Authors: Joanne Cleary‐Holdforth, Ellen Fineout‐Overholt, Dónal O'Mathúna
Categories: Original Articles, education, evidence‐based practice, midwives, nomenclature, nurses, Original Article
Source: Worldviews on Evidence-Based Nursing
Doi: 10.1111/wvn.12593
Evidence‐based practice (EBP) has garnered increasing exposure in professional healthcare discourse over three decades. While the term is used frequently, its interpretation varies widely. An accurate, shared understanding of what EBP means is essential to the achievement of EBP implementation in clinical practice. As part of a national study in the Republic of Ireland, nurses, midwives, educators, and students shared their personal understanding of what EBP was to them.
To establish nurses', midwives', educators', and students' knowledge and understanding of the concept of EBP in the Republic of Ireland.
In a national study exploring EBP beliefs, implementation, and organizational readiness for EBP among nurses, midwives, educators, and students, an open‐ended question invited participants to explain what EBP is, in their own words. Content analysis was used to interpret participants' responses.
Five themes emerged from the data from the single open‐ended (1) varying definitions of EBP, (2) best practice, (3) nurses' and midwives' role in EBP, (4) knowledge, and (5) barriers and facilitators of EBP. The dominant finding centered on the substantial conflation of EBP with research utilization and other concepts such as quality improvement.
Poor knowledge and understanding of EBP is a fundamental challenge to EBP implementation. Conflation of EBP with research utilization and other healthcare concepts is not uncommon among nurses and midwives globally and has persisted for some time. This has the potential to hinder the advancement of EBP in nursing and midwifery and, therefore, measures to enhance EBP knowledge and promote EBP implementation are key. Professional regulating bodies, educators, and clinical and educational organizations all have a role to play. The findings from this aspect of this national study offer a realistic, context‐specific starting point for tailored educational interventions for clinicians, educators, and students and identify professional and organizational strategies that promote EBP as the expectation and “the way things are done here.”
Keywords: education, evidence‐based practice, midwives, nomenclature, nurses
Evidence‐based practice (EBP) has enjoyed increasing exposure and use in professional healthcare discourse, nomenclature, and literature for three decades. However, its correct interpretation is not always as common as its use might suggest. The World Health Organization (WHO) posited that nurses and midwives are integral to the integration of EBP across the healthcare service (Jylhä et al., 2017). Enhancing their capacity to implement EBP improves outcomes for patients/clients and creates real‐time EBP exposure and experience for the students that they work with, sustaining EBP implementation into the future. Key to EBP implementation is EBP knowledge and understanding. A national study was undertaken to establish the EBP knowledge, beliefs, and implementation of nurses, midwives, educators, and students in the Republic of Ireland to help to identify opportunities for education and advancement of EBP.
Archie Cochrane, David Sackett, and Gordon Guyatt are credited with advancing evidence‐based medicine (EBM) since the 1970s (Beyea & Slattery, 2013; Sur & Dahm, 2011). Sackett et al. (1996, p. 71) defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,” emphasizing the integration of clinical expertise with the best available research evidence and establishing them as core components of EBM. Less emphasis was placed on the third core component, patient participation. As the principles of EBM were increasingly adopted by other healthcare professions, Dawes et al. (2005) proposed that EBM be expanded to EBP to reflect these changes. Numerous definitions of EBP have emerged, and while they vary somewhat, the inclusion of three core components of EBP is integral.
Building on Sackett et al.'s (1996) definition, Melnyk and Fineout‐Overholt et al. (2019) presented a definition of EBP in 2005 that similarly incorporated clinical expertise and the best available evidence, but arguably placed a more inclusive and explicit focus on patient participation. They defined EBP
a lifelong problem‐solving approach to clinical practice that integrates the
This definition presented EBP as a problem‐solving approach to patient care and illustrated its timeless, versatile, and dynamic nature. It established the three distinct core components and recognized the important contribution of each component to the achievement of EBP. Furthermore, it presented EBP is an active, participatory partnership between healthcare professionals and patients, as well as a theoretical concept of how care should be delivered. As such, this definition aligns more closely with the ethos of nursing and midwifery. As a long established, and widely used definition, it was selected as the operational definition for the national study.
Educating nurses and midwives with the necessary knowledge and skills to integrate EBP into their day‐to‐day practice is crucial to promote and advance system‐wide EBP implementation. The journey starts here. The question is, are we here yet? The national study was conducted from 2016 to 2017 to answer this question in the Irish context.
Nursing and midwifery in Ireland has seen significant and rapid change since the 1990s (Begley, 2008). Change focused on elevating the educational level and professional status of these professions, as well as carving out clear clinical and academic career pathways. Until 1995, nurse and midwifery education was based on the certificate level apprenticeship model, with programs delivered in hospital‐based schools of nursing and midwifery, emphasizing on‐the‐job training over academic learning (Fallon et al., 2018; Leufer & Cleary‐Holdforth, 2020; O'Dwyer, 2007; O'Shea, 2012). There was considerable resistance to attempts to transition nursing and midwifery education into the university setting for many years (An Bord Altranais, 1994; Department of Health, 1980; Government of Ireland, 1998). Finally, having forged partnerships with higher educational institutions (HEIs), nursing and midwifery education was elevated to diploma level in 1995 (Begley, 2008; O'Dwyer, 2007) and to university‐granted degree level in 2002 for nursing, and in 2006 for midwifery. The planning and delivery of nursing and midwifery education in the Republic of Ireland is now the shared remit of three the Nurse and Midwifery Board of Ireland (NMBI), which is the regulatory body for nursing and midwifery, the thirteen HEIs that provide nursing and/or midwifery education, and their clinical partner services.
The goal of the nursing degree program is “to ensure that the graduate acquires the competencies for critical analysis, problem‐solving, decision‐making, collaborative team‐working, leadership, professional scholarship, effective interpersonal communication and reflection that are essential to the art and science of nursing” (Nursing and Midwifery Board of Ireland, 2022, p. 23). The midwifery degree program aim is to “prepare future midwives to provide safe, effective and evidence‐based practice to women, their babies, and their families in a holistic and compassionate manner” (Nursing and Midwifery Board of Ireland, 2016, p. 18). Such goals demonstrate growth and movement beyond the expectations of the apprentice‐trained clinicians of the recent past. A reasonable expectation of this transition might be that graduates of these programs would be equipped with EBP knowledge and skills.
Nurses and midwives are generally affirmative in their belief in the positive impact of EBP on patient care, yet their implementation of EBP remains inconsistent (Azmoude et al., 2017; Cleary‐Holdforth et al., 2021; Heydari et al., 2014; Leufer & Cleary‐Holdforth, 2007; Malik et al., 2015; Melnyk et al., 2016; Stokke et al., 2014; Ubbink et al., 2013; Voldbjerg et al., 2017). Many healthcare practitioners possess inadequate knowledge to implement EBP in their patient care delivery (Lam & Schubert, 2019; Leufer & Cleary‐Holdforth, 2007; Melnyk et al., 2018; Saunders & Vehviläinen‐Julkunen, 2016; Ubbink et al., 2013; Yoo et al., 2019). Considerable confusion about and varied familiarity with EBP existed among nurses and midwives, and they rarely engaged in EBP predominantly due to inadequate EBP knowledge and skills (Azmoude et al., 2017; Belowska et al., 2015; Heydari et al., 2014; Saunders et al., 2019; Saunders & Vehviläinen‐Julkunen, 2016). Lack of clarity and understanding of EBP is concerning and represents a substantial challenge to EBP implementation in health care. Lack of clarity not only hinders EBP implementation, but it may also lead healthcare professionals to believe that the care they deliver is evidence‐based when it is not (Saunders et al., 2019).
Nurse and midwifery educators similarly perceive EBP favorably, but their knowledge and implementation are inadequate (Cleary‐Holdforth et al., 2021; Malik et al., 2015; Mehrdad et al., 2012; Mthiyane & Habedi, 2018). Many educators do not appreciate the differences between EBP and traditional research, and competence in research does not always translate into competence in EBP (Stichler et al., 2011). Nurse educators reported a variety of understandings of EBP, ranging from research utilization to appreciation of the three core components of EBP (Malik et al., 2016), demonstrating that, like clinicians, educators can conflate these two concepts. Few nurse educators (16%) specifically mentioned EBP in their teaching philosophy statements, while a further 39% mentioned components of EBP (Felicilda‐Reynaldo & Utley, 2015). Paucity of inclusion of EBP in educational philosophy statements potentially indicates little value on EBP. If educational philosophies do not include EBP, its inclusion in the respective nursing curricula and program delivery is likely to be minimal.
While current standards and requirements set forth by the Nursing and Midwifery Board of Ireland (2015, 2016) emphasize the research aspect of program content, EBP has been included less explicitly. However, a focus on research without explicit definition of EBP may reinforce its conflation with research utilization. Such professional guiding documents need to be explicit in their handling of EBP, if EBP is to be a priority within program curricula, content delivery, or clinical practice.
Fostering EBP as a priority in nursing and midwifery begins with consistent EBP knowledge and understanding. It is prudent, therefore, to consider the baseline knowledge and understanding of the concept of EBP in these professions, as was the aim of the qualitative question in the national study survey. This had not been done previously in the Irish context. This paper reports these qualitative findings. The quantitative findings from the national study have been reported elsewhere (Cleary‐Holdforth et al., 2021).
A national cross‐sectional study was conducted in nine Schools of Nursing and Midwifery in Ireland, and in their affiliated teaching hospitals.
Two hundred and twenty‐two nursing and midwifery students and 71 educators from 9 schools that were randomly selected from the 13 Higher Education Institutions (HEI) that provide nurse and midwifery education in Ireland, and 292 clinical nurses and midwives from 7 of their affiliated teaching hospitals comprised the national study sample. The sample was stratified according to type of HEI (university or institute of technology), and the five divisions of the NMBI Register for which students undertake pre‐registration programs of study (general nursing, psychiatric nursing, intellectual disability nursing, midwifery, and children's and general nursing). The survey was made available to all eligible participants at each site.
Anonymous surveys were employed to collect data from the three cohorts, students, educators, and clinicians. Results of the quantitative data of the anonymous surveys collected between March and July 2017 via Survey Monkey® have been reported in a prior article (Cleary‐Holdforth et al., 2021). O'Cathain and Thomas (2004) suggested that the inclusion of an open‐ended question on a quantitative survey can offer insight into some of the quantitative findings. It has also been suggested that quantitative survey items represent the researcher's agenda, whereas the inclusion of open questions provides an opportunity for participants to raise issues or questions that are of importance to them (O'Cathain & Thomas, 2004; Stoneman et al., 2013; Vitale et al., 2008). Therefore, to better understand student, educator, and clinician perceptions of the definition of EBP, one open‐ended question was asked at the beginning of the survey, “In advance of completing the questionnaires that follow, could you please take a few moments to explain in your own words what you believe the term ‘evidence‐based practice’ means?”
Participant responses to the single open‐ended question were transcribed into a Microsoft® Word document, organized by participant group, and were read through repeatedly to ensure accuracy. Content analysis was used to analyze the responses. Responses tended to be short and factual, which can make their analysis more challenging than the rich, in‐depth responses more typical of qualitative data (Decorte et al., 2019); consequently, a descriptive approach to content analysis, aimed at identifying the main themes, was taken rather than an interpretative approach. Individual responses were examined, and the process of open‐coding was carried out, breaking down the data phrase‐by‐phrase, and applying labels (codes) that described the content of these phrases. The researcher examined the codes closely to search for common themes. The themes and content analysis were reviewed by the two co‐authors as PhD supervisors to enhance validity and rigor. The qualitative data analysis computer software package, NVivo (version 11), assisted with data management and analysis. Creswell (2009) indicated that qualitative researchers should disclose their own perspective on a subject to help identify how this may have influenced understanding of findings.
I, the principal investigator, have been passionate about EBP for almost 20 years, and I subscribe to Melnyk and Fineout‐Overholt's definition of EBP. I have taught EBP to nurses at under‐ and post‐graduate levels since 2006, and to healthcare professionals generally at “EBP–Ireland,” of which I am a steering committee member. I believe that many nurses and midwives, in both clinical and education settings, believe that they know what EBP is and that their practice is evidence‐based, but that in many cases they are conflating EBP with research utilization. My perspective is congruent with the professional literature. I suspected that knowledge and understanding of EBP was lacking among some nurses and midwives, compounded, I believe, by common usage of the term EBP, leading to the development of much, often inaccurate, discourse about EBP. It is useful for readers to know that this is my lens on EBP, and this is the perspective that served to underpin my analysis of the responses to the open question. It is possible that the lens through which a researcher views a phenomenon also can be a source of bias. It is possible that my lens caused me to see in the data what I had anticipated. This bias is referred to by Morse (2015) as pink elephant bias. It is also called confirmation bias because it fosters interpretation of the data in a way that would support my perspective. To overcome these biases, verbatim quotes from participants were used to substantiate the themes identified and the findings were also discussed in the context of relevant professional literature on the subject in question.
Ethics approval was obtained for the national study from each site's Research Ethics Committee and is reported in a prior article (Cleary‐Holdforth et al., 2021). All data from the survey were unidentified to assure anonymity and confidentiality.
Five hundred and eighty‐five participants completed the survey, of which 402 answered the open‐ended question. This group comprised 59 educators, 188 students, and 155 clinicians. Eight codes were identified from the recurring descriptions of EBP proffered by participants. Table 1 provides the frequency of each code within each cohort. Similar codes or responses containing similar ideas were identified and merged, giving rise to five (1) definitions of EBP, (2) best practice, (3) nurses' and midwives' role in EBP, (4) knowledge, and (5) barriers and facilitators of EBP.
Table 2 illustrates the codes that informed the five themes identified. Verbatim quotes (including typos) from the open‐ended question are presented narratively to substantiate conclusions reached.
Most participants described EBP in terms of, “research led practice/research utilization/proven practice” (75% educators; 66% students; and 68% clinicians), reinforcing the conflation of EBP with research and research utilization in the Irish context, as the following excerpts
In contrast, 11 clinicians (7%), 10 students (5%), and 10 educators (17%) described EBP in the context of its three core
A clear association was found between EBP and “best practice,” as evidenced in these participant
The most infrequently referenced theme concerned nurses' roles in EBP and EBP‐related activities, as illustrated by these
Some clinicians and educators alluded to the knowledge and/or skills needed for EBP. This was not something that students
Descriptions of EBP that indicated little or no knowledge of EBP (i.e., no reference to evidence, research, clinical expertise, or patient preferences/values) were identified, as the following excerpts
While participants were not asked about barriers and facilitators of EBP, a small number of participants alluded to them, perhaps indicating their misunderstanding of the open‐ended question. Barriers were not identified by students or educators. A few clinicians mentioned factors that made EBP difficult, which mirrored factors cited already in professional
In contrast, one educator referred to information technology (IT) support and a librarian as enabling
These findings as part of the national study (Cleary‐Holdforth et al., 2021) substantiated the expected confusion around what EBP is among nurses, midwives, educators, and students in the Republic of Ireland. These findings reinforce similar results from several other studies around the world. For example, Saunders and Vehviläinen‐Julkunen (2016) found extensive confusion among nurses about the meaning of EBP, widely varying interpretations of EBP, and descriptions of EBP that did not reflect accepted definitions. Similar findings are echoed throughout the professional nursing literature (Baker et al., 2014; Carter et al., 2017; Newhouse, 2007; Rycroft‐Malone & Stetler, 2004; Scott‐Findlay & Pollock, 2004; Shirey et al., 2011). Estabrooks (1999) posited that the term evidence‐based practice made its way somewhat covertly into the nursing vernacular and was being used without due consideration of its origins or meaning. Findings from the open‐ended question arguably corroborate this theory.
The dominant misinterpretation of EBP as “research led practice/research utilisation/proven practice” by participants in the national study agrees with the literature (Baker et al., 2014; Carter et al., 2017; Newhouse, 2007; Rycroft‐Malone & Stetler, 2004; Saunders & Vehviläinen‐Julkunen, 2016; Scott‐Findlay & Pollock, 2004; Shirey et al., 2011). The terms EBP and research utilization have often been used interchangeably (Baker et al., 2014; Carter et al., 2017; Cleary‐Holdforth, 2020; Estabrooks, 1999; Fineout‐Overholt et al., 2019; Leufer & Cleary‐Holdforth, 2009; Newhouse, 2007; Saunders & Vehviläinen‐Julkunen, 2016), perhaps laying the foundation for the reported confusion. However, Saunders and Vehviläinen‐Julkunen (2016) argued that the increasing prevalence of EBP in nursing has happened in language only as nurses' employment of evidence, and their teaching of EBP continues to reflect the more traditional focus on research methods and single studies rather than the three core components of EBP and use of pre‐appraised and synthesized evidence. Quantitative findings reported by Cleary‐Holdforth et al. (2021) revealed low EBP implementation across clinicians, educators, and students in the Republic of Ireland, which would support that this understanding is a fundamental challenge to EBP implementation. The qualitative findings from the same study (reported in this paper), attest to poor knowledge and understanding of EBP. This discrepancy could explain, to some degree, the low EBP implementation reported by the same participants. Participants demonstrated a general perception that EBP is “somewhat” central to the philosophy and mission statements of, and “somewhat” practiced in, their organizations. Furthermore, the more supportive of EBP the organizational culture was, the higher the EBP beliefs and EBP implementation (Cleary‐Holdforth et al., 2021). Arguably, an organization supportive of EBP also would support EBP education and training of their staff. Organizational culture, therefore, plays an integral role in the advancement of EBP in nursing and midwifery and represents a repertoire of factors that can be considered carefully and enhanced to expedite this goal.
Poor EBP knowledge among nurses and midwives in the Irish healthcare system may be the greatest obstacle to EBP implementation as it is difficult to implement something one knows little about. Good EBP knowledge and understanding is integral to EBP implementation. Without it, EBP implementation will not materialize. The gap in knowledge identified in this study offers an important starting point and opportunity for education within the three cohorts. In contrast, participant descriptions that referenced improved patient care decision‐making, patient care delivery, practice improvement, and best practice offer a foundation to build upon since these are outcomes of EBP. This entry level affords invaluable opportunity to elevate clinician EBP knowledge to where the goal of EBP implementation can become a reality. Tailored, context‐specific education and interventions are needed. Within each cohort, their respective organizations should work to enhance their knowledge and understanding of EBP in sustainable and meaningful ways, including focused education, integration of EBP values, competencies, and expectations in organizational philosophies, mission statements, and job descriptions. Greater focus and emphasis in guidance documents from professional regulating bodies are crucial to establish the value of EBP, direct its explicit inclusion in program curricula and content delivery, and demonstrate the expectation of its implementation in professional nursing and midwifery practice. Further research using direct measures of EBP knowledge among nurses and midwives, educators, and students would be beneficial.
The findings reported here are analysis of qualitative data collected within a larger study (Cleary‐Holdforth et al., 2021). It is not to be considered or represented as a qualitative study in its own right. A single open‐ended question inviting participants to describe EBP in their own words was included on a quantitative survey. Therefore, it was not possible to validate the data in the same way that data in a qualitative study would be validated. For example, employing measures such as prolonged engagement, persistent observation, member checks, and obtaining thick rich description (Morse, 2015) offer lenses on qualitative data that were not possible with these data. The participants who answered the open‐ended question offered short responses, were entirely anonymous and were not known to the researcher. Therefore, the data provided are a closed set of data and cannot be amended in any way to validate participant responses. As with other qualitative studies, a risk of bias exists due to the researcher's preexisting perspective. This was described earlier and reflected on during the research, and by having the full research team check the analysis.
Four hundred and two participants responded to the open‐ended question posed in this study and their data have afforded a unique, preliminary insight into nurses', midwives', educators', and students' knowledge and understanding of EBP in the Republic of Ireland for the first time. Such novel, unique findings justify the use of open‐ended questions on a quantitative survey and their subsequent dissemination. Furthermore, these findings enhanced the quantitative findings of the national study and provided direction for future research in the area, further benefits of including an open‐ended question on a quantitative study. Participants generally perceived EBP in a positive light, associating it with improved outcomes for patients; however, their knowledge and understanding of how to define EBP is lacking. The findings reveal substantial conflation of EBP with research utilization. Given this fundamental barrier to EBP implementation, the lack of definitional clarity permits confusion about EBP to endure. Going forward it will be crucial to ensure that upon graduation, nurses and midwives possess clear, consistent knowledge and understanding of EBP and can clearly define its purpose and components. “Here” is where the journey toward sustainable, system‐wide EBP implementation can begin.
Open access funding provided by IReL. WOA Institution: Dublin City University.
Cleary‐Holdforth, J. , Fineout‐Overholt, E. & O’Mathúna, D. (2022) How nursing stakeholders in the Republic of Ireland define evidence‐based practice and why it matters. Worldviews on Evidence‐Based Nursing, 19, 396–404. Available 10.1111/wvn.12593