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JONA Volume 42, Number 9, pp 410-417 Copyright B 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

The State of Evidence-Based Practice in US Nurses Critical Implications for Nurse Leaders and Educators

Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP,

FNAP, FAAN

Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN

Lynn Gallagher-Ford, PhD, RN

Louise Kaplan, PhD, RN, ARNP, FNP-BC, FAANP

This descriptive survey assessed the perception of evidence-based practice (EBP) among nurses in the United States. Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence- based best practices. A descriptive survey was con- ducted with a random sample of 1015 RNs who are members of the American Nurses Association. Al- though nurses believe in evidence-based care, barriers remain prevalent, including resistance from colleagues, nurse leaders, and managers. Differences existed in responses of nurses from MagnetA versus non-Magnet institutions as well as nurses with master’s versus nonmaster’s degrees. Nurse leaders and educators must provide learning opportunities regarding EBP and facilitate supportive cultures to achieve the Institute of Medicine’s 2020 goal that 90% of clinical decisions be evidence-based.

Evidence-based practice (EBP) is a problem-solving approach to clinical decision making in healthcare that integrates the best evidence from well-designed studies with a clinician’s expertise, which includes in- ternal evidence from patient assessments and practice data, and a patient’s preferences and values.1,2 Find- ings from research support that the implementation of EBP leads to a higher quality of care, improved patient outcomes, and decreased healthcare costs.3-5 Most im- portantly, EBP assists organizations in attaining high reliability (ie, safety).6 Because of the multiple benefits, hospitals and healthcare providers are being incentiv- ized by insurers to implement best EBPs through such mechanisms as pay for performance.

Anecdotal reports from nurses support that en- gaging in EBP renews the professional spirit of the nurse, a key variable in professional satisfaction.7 Nurses com- ment that ‘‘EBP gives us a voice’’ and allows them to ‘‘reclaim their authentic self as a ‘real nurse’ as well as supports them to ‘become strong patient advocates, fo- cused on improving the quality of the care given to patients.’’’8(p39)

In the landmark summit sponsored by the Institute of Medicine (IOM) on health professions education, it was recommended that all health professional educa- tional programs include 5 competencies, including (a) providing patient-centered care, (b) applying quality im- provement principles, (c) working in interprofessional teams, (d) using EBPs, and (e) using health information technologies.9 EBP is an essential criterion for obtaining MagnetA status, a designation awarded to organiza- tions by the American Nurses Credentialing Center for excellence in nursing.10 EBP has become the driver of transformation for the 6 priorities and goals developed

410 JONA � Vol. 42, No. 9 � September 2012

Author Affiliations: Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor (Dr Melnyk), The Ohio State University; Director, Center for Transdisciplinary Evidence-Based Practice (Dr Gallagher-Ford), The Ohio State University College of Nursing, Columbus; Groner School of Professional Studies Dean and Professor and Department of Nursing Chair (Dr Fineout-Overholt), East Texas Baptist University, Marshall; Associate Professor of Nursing and Director (Dr Kaplan), Nursing Program, Saint Martin’s University, Lacey, Washington.

Dr Kaplan was employed by the American Nurses Association at the time of this survey.

The authors declare no conflicts of interest. Correspondence: Dr Melnyk, The Ohio State University Col-

lege of Nursing, 1585 Neil Ave, Columbus, OH 43210 (Melnyk.15@ osu.edu).

DOI: 10.1097/NNA.0b013e3182664e0a

by the national priorities partnership, a group of 48 organizations that play a key role in identifying strat- egies for achieving better care, affordable care, and healthy people and communities.11

Although it is widely recognized that EBP re- duces morbidities, mortality, medical errors, and the geographic variation of healthcare, it is not imple- mented consistently by nurses and other clinicians in healthcare systems across the United States.3,4,12,13

Many educational programs throughout the United States continue to emphasize the rigorous process of how to conduct research in their curricula for nursing students at the bachelor’s and master’s levels instead of how to translate research and clinical data into an evidence-based approach supporting care. As a re- sult, negative attitudes toward utilizing research in practice exist, and care is often based on content that was learned in academic programs years ago as well as outdated policies and procedures.

Historically, the major barriers reported blocking the implementation of EBP in healthcare institutions are a lack of EBP knowledge and skills in clinicians, a perception that EBP is timely, a belief that EBP is burdensome and organizational cultures that do not support EBP.14-16 Conversely, key factors facilitating EBP adoption include strong beliefs that EBP im- proves patient care and outcomes, a solid founda- tion of knowledge and skills, access to EBP mentors, and organizational cultures that support evidence- based care.2,17,18 If strategies to improve EBP knowl- edge and skills of nurses and other clinicians as well as organizational cultures to support EBP are not im- plemented and sustained, the IOM’s goal that 90% of healthcare decisions will be evidence-based by 2020 is not likely to be realized.19

This survey was undertaken to obtain a contem- porary assessment of the needs and state of EBP of US nurses.12 The aims were to

1. assess the state of EBP as reported by US nurses who are members of the American Nurses Association (ANA),

2. assess the needs of US nurses regarding EBP, 3. determine whether the needs and reported

state of EBP differ between master’s degreeY and nonYmaster’s degreeYprepared nurses, and

4. determine whether the needs and reported state of EBP differ between nurses from Magnet versus non-Magnet institutions.

About the Study

Methods

A descriptive survey was conducted to assess the needs and current state of EBP implementation in nurses across the United States. The survey was granted

exempt status from the institutional review board at the primary author’s university.

Sample

The sample of 20 000 nurses was randomly drawn using a computer program from an electronic data- base of nurses who belong to the ANA.

The Survey

The survey was composed of demographic questions (eg, age, level of education) along with 18 5-point Likert-scale items, ranging from 1 (strongly disagree) to 5 (strongly agree), capturing the state of EBP from a clinician’s perspective and his/her current needs re- garding evidence-based care. Examples of items on the survey included (a) It is important for me to gain more knowledge and skills in EBP, and (b) I consis- tently implement EBP with my patients. Ten of the 18 items were taken directly from the Evidence- Based Practice Beliefs Scale20 and the Evidence-Based Practice Implementation Scale (EBPIS),21 which have well-established construct validity and excellent in- ternal consistency reliability.22 Examples of these questions included (a) I am clear about the steps in EBP, and (b) EBP is consistently implemented in my healthcare system.

Content validity of the survey was supported by 3 EBP experts. Cronbach’s " for the 18 Likert-scale items was .88. Seven additional items assessed the respondents’ needs regarding EBP on a 5-point Likert scale from 1 (not needed) to 5 (greatly needed). Ex- amples of these needs included on-site education and skills building in EBP and consistent access to an EBP mentor in the clinician’s clinical setting. Lastly, the following open-ended questions were included on the survey: (1) ‘‘What one thing most prevents you from implementing EBP in your daily clinical practice?’’ and (2) ‘‘What one thing would help you the most to implement EBP in your daily clinical practice?’’

Procedure

An e-mail was sent to the randomly selected ANA members. In the context of the e-mail, a link to the SurveyMonkey survey was provided. Completion of the survey indicated the member’s consent to partic- ipate in the study. A total of 1015 ANA members responded to the survey for a response rate of 5%.

Findings

Respondents’ ages ranged from 21 to 79 years (mean, 51.2 years). Ninety-three percent (n = 936) of respon- dents were female; 7% (n = 72) were male. Nearly

JONA � Vol. 42, No. 9 � September 2012 411

56% (n = 561) of the respondents held master’s de- grees or higher, with 44% (n = 449) holding a bac- calaureate degree, associate degree, or diploma. Years of clinical practice ranged from 0 to 52 years (mean, 24 years). Approximately 37% (n = 344) of the re- spondents described themselves as staff nurses, and nearly 25% (n = 216) described themselves as nurse educators, with 16.3% (n = 140) of these nurse educa- tors reporting working in an educational organization. Nearly 47% (n = 400) of the respondents practiced in community hospitals, and approximately 23% (n = 195) practiced in academic medical centers. The remainder of respondents reported practicing either in a primary care or community health setting. Twenty- five percent (n = 251) of the nurses practiced in Magnet- designated institutions.

Five hundred forty-four of the survey respondents (53.6%) agreed or strongly agreed that EBP was con- sistently implemented in their organization, and only 350 (34.5%) agreed or strongly agreed that their col- leagues consistently implement EBP with their patients. Only 329 (32.5%) agreed or strongly agreed that EBP mentors were available in their healthcare systems to assist them with EBP, and 471 (46.4%) agreed or strongly agreed that findings from research studies are routinely implemented to improve patient out- comes in their institution. Seven hundred seventy- three respondents (76.2%) agreed or strongly agreed that it was important for them to receive more educa- tion and skills building in EBP. Six hundred twenty- four respondents (61.5%) reported that they would be

interested in participating in Web seminars with EBP experts to learn more about EBP. Table 1 reports the mean scores for each of the 18 items from the survey.

The following data represent the number and percentage of respondents who responded that they either needed or strongly needed the following:

� an online resource center where best EBPs for patients are housed and experts are available for consultation (n = 776, 77.5%)

� tools that can help implement EBP with pa- tients (n = 764, 75.3%)

� online education and skills building modules in EBP (n = 740, 72.9%)

� an online distance continuing education EBP fellowship program with expert EBP mentors (n = 699, 69.0%)

� access to an EBP mentor (n = 690, 68.0%) � regular Web seminars conducted by experts in

EBP (n = 651, 64.1%)

Significantly more nonYmaster’s degreeYprepared nurses versus master’s degree nurses indicated that (a) it is important to gain more knowledge and skills in EBP (P G .001); (b) they are interested in partic- ipating in an online distance continuing education fellowship program with EBP experts to enhance their knowledge and skills in EBP (P = .001); (c) they are interested in receiving more education and skills building in EBP (P G .001); and (d) they are interested in participating in Web seminars with EBP experts to learn more about EBP (P G .05). Significantly more

Table 1. Mean Scores for Each of the 18 Items From the Survey (N = 876)

Mean SD

EBP1: My educational program prepared me well to consistently implement EBP. 3.67 1.138 EBP2: I believe that EBP results in the best clinical care for patients. 4.39 0.746 EBP3: I am clear about the steps of EBP. 3.90 0.968 EBP4: It is important for me to gain more knowledge and skills in EBP. 4.19 0.834 EBP5: I am interested in participating in an online distance continuing education fellowship

program with EBP experts to enhance my knowledge and skills in EBP. 3.58 1.170

EBP6: I consistently implement EBP with my patients. 3.82 0.883 EBP7: EBP is consistently implemented in my healthcare system or clinical setting. 3.51 1.021 EBP8: I am interested in receiving more education and skills building in EBP. 3.97 0.952 EBP9: EBP experts are routinely available in my healthcare system to mentor me in EBP. 2.94 1.167 EBP10: I am interested in participating in Web seminars with EBP experts to learn more about EBP. 3.65 1.104 EBP11: My colleagues consistently implement EBP with their patients. 3.12 0.965 EBP12: There are many barriers that exist in my clinical setting that make it difficult to

implement EBP. (Reversed) 3.03 1.053

EBP13: I believe that the findings from research studies are routinely implemented to improve patient outcomes in my institution.

3.30 1.035

EBP14: My organizational culture encourages and supports EBP. 3.65 1.062 EBP15: My nurse leaders/managers consistently make evidence-based decisions. 3.24 1.008 EBP16: I am confident in routinely implementing EBP with my patients. 3.69 0.907 EBP17: My organization has routine educational offerings or an ongoing EBP program to enhance

EBP in nurses and other clinicians. 3.03 1.176

EBP18: My organization routinely recognizes EBP efforts by nurses and other clinicians. 3.14 1.172

412 JONA � Vol. 42, No. 9 � September 2012

master’s degree nurses than nonYmaster’s degree nurses indicated that they were clear about the steps in EBP (P G .001) and were more confident in im- plementing EBP (P G .001).

Nurses in Magnet-designated versus nonYMagnet- designated organizations reported differences in their needs and state of EBP. These included that nurses in Magnet institutions reported higher levels of (a) more consistent implementation of EBP by their healthcare systems, (b) availability of EBP experts, (c) organi- zational cultures supporting EBP, (d) routine educa- tional offerings in EBP, and (e) routine recognition of

EBP efforts. Furthermore, there were no significant differences in 8 of the 18 items related to needs and access to support for EBP, including (a) being clear about the steps of EBP, (b) interest in participating in continuing education to enhance knowledge and skills in EBP, (c) on-site education and skills building in EBP, and (d) consistent access to an EBP mentor (Table 2).

Negative correlations existed between number of years in clinical practice and (a) importance of gaining more knowledge and skills in EBP (r = j0.12; P G .01) and (b) interest in receiving more education and skills building in EBP (r = j0.10; P G .01). In other words,

Table 2. Differences Between Magnet Designated and Non-Magnet Designated Institutions

Do You Work in a Magnet-Designated

Institution? n Mean SD P

EBP scale total score No 727 62.1575 10.27187 G.001a

Yes 249 67.6217 10.34857 EBP1: My educational program prepared me well to

consistently implement EBP. No 740 3.71 1.132 .164 Yes 251 3.59 1.154

EBP2: I believe that EBP results in the best clinical care for patients.

No 744 4.36 0.775 .124 Yes 249 4.45 0.712

EBP3: I am clear about the steps of EBP. No 738 3.86 0.965 .325 Yes 250 3.93 1.006

EBP4: It is important for me to gain more knowledge and skills in EBP.

No 728 4.19 0.834 .340 Yes 248 4.13 0.872

EBP5: I am interested in participating in an online distance continuing education fellowship program with EBP experts to enhance my knowledge and skills in EBP.

No 740 3.59 1.181 .438 Yes 250 3.53 1.152

EBP6: I consistently implement EBP with my patients. No 731 3.78 0.862 .073 Yes 249 3.90 0.970

EBP7: EBP is consistently implemented in my healthcare system or clinical setting.

No 727 3.37 1.012 G.001a

Yes 248 3.88 0.947

EBP8: I am interested in receiving more education and skills building in EBP.

No 737 3.98 0.964 .322 Yes 248 3.91 0.941

EBP9: EBP experts are routinely available in my healthcare system to mentor me in EBP.

No 728 2.73 1.148 G.001a

Yes 246 3.51 1.037

EBP10: I am interested in participating in Web seminars with EBP experts to learn more about EBP.

No 735 3.65 1.119 .467 Yes 248 3.59 1.049

EBP11: My colleagues consistently implement EBP with their patients.

No 725 3.01 0.962 G.001a

Yes 248 3.42 0.928

EBP12: There are many barriers that exist in my clinical setting that make it difficult to implement EBP.

No 729 3.06 1.041 .001a

Yes 246 2.79 1.066

EBP13: I believe that the findings from research studies are routinely implemented to improve patient outcomes in my institution.

No 727 3.14 1.041 G.001a

Yes 249 3.65 0.947

EBP14: My organizational culture encourages and supports EBP.

No 731 3.48 1.072 G.001a

Yes 247 4.11 0.895

EBP15: My nurse leaders/managers consistently make evidence-based decisions.

No 721 3.11 1.013 G.001a

Yes 247 3.60 0.923

EBP16: I am confident in routinely implementing EBP with my patients.

No 723 3.61 0.926 .001a

Yes 244 3.84 0.884

EBP17: My organization has routine educational offerings or an ongoing EBP program to enhance EBP in nurses and other clinicians.

No 725 2.81 1.147 G.001a

Yes 247 3.63 1.066

EBP18: My organization routinely recognizes EBP efforts by nurses and other clinicians.

No 725 2.89 1.158 G.001a

Yes 248 3.73 1.036

aItems with significant differences.

JONA � Vol. 42, No. 9 � September 2012 413

the greater the number of years in practice, the less nurses were interested in and felt it was important to gain more knowledge and skills in EBP. Levels of edu- cation were positively correlated with being clear about the steps in EBP (r = 0.26; P G .01) and reporting more confidence in implementing EBP (r = 0.13; P G .01). Specifically, more highly educated nurses reported be- ing more clear about the steps in EBP and having more confidence implementing evidence-based care.

Study participants also responded to 2 open- ended questions, which were categorized and tallied (Table 3). The 5 most frequently reported responses to the question that asked participants about the one thing that prevents them from implementing EBP were (a) time, (b) organizational culture, (c) lack of EBP knowledge/skills, (d) lack of access to information/ evidence, and (e) leader/manager resistance. Con- versely, the top 5 responses to the question regard- ing what one thing would help the most in daily implementation of EBP were (a) education, (b) access to information, (c) time, (d) an online clearinghouse of evidence-based information, and (e) organizational support/awareness (Table 4).

Discussion

In 2005, Pravikoff et al12 conducted a descriptive ex- ploratory study with 1097 randomly selected RNs from across the United States to determine their read- iness for EBP. Findings from the survey of Pravikoff

et al12 indicated that the nurses were not ready to implement or embrace EBP. The individual barrier to EBP that nurses reported most often was lack of value for EBP, with the greatest organizational bar- rier to EBP identified most often was time to do EBP. In contrast to the research by Pravikoff and col- leagues,12 this study indicates that nurses surveyed across the country are ready for and do value EBP. The participants reported wanting to gain more knowledge and skills in order to deliver evidence- based care in their institutions. However, many of the barriers to implementing EBP cited by the par- ticipants in this survey are the same ones that have been cited by nurses for over 2 decades, including lack of time, knowledge, mentors, and organiza- tional support.12,15,23,24 Lack of an organizational culture that supports EBP, a major factor noted in other prior studies, also was cited by the partic- ipants in this study as a major barrier for imple- menting EBP.

Barriers not frequently cited in previous litera- ture that were noted by this sample of nurses included the lack of available information (55 respondents, 8%) and evidence (15 respondents, 2%) to support EBP efforts. This finding was reinforced in the free- text comments of the participants where a clearing- house of evidence/information was the most commonly noted identified need. In addition, the respondents in this survey repeatedly reported resistance toward EBP from work colleagues including physicians (34 respondents, 5%) and fellow nurses (46 respondents,

Table 3. Respondents’ Answers Regarding the One Thing That Prevents Them From Implementing EBP in Their Daily Practicea

Total Responses

1. Time 151 2. Organizational culture, including

policies and procedures, politics, and a philosophy of ‘‘that is the way we have always done it here’’

123

3. Lack of EBP knowledge/education 61 4. Lack of access to evidence/

information 55

5. Manager/leader resistance 51 6. Workload/staffing, including

patient ratios 48

7. Nursing (staff) resistance 46 8. Physician resistance 34 9. Budget/payors 24

10. Lack of resources 20 11. Lack of available evidence 15 12. Patient resistance/noncompliance 11

aOther barriers reported (92 but G10): inability to change practice, lack of communication, lack of value for EBP, lack of EBP mentors.

Table 4. Respondents’ Answers Regarding the One Thing That Would Help Them Implement EBP in Their Daily Practicea

The ‘‘One Thing’’ That Would Help You Implement EBP in Your Daily Practice

Total Responses

1. Education 114 2. Access to information 100 3. Time 66 4. Clearinghouse of evidence-based

information (online) 63

5. Organizational support/awareness 60 6. Manager support 55 7. Mentors available on unit 45 8. Knowledge 29 9. Written EBP standards of practice 25

10. Resources 24 11. Staffing on clinical unit 22 12. Peer support 18 13. MD support 17 14. Tools 14 15. Money to support EBP initiatives 13 16. Increased awareness of the

importance of EBP 11

aOther items reported (92 but G10): networking and teamwork.

414 JONA � Vol. 42, No. 9 � September 2012

7%) as well as resistance from nurse leaders and managers (51 respondents, 8%). These findings may reflect that, as more nurses are integrating evidence into their practices, pockets of resistance are being experienced that make EBP implementation chal- lenging. Resistance to EBP from colleagues/peers is not a new phenomenon, but resistance from nurse leaders and managers is a newly identified barrier that requires attention as their support is critical for point-of-care staff to implement EBP. Although a recent study found that nurse executives report that they strongly believe in and value EBP, findings in- dicated that they themselves engaged little in EBP.25

If nurse executives/leaders are not engaging in EBP, serving as role models, and facilitating evidence-based care, it follows that their staff will not engage in evidence-based care as the behaviors of nurse executives and managers influence staff behaviors.25

Nurses need an organizational culture that sup- ports EBP. The results from this survey suggest that Magnet hospitals promote this culture, provide EBP experts and education, facilitate routine implementa- tion of EBP, and recognize nurses for their EBP efforts more so than non-Magnet facilities. As part of the Magnet recognition program, hospitals must describe and demonstrate programs related to EBP, including an infrastructure and resources to support the advancement of EBP.26 Efforts to establish EBP at Magnet facilities include establishment of research and EBP councils, EBP-focused grand rounds, educational sessions, and use of outcome measures to evaluate evidence-based initiatives.27 Nurses working in hospi- tals applying for or having attained Magnet desig- nation generally report having a better work environment compared with nurses working in hospi- tals without Magnet designation.28 However, findings from this survey indicated that nurses in both Magnet and non-Magnet institutions believe in the value of EBP and feel it is important for them to gain more knowledge and skills in EBP as well as to have access to EBP mentors.

Implications for Nurse Leaders and Educators

These findings have important implications for nurse executives, leaders, managers, and educators who are in key positions to build a supportive culture for EBP and to provide the time, educa- tional skills building sessions, and resources neces- sary for staff nurses to implement evidence-based care. Nurse leaders and educators are responsible for designing and supporting clinical environments that support best practices for optimal patient out- comes and play a key role in creating the contextual milieu necessary for implementation. The American Organization of Nurse Executives Guiding Principles

for Future Patient Care Delivery29 reflects the critical role of nurse leaders, who will need to ‘‘Iparticipate in the design and management of delivery systems focusing on coordinated care along the continuum,’’ which may include elements such as ‘‘Iincorporate use of evidence-based care processes across disciplines and continuum.’’29(p1) Since organizational culture for EBP has been significantly and positively related to EBP beliefs and EBP implementation by nurses and other clinicians,18 it is imperative for nurse executives and leaders to invest in creating EBP cultures. Without a culture that supports EBP, evidence-based care is not likely to be sustained.2 A key factor in sustaining EBP is the availability of mentors within a healthcare system.4 EBP mentors are typically advanced practice nurses with not only excellent knowledge and skills in EBP, but also skills in individual and organizational behavior change strategies.2

As 1st proposed in the Advancing Research and Clinical practice through close Collaboration model,18 EBP mentors work directly with point- of-care staff and other clinicians to consistently implement and sustain EBP in order to ultimately improve quality of care and patient outcomes. Other recent studies have supported the positive outcomes achieved by having EBP mentors in healthcare systems.30,31

Findings from this study have important impli- cations for nurse leaders and educators in both academic and clinical settings. In the recent IOM report, The Future of Nursing: Leading Change, Advancing Health, it is acknowledged that EBP is a necessary competency for nurses and that increas- ing the proportion of the workforce with a BSN from the current 50% to 80% by 2020 will help to prepare nurses who are competent in areas such as EBP.32 Many members of the faculty in nursing colleges continue to teach EBP in a single course or teach BSN students the rigorous process of how to do research instead of how to use research to take an evidence-based approach to care. Consequently, graduates continue to leave their educational experience with negative attitudes toward research along with perceptions that EBP takes too much time and cannot be realistically implemented in real-world clinical practice settings. Teaching the rigorous process of research instead of how to use research to promote an evidence-based approach to care is also prevalent in master’s degree programs and creates the same negative attitudes toward re- search in graduate students. Correcting this situation in academia will not be an easy fix; however, re- cognizing that nursing faculty cannot teach what they themselves do not know is a critical place to begin. Faculty must be equipped with excellent EBP

JONA � Vol. 42, No. 9 � September 2012 415

knowledge and skills so that they can teach it to their students as well as integrate EBP throughout entire academic programs in order to produce grad- uates who are competent in evidence-based care. Graduates from academic programs and practicing nurses also must be equipped to work effectively with physicians, nurse leaders, and fellow nurses who resist implementation of EBP. Often, EBP mentors help to achieve this goal.

Limitations of the Study

One limitation of this study is its low response rate, which may not have captured the entire view of the members of the ANA. It also is not possible to know how the characteristics of the responders compared with those of the nonresponders or how the char- acteristics of ANA members compare with RNs in general. Therefore, caution should be used in gen- eralizing these findings to all nurses across the United States.

Conclusions

Evidence-based practice improves the quality and costs of healthcare along with patient outcomes as well as reduces unnecessary variation of care. Al- though nurses across the United States believe that EBP results in the best patient outcomes and have a desire to gain more knowledge and skills in EBP, bar- riers continue to exist in healthcare systems that pre- vent consistent implementation of evidence-based care. This recent survey reflects the persistence of ma- jor barriers in healthcare systems as well as brings forward some new and emerging concerns regarding EBP. The study reinforces the tremendous need for nurse executives/leaders to build organizational cul- tures that support EBP, implement strategies to en- hance nurses’ EBP knowledge and skills, and provide environments where EBP can thrive and be sustained. Only with urgent acceleration of and investment in EBP strategies and cultures will there be realization of the IOM’s 2020 goal33 that 90% of clinical decisions be evidence based, achieving the best patient outcomes.

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