Outcome Measurements and Tools

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References Saunders, H., Gallagher-Ford, L., Kvist, T., & Vehvilainen-Julkunen, K. (2019). Practicing Healthcare

Professionals’ Evidence-Based Practice Competencies: An Overview of Systematic Reviews. Worldviews on Evidence-Based Nursing, 16(3), 176. https://doi.org/10.1111/wvn.12363

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Practicing Healthcare Professionals' Evidence‐Based Practice Competencies: An Overview of Systematic Reviews Background: Evidence‐based practice (EBP) competencies are essential for all practicing healthcare professionals to provide evidence‐based, quality care, and improved patient outcomes. The multistep EBP implementation process requires multifaceted competencies to successfully integrate best evidence into daily healthcare delivery. Aims: To summarize and synthesize the current research literature on practicing health professionals' EBP competencies (i.e., their knowledge, skills, attitudes, beliefs, and implementation) related to employing EBP in clinical decision‐making. Design: An overview of systematic reviews. Methods: PubMed/MEDLINE, CINAHL, Scopus, and Cochrane Library were systematically searched on practicing healthcare professionals' EBP competencies published in January 2012–July 2017. A total of 3,947 publications were retrieved, of which 11 systematic reviews were eligible for a critical appraisal of methodological quality. Three independent reviewers conducted the critical appraisal using the Rapid Critical Appraisal tools developed by the Helene Fuld National Institute for Evidence‐Based Practice in Nursing & Healthcare. Results: Practicing healthcare professionals' self‐ reported EBP knowledge, skills, attitudes, and beliefs were at a moderate to high level, but they did not translate into EBP implementation. Considerable overlap existed in the source studies across the included reviews. Few reviews reported any impact of EBP competencies on changes in care processes or patient outcomes. Most reviews were methodologically of moderate quality. Significant variation in study designs, settings, interventions, and outcome measures in the source studies precluded any comparisons of EBP competencies across healthcare disciplines. Linking Evidence to Action: As EBP is a shared competency, the development, adoption, and use of an EBP competency set for all healthcare professionals are a priority along with using actual (i.e., performance‐based), validated outcome measures. The widespread misconceptions and misunderstandings that still exist among large proportions of practicing healthcare professionals about the basic concepts of EBP should urgently be addressed to increase engagement in EBP implementation and attain improved care quality and patient outcomes.

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Keywords: evidence‐based practice; knowledge; competence; systematic review; healthcare professional

Knowledge of the principles of evidence‐based practice (EBP) and skills to perform the steps of the EBP implementation process are essential competencies for all practicing healthcare professionals (Melnyk, Gallagher‐Ford, & Fineout‐Overholt, [16]). In nursing, competence has been defined as the "ability to perform the task with desirable outcomes under the varied circumstances of the real world" (Benner, [ 3], p. 304), referring to the expected knowledge, attitudes, beliefs, skills, and abilities (i.e., competencies) for successful performance of critical work functions. In health care, "core competencies offer a common shared language for all health professions for defining what all are expected to be able to do to work optimally" (Albarqouni et al., [ 1], p. 2). However, defining core competencies in EBP (i.e., outlining the expected EBP knowledge, skills, attitudes, beliefs, and implementation, which are crucially important for improving care quality and patient outcomes because they enable healthcare professionals to make clinical decisions grounded on best available evidence and integrate the evidence into their daily practice; Melnyk et al., [18]; Wallen et al., [34]) has been a relatively recent development both in nursing (Melnyk et al., [16]; Stevens, [28]) and in health care (Albarqouni et al., [ 1]). Moreover, the uptake and use of the EBP core competencies in daily practice have been slow, which hinders healthcare organizations from delivering highest quality, evidence‐based health care via consistent, broad‐based EBP implementation. Furthermore, systematic integration of best evidence into practice is challenging due to the complexity of the EBP implementation process consisting of multiple sequential steps, the mastery of which requires multifaceted interventions, such as developing individual readiness for EBP, translating and ensuring availability of best evidence in usable forms for clinical practice, and building organizational readiness, culture, and structures supportive of EBP (Melnyk, Gallagher‐Ford, & Fineout‐Overholt, [17]; Saunders, Vehviläinen‐Julkunen, & Stevens, [25]).

Similar to the idea of EBP itself (DiCenso, Cullum, & Ciliska, [ 6]; Sackett, Rosenberg, Gray, Haynes, & Richardson, [22]), the realization about the importance for all healthcare professionals to develop a sufficient level of EBP competence is not new, as the first Sicily statement (Dawes et al., [ 5]) outlined that it is a minimum requirement for all healthcare professionals to understand and implement the principles and process of EBP. To this end, two sets of nurses' EBP competencies have been developed through separate national consensus processes in the USA to evaluate practicing nurses' abilities to employ EBP (Melnyk et al., [16]) and to guide EBP professional development and education programs in nursing (Stevens, [28]). However, the EBP competencies published thus far in nursing have been self‐reported and discipline‐specific (i.e., they have focused on measuring the perceived EBP competencies of nurses). Although there have been a few actual (i.e., performance‐based) evaluation tools developed in the last 10 years for more objective measurement of EBP competencies, they have also been discipline‐specific and undertaken primarily in the fields of medicine, occupational therapy, physical therapy, and most recently, in nursing (Halm, [ 8]; Ilic, Nordin, Glasziou, Tilson, & Villanueva, [10]; Laibhen‐Parkes, Kimble, Melnyk, Sudia, & Codone, [11]; McCluskey & Bishop, [12]; Spurlock & Wonder, [27]; Tilson, [29]). However, as EBP is a shared competency (i.e., the key principles and steps of the EBP process are universal and applicable to all healthcare disciplines), a unique opportunity exists to jointly develop interprofessional core competencies in EBP that objectively measure the actual EBP performance of all healthcare professionals.

The Current State of Practicing Healthcare Professionals' EBP Competencies

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A recent integrative review on EBP readiness of nurses (Saunders & Vehviläinen‐Julkunen, [24]) concluded that EBP competencies of nurses internationally are at a low to moderate level, particularly in terms of their EBP knowledge, EBP skills, and their confidence in employing EBP. These results are consistent with the findings from other recent reviews of EBP competencies across other healthcare disciplines (Mota da Silva, da Cunha Menezes Costa, Narciso Garcia, & Oliveira Pena Costa, [20]; Scurlock‐Evans, Upton, & Upton, [26]; Upton, Stephens, Williams, & Scurlock‐Evans, [32]). Therefore, instead of setting high performance expectations for EBP, it is essential to first focus on advancing practicing healthcare professionals' EBP competencies, before they will be capable of consistently implementing EBP and integrating best evidence into their daily care delivery. Once healthcare professionals are competent in EBP, they will be more likely to engage in EBP in their daily work, and patient care delivery in most healthcare organizations will likely become more evidence‐based. This substantial chasm between the EBP implementation goals of healthcare organizations and the current EBP implementation capabilities of large numbers of healthcare professionals due to their low level of EBP competence is precisely the gap that urgently requires attention and immediate action in healthcare organizations worldwide.

Aims The aim of this overview of systematic reviews was to summarize and synthesize the current international research literature on practicing healthcare professionals' EBP competencies (i.e., their knowledge, skills, attitudes, beliefs, and implementation of EBP) related to employing EBP in clinical decision‐making. This overview addresses the following research question: What do systematic reviews published in international peer‐reviewed journals state about practicing healthcare professionals' EBP competencies?

Design Published systematic reviews on the EBP competencies of all practicing healthcare professionals, including nurses, physicians, physical therapists, occupational therapists, and other allied health professionals, were considered for inclusion in this overview of systematic reviews. The relevant data in the reviews were systematically extracted, summarized, and synthesized according to the guidelines provided by the Cochrane Collaboration (Becker & Oxman, [ 2]). The review process is presented according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement or guideline for reporting study methods and results (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, [19]).

Methods Systematic literature search methods were used to conduct electronic database searches in PubMed/MEDLINE, Cumulative Index for Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Library for primary empirical studies and reviews published between January 1, 2012, and July 31, 2017 (i.e., for a period of approximately the last 5 years), without any language restrictions. With the expert assistance of a university librarian, keywords and search terms related to the various healthcare disciplines, EBP, and competencies were first searched independently and then in combination, with appropriate modifications made for the various databases (e.g., MeSH terms in PubMed). The term "research utilization" was not used as the aim of this overview of systematic reviews was to focus on healthcare professionals' EBP competencies (i.e., their EBP knowledge, skills, attitudes, beliefs, and implementation). Moreover, research utilization focuses on the retrieval, critique, and use of

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the research results from a single primary study, whereas EBP is commonly considered to be a much broader concept including research utilization and the integration of summarized and translated best evidence from several well‐defined studies into clinical practice (Melnyk & Fineout‐Overholt, [14]). In addition to the searched databases, authors of the included reviews were contacted for any missing key information, the reviews were reference‐chased, and the lists of contents of the following peer‐reviewed journals between the years of 2012–2017 were hand‐searched: Worldviews on Evidence‐Based Nursing, Journal of Advanced Nursing, BMC Health Services Research, BMC Medical Education, BMJ Open, Physiotherapy, and British Journal of Occupational Therapy. These journals were selected because they had published the majority of the reviews focusing on the topic of healthcare professionals' EBP competencies yielded by the systematic literature searches conducted for this overview.

Inclusion and Exclusion Criteria The inclusion and exclusion criteria for systematic reviews are listed in Table S1. Systematic reviews were defined as reviews that had clearly stated aims or objectives, predetermined inclusion criteria, searched at least three databases, performed data extraction, provided a synthesis of data, and performed a quality appraisal of the included studies. To be eligible for inclusion in this overview, reviews were required to (a) focus on one or more of the outcomes of interest (i.e., EBP competencies of healthcare professionals), (b) fulfill the definition of a systematic review, (c) meet the inclusion and exclusion criteria, and (d) meet the benchmark set for the methodological quality of the reviews. Before undertaking this overview of systematic reviews, the Cochrane Library and the Joanna Briggs Institute Library of Systematic Reviews were searched. No published or in‐progress systematic reviews or overviews of systematic reviews on this topic were found.

Search Results and Data Evaluation The database searches yielded a total of 3,932 publications, and 15 additional publications were identified through other sources. Titles were screened, and duplicates as well as those not clearly indicating a focus on practicing healthcare professionals' EBP competencies were excluded. All remaining abstracts (n = 407) were screened against the purpose and inclusion criteria before being selected for further appraisal. After eliminating a total of 392 records that did not meet one or more inclusion criteria, the second screening resulted in 12 reviews. Three reviews were added through reference‐chasing and hand‐searching tables of content of the selected peer‐reviewed journals, resulting in a total of 15 full‐text reviews, which were assessed for eligibility. Four full‐text reviews were excluded from the overview, as they contained no critical appraisal of methodological quality and therefore did not meet the definition of a systematic review outlined for this overview. As a result, data were extracted from 11 systematic reviews. Figure S1 details the stages of searching and selecting reviews for inclusion or exclusion using the PRISMA flow diagram (Moher et al., [19]).

Data Extraction The following data were extracted for each of the 11 reviews and organized in a data matrix, using a standardized data extraction form developed according to the guidance from the PRISMA statement (Moher et al., [19]): Author(s), country, year of publication, types of participants, settings, study design(s) included, EBP aspects reviewed, quality appraisal(s) performed, main findings, and author's conclusions. The data were extracted by one reviewer and independently checked for accuracy and consistency by two other reviewers to ensure rigor and reproducibility. Any differences in opinion

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between the three researchers were discussed until a mutual agreement was formed. All 11 reviews were included in the critical appraisal of methodological quality.

Critical Appraisal of Methodological Quality The overall quality and differences in quality between the included reviews were compared and contrasted, in order to help interpret the results of the reviews synthesized in this overview. The overall quality of the reviews was not used as a criterion for inclusion, as the reviews included in this overview were required to meet the definition of a systematic review, specific inclusion criteria, and to pass a critical appraisal of methodological quality, the main purpose of which was to ensure that the included reviews conformed to usual research norms.

The criteria used by the three independent reviewers for evaluating the methodological quality were those in the Rapid Critical Appraisal (RCA) tool for systematic reviews and meta‐analyses of quantitative studies developed by the Helene Fuld National Institute for Evidence‐Based Practice in Nursing & Healthcare of the Ohio State University College of Nursing ([OSUCN] 2017). The reviewers used the tool to critically appraise the validity, reliability, and applicability and generalizability through independently answering a series of 15 appraisal questions and subquestions. In addition, an evaluation quantifying the strength of evidence (i.e., quality + level of evidence) in the included reviews was added to the standardized form for conducting the critical appraisal of methodological quality. The three independent reviewers critically appraised the strength of evidence as being low, moderate, or high, based on the percentage of critical appraisal criteria fulfilled (0–33%, 34–66%, and 67% and over). Any discrepancies and differences in opinion in the critical appraisals of methodological quality related to the included reviews were discussed among the three researchers until consensus was reached. The benchmark of methodological quality for the reviews included in this overview was set at a total minimum score of at least five out of a total of 15 appraisal criteria on the RCA tool fulfilled (i.e., 34%), indicating acceptable scientific rigor.

Data Synthesis To answer the primary research question of this overview, the data from the 11 included reviews on practicing healthcare professionals' EBP competencies were summarized, analyzed, and synthesized by using guidance from the Cochrane Collaboration (Becker & Oxman, [ 2]). A narrative synthesis is presented, as a meta‐analysis was not possible due to the heterogeneity of the source studies contained in the reviews, including substantial variation in outcomes and educational interventions, as well as the poor quality of reporting of the results in some of the included reviews.

Findings

Characteristics of the Systematic Reviews Included in the Overview The 11 included reviews originated from all around the globe: Though the majority (n = 6, 55%) were from Europe, another two were from Australia, and one each were from Asia, South America, and North America. As expected, almost one‐half (n = 5, 45%) of the included reviews originated from English‐ speaking countries, which traditionally comprise the nations leading the international EBP movement. Unexpectedly, the majority (n = 6, 55%) of the reviews originated from smaller countries, such as Ireland, Greece, Finland, and the Netherlands, many of which are non‐English‐speaking and have embarked on the EBP journey more recently. The number of source studies in the 11 included

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systematic reviews ranged from n = 6 to n = 32, with a total of 204 source studies from 24 different countries on six continents of the world.

Seven (64%) of the 11 reviews included source studies using a cross‐sectional survey design, another seven (64%) included randomized controlled trials (RCTs) or cluster RCTs, six (55%) included source studies using a pretest–posttest intervention or a cluster nonrandomized study design, four (36%) included qualitative study designs, two each of the 11 systematic reviews included mixed‐methods study designs and longitudinal observational designs, and one each of the 11 reviews included prospective cohort designs or reviews. Although the majority (n = 7, 64%) of the 11 included systematic reviews contained one or more source studies using an experimental design (i.e., used a second group for comparison), the vast majority of the source studies were nonrandomized, one‐group quasi‐ experimental study designs, cross‐sectional surveys, or qualitative study designs. Similarly, although the vast majority of the total number of source studies used a nonrandom sample (e.g., a convenience or purposive sample), seven of the 11 (64%) systematic reviews included at least one source study that used a random sample.

Only five of the 11 included reviews discussed or displayed (e.g., in their extracted data tables) the response rates of their source studies, and even when they were actually reported, they frequently were not reported for all source studies in the reviews. Overall, the reported response rates were relatively low, and there was wide variability in the response rates from 9% to 100%. Furthermore, healthcare professionals' EBP competencies were measured using a wide variety of published and unpublished instruments, some of which were general instruments measuring several EBP competencies, such as the EBP Questionnaire (Upton & Upton, [33]), whereas other instruments measured one specific EBP competency, such as the EBP Beliefs Scale (Melnyk & Fineout‐Overholt, [13]). Selected characteristics of the included reviews (n = 11) are presented in Table S2.

Participants and Practice Settings in the Systematic Reviews A total of 59,382 healthcare professionals participated in the source studies of the 11 included reviews published between January 2012 and July 2017. Healthcare disciplines represented in the reviews were primarily nursing, medicine, physical therapy, and occupational therapy, but participants from at least 10 additional allied health disciplines were included in the source studies of the reviews, as listed in the Turnbull et al. ([30]) model for allied health professionals. In almost one‐half (n = 5, 45%) of the systematic reviews, the source studies focused on only one healthcare discipline (e.g., nurses). However, six of the 11 included systematic reviews contained source studies with multidisciplinary samples, which included health professionals other than nurses, doctors, physical therapists, and occupational therapists. All 11 included systematic reviews focused on practicing healthcare professionals, but four of the 11 (36%) systematic reviews also contained small subsamples of healthcare students in some of their source studies. The clinical settings of the source studies were poorly identified with only general statements such as "various settings" or "any clinical setting," or the settings were not described at all in the majority (n = 7, 64%) of the included reviews. However, some of the included reviews did disclose containing source studies from hospital, primary care, and community care settings.

Outcomes Measured and Overlap Between the Included Reviews

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Outcomes measured in the included reviews varied considerably, with several reviews containing other outcomes in addition to those related to healthcare professionals' EBP competencies. Moreover, the instruments used to measure the outcomes also varied considerably. Healthcare professionals' EBP competencies were measured by using self‐report assessments in the source studies of all of the 11 included reviews (i.e., perceived EBP competencies were measured, instead of using more objective measures of actual performance, such as EBP knowledge tests). A total of 204 source studies were contained in the 11 reviews included in this overview. There was substantial overlap across the included reviews in terms of their source studies, as the 11 included reviews with a total of 204 source studies referred to a total of 133 separate studies, of which 48 were included in more than one review. An effort was made to avoid double counting which might lend extra weight to those study results that had been included in more than one review. A summary of the main findings from the source studies can be found in the fuller version of this overview published online. Table S3 summarizes the EBP competency outcomes of healthcare professionals from the included reviews.

Overall Quality and Completeness of Reporting in the Included Systematic Reviews The overall quality of the included reviews was appraised using guidance from the Cochrane Collaboration (Becker & Oxman, [ 2]). All of the reviews met the definition of systematic reviews as outlined for this overview. Interestingly, although two of the 11 included reviews were characterized as a "scoping review" or a "systematic scoping review," they nevertheless included a critical appraisal of methodological quality of their source studies, which reflects the wide variety of terms that are used, sometimes inconsistently, to describe the various types of reviews published in the international literature.

The critical appraisal of methodological quality conducted by the three reviewers with the RCA tool (OSUCN, [21]) revealed a broad range of strength of evidence among the included reviews. The benchmark for the strength of evidence indicating acceptable methodological quality was set at 34% (i.e., a total minimum score of at least 5 out of a total of 15 critical appraisal criteria fulfilled). All 11 included reviews met this minimum standard for acceptable scientific rigor, with 10 out of the 11 reviews appraised at moderate quality. The median score (0–15) was 8 (moderate), with the scores ranging from 5 to 10 (out of 15). Only one of the 11 included reviews barely attained a high score (i.e., a score of at least 10 out of 15 appraisal criteria fulfilled).

The pronounced heterogeneity in the source studies of the included reviews in terms of their study designs, practice settings, outcome measures, outcomes of interest, and educational interventions, combined with poor and inconsistent reporting quality (e.g., not reporting source study settings) and missing or incomplete data (e.g., only one of the 11 reviews reported effect sizes for the source studies and few reported p‐values or confidence intervals), prompted the results of this overview to be narratively summarized. This also precluded any comparisons of EBP competencies across healthcare disciplines. In particular, there was considerable variation in the outcome measures used in the source studies of the reviews, including unpublished, not theoretically based, and not psychometrically tested instruments, which were inconsistently or incompletely described. Moreover, many assertions were made in the reporting of the source studies, but few assertions were backed up by actual data in the reviews. Furthermore, although the educational interventions may have had a positive effect on EBP competencies, the impact of the improved EBP competencies on patient outcomes or practice changes

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remains unclear, as healthcare professionals' improved EBP competencies may not necessarily have influenced practice in any way.

On the other hand, although the vast majority of the source studies in the included reviews used nonprobability sampling methods and cross‐sectional survey, pretest–posttest intervention, or qualitative study designs, it is important to acknowledge that seven (64%) of the 11 reviews contained at least one RCTs or cluster RCT as a source study. In total, the 11 reviews contained 33 RCTs or cluster RCTs as source studies, some of which were included in more than one review. These results are consistent with the findings of Young, Rohwer, Volmink, and Clarke ([36]), who found that despite the commonly held perception of relatively rare use of experimental study designs such as RCTs in some healthcare disciplines, the reviews included in their overview nevertheless included a total of 25 RCTs. In summary, the overall quality and completeness of evidence in the included reviews of this overview was low to moderate at best, as the majority of the reviews did not contain a comprehensive literature search, report on both included and excluded studies, or discuss the potential biases of the reviews. Lastly, some of the reviews did not report on the response rates, the number of participants in their source studies, or match the stated objectives of the review with what was actually discussed in the review.

Discussion The first Sicily statement (Dawes et al., [ 5]) outlined that knowledge and understanding of the principles of EBP and skills to implement the steps of the EBP process are essential competencies for all practicing healthcare professionals. To that end, this overview of systematic reviews summarized and synthesized evidence from 11 systematic reviews containing 204 source studies that assessed the current state of the EBP competencies for practicing healthcare professionals, provided critical appraisals of their ability to implement the steps of the EBP process, and evaluated the effectiveness of various educational interventions for advancing their EBP competencies using a wide variety of study designs, outcome measures, and outcomes of interest.

Although the majority of healthcare professionals across disciplines indicated familiarity with both the concept of "evidence‐based practice" and the discipline‐specific terms of (e.g., "evidence‐based nursing" or "evidence‐based medicine") widespread confusion appeared to exist among large proportions of healthcare professionals about the commonly accepted definitions of EBP and the meanings of the basic concepts related to EBP (Condon, McGrane, Mockler, & Stokes, [ 4]; Scurlock‐ Evans et al., [26]; Ubbink, Guyatt, & Vermeulen, [31]; Upton et al., [32]), which were consistent with the results of other reviews (Saunders & Vehviläinen‐Julkunen, [24]). This is disconcerting because the lack of clarity about even the most basic definitions and concepts of EBP among large proportions of healthcare professionals impedes healthcare organizations from delivering the highest quality, evidence‐ based health care. It also may contribute to a perception among healthcare professionals and organizations that EBP is being implemented, when in reality, clinical care delivery is still more closely associated with the traditions, routines, and customs of opinion‐based practice (Saunders & Vehviläinen‐Julkunen, [24]; Wonder, Spurlock, Lancaster, & Gainey, [35]). Furthermore, large proportions of healthcare professionals across disciplines appear to hold a variety of misconceptions, misinterpretations, and misunderstandings of what actually constitutes EBP (Saunders, Stevens, & Vehviläinen‐Julkunen, [23]; Scurlock‐Evans et al., [26]; Upton et al., [32]). For example, Scurlock‐Evans et al. ([26]) contended that physical therapists may not only be confused as to the meaning of the term

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"evidence," they may also be confused about how they should go about integrating evidence and about what type of evidence they should be implementing in practice.

Practicing healthcare professionals' self‐reported EBP attitudes toward and beliefs in the importance and value of EBP for improving care quality and patient outcomes were mainly positive across health disciplines, and generally at a higher level than their self‐reported EBP knowledge and skills. Unfortunately, however, these EBP competencies did not translate into EBP behaviors, as EBP implementation in daily practice was generally at a low level across disciplines (Saunders & Vehviläinen‐ Julkunen, [24]; Scurlock‐Evans et al., [26]; Ubbink et al., [31]; Upton et al., [32]). Furthermore, although healthcare professionals' self‐rated EBP knowledge and skills were higher than their EBP implementation, healthcare professionals across disciplines rated their EBP knowledge and skills to be at an insufficient level for integrating best evidence into daily practice. Perhaps for this reason, large proportions of healthcare professionals across disciplines did not use best available evidence or implement EBP in daily care delivery. This is consistent with the findings of previous studies indicating that the majority of clinicians do not consistently engage in EBP (Melnyk, Fineout‐Overholt, Gallagher‐ Ford, & Kaplan, [15]; Melnyk et al., [17]; Wallen et al., [34]).

Another concern related to the included reviews was failing to measure the impact of healthcare professionals' EBP competencies on patient outcomes, even when it was explicitly stated as one of the objectives of the review. Although four of the 11 included reviews reported measuring the impact of healthcare professionals' EBP competencies on practice changes or patient outcomes as a stated objective, only one review actually discussed any results related to patient outcomes. The lack of measuring the impact on patient outcomes of healthcare professionals' EBP competencies and that of educational interventions promoting healthcare professionals' EBP competencies is consistent with the results of other reviews (Hecht, Buhse, & Meyer, [ 9]; Häggman‐Laitila, Mattila, & Melender, [ 7]) and overviews (Young et al., [36]).

Limitations in the Overview The main limitation of this overview of systematic reviews is the potential for various biases, including selection, publication, and indexing biases. To reduce the potential for bias, we followed guidance from the Cochrane Collaboration and PRISMA on the methodology for conducting rigorous systematic reviews and reporting their results, followed a prespecified review protocol, and systematically searched multiple electronic databases in collaboration with a university librarian, using keywords and search terms modified appropriately for the various databases. In addition, we searched for ongoing systematic reviews prior to undertaking this overview, reference‐chased the systematic reviews included in this overview, and hand‐searched the tables of contents of the peer‐reviewed scientific journals in which the majority of the systematic reviews on healthcare professionals' EBP competencies had been published. As hand‐searching the tables of contents did not result in additional searches, we believe that our search strategy would effectively capture most of the relevant systematic reviews published on this topic between January 2012 and July 2017. However, as in any review, it is possible that some relevant systematic reviews were not identified.

Second, three reviewers independently used a study design‐specific critical appraisal tool to evaluate the methodological quality of each included review, with any discrepancies and differences discussed to form a mutual agreement, which increased the reliability of the data. In addition, all of the included

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reviews, originating from 10 different countries worldwide, had passed an international peer review and had been published in high‐quality scientific journals. As the majority (n = 6, 55%) of the included reviews originated from non‐English‐speaking countries representing six different languages, publication and language biases, although possible, are unlikely.

Third, self‐reported assessments were used to measure healthcare professionals' EBP competencies in all of the 11 included reviews (i.e., perceived EBP competencies were assessed, instead of using more objective measures of actual performance, such as EBP knowledge tests). Because of a lack of congruence between self‐reported and more objectively measured knowledge and ability, especially when measuring complex tasks such as EBP implementation (Saunders, Vehviläinen‐Julkunen, et al., [25]; Scurlock‐Evans et al., [26]; Wonder et al., [35]), using self‐reports may result in bias (through the participants giving more socially acceptable responses than nonrespondents), and in overestimation of some EBP competencies, such as EBP knowledge, for which more objective measures are available.

Fourth, the search term "research utilization" was not used for our overview of systematic reviews as the aim was to focus on the EBP competencies that practicing healthcare professionals need to successfully integrate translated best evidence into daily clinical practice. However, we acknowledge that it is not uncommon for research utilization to be used in studies as if it were an alternative term for EBP, and therefore, we are aware that some of the published systematic reviews may have been missed by our search. Fifth, the modest methodological quality of the identified systematic reviews and the relatively low quality of reporting of the results in the systematic reviews may have affected the results of this overview. Finally, effect sizes were not reported in all but one of the included systematic reviews. Therefore, generalizability of the results is limited, and the results of this overview should be extrapolated with caution.

Implications for Practice and Research Evidence‐based practice competencies are essential for all practicing healthcare professionals in guiding their integration of best evidence into their clinical decision‐making and thus enabling them to provide higher‐quality care and produce better patient outcomes. However, as EBP is a shared competency and the steps of EBP implementation are universal, there is an urgent need for the collaborative development, implementation, and evaluation of an EBP competency set for all healthcare professionals (i.e., an interprofessional set of EBP competencies that can be used by all practicing healthcare professionals from any healthcare discipline). Recently, the development of a first set of such interprofessional core competencies in EBP for all healthcare professionals was published as a consensus statement based on a systematic review and Delphi survey (Albarqouni et al., [ 1]), which contained 68 core competencies in EBP applicable to all healthcare professionals. This type of interprofessional core competencies in EBP for all healthcare professionals should be the focus of future research studies, as the EBP competencies will guide the development of interprofessional EBP competency measures (via self‐ratings or actual performance) as well as joint EBP curricula for practicing healthcare professionals, and thus, their subsequent uptake, adoption, and use in clinical practice should be a high priority for all practicing healthcare professionals. In addition, addressing the widespread misconceptions and misunderstandings currently existing among large proportions of healthcare professionals about the basic concepts of EBP is crucially important for increasing their engagement in EBP implementation and for attaining improved care quality and patient outcomes.

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Nursing and some allied health disciplines, such as physical therapy and occupational therapy, have traditionally relied on measuring competencies through self‐report assessments even when the constructs of interest, such as EBP knowledge, ability, or competence, could be assessed through more objective measures. Therefore, future studies should focus on developing and using actual, that is, performance‐based, validated outcome measures for EBP competencies through using rigorous study and review methodologies and robust reporting practices. Although EBP is a shared competency, implementation of EBP is a complex process requiring multifaceted educational interventions that contain interacting components, and thus, it should be investigated whether the differences in healthcare professionals' primary roles, educational backgrounds across disciplines, and in contextual factors may influence the effects of the EBP educational interventions.

Conclusions The findings of this overview of systematic reviews suggest that irrespective of their healthcare discipline, large proportions of practicing healthcare professionals perceive their EBP competencies to be insufficient for employing EBP in daily care delivery. These perceptions as well as widespread confusion, misconceptions, and misunderstandings about the meanings of the most basic concepts of EBP among healthcare professionals across disciplines contribute to their low levels of EBP implementation both in terms of the principles and in terms of the process of EBP (i.e., healthcare professionals neither using translated best evidence as the basis for clinical decision‐making in daily practice nor implementing all the steps of the EBP process). As EBP is a shared competency, practicing healthcare professionals should actively participate in the uptake, adoption, and use of the interprofessional core competencies in EBP for all healthcare professionals as well as collaboratively advance EBP implementation through the development and evaluation of the effectiveness of research‐ based EBP interventions, strategies, and tools.

EBP competencies are essential for all practicing healthcare professionals as they guide healthcare professionals' integration of best evidence into their clinical decision‐making and thus, enable them to provide higher‐quality care to patients, resulting in better patient outcomes.

It is important to recognize that EBP is a shared competency; that is, the key principles and steps of the EBP implementation process are universal and applicable to all healthcare disciplines.

There is an urgent need for conducting research studies on the applicability in practice, as well as the uptake, adoption, and evaluation of the interprofessional core competencies in EBP for all healthcare professionals recently published as a consensus statement based on a systematic review and Delphi survey (Albarqouni et al., [ 1]).

Future research studies should also focus on developing and using actual, that is, performance‐based, validated outcome measures for assessing nurses' EBP competencies, instead of continuing to evaluate perceived (i.e., self‐rated) competencies via self‐assessments, even when the constructs of interest, such as EBP knowledge and ability, could be assessed through more objective, performance‐based measures. Linking Evidence to Action

GRAPH: Figure S1. The modified PRISMA Flow diagram (Moher et al., [19]): Identification, screening and selection of systematic reviews for inclusion in the overview.

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GRAPH: Table S1. Inclusion and Exclusion Criteria for the Overview of Systematic Reviews.Table S2. Characteristics of Included Systematic Reviews in the Overview.Table S3. Summary Table of EBP Outcomes in the Systematic Reviews Included in the Overview.

Footnotes 1 This research was supported by grants awarded to Dr. Saunders from the Finnish Work Environment Fund, which are gratefully acknowledged.

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~~~~~~~~ By Hannele Saunders; Lynn Gallagher‐Ford; Tarja Kvist and Katri Vehviläinen‐Julkunen

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This article is copyrighted. All rights reserved. Source: Worldviews on Evidence-Based Nursing