level 3- policy
lolo1339
e001881.full.pdf
Framework of policy recommendations for implementation of evidence-based practice: a systematic scoping review
Dirk T Ubbink, 1,2
Gordon H Guyatt, 3 Hester Vermeulen
1,4
To cite: Ubbink DT, Guyatt GH, Vermeulen H. Framework of policy recommendations for implementation of evidence- based practice: a systematic scoping review. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012- 001881
▸ Prepublication history for this paper are available online. To view these files please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2012-001881).
Received 26 July 2012 Accepted 21 December 2012
This final article is available for use under the terms of the Creative Commons Attribution Non-Commercial 2.0 Licence; see http://bmjopen.bmj.com
1Department of Quality Assurance & Process Innovation, Academic Medical Center, Amsterdam, The Netherlands 2Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands 3Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada 4Amsterdam School of Health Professions, University of Amsterdam, Amsterdam, The Netherlands
Correspondence to Dr Dirk T Ubbink; [email protected]
ABSTRACT Objectives: Evidence-based practice (EBP) may help improve healthcare quality. However, not all healthcare professionals and managers use EBP in their daily practice. We systematically reviewed the literature to summarise self-reported appreciation of EBP and organisational infrastructure solutions proposed to promote EBP. Design: Systematic review. Two investigators independently performed the systematic reviewing process. Information sources: MEDLINE, EMBASE and Cochrane Library were searched for publications between 2000 and 2011. Eligibility criteria for included studies: Reviews and surveys of EBP attitude, knowledge, awareness, skills, barriers and facilitators among managers, doctors and nurses in clinical settings. Results: We found 31 surveys of fairly good quality. General attitude towards EBP was welcoming. Respondents perceived several barriers, but also many facilitators for EBP implementation. Solutions were proposed at various organisational levels, including (inter)national associations and hospital management promoting EBP, pregraduate and postgraduate education, as well as individual support by EBP mentors on the wards to move EBP from the classroom to the bedside. Conclusions: More than 20 years after its introduction, the EBP paradigm has been embraced by healthcare professionals as an important means to improve quality of patient care, but its implementation is still deficient. Policy exerted at microlevel , middlelevel and macrolevel, and supported by professional, educational and managerial role models, may further facilitate EBP.
INTRODUCTION Evidence-based practice (EBP) provides a structure for the bedside use of research and consideration of patient values and preferences to optimise clinical decision-making and to improve patient care.1 2 EBP could potentially be used to improve quality of healthcare.3 4
In 2001, the Institute of Medicine’s Quality
Chasm series suggested EBP as one of the five core competencies for professional healthcare curricula.5 More recently, the growing societal demand for quality, safety, equality and accountability of healthcare and credentialing programmes as exerted by the Joint Commission International and Magnet hospi- tals have further promoted EBP.6 7 To date, hos- pital executive boards, insurance companies and consumers recognise that EBP may help prevent unsafe or inefficient practices, as part of a strategy to achieve quality improvement in healthcare.8
Thus far, however, educational efforts have failed to achieve EBP at the bedside or in daily clinical problem-solving. While there is an ongoing debate on how to measure quality of care in general, attitude, awareness, knowledge or behaviour are relevant to
ARTICLE SUMMARY
Article focus ▪ Systematic review of the literature to summarise
self-reported appreciation of evidence-based practice (EBP) and organisational infrastructure solutions proposed to promote EBP.
Key messages ▪ More than 20 years after its introduction, the
EBP paradigm has been embraced by healthcare professionals as an important means to improve quality of patient care, but its implementation is still deficient.
▪ Policy exerted at microlevel, middlelevel and macrolevel, and supported by professional, edu- cational and managerial role models, may further facilitate EBP.
Strengths and limitations of this study ▪ Worldwide overview of EBP appreciation and
implementation strategies useful for all centres striving at a better EBP implementation.
▪ Self-reporting may have led to an overestimation of the results.
▪ The success of implementation strategies is still unclear.
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 1
Open Access Research
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understand application of EBP. Various questionnaires have been developed and used to appreciate these aspects (eg, McColl and Funk).9 10 This information sug- gested the implementation of EBP by doctors is ham- pered by a perceived lack of time, knowledge or EBP resources,9 11 whereas in the nursing realm EBP aware- ness, the body of knowledge and research utilisation, as well as managerial support are still developing.12 13
Based on these findings, many different recommenda- tions for improvement have been proposed. Hence, it is timely to synthesise these recommendations for more structural organisational initiatives that may help over- come barriers and facilitate the uptake of EBP. Therefore, the purpose of this study was to collect
surveys of healthcare professionals’ views on EBP in terms of self-reported attitude, knowledge, awareness, skills, barriers and behaviour regarding EBP among clin- ical doctors, nurses and managers, and to summarise proposed recommendations as derived from these views to improve the use of EBP. We subsequently used the findings of this review to propose a framework for implementation of EBP, tailor-made for different man- agerial levels and suitable to structurally facilitate and sustain evidence-based behaviour in clinical healthcare organisations.
METHODS Literature search and study selection Two of the authors (DTU, HV) searched the MEDLINE (using PubMed), EMBASE (using Ovid) and Cochrane databases from 2000 through 2011 for surveys or reviews of EBP attitude, knowledge, awareness, barriers and facil- itators among nurses, physicians and managers in any clinical setting, that is, hospitals or other healthcare institutions, rather than general practice settings, on which a review has recently been published.14 Reference lists of the included studies and reviews were checked for additional eligible papers. In brief, our search strategy was (evidence-based[ti]
practice OR evidence-based medicine OR EBM OR EBP) and (questionnaire* OR survey OR inventory) and ((barriers OR McColl) AND (knowledge OR attitude* OR aware* OR behavio*) and (hospital* OR clinic* OR medical cent*)). No language restrictions were applied. Papers in foreign languages, if any, would be translated if possible. We excluded studies in an undergraduate educational
setting, studies with a purely qualitative design, studies not including clinical doctors or nurses, and those focus- ing on a specific disorder, guideline, model or tech- nique. We focused on surveys rather than the latter studies, because merely following (particularly expert- based) guidelines or focusing on a specific disorder or technique does not necessarily indicate the general application of the five steps of EBP. Studies before 2000 were also excluded because in these years the EBP para- digm was in an early phase with a limited dispersion
among healthcare professionals. Study selection and quality assessment was performed by two investigators independently.
Quality assessment Judgment of the quality of the surveys was based on the number of centres and respondents involved, response rates and robustness of the questionnaires used (through pilot testing, prior validation or internal con- sistency based on a Cronbach’s α).
Data items and synthesis of results By means of a structured form, two researchers inde- pendently extracted data on study characteristics (including country of origin, publication year, type and number of respondents and type of clinics included), questionnaires used and EBP characteristics studied, in particular EBP attitude, knowledge, skills and awareness, and perceived barriers and facilitating factors for EBP implementation. We extracted in a qualitative manner the reported recommendations, if any, on how to over- come these barriers or how to exploit facilitators. These were grouped into solutions to be executed at various organisational levels. After one investigator had entered the data in the database, these data were checked for accuracy by a second. Meta-analysis was not planned because of the expected
large range in geographical locations, caregivers investi- gated and questionnaires used. To summarise the results of the studies reporting on EBP attitudes and knowl- edge, we calculated the medians and report the ranges of the scores given for each item, for doctors and nurses separately. A possible association between response rate, year of publication and attitude towards EBP was calcu- lated using Spearman’s correlation coefficient. Statistical analysis was performed using PASW Statistics V.18.0 (IBM Inc, Armonk, New York, USA).
RESULTS Study inclusion Our search yielded 286 potentially relevant studies. We also found two recent reviews of studies on barriers towards EBP,15 16 from which other relevant studies were derived. Some more recent studies not included in these reviews were also found by hand-searching the refer- ences of included studies. Four surveys among medical postgraduates were excluded because these publications were in Chinese. In total, 31 studies that included 10 798 respondents from 17 countries proved eligible (table 1). Studies represented nearly all continents, one-third (11/31) were European and a quarter (8/31) were from North America (figure 1). In four of the studies, EBP questions were administered in the context of an educa- tional meeting. Seventeen studies focused specifically on doctors, 11 on nurses. Three of the 31 studies enrolled both doctors and nurses.24 30 43 Wherever possible, results from doctors and nurses are presented separately.
2 Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881
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All studies applied postal or electronic questionnaires. To assess EBP attitude, knowledge, skills and awareness, most studies used the questionnaires developed by McColl, Upton or Estabrooks.9 47 48 To assess EBP bar- riers and facilitators, most investigators used the Funk questionnaire.10 Half of the studies investigated both EBP attitude and barriers.
Study characteristics The studies enrolled from 1910 to 115624 respondents (median 273), consisting of doctors (residents, specia- lists) and nurses (ward and staff nurses, nurse managers and educators) from various clinical specialties. Seven of
the 31 studies were conducted in a single centre. Response rates varied from 9% in nationwide surveys to 100% in questionnaires during trainings, with a median of 72%. Twenty-four of the 31 studies (77%) used robust questionnaires. So, overall quality of the included studies was good (table 2). Most studies addressed EBP attitude, skills and barriers (table 1).
EBP attitude Fifteen of the 18 studies addressing EBP attitude used a (sometimes modified) McColl questionnaire. Based on these 15 studies, both doctors and nurses strongly felt that EBP improves patient care and is important for
Table 1 Characteristics of included studies
Author Year Country
Teaching
hospital(s) Respondents
EBP aspects
studied*
Ahmadi 17
2008 Iran Yes Internal medicine interns, residents and
fellows
1,2,3
Al-Almaie 18
2004 Saudi Arabia No Doctors from various specialties 5
Al-Omari 19
2009 Jordan Both Specialists, fellows, residents from various
specialties
1,2,4,5,6
Al-Omari 20
2006 Saudi Arabia Both Consultant physicians from various
specialties
1,2,3,5
Amin 10
2007 Ireland Yes Otorhinolaryngology surgical trainees 1,4
Andersson 21
2007 Sweden Yes Trainee and specialist paediatric nurses 5
Brown 22
2009 USA Yes Nurses from various specialties 5,6
Brown 23
2010 USA Both Nurses from various specialties 5
Chiu 24
2010 Taiwan No Doctors and nurses from various specialties 1,2,5
Gale 25
2009 USA No Staff nurses and nurse managers from 8
ICUs
1,5,6
Gerrish 26
2008 UK Both Nurses from various specialties 5
Hadley 27
2007 UK No Junior doctors 1,2
Kitto 28
2007 Australia No Surgeons 5
Koehn 29
2008 USA No Staff nurses, unit managers, clinical advisors 1,5
Lai 30
2010 Malaysia No Doctors, nursing and allied health staff before
attending EBM workshop
1,5
Melnyk 31
2004 USA Unknown Nurses before attending EBP workshops 1,5
Mehrdad 32
2008 Iran Yes Clinical nurses and nurse educators 5,6
Mittal 33
2010 India No Surgical trainees attending continuing
education meeting
1,2,3,4,5
Nwagwu 34
2008 Nigeria Yes Consultants in tertiary healthcare institutions 2,3
Olivieri 35
2004 Denmark Yes Doctors from various specialties 2,4
Oranta 36
2002 Finland No Staff and ward nurses 5,6
Palfreyman 37
2003 UK Yes Nurses and physiotherapists from various
specialties
2,5
Parahoo 38
2001 N-Ireland No Medical and surgical nurses 1,5,6
Poolman 39
2007 Netherlands Unknown Orthopaedic surgeons 1,2,4
Roth 40
2010 Canada Unknown English-speaking urology residents
participating in national review course
2,3,4,5
Scales 41
2008 USA Both American Urology Association members 1,5
Sur 42
2006 USA Unknown American Urology Association members 1,3,4
Ubbink 43
2011 Netherlands Yes Doctors and nurses from various specialties 1,2,3,4,5,6
Ulvenes 44
2009 Norway Unknown Reference panel of Norwegian physicians 1,2
Upton 45
2005 UK Unknown Doctors from various specialties 2,5,6
Veness 46
2003 Australia &
New Zealand
Unknown Radiation oncologists and registrars 1,2,3,4,6
*1=Attitude; 2=skills; 3=awareness; 4=knowledge; 5=barriers; 6=facilitators. EBM, evidence-based medicine; EBP,evidence-based practice; ICU, intensive care unit.
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 3
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their profession (table 3). Their overall attitude towards EBP was welcoming and appreciated the use of research evidence in daily clinical practice. However, they considered only half of their clinical practice to be evidence-based, although what they meant by this was, in most cases, not specified and unclear. These findings were consistent among the various countries. We did not find significant correlations between either response rate (−0.112; p=0.703) or year of publication (−0.286; p=0.321) and attitude towards EBP.
EBP knowledge and skills The majority (median 64%) of doctors and nurses reported they considered their EBP knowledge was insufficient. Similarly, a median of 70% of the respon- dents regarded their skills as insufficient, even in the most recent studies, and desired (more) EBP training. The percentage of doctors who had had EBP training ranged from 13% (Indian surgical trainees) to 80% (Iranian internal medicine doctors). The most appropri- ate way, respondents thought to move towards EBP, was through evidence-based guidelines (median 68%), evi- dence summaries (median 39%) or critical appraisal skills (median 36%). PubMed accessibility was high (at least 88%, except
for India, 58% and Jordan, 70%), either at home or at
work. However, clinical decision-making was based on consulting textbooks and colleagues rather than by searching electronic databases. Figure 2 depicts the knowledge of common EBP terms
among doctors. Not all studies used the same EBP terms, but in general, half of the doctors had at least some knowledge about 83% (20/24) of the presented EBP terms. Three of the four terms they were unfamiliar with were meaningless dummy terms. Hence, the results of this part of the questionnaire seemed not biased by socially desired answering. Only one study examined the nurses’ knowledge of
EBP terms (figure 3).43 Half of the nurses had at least some knowledge of 4 (40%) of the 10 terms presented. The dummy terms appeared more familiar than terms like ‘bias’, ‘power calculation’ and ‘number needed to treat’, suggesting some socially desired answering.
Awareness of common sources of evidence Eight studies addressed this issue (table 1). About a quarter of the responding doctors used the Cochrane Library (median 25%), whereas 39% of them were unaware of this database. The journal Evidence-Based Medicine was used by 14%, but unknown in 34% of the doctors. Guidelines from the National Guideline Clearinghouse were used by 8% and unknown in 48%, the
Figure 1 Countries from which studies were included.
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ACP Journal Club used by 3% but unknown in 68% and the TRIP database was used by 15% and unknown in 71%. Two studies showed this awareness was even less among nurses.24 43
EBP barriers and facilitators Responses regarding the 29 barriers presented in Funk’s questionnaire were usually dichotomised, that is, items scored as ‘barrier’ or ‘large barrier’ were counted as bar- riers. To give an overview of the barriers to EBP most fre- quently mentioned by doctors and nurses, we merged our data with the barriers found among nurses in the systematic review by Kajermo et al.15 These barriers are summarised in table 4. Worldwide, EBP barriers were strikingly convergent, except the language barrier for non-English speaking countries and the limited access to electronic databases in some countries. The major facilitating initiatives as desired by doctors
and nurses were mostly collected through open ques- tions. These facilitators include continuing EBP-teaching efforts in pregraduate and postgraduate curricula,
constant involvement by colleagues in daily practice, staff and management support to learn and apply EBP in daily clinical practice, structural promotion and facili- tation of EBP activities by the management and experts, and clear and easily accessible sources of evidence, pro- tocols and guidelines.
Recommendations reported to implement EBP All studies gave recommendations to overcome or address the identified barriers (table 5). From macrole- vel, middlelevel and microlevel perspectives, that is, at (inter)national, hospital and ward levels, various solu- tions were proposed, ranging from advocating EBP by national regulatory bodies to specific interventions at ward level, including availability of computers and internet. A qualitative evaluation of the recommendations
shows they mainly focused on education for both preg- raduates and postgraduates. The following aspects were considered important: how and with whom to build EBP curricula, tiered education based on needs assessments,
Table 2 Quality characteristics of included studies
Author Centres (N) Respondents (N) Response rate (%) Questionnaire robustness*
Ahmadi 17
1 104 80 +
Al-Almaie 18
3 273 67 –
Al-Omari 19
5 386 97 ++
Al-Omari 20
9 178 86 ++
Amin 10
Countrywide 19 95 ++
Andersson 21
2 113 80 ++
Brown 22
1 458 45 ++
Brown 23
4 974 75 ++
Chiu 24
61 1156 69 ++
Gale 25
1 92 22 ++
Gerrish 26
2 598 42 ++
Hadley 27
Several 317 100 ++
Kitto 28
Several 25 50 +
Koehn 29
1 422 41 ++
Lai 30
2 144 72 +
Melnyk 31
Several 160 100 +
Mehrdad 32
15 410 70 ++
Mittal 33
22 93 85 ++
Nwagwu 34
10 89 89 –
Olivieri 35
1 225 60 ++
Oranta 36
2 253 80 ++
Palfreyman 37
1 106 24 ++
Parahoo 38
10 479 53 ++
Poolman 39
Countrywide 367 60 ++
Roth 40
Several 29 100 ++
Scales 41
Countrywide 365 72 ++
Sur 42
Countrywide 714 9 ++
Ubbink 43
1 701 72 ++
Ulvenes 44
Countrywide 976 70 –
Upton 45
Countrywide 381 76 ++
Veness 46
Countrywide 191 79 ++
Total 24 (77%)
>1 Centre
25 (81%)
>100 Respondents
23 (74%)
≥60% Response 24 (77%)
*Robustness based on pilot testing, previous validation, or Cronbach’s α.
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 5
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learning by interaction and transfer of the education from the classroom to the bedside. Regarding preconditions to strategically implement
EBP, authors put emphasis on the role of the manage- ment in terms of facilitating prerequisites as well as
creating a positive culture towards EBP. They also sug- gested that solutions to the problems encountered when implementing EBP should start with an analysis of the organisation to identify problems at both local and organisational levels to tailor the interventions.
Table 3 Attitudes of doctors and nurses towards EBP
Doctors
Median (range)
Nurses
Median (range)
Your current attitude towards EBP
Least positive (0) to Extremely positive (100)
72.3 (49–97) 66.7 (55–85)
Attitude of your colleagues towards EBP
Least positive (0) to Extremely positive (100)
61.0 (41–89) 48.0 (48–48)
How useful are research findings in daily practice?
Useless (0) to Extremely useful (100)
80.0 (46–97) 62.0 (34–82)
What percentage of your clinical practice is evidence-based?
0% to 100%
52.6 (40–80) 44.9 (44–46)
Practicing EBP improves patient care
Completely disagree (0) to Fully agree (100)
80.1 (52–97) 80.7 (74–87)
EBP is of limited value in clinical practice, because a scientific basis is lacking
Completely disagree (0) to Fully agree (100)
36.3 (3–43) 48.3 (48–49)
Implementing EBP, however worthwhile as an ideal, places another demand on
already overloaded surgeons/nurses
Completely disagree (0) to Fully agree (100)
51.4 (37–56) 55.2 (17–61)
The amount of evidence is overwhelming
Completely disagree (0) to Fully agree (100)
53.5 (50–57) No data
EBP fails in practice
Completely disagree (0) to Fully agree (100)
39.7 (15–84) 41.0 (39–63)
EBP is important for my profession
Completely disagree (0) to Fully agree (100)
68.3 (52–95) 61.6 (30–93)
Scores can range from 0 to 100. EBP, evidence-based practice.
Figure 2 Doctors’ knowledge of common evidence-based practice terms. The numbers between brackets indicate the number
of studies that used this term. Terms with an asterisk are meaningless dummy terms.
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DISCUSSION Our systematic review shows that, worldwide, many pro- fessionals in clinical healthcare welcome EBP, although the awareness of, education in and actual bedside appli- cation of EBP leaves room for improvement. Based on the reasons given for the limited uptake of EBP, a struc- tural implementation of EBP in clinical healthcare orga- nisations will require a culture change at various organisational levels, that is, patient care, education and management. The framework of policy recommenda- tions, as presented here, encompasses the wide range of possible entries to implement in a multifocal manner and sustain EBP. Because recommendations were found for virtually all levels of management, a general policy seems indicated to address and govern these EBP
implementation issues. Some recommendations might also be useful as indicators to monitor the usage of EBP in daily clinical practice. Furthermore, this review could stimulate the testing of some of our recommendations through appropriately designed studies. Although the majority of healthcare professionals
appear quite EBP-minded and the uptake of EBP is pro- gressing,49 important barriers are still obstructing the full implementation of EBP in daily clinical practice. These findings occur consistently among the various medical specialists and nurses alike, and in many specific settings and specialties throughout the world. However, Brown et al found in a multiple regression analysis that perceived barriers to research use predicted only a frac- tion of practice, attitude and knowledge/skills associated
Table 4 Barriers to apply EBP as mentioned by doctors and nurses
Doctors and nurses alike
▪ Lack of time to read evidence or implement new ideas ▪ Lack of facilities or resources ▪ Lack of staff experienced in EBP ▪ Lack of training in EBP ▪ EBP is insufficiently supported by staff and management ▪ Evidence is not easily available ▪ Unawareness of research ▪ Evidence is not generalisable to own setting Doctors Nurses
▪ Lack of evidence ▪ Conflicting evidence ▪ Evidence is not incorporated in clinical practice ▪ EBP negatively impacts medical skills and freedom
▪ Evidence is written in foreign language ▪ Lack of authority to change practice ▪ Statistics or research is unintelligible ▪ Implications for practice are unclear
Stated are those ranked among the top ten in most studies. EBP, evidence-based practice.
Figure 3 Nurses’ knowledge of
common evidence-based practice
terms. Terms with an asterisk are
meaningless dummy terms.
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 7
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Table 5 Structural incorporation of EBP at various levels as stated by the authors of the individual studies
Level Intervention by Effect Author
Worldwide International collaboration Expansion and acceleration of the
production and maintenance of
Cochrane Systematic Reviews
Oliveri
Global and international associations Promotion of EBP
Making EBP courses available
Olivieri
Sur
Scientific journals Educational efforts
Publishing high quality research
Poolman, Veness
Scales, Sur
National Governmental enforcement EBP in all undergraduate and
postgraduate healthcare educational
institutions
Melnyk, Ubbink
Installing and financing regulatory
professional bodies
Quality assurance
Practicing EBP
Use of guidelines
Al-Almaie
Melnyk
Ubbink
Installing and financing a national institute Development of evidence based
guidelines
Al-Almaie
Arranging and financing Free use of the Cochrane Library Oliveri
Policy makers, professional associations,
health insurance companies and
regulatory bodies
Promotion of EBP Scales, Oliveri, Poolman,
Melnyk
Board of
hospital
directors
Incorporating EBP in strategic aims Goals tailored on systematic
evaluations
Implementation of EBP and research
utilisation
Brown 2009, Ubbink
Installing research councils High-quality research Brown 2009, Melnyk
Allocating budget High-quality research Mehrdad
Performing systematic evaluations during
working visits, quarterly meetings with
managers
Increased hospital‘s level of EBP
implementation and quality of care
Ubbink
Incorporating performance of EBP
activities by directors, managers and
administrators in annual interviews
Increased hospital‘s level of EBP
implementation and quality of care
Ubbink
Providing management, administrators
and directors with tools and means
Effective learning and practising EBP Al Ohmari 2006, Lai
Managers Integrating EBP and policy setting Evidence-based management Al Ohmari 2009
Recruitment, selection, employment of
new personnel
Identifying EBP role models among
current personnel
EBP-minded working force Ubbink, Brown 2010
Building an infrastructure and environment
with an atmosphere that supports,
promotes and embraces EBP
(ie, incentives, prizes or rewards,
positive attitude)
Effective tools for implementing,
learning and practising EBP
Knowledgeable (nurse) researchers,
(nurse) specialists, master’ prepared
professionals, faculty, research
departments
Al-Almaie, Al Ohmari
2006, Brown 2009, Chui,
Gale, Gerrish, Melnyk,
Mehrdad, Mittal, Oranta,
Parahoo, Ubbink
Collaborating with educators Organisational barriers and
education addressed
Brown 2009
Allocating budget (More) dedicated EBP personnel,
education, activities, computers and
facilities at each point of care.
Attending continuous education,
(inter)national conferences
Brown 2009, Gale,
Gerrish, Mehrdad, Melnyk,
Lai
Provide non-patient hours to personnel Time for EBP activities and
implementation, changing practice,
and quality care development
Brown 2009, Gale,
Mehrad, Palfeyman
Regular evaluation (audit and feedback)
of ward-level EBP activities, knowledge,
skills, behaviour and research utilisation
during annual interviews
Annual evaluation of implementing
EBP-activities
Ahmandi, Al-Almaie,
Al Ohmari 2009, Ubbink
Continued
8 Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881
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Table 5 Continued
Level Intervention by Effect Author
Educators Incorporating and inflating time spent on
EBP by refining and modifying curriculum
and education style in postgraduate and
undergraduate medical and nursing
curricula
Each non-academic degree
professional produces a Cochrane
Systematic review
Improved audit and feedback,
systematic evaluation, and needs
assessment
Tiered, feasible and realistic
education
Ahmandi, Al-Almaie,
Al-Ohmari 2006, Amin,
Andersson, Brown 2009,
Gale, Gerrish, Hadley,
Kitto, Koehn, Lai,
Mehrdad, Melnyk, Mittal,
Nwagwu, Oliveri, Parahoo,
Poolman, Scales, Sur,
Ubbink, Upton
Formulating the curriculum and educating
in collaboration with healthcare
professionals
EBP integration Al-Almaie, Al Ohmari
2006, Brown 2009, Gale,
Gerrish, Lai
Interactive, face-to-face education in
clinical practice and at the bed side
EBP integration Ahmandi, Al-Almaie, Amin,
Al Ohmari 2006, Kitto,
Melnyk, Poolman
Interactive education E-learning modules Kitto, Poolman, Ubbink
EBP internship programme
In-service training
Extended EBP education Brown 2009
Gerrish
Accessing, appraising and interpreting
guidelines, research and protocols, basic
statistical analysis, research training,
IT-technology, quality development,
change management, being a role model,
English language
Optimum content of education Al Ohmari 2006,
Andersson, Gerrish, Lai,
Mehrdad, Mittal, Nwagwu,
Oranta, Parahoo
Educating all educators in EBP Well-equipped educators Oranta
Emphasising professionals’ own
responsibility
Professional skills and competencies
maintained
Oranta
Evaluating effectiveness of EBP teaching Optimum EBP education Ulvenes, Veness
Faculty and
researchers
Documenting, analysing and interpreting
the effectiveness of actions undertaken
EBP implementation Brown 2009
Support professionals in clinical setting by
simple and clear (written) communication
EBP implementation Mehrdad, Brown 2009
Using a variety of strategies Dissemination of research findings
Valorisation of results in practice
Brown 2009
Melnyk
Close collaboration with practicing
professionals
Shared language and understanding
of concepts
Actual relevant clinical questions are
addressed
Oranta
Being a role model Real-life discussions about patients Poolman
Performing and promoting research Well-designed high quality research Scales, Sur
Services Medical library facilities Service for searching databases
Clinical letters, journals and
guidelines
Al Ohmari 2006, Melnyk,
Mittal, Parahoo, Ubbink,
Al Ohmari 2006,
Computer and internet facilities at point of
care, ward, or in EBP suites
Liberal access to databases
Tailored to EBP level of
professionals
Al Ohmari 2006, Gale, Lai,
Mehrdad, Nwagwu, Chui,
Melnyk, Ubbink
Content management system allowing
access to guidelines, protocols, critically
appraised topics and condensed
recommendations
User-friendly and reliable, readable
and pre-appraised information
Provide work-based information
Al Ohmari 2009, Gerrish,
Lai, Ubbink
Computer based decision support system
with priority to systematic reviews
Computer-based guideline
implementation
Alerts and reminders
Al-Almaie, Al Ohmari 2009
Accessible critical appraisal committee Easy assessment of relevant
literature
Mehrdad
Implementation guidance Overcomes obstacles to implement
EBP or recommendation
Change in practice
Chui, Mehrdad
Continued
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 9
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with EBP.23 Apparently, the most frequently reported barriers are not necessarily the main reason for a poor implementation of EBP. Rather, a change in mind set seems indicated among the various healthcare profes- sionals who perceive these barriers. Additional barriers to EBP implementation may lie at the organisational level.4 Hence, an integrative approach, involving all pro- fessionals and supported by initiatives from various organisational levels, may be a more fitting solution. An integrative approach to overcome perceived bar-
riers to EBP has also been suggested by other authors,50
who reasoned that the best implementation strategy should be a multifocal, comprehensive programme involving all professionals and should be tailored to their desires and perceived barriers. A systematic review of 235 studies on (multifaceted) guideline implementa- tion strategies presented imperfect evidence to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances.51 Opinion leaders and role models appear to have a key function.52 A recent system- atic review, comprising seven observational studies, described the relation between EBP implementation and leadership among nurses.53 The evidence suggested that initiatives on the level of leadership, organisation and culture are pivotal for the process of implementing EBP in nursing. However, available evidence for the effect- iveness of organisational infrastructures in promoting
evidence-based nursing is scarce.4 In the medical realm, such evidence is also limited.28 54–56
Other frameworks or multidimensional programmes have been proposed to improve research utillisation,13 or to stimulate the use of EBP by nurses,57 or on specific wards.58 Others have promoted a dedicated research agenda,59 integrated EBP education56 60 or the imple- mentation of EBP in specific medical specialties.16 61
Clinically integrated rather than stand-alone EBP teach- ing initiatives have been shown to improve EBP behaviour and may therefore help implement EBP in clinical prac- tice.62 These initiatives per se seem defective because none of these aspects can be omitted to arrive at a truly evidence-based healthcare: if EBP education falls short, managers do not facilitate EBP activities, doctors do not apply EBP in their daily practice or nurses are lagging behind in EBP knowledge, optimum evidence-based healthcare eventually will not (fully) reach the patients who deserve it. This has been one of the reasons why a European teaching project has started to incorporate evidence-based medicine in clinical practice.63
LIMITATIONS Although not all studies found were performed in teach- ing hospitals, the majority may have been performed in centres that already had the aim, or were in the process of implementing EBP. Many other centres are likely to
Table 5 Continued
Level Intervention by Effect Author
Local
workplace
Journal clubs, grand rounds, handovers,
regular (research) meetings
EBP implementation Oranta, Poolman, Ubbink
Dedicated time and personnel for EBP
activities
Individual support at the units Andersson, Ubbink
Easy access to EBP mentors, change
mentors, innovators and educators,
computers, databases and relevant EBP
websites or links
EBP implementation Al-Almaie, Chui, Gale, Lai,
Mehrdad, Ubbink, Veness
Culture Emphasis on EBP in day-to-day practice Amin
Emphasis on patient benefit of EBP Gale, Melnyk
Sharing experience, knowledge and
support
Andersson
Activating autonomy and empower nurses
to influence change
Brown 2009, Gerrish
Shared governance structures Brown 2009
Engaging in research Gerrish
Willingness to facilitate the process of
implementing
Koehn
Innovative strategies including a culture of
research implementation
Mehrdad
Displaying interest and belief in value of
research utilization
Mittal
Enlightening professionals to use EBP in
decision making
Nwagwu
Supportive culture to research Parahoo
EBP, evidence-based practice.
10 Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881
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be lagging further behind. However, higher response rates were not associated with more positive attitudes towards EBP. Given the settings and types of respondents in the studies included here, the inferences of our review appear primarily valid for clinical doctors and nurses from various specialties in centres that aim at implementing EBM. Second, the questionnaires used were self-reported
and response rates varied considerably. For both reasons, our results may overestimate enthusiasm, knowl- edge and uptake of EBP. On the other hand, the frame- work of implementation recommendations we derived from these studies may be useful for all centres striving at a better EBP implementation. Third, in our review, we searched for surveys of EBP
attitude, knowledge, awareness, barriers and facilitators rather than studies specifically focusing on testing alter- natives to improve implementation of EBP. Such studies, however, are rare.4 28 53 The implementation factors these studies mentioned also became clear from our review, while the success of these implementation strat- egies is still unclear. One of the reasons for this is the absence of a valid means of assessing actual EBP behav- iour during daily practice.62 64–66
Finally, we realise EBP is an essential but not the sole factor to improve quality of care. Even if clinicians are aware of available evidence, the right thing to do does not always happen. Continuous quality improvement strategies also involve active implementation of available evidence and existing guidelines. Nevertheless, a critical evidence-based attitude towards current practice remains the first step towards quality improvement.
CONCLUSION Our review of all available surveys on the barriers for, and promotion of, EBP activities as perceived by clinical doctors and nurses suggests that EBP implementation needs a multilevel approach, involving interventions in the policy-making, managerial, educational and practical areas. We offer a summary of the suggested interventions at these different levels. These may be used not only to implement, but also to monitor the usage of EBP in daily clinical practice. This requires a joint effort and cultural change within the whole healthcare organisa- tion, but is likely to result in a better quality of care.
Contributors DTU and HV conceived the idea of the study and were responsible for its design. They also performed data acquisition and analysis. DU drafted the paper, HV revised it critically. GHG contributed substantially to the draft of the article, provided input to the data analysis and the interpretation of the results, and revised the manuscript critically. All authors gave approval for the final version.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional data available .
REFERENCES 1. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based
medicine: what it is and what it isn’t. BMJ 1996;312:71–2. 2. Evidence-Based Medicine Working Group. Evidence-based
medicine. A new approach to teaching the practice of medicine. JAMA 1992;268:2420e5.
3. Claridge JA, Fabian TC. History and development of evidence-based medicine. World J Surg 2005;29:547–53.
4. Flödgren G, Rojas-Reyes MX, Cole N, et al. Effectiveness of organisational infrastructures to promote evidence-based nursing practice. Cochrane Database Syst Rev 2012;2:CD002212.
5. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press, 2001.
6. Nyweide DJ, Anthony DL, Chang CH, et al. Seniors’ perceptions of health care not closely associated with physician supply. Health Aff (Millwood) 2011;30:219–27.
7. Balakas K, Potter P, Pratt E, et al. Evidence equals excellence: the application of an evidence-based practice model in an academic medical center. Nurs Clin North Am 2009;44:1–10, ix.
8. Glasziou P, Ogrinc G, Goodman S. Can evidence-based medicine and clinical quality improvement learn from each other? BMJ Qual Saf 2011;20:i13–17.
9. McColl A, Smith H, White P, et al. General practitioner’s perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998;316:361–5.
10. Funk SG, Champagne MT, Wiese RA, et al. BARRIERS: the barriers to research utilization scale. Appl Nurs Res 1991;4:39–45.
11. McCaughey D, Bruning NS. Rationality versus reality: the challenges of evidence-based decision making for health policy makers. Implement Sci 2010;5:39.
12. Carlson CL, Plonczynski DJ. Has the BARRIERS Scale changed nursing practice? An integrative review. J Adv Nurs 2008;63:322–33.
13. Tagney J, Haines C. Using evidence-based practice to address gaps in nursing knowledge. Br J Nurs 2009;18:484–9.
14. Zwolsman S, te Pas E, Hooft L, et al. Barriers to GPs’ use of evidence-based medicine: a systematic review. Br J Gen Pract 2012;62:e511–21.
15. Kajermo KN, Boström AM, Thompson DS, et al. The BARRIERS scale—the barriers to research utilization scale: a systematic review. Implem Sci 2010;5:32.
16. Van Dijk N, Hooft L, Wieringa-de Waard M. What are the barriers to resident’s practicing evidence-based medicine? A systematic review. Acad Med 2010;85:1163–70.
17. Ahmadi-Abhari S, Soltani A, Hosseinpanah F. Knowledge and attitudes of trainee physicians regarding evidence-based medicine: a questionnaire survey in Tehran, Iran. J Eval Clin Pract 2008;14:775–9.
18. Al-Almaie SM, Al-Baghli N. Barriers facing physicians practicing evidence-based medicine in Saudi Arabia. J Contin Educ Health Prof 2004;24:163–70.
19. Al Omari M, Khader Y, Jadallah K, et al. Evidence-based medicine among hospital doctors in Jordan: awareness, attitude and practice. J Eval Clin Pract 2009;15:1137–41.
20. Al-Omari FK, Al-Asmary SM. Attitude, awareness and practice of evidence-based medicine among consultant physicians in western region of Saudi Arabia. Saudi Med J 2006;27:1887–93.
21. Andersson N, Jylli L, Kajermo KN, et al. Nurses in paediatric care— self-reported professional self and perceived research utilization. Scand J Caring Sci 2007;21:426–33.
22. Brown CE, Wickline MA, Ecoff L, et al. Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center. J Adv Nurs 2009;65:371–81.
23. Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA 2008;300:1814–16.
24. Chiu YW, Weng YH, Lo HL, et al. Comparison of evidence-based practice between physicians and nurses: a national survey of regional hospitals in Taiwan. J Contin Educ Health Prof 2010;30:132–8.
25. Gale B, Schaffer MA. Organizational readiness for evidence-based practice. J Nurs Admin 2009;39:91–7.
26. Gerrish K, Ashworth P, Lacey A, et al. Developing evidence-based practice: experiences of senior and junior clinical nurses. J Adv Nurs 2008;62:62–73.
27. Hadley JA, Wall D, Khan KS. Learning needs analysis to guide teaching evidence-based medicine: knowledge and beliefs amongst trainees from various specialties. BMC Med Educ 2007;7:11.
28. Oude Rengerink K, Thangaratinam S, Barnfield G, et al. How can we teach EBM in clinical practice? An analysis of barriers to implementation of on-the-job EBM teaching and learning. Med Teach 2011;33:e125–30.
Ubbink DT, Guyatt GH, Vermeulen H. BMJ Open 2013;3:e001881. doi:10.1136/bmjopen-2012-001881 11
Implementation framework for evidence-based practice
o n 1
0 S
e p
te m
b e
r 2 0 1
8 b
y g u e
st. P ro
te cte
d b
y co p yrig
h t.
h ttp
://b m
jo p e n .b
m j.co
m /
B M
J O p
e n
: first p u
b lish
e d
a s 1
0 .1
1 3
6 /b
m jo
p e
n -2
0 1
2 -0
0 1
8 8
1 o
n 2
4 Ja
n u a ry 2
0 1 3 . D
o w
n lo
a d e d fro
m
29. Koehn ML, Lehman K. Nurses’ perceptions of evidence-based nursing practice. J Adv Nurs 2008;62:209–15.
30. Lai NM, Teng CL, Lee ML. The place and barriers of evidence-based practice: knowledge and perceptions of medical, nursing and allied health practitioners in Malaysia. BMC Res Notes 2010;3:279.
31. Melnyk BM, Fineout-Overholt E, Fishbeck Feinstein N, et al. Nurses’ perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift. Worldviews Evid Based Nurs 2004;1:185–93.
32. Mehrdad N, Salsali M, Kazemnejad A. The spectrum of barriers to and facilitators of research utilization in Iranian nursing. J Clin Nurs 2008;17:2194–202.
33. Mittal R, Peraketh B. Evidence-based surgery: knowledge, attitudes, and perceived barriers among surgical trainees. J Surg Educ 2010;67:278–82.
34. Nwagwu W. Levels of consciousness and awareness about evidence-based medicine among consultants in tertiary health care institutions in Nigeria. Health Info Libr J 2008;25:278–87.
35. Oliveri RS, Gluud C, Wille-Jørgenson PA. Hospital doctors’ self-rated skills in and use of evidence-base medicine—a questionnaire survey. J Eval Clin Pract 2004;10:219–26.
36. Oranta O, Routalaso P, Hupli M. Barriers to and facilitators of research utilization among Finnish registered nurses. J Clin Nurs 2002;11:205–13.
37. Palfreyman S, Tod A, Doyle J. Comparing evidence-based practice of nurses and physiotherapists. Br J Nurs 2003;12:246–53.
38. Parahoo K, McCaughan EM. Research utilization among medical and surgical nurses: a comparison of their self reports and perceptions of barriers and facilitators. J Nurs Manag 2001;9:21–30.
39. Poolman RW, Sierevelt IN, Farrokhyar F, et al. Perceptions and competence in evidence-based medicine: are surgeons getting better? A questionnaire survey of members of the Dutch Orthopaedic Association. J Bone Joint Surg Am 2007;89:206–15.
40. Roth K, Siemens DR. The status of evidence-based medicine education in urology residency. Can Urol Assoc 2010;4:114–20.
41. Scales CD, Voils CI, Fesperman SF, et al. Barriers to the practice of evidence-based urology. J Urol 2008;179:2345–50.
42. Sur RL, Scales CD, Preminger GM, et al. Evidence-based medicine: a survey of American Urological Association members. J Urol 2006;176:1127–34.
43. Ubbink DT, Vermeulen H, Knops AM, et al. Implementation of evidence-based practice: outside the box, throughout the hospital. Neth J Med 2011;69:87–94.
44. Ulvenes LV, Aasland O, Nylenna M, et al. Norwegian physicians’ knowledge of and opinions about evidence-based medicine: cross-sectional study. PLoS One 2009;4:e7828.
45. Upton D, Upton P. Knowledge and use of evidence-based practice of GOPs and hospital doctors. J Eval Clin Pract 2005;12:376–84.
46. Veness M, Rikard-Bell G, Ward J. Views of Australian and New Zealand radiation oncologists and registrars about evidence-based medicine and their access to internet based sources of evidence. Australas Radiol 2003;47:409–15.
47. Upton D, Upton P. Development of an evidence-based practice questionnaire for nurses. J Adv Nurs 2006;53:454–8.
48. Estabrooks CA. Mapping the research utilization field in nursing. Can J Nurs Res 1999;31:53–72.
49. Amin M, Saunders JA, Fenton JE. Pilot study of the knowledge and attitude towards evidence-based medicine of otolaryngology higher surgical trainees. Clin Otolaryngol 2007;32:120–35.
50. Brown CC, Ecoff L, Kim SC, et al. Multi-institutional study of barriers to research utilization and evidence-based practice among hospital nurses. J Clin Nurs 2010;19:1944–51.
51. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225–30.
52. Grimshaw J, Eccles M, Thomas R, et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966–1998. J Gen Intern Med 2006;21 (Suppl 2):S14–20.
53. Flödgren G, Parmelli E, Doumit G, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2011;8:CD000125.
54. Sandström B, Borglin G, Nilsson R, et al. Promoting the implementation of evidence-based practice: a literature review focusing on the role of nursing leadership. Worldviews Evid Based Nurs 2011;8:212–23.
55. Pronovost PJ, Berenholtz SM, Dorman T, et al. Evidence-based medicine in anesthesiology. Anesth Analg 2001;92:787–94.
56. Swanson JA, Schmitz D, Chung KC. How to practice evidence-based medicine. Plast Reconstr Surg 2010;126:286–94.
57. Kitto S, Petrovic A, Gruen RL, et al. Evidence-based medicine training and implementation in surgery: the role of surgical cultures. J Eval Clin Pract 2011;17:819–26.
58. Olade RA. Strategic collaborative model for evidence-based nursing practice. Worldviews Evid Based Nurs 2004;1:60–8.
59. Aitken LM, Hackwood B, Crouch S, et al. Creating an environment to implement and sustain evidence based practice: a developmental process. Aust Crit Care 2011;24:244–54.
60. Neugebauer EA, Morino M, Habermalz B. Surgical research or comic opera? Let’s give answers! Surg Endosc 2008;22:1411–12.
61. Glasziou P, Burls A, Gilbert R. Evidence based medicine and the medical curriculum. BMJ 2008;337:a1253.
62. Ubbink DT, Legemate DA. Evidence-based surgery. Br J Surg 2004;91:1091–2.
63. Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ 2004;329:1017.
64. Thangaratinam S, Barnfield G, Weinbrenner S, et al. Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project. BMC Med Educ 2009;9:59.
65. Shaneyfelt T, Baum KD, Bell D, et al. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA 2006;296:1116–27.
66. Oude Rengerink K, Zwolsman SE, Ubbink DT, et al. Tools to assess evidence-based practice behaviour among healthcare professionals—a systematic review. Evid Based Med 2013;in press.
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