CRITICAL R

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CEOriginal Article

The First U.S. Study on Nurses’ Evidence-Based Practice Competencies Indicates Major Deficits That Threaten Healthcare Quality, Safety, and Patient Outcomes Bernadette Mazurek Melnyk, RN, PhD, CRNP, FAANP, FNAP, FAAN • Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC, FAAN • Cindy Zellefrow, RN, DNP, LSN, PHNA-BC • Sharon Tucker, RN, PhD, FAAN • Bindu Thomas, MEd, MS • Loraine T. Sinnott, PhD • Alai Tan, PhD

Keywords

evidence-based practice,

competency, nurses,

advanced practice nurses

ABSTRACT Background: Tremendous variability in EBP persists throughout the United States even though research supports that implementation of EBP leads to high-quality cost-effective care. Although the first set of EBP competencies for nurses was published in 2014, the state of EBP competency in U.S. nurses is currently unknown.

Aims: The purposes of this study were to: (a) describe the state of EBP competency in nurses across the United States; and (b) determine important factors associated with EBP competency.

Methods: A cross-sectional descriptive study was conducted that gathered data from an anony- mous online survey of practicing nurses throughout the U.S. Measures tapped EBP knowledge, beliefs, culture, mentorship, implementation, and reported competency for each of the 13 EBP competencies for practicing nurses and an additional 11 competencies for advanced practice nurses.

Results: A total of 2,344 nurses completed the survey from 19 hospitals or healthcare systems. Overall, the nurses reported that they were not yet competent in meeting any of the 24 EBP competencies. Younger nurses and those with higher levels of education reported higher EBP competency (p < .001). The EBP competency scores were not significantly different between nurses in Magnet and non-Magnet designated organizations (p = .28). There were strong positive associations between EBP competency with EBP beliefs (r = .66) and EBP mentorship (r = .69), a moderate positive association between EBP competency and EBP knowledge (r = .43), and a small positive association between EBP competency and culture (r = .29).

Linking Evidence to Action: There is a tremendous need to enhance nurses’ skills so that they achieve competency in EBP in order to ensure the highest quality of care and best population health outcomes. Academic programs should ensure competency in EBP in students by the time of graduation and healthcare systems should set it as an expectation and standard for all clinicians.

BACKGROUND It is well known that consistent implementation of evidence- based practice (EBP) leads to high-quality safe care, improved patient outcomes, and reduced costs. In addition, EBP empowers clinicians and leads to higher levels of engagement, teamwork, and job satisfaction (Kim et al., 2017; Melnyk, Fineout-Overholt, Giggleman, & Cruz, 2010). Therefore, healthcare organizations that are effective in building EBP

cultures and invest in resources that build EBP competencies among clinicians are more likely to achieve the quadruple aim in health care. Yet, EBP is not the standard of care in many healthcare systems across the United States and globe. Multiple barriers that prevent clinicians from consistently im- plementing evidence-based care persist including inadequate knowledge and skills in EBP because of barriers in academia that impact how EBP is taught, cultures that are steeped in

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Original Article tradition (e.g., that is the way we do it here), misperceptions about the time it takes to engage in EBP, leaders and managers who do not embrace, role model, and support EBP, and lack of EBP mentors available to assist point of care providers with evidence-based care (Melnyk & Fineout-Overholt, 2015; Melnyk et al., 2016).

The American Nurses Association (2010, p. 86) defines competency as “an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice.” Competency encompasses characteristics required in order to act effectively in the nursing setting and facilitate high-quality safe nursing care (American Nurses Association, 2010; Dunn et al., 2000; Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014).

The Quality and Safety Education for Nurses (QSEN, 2013) project established a set of competencies for prelicensure and graduate nursing education in order to support nurses’ acquisition of the knowledge, skills, and attitudes to deliver safe high-quality care. The QSEN competencies were based on the Institute of Medicine’s competency recommendations for healthcare professionals (Institute of Medicine; Committee on Assuring the Health of the Public in the 21st Century, 2003) and addressed the following practice areas: (a) patient-centered care, (b) teamwork and collaboration, (c) EBP, (d) quality improvement, and (e) informatics. The QSEN competency for EBP was to integrate best current evidence with clinical exper- tise, family preferences, and values for delivery of optimal care (American Association of Colleges of Nursing QSEN Educa- tion Consortium, 2012). Stevens developed the first set of EBP competencies for nursing education in order to assist faculty in preparing their students for EBP and to “provide a basis for professional competencies in clinical practice” (Stevens, 2005, p. 8). However, EBP competencies had never been developed for practicing registered nurses (RNs) and Advanced Practice Nurses (APNs) using research methodologies. Therefore, in order to fill a critical gap in nursing EBP competencies for practicing RNs and APNs, Melnyk et al. (2014) implemented a two-step process to develop a set of contemporary EBP com- petencies for RNs and APNs to assist healthcare organizations in ensuring that their clinicians were delivering the highest quality, safest, evidence-based care. These competencies were initially developed by Melnyk and Fineout-Overholt, with consensus from seven nationally recognized EBP experts. A two-round Delphi study was then conducted with EBP mentors throughout the United States that confirmed a final set of 13 competencies for practicing RNs, and an additional 11 competencies for APNs (Melnyk et al., 2014; see Table 1). Availability of the 24 research-based EBP competencies created an opportunity to determine if nurses in hospitals and healthcare systems across the country are meeting these competencies. Knowing the state of EBP competency among nurses will provide a data-driven platform to develop a national action plan to ensure the competencies are met to ensure the delivery of high quality, safe, and cost-effective care. Therefore,

the purposes of this study were to: (a) describe the state of EBP competency in nurses across the United States; and (b) determine important factors associated with EBP competency.

METHODS This study was a cross-sectional descriptive study that gathered data from an anonymous online survey of practicing nurses and APNs throughout the United States. The study was granted ex- empt status by the first author’s institutional review board. A total of 19 hospitals and healthcare systems across the United States agreed to participate in the study by disseminating in- formation about the opportunity to participate in this study through electronic communications to their nurses that pro- vided a link to the study. Upon receiving an email link to the survey, participants were consented to participate in the re- search via an online consent prior to starting the survey. All data were fully deidentified. The data were gathered on an anonymous basis and did not have any of the 18 HIPPA pri- vacy rule identifiers (U.S. Department of Health & Human Services, 2015).

Study Measures Data collected on the survey included (a) demographic ques- tions and (b) six instruments that measured EBP knowledge, EBP beliefs, EBP Implementation, perceived organizational culture and readiness for EBP, mentorship in EBP, and the EBP competencies.

EBP knowledge was measured with a new EBP knowledge scale that consists of 25 multiple choice and 13 true or false questions. Five test items used to develop the EBP Knowledge Assessment Questionnaire were selected from the test item pool developed by Spurlock and Wonder (2015). These items were written according to best practice guidelines, judged by a national panel of EBP content experts, and psychometrically tested using Rasch modeling. The scale has established face, content, and construct validity. The internal consistency relia- bility with this sample was .87.

EBP beliefs were measured with the EBP Beliefs (EBPB) Scale, which measures beliefs about the value of EBP and the ability to implement it (Melnyk, Fineout-Overholt, & Mays, 2008). This is a 16-item Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Sample items include: I am clear about the steps in EBP; I am sure that I can imple- ment EBP; and I am sure that evidence-based guidelines can improve care. The summed total EBP score with higher scores indicate stronger EBP beliefs. The EBPB scale has established face, content, and construct validity with internal consistency reliabilities above 0.85 (Melnyk et al., 2008). Cronbach’s alpha with this sample was .89.

Implementation of EBP was measured with the EBP Implementation (EBPI) Scale (Melnyk et al., 2008), which assessed the extent to which the nurses implement EBP. Participants respond to 18-item Likert-type scale items by answering how often in the last 8 weeks they have performed

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U.S. Study on Nurses’ Evidence-Based Practice Competencies

Table 1. Evidence-Based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses

Evidence-based practice competencies for practicing registered professional nurses

1. Questions clinical practices for the purpose of improving the quality of care.

2. Describes clinical problems using internal evidence.* (internal evidence*= evidence generated internally within a clinical setting, such as patient assessment data, outcomes management, and quality improvement data).

3. Participates in the formulation of clinical questions using PICOT* format. (*PICOT= patient population; intervention or area of interest; comparison intervention or group; outcome; time).

4. Searches for external evidence* to answer focused clinical questions. (external evidence*= evidence generated from research). 5. Participates in critical appraisal of preappraised evidence (such as clinical practice guidelines, evidence-based policies and procedures, and evidence syntheses).

6. Participates in the critical appraisal of published research studies to determine their strength and applicability to clinical practice.

7. Participates in the evaluation and synthesis of a body of evidence gathered to determine its’ strength and applicability to clinical practice.

8. Collects practice data (e.g., individual patient data, quality improvement data) systematically as internal evidence for clinical decision making in the care of individuals, groups and populations.

9. Integrates evidence gathered from external and internal sources in order to plan evidence-based practice changes.

10. Implements practice changes based on evidence and clinical expertise and patient preferences to improve care processes and patient outcomes.

11. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups and populations to determine best practices.

12. Disseminates best practices supported by evidence to improve quality of care and patient outcomes.

13. Participates in strategies to sustain an evidence-based practice culture.

Evidence-based practice competencies for practicing advanced practice nurses

All competencies of registered professional nurses plus:

14. Systematically conducts and exhaustive search for external evidence* to answer clinical questions. (external evidence*: evidence generated from research).

15. Critically appraises relevant preappraised evidence (i.e., clinical guidelines, summaries, synopses, syntheses of relevant external evidence) and primary studies, including evaluation and synthesis.

16. Integrates a body of external evidence from nursing and related fields with internal evidence* in making decisions about patient care (internal evidence*= evidence generated internally within a clinical setting, such as patient assessment data, outcomes management, and quality improvement data).

17. Leads transdisciplinary teams in applying synthesized evidence to initiate clinical decisions and practice changes to improve the health of individuals, groups, and populations.

18. Generates internal evidence through outcomes management and EBP implementation projects for the purpose of integrating best practices.

19. Measures processes and outcomes of evidence-based clinical decisions.

20. Formulates evidence-based policies and procedures.

21. Participates in the generation of external evidence with other healthcare professionals.

22. Mentors others in evidence-based decision making and the EBP process.

23. Implements strategies to sustain an EBP culture.

24. Communicates best evidence to individuals, groups, colleagues, and policy makers.

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Original Article certain EBP tasks, including (a) generated a PICO (Population, Intervention, Comparison, and Outcome) question about their practice, (b) used evidence to change their clinical practice, and (c) shared outcome data collected with colleagues. Item scores are summed for a total score range from 0 to 72, with higher scores indicating greater implementation of EBP. The EBPI has established face, content, and construct validity with internal consistency reliabilities above 0.85 (Melnyk et al., 2008). Cronbach’s alpha with this sample was .96.

Organizational culture was measured with the Organiza- tional Culture and Readiness for System-Wide Integration of Evidence-Based Practice Scale, which measures organizational culture and readiness for EBP (Fineout-Overholt & Melnyk, 2006). This instrument taps the extent to which cultural fac- tors that influence system-wide implementation of EBP exist in the environment and the overall perceived readiness for integration of EBP and how it compares to 6 months ago. Re- spondents are asked to indicate their agreement with each item on a 5-point Likert-type scale, with 1 meaning none at all and 5 meaning very much. Examples of items on the 26-item scale include: (a) To what extent is EBP clearly described as central to the mission and philosophy of your institution? (b) To what extent do you believe that EBP is practiced in your institution? Items are summed to create a total score, ranging from 25 to 125, with higher scores reflecting greater organizational readi- ness for and movement toward a culture of EBP. The scale has established face and content validity, with internal consistency reliabilities above 0.85 (Melnyk et al., 2010). Cronbach’s alpha with this sample was .96.

EBP mentorship was measured with a new 8-item EBP men- torship scale that taps the degree of EBP mentorship available to nurses. Participants respond to a 5-point Likert scale that ranges from 0 “none at all” to 4 “very much so.” Examples of items include: (a) I have access to a mentor who assists me in implementing the seven steps of EBP, and (b) I have a mentor who is consistently available to me when I have questions about EBP. The scale scores are summed for a total score of 0 to 32. Face, content, and construct validity of the scale has been es- tablished. The internal consistency reliability of the scale with this sample was .99.

The EBP competencies were measured by the new EBP competency scale (see Table 1). Participants self-rated their level of competence on each of the 24 EBP competencies on the following 4-point Likert scale: 1 (not at all competent), 2 (need improvement), 3 (competent), and 4 (highly competent) for a possible range of scores from 0 to 96. Face, content, and construct validity of the scale has been established. The internal consistency of the scale with this sample was .98.

Statistical Analysis Descriptive statistics were used to summarize sample char- acteristics and to examine the overall and item score of EBP competency. Bivariate associations were tested between EBP competency and each of the other variables (e.g., sample char- acteristics, EBP culture, knowledge, beliefs, and mentoring)

using analysis of variance and Pearson’s correlations. Next, all variables significantly associated with EBP competency in the bivariate tests were included in a multiple regression model to identify significant predictors of EBP competency, adjusting for other factors in the model. All tests were two-sided with a significance level of 0.05. SAS Software (version 9.4; SAS Institute Inc., Cary, NC, USA) was used for all the analyses.

RESULTS A total of 2,344 nurses completed the survey. Mean age was 44.5 years (SD = 12.5). A majority of the nurses were female (92.0%), non-Hispanic White (85.5%), had a bachelor’s de- gree (53.8%), and worked in a Magnet designated organization (69.2%; see Table 2).

Figure 1 plots the average score of EBP competency by items. No item had an average score between 3 (competent) and 4 (very competent). All items except item 17 were scored between 2 (need improvement) and 3 (competent). Item 1 (Questions clinical prac- tices for the purpose of improving the quality of care) had the highest average score (M = 2.72, SD = 0.76) and item 17 (Leads transdisciplinary teams in applying synthesized evidence to initiate clinical decisions and practice changes to improve the health of individuals, groups and populations) had the lowest average score (M = 1.97, SD = 0.80). Figure 2 plots the average scores on the EBP competencies by educational level.

Table 2 summarizes the nurses’ total EBP competency score, overall and stratified by sample characteristics. The aver- age EBP competency score was 53.5 (SD = 16.1). Younger age and higher education were significantly associated with higher EBP competency (p < .001 for both). The EBP competency scores were not significantly different across gender (p = .09), race or ethnicity (p = .17), and working in a Magnet designated organization or not (p = .28).

There were strong positive associations between EBP com- petency with EBP beliefs (r = .66) and EBP mentoring (r = .69), a moderate positive association between EBP competency and EBP knowledge (r = .43), and a small positive associa- tion between EBP competency and culture (r = .29; Table 2). Table 3 also includes the descriptive statistics for EBP culture (M = 80.2, SD = 21.9), knowledge (M = 19.5, SD = 7.0), be- liefs (M = 56.7, SD = 8.5), and mentoring (M = 21.4, SD = 10.9) and their pair-wise associations (ranging from r = .28 for the correlation of culture with knowledge to r = .69 for the correlation of culture with mentoring).

All the variables significantly associated with EBP compe- tency in the bivariate tests were entered into a multiple linear regression model (see Table 4). After adjusting for other vari- ables in the model, having a master’s or doctoral degree, higher EBP knowledge, higher EBP beliefs, and higher EBP men- toring were strong predictors of higher EBP competency (all p values < .001). Nurses’ age and EBP culture were no longer significant predictors of EBP competency, after adjusting for other factors in the model. Table 4 presents the results when treating the predictors as categorical variables for the ease of

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U.S. Study on Nurses’ Evidence-Based Practice Competencies

Figure 1. Nurses’ reported EBP competency in the overall sample.

understanding. The analysis was repeated and had similar re- sults by treating age, EBP culture, EBP knowledge, EBP beliefs, and mentoring as continuous variables in the model.

DISCUSSION The results of this study indicate that this large sample of nurses from across the United States do not believe they are meeting the EBP competencies. Although the APNs rated themselves somewhat higher in all of the competencies as ex- pected, the group of nurses as a whole did not rate themselves as competent in any of the 24 competencies. Bachelor’s prepared nurses rated themselves somewhat higher on the competen- cies than associate degree nurses. This was not a surprising finding as nurses in baccalaureate programs typically have an EBP or research course in their educational programs. Younger nurses tended to rate themselves higher on the competencies than older nurses. However, there was no difference in rat-

ings on the EBP competencies between nurses who worked in Magnet versus non-Magnet designated hospitals.

These findings are alarming given the great emphasis that has been placed on the importance of EBP in promoting quality and safety of care for several decades. Numerous studies have reported positive patient and provider outcomes associated with EBP (Doyle, Lennox, & Bell, 2013; Melnyk, Fineout-Overholt, Giggleman, & Choy, 2017; Van Bogaert et al., 2014). Our findings suggest that education is a key pre- dictor of the self-reported EBP competencies, which also has been reported by others (Stokke, Olsen, Espehaug, & Nortvedt, 2014). Academic courses that replace research with EBP or incorporate EBP are a fairly new phenomenon. Until recently, most academic nursing programs have taught students the rigorous process of how to conduct research instead of how to best integrate research findings into practice. Even today, many nursing professors continue to teach research instead of EBP at the baccalaureate and master’s levels, which may partially

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Original Article

Figure 2. Strongest to weakest items of nurses’ reported EBP competency by educational level.

explain why nurses in this study were not reporting themselves as competent in EBP. However, based on the findings from this study, teaching EBP instead of research and leveling EBP content appropriately in academic courses may be occurring and having a positive impact on nurses’ EBP competence as demonstrated by higher EBP competency reported by younger nurses and more highly educated nurses. This has critical implications for academic faculty who continue to have debates about the appropriate content for undergraduate and graduate level nursing students; that is, research or EBP? It is critical that EBP, not how to conduct research, be taught to baccalaureate and master’s level students in order to support the development of EBP competent nurses who provide high quality, safe care and drive improved patient outcomes. It also is important for Doctor of Nursing Practice Programs to prepare graduates to be experts in and mentors of EBP, not research.

EBP knowledge was moderately positively associated with EBP competency. Higher education is where future clinicians must gain knowledge and build the skills of EBP, which will al- low them to emerge with a foundation strong enough to partic-

ipate in EBP as outlined in the first 13 competencies. Educators, who often practiced in the years prior to implementation of the Affordable Care Act (when EBP became an expectation and the gold standard of care) were often not privy to formal education around EBP nor the opportunity to engage in EBP in the clini- cal setting themselves. In addition, many educators teaching in master’s and doctoral nursing programs are PhD-prepared and were educated with a research-intensive skills-set, never having been educated in EBP. The result is many academic programs that teach research-centric curricula with a mention of EBP or, even more problematic, curricula where the distinctions be- tween EBP and research and the way they support one another are blurred and confused. The result is a large percentage of graduates who emerge in practice lacking adequate knowledge and skills in EBP.

Knowledge is certainly an important determinant of behav- ior, but it alone is not sufficient for behavior change, which is necessary for a shift to EBP from practice that is often tradition-based. Knowledge alone also does not include all of the attributes that comprise competence, which is a combina- tion of knowledge, skills, and attitude. Nevertheless, having

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U.S. Study on Nurses’ Evidence-Based Practice Competencies

Table 2. Sample Characteristics and Their Associa- tions With EBP Competency

Characteristicsa N (%) EBP competency, mean (SD)

All 2,344 (100) 53.5 (16.1)

Ageb (M= 44.5, SD= 12.5) <25 111 (4.7) 55.6 (12.4)

25–34 532 (22.7) 54.8 (14.2)

35–44 483 (20.6) 54.0 (15.4)

44–54 555 (23.7) 53.3 (16.3)

55+ 646 (27.6) 51.7 (18.0)

Genderc

Male 186 (7.9) 55.4 (16.0)

Female 2,156 (92.0) 53.3 (16.0)

Race/ethnicityc

Non-Hispanic White 2,003 (85.5) 53.4 (16.0)

Non-Hispanic Black 116 (4.9) 55.1 (16.6)

Hispanics 98 (4.2) 51.5 (15.3)

Other 105 (4.5) 55.8 (16.2)

Educationa

Diploma/associates 514 (21.9) 48.6 (15.4)

Bachelors 1,261 (53.8) 51.8 (14.8)

Masters or higher 503 (21.5) 63.3 (15.5)

Working in a Magnet designated organizationc

Yes 1,622 (69.2) 53.8 (16.2)

No 638 (27.2) 53.0 (15.9)

aNumbers may not equal the total sample due to missing data, including 17 (0.7%) for age, 2 (0.1%) for gender, 22 (0.9%) for race or ethnicity, 66 (2.8%) for education, and 84 (3.6%) for working in a Magnet designated organization. bHighly associated with EBP competency (p< .001). cNot significantly associated with EBP competency (gender: p = .09; race/ethnicity: p = .17; working in a Magnet designated organization: p= .28).

knowledge of EBP as the foundation for evidence-based deci- sion making cannot be underestimated. Knowledge lays the foundation for behavior change, but skills building in the form of actual implementation of evidence-based care must occur re- peatedly in order for clinicians to consistently implement EBP. Knowledge of what worked in a systematic review of random- ized controlled trials does not lead to automatic adoption of an evidence-based intervention in real world clinical settings. Research also must be integrated with clinician expertise and a

Table 3. Correlation of EBP Competency With EBP Culture, Knowledge, Beliefs, and EBP Mentoring

Pearson’s correlation coefficients, ra

Mean (SD) Competency Culture Knowledge Beliefs

Culture 80.2 (21.9) .29 ̶- ̶- ̶-

Knowledge 19.5 (7.0) .43 .28 ̶- ̶-

Beliefs 56.7 (8.5) .66 .47 .42 ̶-

Mentoring 21.4 (10.9) .69 .69 .24 .47

ap< .001 for all the Pearson’s correlation coefficients in the table.

patient’s preferences and values in the execution of EBP (Mel- nyk & Fineout-Overholt, 2015).

The strongest associations with EBP competency were men- torship in EBP and beliefs about the value of EBP and the ability to implement it. EBP mentorship was first described in the ARCC (Advancing Research and Clinical Practice through Close Collaboration) Model as a key strategy for the implemen- tation and sustainability of EBP in healthcare systems (Melnyk & Fineout-Overholt, 2002). Since then, several studies have supported the key role that EBP mentors have in facilitating the implementation of EBP in point of care clinicians (Kim et al., 2017; Levin, Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk et al., 2017; Wallen et al., 2010). EBP mentors are typically advanced practice clinicians whose role is to work with point of care clinicians in consistently implementing EBP to ultimately improve patient outcomes (Melnyk & Fineout- Overholt, 2015). They not only have proficient skills in EBP, but also are skilled in individual and organizational behavior change. Multiple prior studies have supported that stronger cognitive beliefs in EBP have a potent positive influence on EBP implementation.

EBP culture was correlated positively with competency, however, the associations among competency, EBP beliefs, and EBP mentorship were stronger. These associations make sense when the following critical components of an EBP culture are considered: (a) EBP must be in the organizational vision, mission, and goals; (b) clinical inquiry must be promoted and supported; (c) EBP mentors must be available to clinicians; (d) leaders must embrace, role model and support EBP; (e) an infrastructure and resources for EBP must be available; and (f) recognition of EBP achievements must be consistently pro- vided (Melnyk & Fineout-Overholt, 2015). Culture is the under- pinning for how people feel at work, including their beliefs and attitudes about what is possible in a particular workplace. Because attitude is one of the components of competency (knowledge, skills, and attitude), it would reasonably follow that beliefs are more directly associated with culture and compe- tency is a derivative of that relationship. The findings from this

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Original Article Table 4. Predictors of EBP Competency From a Multiple Linear Regression Model

Parameter Coefficient estimate Standard error t value p value

Agea

<25 2.68 1.426 1.88 .06

25–34 1.69 0.82 2.07 .04

35–44 1.56 0.82 1.89 .06

44–54 0.06 0.79 0.07 .94

55+ Reference

Educationb

Diploma/associate degree Reference

Bachelor –0.30 0.73 –0.42 .67

Master/doctoral 8.73 0.93 9.35 <.001

EBP culture

High (�80) 0.30 0.66 0.45 .65

Low (<80) Reference

EBP knowledge

High (�20) 4.32 0.64 6.71 <.001

Low (<20) Reference

EBP beliefs

High (�48) 11.50 0.83 13.84 <.001

Low (<48) Reference

EBP mentoring

Some-very much (�24) 7.12 0.66 10.83 <.001

None/little (<24) Reference

aThe overall p= .06 for age. bThe overall p< .001 for education.

study support that it is the combination of EBP culture, EBP knowledge, believing in the value of EBP and one’s ability to implement it, and EBP mentorship that makes EBP implemen- tation and competency possible and sustainable. Incorporation of the EBP competencies into healthcare system expectations, orientations, performance appraisals, job descriptions, and clinical ladder promotion processes could drive higher quality, reliability, and consistency of health care as well as reduce costs.

A major limitation of this study was that the sample was one of convenience and, therefore, the findings may not be general- izable to all nurses across the United States. The response rate also could not be calculated because it is unknown how many nurses actually opened the emails with information about the study or the link to the study in their newsletter communica- tions. Self-report by the nurses also measured their level of EBP

competency, which could be underestimated or overestimated. In the future, studies that include an objective measure of the EBP competencies in nurses will be important to determine if self-report converges with objective measurement.

Future studies should include the testing of interventions to achieve the competencies in practicing nurses and APNs. Re- search also should test models to determine what variables have the most influence on EBP competency. In addition, research is needed on EBP implementation, that is, how to most ef- fectively integrate research, clinician expertise, and a patient’s preferences, values and capacity. A better understanding is needed of how to plan and implement EBP changes in the context of multiple variables that influence the uptake of ev- idence. Likewise, clinicians must know how to apply quality improvement principles to measure, track, trend, and evaluate

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U.S. Study on Nurses’ Evidence-Based Practice Competencies

outcomes in order to determine whether their EBP changes accomplished what they were intended to do. WVN

LINKING EVIDENCE TO ACTION

� There is a tremendous need to provide nurses across the United States with the knowledge and skills to achieve the EBP competencies.

� Multiple variables influence EBP competency, including EBP culture, EBP knowledge, beliefs about the value of EBP and the ability to implement it, and having mentors available to assist with the implementation of evidence-based care.

� The EBP competencies should be integrated into both academic and clinical education programs to establish and continuously reinforce EBP as the foundation of practice.

� Ensuring that nurses and all clinicians achieve the EBP competencies will facilitate high-quality, safe and cost-effective health care.

Author information

Bernadette Mazurek Melnyk, Vice President for Health Promo- tion, University Chief Wellness Officer, Dean and Professor, College of Nursing, Professor of Pediatrics and Psychiatry, Col- lege of Medicine, and Executive Director, Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nurs- ing and Healthcare, The Ohio State University, Columbus, OH, USA; Lynn Gallagher-Ford, Senior Director, Helene Ford Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare, The Ohio State University College of Nursing, Columbus, OH, USA; Cindy Zellefrow, Assistant Pro- fessor of Practice and Director, Academic Core, Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare, The Ohio State University College of Nursing, Columbus, OH, USA; Sharon Tucker, Director, Implementation Science Core, Helene Fuld Health Trust Na- tional Institute for Evidence-Based Practice, in Nursing and Healthcare, Columbus, OH, USA; Bindu Thomas, Technol- ogy & Research Coordinator, Helene Fuld Health Trust Na- tional Institute for Evidence-Based Practice in Nursing and Healthcare, Columbus, OH, USA; Loraine T. Sinnott, Statisti- cian, The Ohio State University College of Nursing, Columbus, OH, USA; Alai Tan, Research Associate Professor, The Ohio State University College of Nursing, Columbus, OH, USA

Address correspondence to Bernadette Mazurek Melnyk, College of Nursing, The Ohio State University, 1585 Neil Avenue, Columbus, OH 43210, USA; [email protected]

References American Association of Colleges of Nursing QSEN Education

Consortium. (2012). Graduate level QSEN competencies. Wash- ington, DC: Author.

American Nurses Association. (2010). Nursing. Scope and standards of practice (3rd ed.). Washington, DC: Author.

Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open, 3, 1–18.

Dunn, S. V., Lawson, D., Robertson, S., Underwood, M., Clark, R., Valentine, T., & Herewane, D. (2000). The development of competency standards for specialist critical care nurses. Journal of Advanced Nursing, 31(2), 339–346.

Fineout-Overholt, E., & Melnyk, B. M. (2006). Organizational cul- ture and readiness scale for system-wide integration of evidence-based practice. Gilbert, AZ: ARCC, LLC.

Institute of Medicine; Committee on Assuring the Health of the Public in the 21st Century. (2003). The future of the public’s health in the 21st century. Washington, DC: National Academies Press.

Kim, S. C., Ecoff, L., Brown, C. E., Gallo, A. M., Stichler, J. F., & Davidson, J. E. (2017). Benefits of a regional evidence-based prac- tice fellowship program: A test of the ARCC Model. Worldviews on Evidence-Based Nursing, 14(2), 90–98.

Levin, R. F., Fineout-Overholt, E., Melnyk, B. M., Barnes, M., & Vetter, M. J. (2011). Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: A pilot test of the advancing research and clinical practice through close collaboration model. Nursing Administration Quarterly, 35(1), 21– 33.

Melnyk, B. M., & Fineout-Overholt, E. (2002). Putting research into practice. Reflections on Nursing Leadership, 28(2), 22–25.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based prac- tice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Choy, K. (2017). A test of the ARCC C© model improves implementation of evidence-based practice, healthcare culture, and patient out- comes. Worldviews on Evidence-Based Nursing, 14(1), 5–9.

Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Cruz, R. (2010). Correlates among cognitive beliefs, EBP implementa- tion, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nursing Outlook, 58(6), 301–308.

Melnyk, B. M., Fineout-Overholt, E., & Mays, M. Z. (2008). The evidence-based practice beliefs and implementation scales: Psy- chometric properties of two new instruments. Worldviews on Evidence-Based Nursing, 5(4), 208–216.

Melnyk, B. M., Gallagher-Ford, L., Koshy, B., Troseth, M., Wyn- garden, K., & Szalacha, L. (2016). A study of chief nurse execu- tives indicates low prioritization of evidence-based practice and shortcomings in hospital performance metrics across the United States. Worldviews on Evidence-Based Nursing, 13(1), 6–14.

Melnyk, B. M., Gallagher-Ford, L., Long, L. E., & Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11(1), 5–15.

17416787, 2018, 1, D ow

nloaded from https://sigm

apubs.onlinelibrary.w iley.com

/doi/10.1111/w vn.12269 by Southern C

ross U niversity B

ronw yn K

ohlm an L

ibrary, W iley O

nline L ibrary on [24/11/2022]. See the T

erm s and C

onditions (https://onlinelibrary.w iley.com

/term s-and-conditions) on W

iley O nline L

ibrary for rules of use; O A

articles are governed by the applicable C reative C

om m

ons L icense

Original Article Quality and Safety Education for Nurses. (2013). Project overview,

the evolution of the quality and safety education for nurses (QSEN) initiative. Retrieved from https://qsen.org/about- qsen/project-overview/

Spurlock, D., & Wonder, A. (2015). Validity and reliability of a new objective measure: The evidence-based practice knowledge assessment in nursing (EKAN). Journal of Nursing Education, 54(11), 605–613.

Stevens, K. R. (2005). Essential competencies for evidence-based prac- tice in nursing. Academic Center for Evidence-Based Practice (1st ed.). San Antonio, TX: University of Texas Health Science Cen- ter at San Antonio.

Stokke, K., Olsen, N. R., Espehaug, B., & Nortvedt, M. W. (2014). Evidence based practice and implementation among nurses: A cross sectional study. BMC Nursing, 13(1), 8. https://doi.org/ 10.1186/1472-6955-13-8

U.S. Department of Health & Human Services. (2015). Guidance re- garding methods for deidentification of protected health information

in accordance with the Health Insurance Portability and Account- ability Act (HIPAA). Health information privacy. Retrieved from https://www.hhs.gov/hipaa/for-professionals/privacy/special- topics/de-identification/index.html

Van Bogaert, P., Timmermans, O., Weeks, S. M., Van Heusden, D., Wouters, K., & Franck, E. (2014). Nursing unit teams mat- ter: Impact of unit-level nurse practice environment, nurse work characteristics, and burnout on nurse report job outcomes, qual- ity of care, and patient events: A cross sectional survey. Interna- tional Journal of Nursing Studies, 51(8), 1123–1134.

Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implement- ing evidence-based practice: Effectiveness of a structured mul- tifaceted mentorship programme. Journal of Advanced Nursing, 66(12), 2761–2771.

doi 10.1111/wvn.12269 WVN 2018;15:16–25

Continuing Education Worldviews on Evidence-Based Nursing is pleased to offer readers the opportunity to earn credit for its continuing education articles. Learn more here: www.nursingknowledge.org/journaleducation

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https://qsen.org/about-qsen/project-overview/

https://doi.org/10.1186/1472-6955-13-8

https://www.hhs.gov/hipaa/for-professionals/privacy/special-topics/de-identification/index.html