursing, studies have been published in English language journals, while most of the Egyptian nurses’ proficiency in the English language is comparatively low. This fact highlights the considerable need for support of nurses to develop their English language skills.32 Additionally, the absence of translated researches from English to Arabic is considered as the main obstacle to research implementation as most nurses in this study affirmed. This is in line with other studies, which stated that nurses’ English language skills are almost low and the majority of high-quality nurses studies are published in English language.40,41,42

Literature with conflicting results was presented in the top five obstacles that allied with the quality of research. This may be attributed to lack of nurses’ fluency with research methodology, as well as the fact that great number of doctors and nurses do not think that research is a nursing duty, which has directed to poor collaboration between doctors and nurses to apply research findings into practice.33 Unfortunately, the largest part of the nursing research was conducted by the academic staff at the nursing faculties, and the contact between these researchers and the nursing practitioners is missing. This deficiency in valuable communication may occur because there have different beliefs and levels of education and they do not see each other or speak the same language.43 These results are confirmed by another study which reported that nurses in their study had a trouble in appraising the quality of research. So, the research may be complex to be implicated by nurses, or the study results may not congregate the actual requirements of the clinical practice.44

The accessibility of the research was ranked by the study subjects as the third greatest barrier. The nurses agreed that the implications of EBP are vague and not clear, researches are irrelevant to practice, and difficulty in understanding statistical analysis were the main obstacles for research accessibility. This may be due to nurses’ inadequate knowledge and training in research methods find it complex to appraise scientific articles and nurses do not have the institution to use the library services. These results are confirmed by previous studies that identified that undependable basic knowledge and familiarity with research have been the main obstacles for utilization of EBP.27,45 In addition, previous studies noticed insufficient comprehending of expressions used in research articles as one of the top barriers to EBP.36,46 Additionally, another study recognized that nurses deemed insufficient authority and the inaccessibility of research findings to be major barriers to implementing research reports in practice.37 Furthermore, a study for evaluation of barriers to the implementation of EBP among nurses working at federal teaching hospital Abakaliki reported understandability of research findings as a main identified barrier by respondents.36 However, in contrast, another one that studied “Nurses’ wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria” found that more than half percent of the study subjects believed nursing research and research used as valuable portions in nursing care, helpful to nurses, and not only pertinent to the actual day-to-day work but also significant to nursing education.47

The lowest obstacle ranked by nurses in this study was the individual characteristics. The majority of subjects agreed that most individual obstacles in EBP utilization were unwilling to try new ideas, low benefits from changing practice, and research is not valuable for practice. These findings are in agreement with those of other several previous studies that concluded that a lack of assurance in recovering and estimating nursing practice evidence was an extraordinary barrier to approving EBP in none English-speaking countries.17,25,48 In addition, the findings of this study are in line with previous studies.26,49 These results may be due to nurses with a Master or Ph.D. are not being sufficiently implicated in practical areas, but they speedily look for growing to be faculty staff in various universities or travel for higher income. This will guide to enlarge the gap between theory and practice; they do not profit their hospitals from evidence-based research findings as well as non-existence for role models to other nurses. This was supported by another study that reported that most of the nurses in the developing countries after obtaining a Master or Ph.D. favor going abroad to other countries for enhanced pecuniary and job odds.24 On the other hand, one study found that the great bulk of barriers to implementation of EBP are related to individual aspects.50 While another one identified cognitive maturity as one of the most important individual factors affecting participation in EBP.51

Findings of the present study revealed that most nurses consider themselves unable to evaluate the quality of the research and unable to see the value of the research. This result may be due to a deficiency in nurses’ education, training, and participation in research activities, as well as incapability of ongoing education in the hospital to carry out its role in educating and training nurses about the research and evidence-based nursing practice. When nurses comprehend nursing research, this will permit them to enhance research utilization. These findings are in line with previous studies that found that there is a lack of knowledge and skills related to research utilization and EBP.32,52 So, the problem of using research findings in nursing is generally described as why nurses in the clinical setting do not adapt their practice in reply to the new data that have been created from nursing research findings.53

The sociodemographic variables such as age, educational level, and years of experience were found to be significantly associated with obstacles to implementation of EBP. According to the results of the current study, there is a statistically significant correlation between nurses’ age and the obstacles related to individual characteristics, research quality, and accessibility of research. This may be because younger nurses are more overloaded with many job tasks than older. These results are in alignment with the findings of another study.40 On the other hand, these findings are inconsistent with the results of a previous study that revealed that there was no relationship between the nurses’ age and EBP.54

In relation to the level of education, the present study reveals that there are statistically significant correlations between educational level and individual characteristics, research quality, and accessibility-related obstacles to EBP. This may be justified as nurses graduated from nursing schools and nursing institutes that signified that the vast number of the study subjects have lack of knowledge and skills about scientific research, how to contact research sources, and research appraisal. In addition, the hospitals do not provide research-associated education for these nurses. These results are confirmed by a recent study that stated that educational level was extensively linked with organizational barriers to the execution of EBP.50 Furthermore, another one noted a statistically significant relationship between nurses’ obstacles in the implementation of EBP and educational level.46 Contrary to the findings, two studies showed that there is no significant relationship between professional qualification of nurses and exploitation of evidence-based nursing practice.17,36

Regarding the nurses’ experience, the present study reveals that there is a statistically significant correlation between nurses’ experience and obstacles to EBP, except for the organizational limitation-related obstacles. These results may be rationalized as nurses who have adequate experience have superior obstacles to EBP than others. This may be reasonable as a great bulk of the study subjects are young-aged nurses. They may be challenged with many clinical inquiry and questions that need answers from research articles. Accordingly, they may be faced with further research allied obstacles than older nurses. This result is sustained by another one carried out on the individual determinants of nursing research utilization that revealed that current roles, experience working in a specialty area, and job satisfaction were all significant individual characteristics that endorsed nursing research implementation.55 In addition, one study showed significant differences in greater utilization intent for EBP according to nurses’ professional position in the hospital.56 Additionally, another one noted that there was a significant association between job experience and organizational barriers of EBP execution.50 While, a recent study found a highly statistical significant relationship between nurses’ obstacles toward EBP and years of experience.44