Evidence-based practice profiles of nurses: a transcultural study^†

Attempts to change from disease-centric care to patient-and family-centered care require nurses equipped with credible evidence and skills to engage with patients and other healthcare providers.¹ Evidence-based practice (EBP) has been identified as a cornerstone for such a transition and a core competency for practice.² EBP is an approach where healthcare decisions are based on the available, current, valid, and relevant evidence and experience. Here, personal clinical experience is combined with the most credible and recent research evidence to make practice decisions.³ This evidence is available in various sources (that is, systematic reviews, meta-analyses, or well-designed clinical guidelines).^4,5 The main features of EBP are reliance and judicious use of current best evidence, clinical expertise, and individual patient needs and choices.⁵

Efforts to foster EBP are in place in various settings.⁶ Indeed, an evidence-based approach to healthcare has been recognized globally as one of the critical competencies for healthcare workers.⁷

Nurses contribute to the largest healthcare provider workforce globally. EBP is advocated for in nursing practice. However, 10–40% of care is not based on credible evidence.⁸ Moreover, most nurses have limited skills in searching and appraising, and understanding literature.⁹ Many nurses do not know how to use Boolean and proximity operators, indexing, and truncation properly, and lack the skills to appraise evidence.¹⁰ One of the most consistent findings is the gap between best practice and actual clinical care.¹¹ Albeit the heightened importance of EBP and global recognition of EBP, evidence on the extent of its practice/use, attitude, and knowledge/skills among nurses in low and middle incomes countries (LMICs) is scanty. Incorporating EBP is a challenge in healthcare settings in LMICs. This is observed in the difference between what is taught in nursing curriculums and the reality of practice in the hospital settings,¹² especially in LMICs.

Education of nurses also varies across countries, and the nursing professional uniquely has numerous entry levels in most countries, including enrolled nurses (EN), Registered Nurses (RN), and graduate nurses (that is, Bachelor of Nursing [BSN] and Master of Science in Nursing [MSN]). The World Health Organization (WHO, 2019) advocates the entry-level for nurses to be a bachelor's degree. This entry-level has been correlated to patient safety. The BSc in nursing has been the minimum degree needed to work as a nurse in Iran for several decades, and accordingly, most nurses in Iran hold a BSc in nursing. In contrast, basic nursing education in Afghanistan is still at the diploma level, offered by both public and private institutions.¹³ Many countries, including Uganda, Malawi, Zambia, Kenya, and Zimbabwe, still have most of their nurses at the technician level as compared to the registered nurse level. However, nursing and midwifery education in Africa has shown signs of development over the past two decades.¹⁴ WHO reported that many countries have now included masters or doctoral levels studies in their programs. Nursing colleges in many countries are affiliating their programs to universities.¹⁵ Most nurses in Ghana are educated in training colleges, often, but not necessarily, affiliated with teaching hospitals.¹⁶ In Uganda, nurses and midwives constitute >60% of the health workforce. The hierarchical nursing cadre order comprises EN, diploma nurses, BSN, and MSN trained nurses.¹⁷ Although training of the BSN commenced in the ’90s, Uganda's nursing culture does not favor integrating this level of nursing training in clinical nursing.¹⁸

Nursing education is consistent with competency in EBP; consequently, this is paramount for nursing practice.¹⁹ This in part stimulated the call for improving nursing. However, evidence for practice gaps still prevails internationally. Strategies to bridge these gaps should be informed by evidence on EBP practice, attitude, and nurses’ skills. Developing robust, methodologically rigorous studies is the cornerstone of the generation of discipline-specific skills and practice.²⁰ This transcultural study in developing countries adds to the growing body of literature on EBP profiles of nurses.

A total of 677 nurses participated in the study from 4 countries. In Afghanistan (n = 66) and Uganda (160), all completed the survey, making a 100% response rate. In Iran and Ghana, 225 and 226 nurses returned the questionnaire, making the response rate 96.1% and 96.5%, respectively. The characteristics of the respondents who participated in this study are shown in Table 1. The mean age of the respondents was 32 (SD ± 6.3). The minimum age was 20 years, while the maximum was 58 years. Most respondents were female (57.2%), while males constituted 41.4% of the sample. Concerning education, most nurses had attained a bachelor's degree in nursing (68.7%). The majority of the nurses were working full-time duties (87.7%). The participants’ mean working experience was 7.2 years (SD = 6), while the maximum working experience was 38 years (Table 1).

All the four countries had moderate to high scores in EBP practice, attitude, or knowledge. Baseline data on the status of EBP in nursing in individual countries and the developing world is needed to better understand and address global nursing practice issues. We believe that it is essential for the international nursing community to understand EBP in low-resource countries. This research is one among the very few that give a clear picture of this in LMICs.

The findings indicate that nurses in different countries had different EBP practice levels, attitudes, and knowledge. This could be attributed to differences in educational level because baccalaureate nursing students receive training in research as part of their education and commitment to improving the quality and view of EBP across health systems. However, facilitators and barriers to EBP across the settings could be different. Goosby and von Zinkernagel highlighted that partnerships form a strong foundation for planning and delivering evidence-based health services.²⁴ While evidence to conceptualize the former sentiment is lacking, barriers to EBP in LMICs seem to be similar.⁹ This indicates that providing opportunities for nurses to engage in postgraduate education and continuous professional development may enhance EBP. Indeed, the majority of nurses in this study had bachelors’ training. EBP training is a fundamental component at this level in all 4 countries. Thus, nursing education levels may be beneficial to EBP²³ notwithstanding the global underinvestment in nursing education and lack of dynamism in curriculum, inter-professional preparation of nurses, coordinated collaboration, and support from stakeholders.¹⁴

Supporting EBP despite the economic status of a country may minimize the knowledge of the evidence gap. This may also enhance the attitude of nurses toward the implementation of EPB in their daily practice.

No significant differences were noted in practice, attitude, or knowledge in all countries concerning age, gender, and education qualifications. In the context of education, similar studies have shown that further nursing education has not improved evidence-based nursing practice.²⁵ Practice and knowledge subscales were significantly associated with working schedules. Part-time nurses had a higher score on the EBPQ-practice scale, while full-time nurses had higher scores on attitude and knowledge. One explanation for this finding could be differences in the time available for nurses to access evidence resources. Time has been noted as a significant barrier to the utilization of EBP across studies.^13,23 Studies assessing whether working schedules (that is, part-time or full-time) could be a determinant in utilizing EBP need to be conducted. Such studies could incorporate interventional approaches exploring time-based interventions to improve practice and knowledge on EBP.

Differences were identified regarding EBP subscales and working experience; those having an experience of >20 years had the highest mean scores on the practice scale; while two categories (that is, 6–10 years and 11–20 years) had the same and highest mean scores on the attitude and knowledge subscales. More experience could be related to more excellent knowledge and skills. Changes are also made to practice with experience; nurses also tend to rediscover nursing and champion the profession as they gain experience of EBP and education.²³ Similar to previous findings,²⁶ knowledge of EBP may be experiential. However, it needs a combination of personal clinical experience with the most credible recent research evidence.

This study identified that nurses in these 4 countries have different levels of practice, attitude, and knowledge of EBP. In particular, they may be experiencing different levels of access to resources and other facilitators of EBP. However, they exhibit moderate to high attributes of EBP (that is, practice, attitude, and knowledge). Additionally, this research can guide developing countries’ healthcare officials in understanding EBP requirements at the policy level. Further research is needed to explore the country profiles pertaining to barriers and facilitators of EBP among nurses.

The information in this study was based on self-reports from nurses. There is a probability that self-report responses create validity limitations as the respondent may exaggerate responses to make the prevailing situation either excellent or worse.²⁷ We minimized such limitations by requesting respondents to answer the questionnaire with utmost honesty based on reality.