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EvidenceBasedPracticeBeliefsandBehaviorsofNurses.pdf
Evidence-Based Practice Beliefs and Behaviors of Nurses Providing Cancer Pain Management: A Mixed-Methods Approach
Linda H. Eaton, PhD, RN, AOCN® [project director], School of Nursing at the University of Washington in Seattle and a postdoctoral research fellow in the College of Nursing at the University of Utah in Salt Lake City
Alexa R. Meins, BS [PhD student], School of Nursing at the University of Washington in Seattle
Pamela H. Mitchell, PhD, RN, FAHA, FAAN [Professors], School of Nursing at the University of Washington in Seattle
Joachim Voss, PhD, RN, FAAN [Professors], and School of Nursing at the University of Washington in Seattle
Ardith Z. Doorenbos, PhD, RN, FAAN [Professors] School of Nursing at the University of Washington in Seattle
Abstract
Purpose/Objectives—To describe evidence-based practice (EBP) beliefs and behaviors of nurses who provide cancer pain management.
Design—Descriptive, cross-sectional with a mixed-methods approach.
Setting—Two inpatient oncology units in the Pacific Northwest.
Sample—40 RNs.
Methods—Data collected by interviews and web-based surveys.
Main Research Variables—EBP beliefs, EBP implementation, evidence-based pain management.
Findings—Nurses agreed with the positive aspects of EBP and their implementation ability, although implementation level was low. They were satisfied with their pain management
practices. Oncology nursing certification was associated with innovativeness, and innovativeness
was associated with EBP beliefs. Themes identified were (a) limited definition of EBP, (b) varied
evidence-based pain management decision making, (c) limited identification of evidence-based
pain management practices, and (d) integration of nonpharmacologic interventions into patient
care.
Copyright 2015 by the Oncology Nursing Society
HHS Public Access Author manuscript Oncol Nurs Forum. Author manuscript; available in PMC 2015 May 07.
Published in final edited form as: Oncol Nurs Forum. 2015 March 1; 42(2): 165–173. doi:10.1188/15.ONF.165-173.
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Conclusions—Nurses' low level of EBP implementation in the context of pain management was explained by their trust that standards of care and medical orders were evidence-based.
Implications for Nursing—Nurses' EBP beliefs and behaviors should be considered when developing strategies for sustaining evidence-based pain management practices. Implementation
of the EBP process by nurses may not be realistic in the inpatient setting; therefore, hospital pain
management policies need to be evidence-based and reinforced with nurses.
Keywords
evidence-based practice; evidence-based practice beliefs; evidence-based practice behaviors; cancer pain management; mixed methods
Satisfactory pain management remains the single most important challenge to managing quality of life for patients with cancer (Dray, 2010). A seminal study by Cleeland et al.
(1994) found that 42% of patients with cancer pain were not given adequate analgesic
therapy. A systematic review confirmed that patients with cancer continued to report
insufficient treatment of pain (Deandrea, Montanari, Moja, & Apolone, 2008). About 50%
of patients receiving active treatment for cancer experience moderate to severe pain, as do
80%−90% of patients with advanced disease (van den Beuken-van Everdingen et al., 2007).
Although evidence-based guidelines for clinical management of cancer-related pain are
available from organizations such as the Agency for Health Care Policy and Research,
American Pain Society, National Comprehensive Cancer Network, and Oncology Nursing
Society, nurses may continue to implement traditional pain management practices rather
than basing their care on the best research evidence currently available.
Evidence-based practice (EBP) involves clinical decision making based on current best
research evidence, clinical expertise, and patient preferences (Sackett, Rosenberg, Gray,
Haynes, & Richardson, 1996). The Institute of Medicine (2009) has set a goal that, by 2020,
90% of clinical decisions made by healthcare professionals will be evidence-based. EBP, in
the context of pain management, decreases resource use and patient length of stay and
improves patient outcomes, including patient satisfaction, quality of life, and symptom
distress (Chang, Hwang, & Kasimis, 2002; Green et al., 2010; Samuels, 2010). Although
positive outcomes are associated with EBP, nurses are not consistent about adopting
evidence-based pain management practices (Bell & Duffy, 2009; Herr et al., 2012; Idell,
Grant, & Kirk, 2007; Samuels, 2010).
Nurses' Evidence-Based Practice Beliefs
Beliefs about the value of EBP and the ability to implement it are associated with nurses'
delivery of evidence-based care (Melnyk et al., 2004; Squires, Estabrooks, Gustavsson, &
Wallin, 2011). A survey by Pravikoff, Tanner, and Pierce (2005) of 3,000 RNs from across
the United States examined nurses' perceptions of their access to tools to obtain evidence
and their possession of the skills to do so. Of the 1,097 respondents, 68% felt more confident
about asking colleagues or peers and searching the Internet than about using bibliographic
databases such as PubMed or CINAHL®. A more recent survey (Melnyk, Fineout-Overholt,
Gallagher-Ford, & Kaplan, 2012) of 1,015 members of the American Nurses Association
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found that nurses wanted to obtain the knowledge and skills necessary to deliver evidence-
based care but continued to face implementation barriers.
Nurses' top reasons for adopting EBP are having a personal interest in the change in
practice, avoiding risk of negative consequences to the patient, and personally valuing the
evidence (Brown, Wickline, Ecoff, & Glaser, 2009). A positive relationship exists between
nurses' intentions to use research in practice and participatory management, academic
degrees, education, availability of relevant research, time, positive attitudes, and mentorship.
A systematic review by Squires et al. (2011) found that the only individual characteristic
consistently related to the use of research in practice was nurses' attitude toward research.
Little is known about the relationship between EBP beliefs and evidence-based pain
management implementation among oncology nurses.
Challenges
Evidence-based pain management is highly complex and not easily incorporated into
healthcare systems and processes (Samuels, 2010). Evidence-based pain management
implementation involves comprehensive assessment of pain with a reliable and valid patient-
report instrument, delivery of pharmacologic and nonpharmacologic interventions based on
assessment findings, frequent reassessment of pain, and repeated delivery of interventions
(Aiello-Laws & Ameringer, 2009). Based on the patient's pain experience, providers make a
decision regarding maintaining the current analgesic regimen or optimizing it by changing
the dose, switching medications, adding treatments for side effects, or adding other
pharmacologic or nonpharmacologic therapies. Provider and organizational factors such as
lack of time, heavy workload, inadequate pain assessment, underuse of pharmacologic
interventions, and lack of knowledge of pain management principles have been found to
influence healthcare organizations' evidence-based pain management practices (Samuels,
2010; Samuels & Fetzer, 2009; Wilson, 2007).
The culture of nursing units within the healthcare setting is an important organization-level
factor in the implementation of EBP (Austin & Claassen, 2008; Estabrooks et al., 2008;
Pepler et al., 2005; Scott & Pollock, 2008) and evidence-based pain management (Lauzon
Clabo, 2008; Wild & Mitchell, 2000). Attitudes about pain and pain management may
extend to the group or unit level, creating a type of “group-think” about pain management
issues (Wild & Mitchell, 2000). An organizational culture that actively supports EBP was
significantly and positively related to EBP beliefs and EBP implementation among nurses in
a community hospital and a research-oriented hospital (Melnyk, Fineout-Overholt,
Giggleman, & Cruz, 2010). A survey of members of the American Nurses Association by
Melnyk et al. (2012) found that 54% of the 1,015 respondents agreed or strongly agreed that
EBP was consistently implemented in their organization, and only 35% agreed or strongly
agreed that their colleagues consistently implemented EBP with their patients. The findings
support the importance of understanding the unit culture for evidence-based pain
management.
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Theoretical Framework
Rogers' (2003) diffusion of innovations model provides a theoretical framework for
understanding why nurses adopt or reject evidence-based pain management. Diffusion is the
process by which an innovation is communicated through channels within a social system.
Evidence-based pain management can be considered an innovation because it requires
shifting an existing idea or practice and developing a new opinion toward a new idea or
practice. The hospital setting is a social system, where nurses and other healthcare providers
work together on problem solving to accomplish a common goal of improving the disease
state of patients. Changing current pain management practice to evidence-based pain
management can be considered a diffusion of innovation process.
Adoption of an innovation often is assumed to occur automatically; however, the rate of
diffusion is affected by the social system's communication strategies and individual's
decision-making process (Rogers, 2003). Antecedents to an individual's decision making
regarding adoption of an innovation are the individual's previous practice, perception of
existing needs or problems, and innovativeness, as well as the norms of his or her social
system. The purpose of the current study was to describe antecedents to evidence-based pain
management decision making of nurses who provide care to patients with cancer pain.
Specifically, the researchers sought to answer the following questions: (a) What are the
antecedents to nurses' evidence-based pain management decision making? and (b) Do
significant relationships exist between nurses' characteristics and their antecedents to
evidence-based pain management decision making?
Methods
A descriptive, cross-sectional, mixed-methods design involving two inpatient oncology units
—one at each of two medical centers—was used. The medical centers were a 450-bed
academic medical center and a 491-bed community-based regional medical center in the
Pacific Northwest. The study was approved by the University of Washington Institutional
Review Board. The study sample was comprised of RNs who were employed at least part-
time at one of the medical centers and who provided direct care to patients with cancer pain.
The academic medical center's 28-bed medical-surgical oncology unit employed 46 RNs.
The regional medical center's 34-bed medical oncology unit, which specialized in end-of-life
care, employed 60 RNs.
Nurses were invited to participate in the study at shift change by the investigator, via flyers
posted on the unit, and through emails sent by the nurse manager or nurse researcher at the
medical center. Nurses who were interested in learning more about the study were directed
to the study website, created with Catalyst Web Tools. Potential participants provided
consent for study participation by completing web-based questionnaires.
Quantitative Data Collection and Measures
Questionnaires included a demographic questionnaire, the EBP Beliefs Scale (Melnyk,
Fineout-Overholt, & Mays, 2008), the EBP Implementation Scale (Melnyk, et al., 2008),
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and Carlson's (2008) Prior Conditions Instruments. Survey data were collected from 44 RNs
in May and June 2013.
The EBP Beliefs Scale measures clinicians' beliefs about the value of EBP and their ability
to implement it. It consists of 16 items using a five-point Likert-type scale. The scale was
treated as a one-factor scale in which items were summed and divided by 16 to yield a mean
score that ranged from 1–5. Higher scores indicated stronger EBP beliefs. Examples of items
include: “I believe that EBP results in the best clinical care for patients,” “I know how to
implement EBP sufficiently enough to make practice changes,” and “I believe the care I
deliver is evidence-based.” The scale has established face, content, and construct validity
with internal consistency reliabilities typically greater than 0.85 and Cronbach alpha greater
than 0.9 (Melnyk et al., 2008).
The EBP Implementation Scale measures the extent to which clinicians perceive themselves
as having implemented EBP in the past eight weeks. It consists of 18 items using a five-
point Likert-type scale. The scale was treated as a one-factor scale in which items were
summed and divided by 18 to yield a mean score that ranged from 1–5. Higher scores
indicated higher levels of performance of EBP activities. Activities addressed by the items
included: “Critically appraised evidence from a research study,” “Used an EBP guideline or
systematic review to change clinical practice where I work,” and “Promoted the use of EBP
to my colleagues.” The scale has established face, content, and construct validity with
internal consistency reliabilities and Cronbach alpha greater than 0.9 (Melnyk et al., 2008).
Carlson's (2008) Prior Conditions Instruments were designed to measure constructs in
Rogers' (2003) Diffusion of Innovations model. These constructs, termed “prior conditions,”
include previous practices, perceived existing needs or problems, innovativeness, and social
system norms. They influence nurses' decisions to use evidence-based pain management
practices. The subscales include 11 items on nurses' perceptions of how often they perform
evidence-based pain management (previous practices), 6 items on nurses' beliefs about pain
and perceptions of pain management (perceived existing needs or problems), 6 items on
nurses' ability to initiate or adapt to change (innovativeness), and 7 items on nurses'
perceptions about colleagues' pain management behaviors (social system norms). All items
use a five-point Likert-type scale. Each instrument was treated as a one-factor scale. Items
were summed and divided by the number of subscale items to yield a mean score that ranged
from 1–5. Higher scores indicated more support for the conditions for the adoption of
evidence-based pain management practices. The subscales have established construct
validity and a Cronbach alpha range of 0.73–0.83 (Carlson, 2008).
Qualitative Data Collection
From August to October 2013, a subgroup of 12 nurses participated in individual
semistructured interviews to share their perceptions of EBP in the context of evidence-based
pain management. Nurses were selected for an individual interview based on their level of
evidence-based pain management documentation in the patient medical record, which was
examined as part of a larger study on barriers and facilitators to evidence-based pain
management in the inpatient oncology setting. Three nurses with low scores and three nurses
with high scores for evidence-based pain management documentation from each medical
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center were selected for the interview. Nurses were invited by email and in person by the
investigator. Two nurses who were invited chose not to participate because of lack of time.
Twelve nurses—six from each medical center—participated in a telephone or in-person
interview with the investigator. The interview questions had been pilot tested with two RNs
who provide pain management at other healthcare organizations. Their feedback on the
clarity and validity of the questions was used to develop the interview guide (see Figure 1).
All interviews were digitally recorded, with consent, and lasted from 30–45 minutes.
Interview responses were transcribed verbatim by an experienced transcriptionist. These
transcriptions provided the narrative data for qualitative analysis.
Data Analysis
Quantitative data from the study questionnaires were entered into SPSS®, version 21.0, for
statistical analysis. Descriptive statistics were used to examine the demographic data and to
answer the study questions. T tests and chi-square tests were performed to compare nurse
characteristics and questionnaire scores between the two groups of nurses. Spearman's rho
correlations were calculated to test relationships between nurse characteristics and the
questionnaire scores. A significance level of 0.05 was set for all analyses.
The transcribed qualitative data were entered into ATLAS.ti. Content analysis and thematic
description (Hsieh & Shannon, 2005; Sandelowski, 2000) were used to identify and
understand the meaning of EBP, show how EBP is operationalized, and show how EBP
influences pain management on the inpatient unit. The investigator and a member of the
research team read each transcript for the set of general themes generated by the nurses.
Ideas and concepts were coded as they were communicated through passages or whole
responses. A reflexive journal was kept to record the researchers' reactions to the data and
examine biases. The emerging set of themes was discussed and used to develop a formal
coding framework. Codes were generated from categories that arose from the data and were
based on relevant literature and Rogers' (2003) diffusion of innovations model. Quotations
exemplifying key themes were identified. The researchers compared individually assigned
codes until agreement was obtained.
Results
Demographics
The final sample included 22 academic medical center nurses and 18 nurses from the
community-based regional medical center (see Table 1). Four regional medical center nurses
who completed questionnaires did not care for the patients whose medical records were
reviewed as part of the larger study on barriers and facilitators to cancer-related, evidence-
based pain management; these four nurses were not included in the final sample. Nurse
demographics did not differ significantly by medical center except for (a) academic degree
(p = 0.013), with more nurses with an associate degree in nursing at the regional medical
center, and (b) part-time versus full-time employment (p = 0.033), with more nurses
working part-time at the regional medical center.
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Antecedents
The two groups' average scores were not significantly different for the EBP Beliefs Scale
(t[38] = –0.43, p = 0.75), the EBP Implementation Scale (t[38] = 0.91, p = 0.37), or
Carlson's Prior Conditions Instruments subscales–previous practices (t[38] = 0.06, p = 0.96);
perceived existing needs or problems (t[38] = −0.29, p = 0.31), innovativeness (t[38] = 0.62,
p = 0.49), and norms of the social system (t[38] = 0.56, p = 0.75) (see Table 2).
Both groups of nurses agreed with the positive aspects of EBP and their ability to implement
it (¯X = 3.76, SD = 0.46), although their perceived level of EBP implementation was low
(¯X = 1.65, SD = 0.68). The nurses supported adopting evidence-based pain management
(¯X = 4.19, SD = 0.40) and were satisfied with their own pain management practices and
that of others in their practice setting (¯X = 3.34, SD = 0.71). The nurses were sometimes or
often innovative (¯X = 3.42, SD = 0.55) and were neutral about their social system being
supportive of adopting evidence-based pain management practices (¯X = 3.39, SD = 0.55).
A significant association was found between Oncology Nursing Certification Corporation
certification and innovativeness (r = 0.46, p = 0.003). Innovativeness also was associated
with EBP beliefs (r = 0.48, p = 0.002). EBP beliefs were associated with nurses' perceived
level of EBP implementation (r = 0.36, p = 0.02). Figure 2 shows the trend for more positive
EBP beliefs and higher perceived EBP implementation among oncology certified nurses.
Themes
Four key themes emerged from the interviews related to EBP and evidence-based pain
management.
Limited definition of evidence-based practice—The nurses' understood meaning of EBP reflected the definition of research utilization: the use of research findings in clinical
practice (Melnyk & Fineout-Overholt, 2010). What was not included in their description of
EBP was the integration of the best available research evidence with clinical expertise and
patient values and preferences. The following response highlights the collective perception
that the use of research improves patient outcomes.
So I guess that's something I haven't thought much about since school, but it just
means to me that there have been a lot of studies done on a subject to find the …
um I guess the most helpful way to do things and prevent bad outcomes like death
and infection.
Varied evidence-based pain management decision making—Some nurses were unsure if they were delivering evidence-based pain management. Most did not describe a
process that included integrating the best scientific evidence with clinical expertise and the
patient's values and preferences. Interventions were not typically identified from published
guidelines or research findings. The following responses explain the variety of evidence-
based pain management decision-making processes.
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Well, as a floor nurse, I think we rely heavily on our policies and what information
is brought to me on education days by clinical nurse specialists. Um, I don't really
individually seek out evidence-based practices to try to implement on my own.
So I guess when I am in a situation that I've been in before, I try whatever worked
previously, which isn't necessarily completely evidence-based. If I've never been in
the situation before, I would go to one of the more experienced nurses.
I'm choosing [evidence-based interventions] based on my experience more than
anything else, primarily, and then the patient's experience secondary.
Limited identification of evidence-based pain management practices—A range of responses was elicited regarding identification of evidence-based pain management
practices. Some nurses were unclear if a pain management policy and procedure existed.
However, nurses were knowledgeable about policies and procedures for medication delivery
systems. Pain management was commonly related to doctors' orders. Nurses at both medical
centers were not clear if doctors' orders were always evidence-based, as described by the
following responses.
Um, personally, I don't really know like what, like what I do that is evidence-based
like as a nurse because I am just carrying out the doctor's notes.
Whether what we are doing is evidence-based when I'm there, I go off of orders. I
don't go off and look it up, you know, but maybe I will go home later and look it
up. You know, like was this a good thing to do?
Evidence-based pain management implementation requires nurses to rely on, ask, or
collaborate with a doctor to order evidence-based pain management pharmacologic
interventions or to adapt a pain management pharmacologic protocol. Evidence of
collaboration existed, but most nurses relied on doctors' orders for implementing evidence-
based pain management practices. The following response is an example of successful
doctor-nurse collaboration after a nurse at the regional medical center learned about a new
medication at a pharmaceutical-sponsored dinner.
Typically, [doctors] are well ahead of us on that. So if I bring it up they will
address why they aren't doing it or they will do it, but they won't blow us off. So
the constipation med I was telling you about, the medical team went to that and
they started researching it and we started using that drug and it has been good for
constipation secondary to narcotic use. They had been researching it on their own
separately, so we ended up coming to the same conclusion.
Integration of nonpharmacologic interventions into patient care—The nurses described different processes for integrating nonpharmacologic interventions into patient
care. Because most nonpharmacologic interventions do not require a doctor's order, nurses
would independently implement them with patients.
I know that there are other ways to relieve pain than just, you know, for example
narcotic pain medication, and to offer hot packs or cold packs or try to distract a
patient sometimes works just as well, or can help narcotics work better and so I try
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to offer those things, especially if their current pain management system, what
they're doing for pain management isn't working as well as it could.
Another implementation process involved collaboration with nurse colleagues to use the
intervention with other patients on the unit.
If it was nonpharmacologic and something I could do without a doctor's orders, you
know, I would, after reading the article or, you know, looking into it, I would
probably consult with my fellow nurses, just to see or get their input and say, you
know, “I found this and I thought it would work really well with our patient
population, you know, would you like to help me try it or implement it?” and see
how well it works for them.
Communication strategies were important in diffusing nonpharmacologic interventions on
the nursing unit and throughout the regional medical center.
Um, usually I would bring it to the charge nurse first or the supervisors if it is
something new that I am feeling like that would change, and then we kinda talk
about it to see if it is something we can trial … and then if it is something more
complex, we will send out an email to all the staff, um, and then we talk about it in
huddle at the beginning of each shift. We'll talk about what it is we are trialing, or
what it is we are wanting to, you know, kinda put it into plan and we will put it,
make notes on the board as well. Um, and then we usually give it at least a week,
and if it is going bad then we kinda cut it off, but if it seems to be working … then
our manager usually presents that to the other managers, and I know we have
adopted things that other floors have started.”
Discussion
The current study provides an understanding of nurses' perspectives regarding the
antecedents to evidence-based pain management decision making through quantitative
results illustrated with qualitative findings. The interview responses supported the
quantitative findings and provided a richer understanding.
The nurses' understood meaning of EBP described research utilization. Although EBP often
is considered to be synonymous with research utilization, the definition of EBP is broader
because clinical decision making is based on the best available research evidence integrated
with clinical expertise and patient values and preferences (Sackett et al., 1996). The nurses'
understanding of EBP was not surprising because the focus of EBP initiatives is often on
adopting practices based on the best scientific evidence rather than on the more nebulous
integration of patient preferences and values with clinician expertise. When probed, the
nurses stated that they considered patient preferences and clinical experience when making
clinical decisions.
The nurses agreed with the positive aspects of EBP and their ability to implement it,
although their perceived level of EBP implementation was low in the context of evidence-
based pain management. Qualitative inquiry showed that the nurses let searching for and
identifying evidence-based pain management strategies be the responsibility of others,
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including physicians and those responsible for developing the hospital's pain management
policies and procedures. Because the mainstay of pain management is analgesic therapy,
nurses relied on the medical team to ensure that the best practice was in place. Therefore,
nurses did not critically appraise the scientific evidence or access evidence-based guidelines
to find best practices for pharmacologic therapies for pain management. In addition, nurses
trusted the unit's standards of care to be evidence-based.
Both hospitals had evidence-based policies and procedures, which nurses learn about at
orientation and are expected to follow. Unfortunately, at the time of the interviews, some of
the nurses were not clear whether a pain management policy and procedure existed or that
these policies and procedures were indeed evidence-based. Nurses' knowledge of their
healthcare organization's pain management policy has been reported to be significantly
related to the individual nurse's knowledge of pain management and perceived
accountability for pain management (Alley, 2001). This would be an important issue to
explore further at both medical centers.
When pain management interventions were not successful in relieving pain, many nurses in
the current study reported that they would seek another nurse to determine other
interventions rather than considering an evidence-based clinical practice guideline or
searching the literature. This has been previously supported in the literature (Pravikoff et al.,
2005) and demonstrates the importance of unit culture in the practice of evidence-based pain
management by nurses. This finding also illustrates the importance of the social system's
communication strategies in diffusing pain management practices in the hospital setting.
The nurses independently integrated nonpharmacologic treatments into patient care. The
qualitative findings indicated a difference between the two groups in collaborating with
other healthcare professionals to integrate new pain management approaches. The academic
medical center nurses did not describe sharing new treatments learned from journals or
continuing education programs with their medical team. These nurses were employed by an
EBP-focused organization, as evidenced by its Magnet® recognition status, where processes
were in place to ensure best practice implementation (Stimpfel, Rosen, & McHugh, 2014).
This may result in nurses not actively collaborating with the medical team when integrating
new approaches into care.
As described by Rogers' (2003) diffusion of innovations model, innovations first are adopted
by innovators; therefore, finding that perceived innovation was positively related to EBP
beliefs was not unexpected. What was not expected was the trend for nurses with oncology
certification to have more positive EBP beliefs and higher perceived EBP implementation
than other nurses in the study. Although this finding needs further exploration through large-
scale studies, the involvement of oncology certified nurses in the planning and
implementation of evidence-based pain management initiatives in the inpatient oncology
setting is worth considering.
Nursing Implications
Findings from the current study have important implications for nurse leaders in clinical and
academic settings. Nurses value EBP and its importance to patient care, but their level of
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EBP implementation is low. In a busy clinical setting, finding and critically appraising the
scientific evidence for best practices often is not practical. Evidence-based clinical practice
guidelines and other resources are readily available for nurses on the Internet; however, to
ensure evidence-based pain management practices among nurses, the best scientific
evidence needs to be embedded in hospital pain management policies and procedures.
Clinical nurse specialists and nurse educators are key people to develop these policies and
procedures because of their training and expertise in EBP.
Although bedside nurses are not responsible for writing orders for pharmacologic
interventions, they need to use critical thinking to ensure that the analgesic protocol is
evidence-based. In addition, nurses need to collaborate with the healthcare team to identify
other evidence-based interventions when current interventions are not successful in
providing pain relief. Nurses also need to learn how to incorporate best scientific evidence
with clinical expertise and patient values and preferences. These skills should be taught in
nursing schools and reinforced in the clinical setting by clinical nurse specialists and
educators through consultation, education, and mentorship.
Because nurses integrate nonpharmacologic pain management interventions into patient
care, scientific evidence for many of these interventions needs to be further established
through well-designed studies. This is an important realm of nursing care because nurses can
independently implement these interventions for improving cancer pain management.
Limitations
Because of the small self-selected sample, caution should be taken in generalizing the
findings of the current study to other healthcare settings or nurses. The use of self-reported
data is an additional limitation. Because diffusion of an innovation takes place over time, a
longitudinal study design will be required to describe the innovation diffusion process.
Conclusion
Through a mixed-methods approach, the current study provided a rich description of the
antecedents to EBP decision making among two groups of nurses caring for patients with
cancer pain. The current study allowed a detailed understanding of oncology nurses'
perspectives regarding EBP. Insights gained should be considered when evaluating
evidence-based pain management behaviors in healthcare organizations. The antecedents to
EBP decision making need to be considered when developing a plan for improving
evidence-based pain management. Making sustained evidence-based pain management a
reality in the healthcare setting is essential for quality cancer care.
Acknowledgments
This study was supported, in part, by scholarships from the American Cancer Society (DSCN-12-201-01-SCN), the ONS Foundation, and the University of Washington. This study was also supported, in part, by an award from the National Institute of Nursing Research of the National Institutes of Health (R01NR012450, K24NR015340, and T32NR013456). Eaton can be reached at [email protected], with copy to editor at ONFEditor @ons.org.
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Knowledge Translation
Nurses value evidence-based practice but often rely on physicians and advanced practice
nurses to identify evidence-based pain management interventions.
To ensure evidence-based pain management practice by nurses, the best scientific
evidence needs to be embedded in hospital pain management policies and procedures.
Additional scientific evidence for nonpharmacologic cancer pain management
interventions is needed.
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Figure 1. Nurse Semistructured Interview Guide
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Figure 2. Scatter Plot of EBP Beliefs and Implementation Scores by Certification
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Table 1 Sample Characteristics (N = 40)
Characteristic ¯X Median SD Range
Years in nursing practice 6.8 4.6 5.9 1–30
Characteristic n
Gender
Male 3
Female 37
Age (years)
20–40 25
41–50 9
51–60 6
Ethnicity
Caucasian 35
Asian 3
African American 1
Other 1
Years employed at workplace
1–2 8
3–5 19
6–10 12
Longer than 10 1
Employment status
Full-time 25
Part-time 15
Oncology certified nurse
Yes 10
No 30
Highest nursing degree
Associate degree 18
Bachelor's degree 22
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