Abstract

Background: Health care organizations consider evidence-based practice as the gold standard for the provision of safe and compassionate health care. Aim of the study: The present study aims to assess the knowledge, perception, and attitude of nurses regarding evidence-based practice. Subjects and Methods: A descriptive design was utilized to achieve the aim of the study. The study included a random sample of (262) staff nurses who were responsible for providing nursing care to patients. Data were collected using three scales; knowledge scale, perception scale, and attitude scale regarding evidence-based practice. Results: The majority of the studied nurses had the knowledge and negative attitude regarding evidence-based practice and two-third of the studied nurses had a moderate level of perception regarding evidence-based practice. There was a statistically significant relationship between nurses’ knowledge and their educational qualification and there was a statistically significant relationship between nurses’ perception and their gender, educational qualification, and experience. Conclusion: There was a significant relationship between nurses’ Knowledge, perception, and attitude towards evidence-based practice. Recommendations: Nursing managers should develop an evidence-based practice training program to help nurses to be familiar with EBP steps. Nursing managers should motivate the nurses who follow up the EBP with different incentives.

1. Introduction

One of the most dynamic human disciplines is Health care, and a lot of money are spent annually on high quality and advanced research, resulting in an exponential growth in health care literature. Regularly, new and more effective medicines and procedures are established. One major objective behind all these efforts is to help doctors, nurses, and medical technicians provide the best possible care and treatment to patients ¹. World health organization has mentioned that health improving in societies is based on nursing services supported by evidence-based practice (EBP) ².

Beginning with Florence Nightingale in the 1800s and developing again within the medical community, EBP continues to advance along with the nursing discipline. EBP is foundational to nursing education and is a way for the nursing discipline to decrease the theory to practice gap. It initiated as an idea to deliver better outcomes for patients who experienced disgraceful and unhealthy conditions, and advanced into a foundation that nursing has adopted and maintained in order to provide safe and competent care ³.

EBP is the use of current best evidence in making decisions for individual patient care or health service delivery. Current best evidence is the use of up-to-date information from important and valid research regarding the effects of different forms of clinical care, the potential for harm from exposure to the particular agent, the accuracy of diagnostic tests, and the predictive power of prognostic factors ^{4, 5, 6, 7, 8}. EBP facilitates the delivery of effective, efficient, and safe patient care. There is a motivated and systemic effort to integrate EBP into every patient encounter among all clinical settings. Numerous strategies used to promote EBP among healthcare professionals with varying degrees of success in increasing knowledge and shifting attitudes towards EBP. These strategies include journal clubs, mentorship programs, and training in scientific research ⁹.

The goals of evidence-based nursing are the following: provide practicing nurses with evidence-based data to deliver effective care defined by the best research; to resolve problems in the clinical setting; to achieve excellence in delivering patient care, even exceeding quality assurance standards; and to introduce innovation. Furthermore, EBP uses a systematic review to emphasize the comprehensive evaluation of all relevant research according to a clinical question ¹⁰. For nurses, EBP considered an effective way of enhancing confidence in clinical decision-making ¹¹.

Nurses have a vital role in ensuring the promotion of health care and delivering better services. EBP is significant to the professional development, responsibility, and capabilities of nurses, and it has become an important subject in nursing and has integrated into daily practice. In addition, nurses who practice based on the scientific evidence have been able to make better decisions in services delivery ¹².

Nurses are in crucial positions to promote EBP within clinical settings and have opportunities to advance practice. Therefore, it is essential to understand their perceptions of factors promoting EBP in clinical settings ¹³. Knowledge, perception and attitude are the keystone of implementing EBP. Consequently, Knowledge, attitudes can potentially predict future behavior about EBP implementation ^{14, 15, 16}.

Attitudes play an important role in adopting, implementing, and maintaining evidence-based practices in clinical settings. Individuals’ positive or negative attitudes and judgments toward the EBP may directly affect their behaviors of either supporting or resisting the implementation of the EBP ¹⁷.

Positive attitudes towards EBP could be important step in adopting EBP. According to the Theory of planned behavior, beliefs, attitudes, and social standards will influence individuals' intentions to engage in selected behaviors. Intentions as self-instructions and motivations to engage in innovative behaviors will lead to adoption and use of EBP.

A growing literature has addressed the importance of attitudes toward EBP in health care settings and explored factors at multiple ecological levels that may influence attitudes toward EBP ¹⁸.

Nurses’ knowledge of EBP and their positive attitude towards it will contribute to its implementation in healthcare system. Obtaining knowledge about research methods and having the skill to evaluate research reports critically may enable overcoming the obstacles delaying the application of research findings and thus will lead to improvement of healthcare quality. Hence, the EBP attitude, knowledge, and skills of nurses are so important ¹⁹.

Nurses increasingly requested to apply evidence in to the practice in order to improve the quality and efficiency of patient care. Nurses need to have a positive attitude, adequate knowledge and applicable research utilization to employ EBP and promote quality of care effectively, ^{20, 21, 22, 23}. Hence, the current study will be conducted to assess the knowledge, attitude and perception of nurses toward EBP.

The aim of this study is to assess the knowledge, perception and attitude of nurses regarding EBP at king Abdullah medical city-Holy Makkah-Saudi Arabia.

1. What is nurses’ knowledge regarding EBP?

2. What is nurses’ perception level regarding EBP?

3. What is nurses’ attitude level regarding EBP?

4. Is there a relationship between nurses’ knowledge and attitude regarding EBP?

5. Is there a relationship between nurses’ perception and attitude regarding EBP?

A descriptive, cross sectional research design was used in the current study. This study was carried out at all units of King Abdullah Medical City (KAMC) -Makkah - Saudi Arabia. The KAMC provides medical care for different patients with 390 beds capacity. A simple random sample of 262 nurses was selected from different units of KAMC proportional to the total number of nurses working in their respective clinical settings. They were responsible for providing patient care during the time of data collection.

Sample size was calculated by Epi Info software with population size 1200, expected frequency 50%, acceptable margin of error 5%, design effect=1.0, and cluster=1. The required sample was 291.

Data were collected through a self-administered questionnaire. It includes four sections as follows:

Section I: It includes personal data of the nurses such as gender, education, and experience years.

Section II: knowledge toward EBP scale.

This scale was adopted from Karki et al ²⁴. It includes five statements to assess nurses’ knowledge regarding adopting EBP (e.g., adopting EBP based on research findings). The responses of nurses were either 2 for yes or 1for no.

Section III: Perception toward EBP scale.

This scale was adapted from Majid et al (2011) ¹. It includes three subscales as follows; (1) EBP activities (9 items) (e.g., Identify clinical issues or problems), (2) EBP motivators (6 items) (e.g., Nursing colleagues who embrace EBP), (3) EBP training needs (7 items) (e.g., Identifying clinical issues for implementing EBP).

Scoring system

The items of first subscale were rated on five point likert scale ranged from 0 (poor) to 4 (excellent), while the items of other subscales were rated on five point likert scale ranged from 0 (no important) to 4 (extremely important). The total score was classified into three levels as follows; poor (<50%), good (50-75%), and excellent (>75%).

Section IV: EBP attitude scale

It was adopted from Aarons et al ²⁵ to assess attitude of nurses regarding adopting EBP. It consists of 50 items that cover 12 subscales as follows; (1) Appeal (4 items) (e.g., Adopting EBP requires enough training) (2) Requirement (3 items) (e.g., Adopting EBP requires supervisor) (3) Openness (4 items) (e.g., I will try therapy/interventions developed by researchers), (4) Divergence (4 items) (e.g., Clinical experience more important for adopting EBP), (5) Limitations (7 items) (e.g., EBP is too simple), (6) Fit (7 items) (e.g., Adopting EBP right for your patients), (7) Monitoring (4 items), (e.g., Work does not need to be monitored), (8) Balance (4 items) (e.g., Overall competence is more important), (9) Burden (4 items), (e.g., Cause too much paperwork), (10) Job security consists (3 items), (e.g., Help me get a new job ), (11) Organizational support (3 items), (e.g., my organization provides ongoing support), and (12) Feedback (3 items) (e.g., Feedback helps me to be better ).

Scoring system

The items are formulated as statements, and responses are given on a 5-point Likert scale ranging from 0-“not at all” to 4-“to a very great extent”. There are 23 items belonging to five subscales divergence, limitations, monitoring, balance, and burden are negatively framed to assess different perspectives. These items were reversed score and the mean score was computed. The total score of attitude was classified into; negative attitude less than 50% (0 – 99) and positive attitude ≥ 50% (100 - 200).

A pilot study was carried out on 10% of the nurses (n=29) in order to test the feasibility and applicability of the tools. These nurses were excluded from the total study sample. The Reliability was tested for the scales of knowledge, perception, and attitude by using Cronbach's coefficient alpha. It was 0.80, 83, and 0.92 for knowledge scale, perception scale, and attitude scale regarding evidence-based practice respectively. The content validity was done by three experts, and the necessary modifications were done accordingly.

An official approval and permission from KAMC IRB were obtained before conducting the research. The aim of the study was explained to the participants and verbal consent was obtained. The anonymity, privacy of the participants, confidentiality of the data, and the right to refuse to participate in the study were assured.

The questionnaire was administered in paper format to nurses at the beginning of the shift with instructions about its filling. The researchers were available all the time of filling questionnaire by the nurses to clarify any doubt. The researchers checked the questionnaire for completeness after receiving it from the nurses. Data were collected from September to November 2019. The time needed to fill the questionnaire was between 20-25 minutes.

Data were analyzed through SPSS package version 22. The categorical variables were expressed as number and percentage while continuous variables were expressed as mean, and standard deviation. Independent t-test used to compare between two mean of continuous variables whereas ANOVA test used to compare between more than two mean of continuous variables. Pearson correlation coefficient utilized to test association between continuous variables. P value was considered statistically significant at ≤0.05 and 0.01.

2. Results

Table 1 shows that the majority of the studied nurses’ age were ranged from 20-30 years with mean± SD (28.20± 3.31), female (61.5%), having a bachelor degree in nursing, with 6.27 mean of experience years, 50.4% of them accessed data base, and 67.2% did not participate in the scientific research.

Table 2 illustrate that the majority of the studied nurses (86.6%) had knowledge regarding EBP. The highest nurses’ knowledge was about adopting EBP based on patient’s subjective and objective data (95.8%), and the lowest was adopting EBP based on Research findings (71.0%).

Table 3 shows that the mean of nurses’ perception toward EBP was 60.71 ±11.14. The highest nurses’ perception was related EBP activities (21.98 ±5.66) and the lowest was regarding EBP motivators (17.91 ±3.40).

Table 4 illustrates that two third of the studied nurses had moderate level of perception regarding EBP.

Table 5 illustrates the mean nurses’ attitude toward EBP was 110.38±11.31. The highest attitude subscale was fit (19.98±4.06), and the balance subscale was the lowest (5.14±2.59).

Table 6 illustrates that the majority of the studied nurses (86.3%) had a negative attitude regarding EBP.

Table 7 illustrates that there was significant relationship between nurses’ Knowledge, perception, and attitude towards EBP.

Table 8 shows that there was statistically significant relation between nurses’ knowledge and their educational qualification and there was statistically significant relation between nurses’ perception and their gender, educational qualification, and experience.

3. Discussion

EBP considered as critical element to improve quality of health services and achieving excellence in patient care. Furthermore, EBP is a keystone for health care quality ²⁶. As nurses play a vital role in the delivery of health care and results of revised studies show nurses do not generally integrate research evidence in their daily practice ²⁷. The current study was conducted to assess the knowledge, perception and altitude regarding EBP among nurses working at King Abdullah Medical City, Makkah, Saudi Arabia. Therefore the findings of the current study will be discussed through four sections as follows:

Findings of the current study indicated that the majority of the studied nurses had knowledge regarding EBP. The highest nurses’ knowledge was about EBP based on patient’s subjective and objective data. This may be due to understanding of research terms used in research articles. They may have enough time to search and read research articles and implement recommendations of research studies into clinical practice, and availability of resources as equipment, materials to implement EBP. This result is in line with Majid et al ¹ who studied adopting EBP in clinical decision making: nurses’ perceptions, knowledge, and barriers and reported that the nurses were open to adopt new health care approaches.

The present study Findings revealed that two third of the studied nurses had moderate level of perception regarding EBP. This result matched with Karki et al ²⁴ who stated that the respondents had moderate level of perception toward EBP.

The current study demonstrated that the majority of the studied nurses had a negative attitude regarding EBP. These finding is in contrast with Mohsen et al ²⁸, Padmanabhanunni ²⁹, Al-Maskari et al ³⁰, and Al-Busaidi et al ³¹ reported that all nurses have a positive attitude toward EBP.

The current study revealed that there is statistically significant relation between nurses’ knowledge related EBP and their educational qualification. These finding is matched with Xie et al ³² who stated that nurses with higher educational level performed better in the knowledge assessment test.

The present study showed that statistically significant relation between nurses’ perception and their gender was found with male scoring significantly higher compared to female. This may be related to lack of time. This result is matched with AbuRuz et al ³³ who and revealed that female nurses have less positive attitude, and less knowledge about research compared to male nurses, In contrast a study done by Padmanabhanunni ²⁹ reported that there was not a significant difference of the studied samples’ knowledge and their gender.

The present study Findings revealed that no statistical significant difference was found between nurses’ level of education and their attitude toward EBP. In contrast AbuRuz et al ³³, Al-Maskari ³¹, and Ammouri et al ³⁵ reported that increased education levels had a positive effect on overall attitudes towards EBP.

Statistical significant correlation was found between perception and knowledge toward EPB. This result is matched with Melnyk et al ³⁶ who added that significant relationships were found among educators' knowledge of EBP and their perception toward EBP.

The present study showed that statistical significant correlation found between knowledge and altitude toward EPB. Theses in line with Bashar ²⁶ who reported that nurses who were more knowledgeable regarding EBP, had a greater positive attitude towards EBP and a stronger tendency to apply EBP. This result is in contrast with Karki et al ²⁷ who reported that although this sample of Nepalese nurses and students had positive attitudes towards EBP, their knowledge and skills were limited, and there are many barriers to implementing EBP in Nepal.

EBP implementation is associated with all aspects of quality in health care such as efficient use of resources, improvement of patient care, decreasing costs and length of hospital stay, and increasing patient satisfaction. Literature has recommended that individuals' attitudes, knowledge and perception always play an important role in adopting, implementing, and maintaining evidence-based practices in clinical settings ³³. Therefore, it is mandatory to increase the nurses' knowledge and improve their practice, through the educational and in-service training programs to enhance the implementation of evidence-based research results.

4. Conclusion

The current study findings indicated that the majority of the studied nurses had knowledge, at the same time a negative attitude regarding EBP. The two third of the studied nurses had moderate level of perception regarding EBP. There was relationship between knowledge, perception and attitude toward EBP.

5. Recommendations

In light of the current study findings, the following recommendations are suggested:

• Nursing managers should develop EBP training program to help nurses to be familiar with EBP steps.

• Nursing managers should motivate the nurses who follow up the EBP procedures and guidelines by different incentives.

• Nursing managers should provide staff nurses with learning facilities such as books, advanced results of researches, posters, up to date scientific journals, in addition to the access to internet to promote self-learning.

• Nursing managers should adjust schedule of nurses to ensure sufficient time for them to learn and implement EBP.

• Nursing managers should provide support, facilities and persuading environment to focus nurses on evidence-based practice.

• Decision makers should direct the hospital budget to provide the needed equipment and supplies to implement EBP.

• Further studies are needed to determine the barriers for implementing EBP.

References