Implementation of evidence-based practice across medical, nursing, pharmacological and allied healthcare professionals: a questionnaire survey in nationwide hospital settings

Evidence-based practice (EBP) is clinical practice consistent with the current best evidence [1]. Implementation of EBP mainly involves four sequential steps [2]: first, framing a clear question based on a clinical problem; second, searching for relevant evidence in the literature; third, critically appraising the validity of contemporary research; and fourth, applying the findings to clinical decision-making. There are increasing examples illustrating that EBP can help healthcare professionals improve care quality [3‐5]. Implementing EBP by all health professionals is thus needed [6‐10].

Numerous studies have investigated the perceptions of EBP among a variety of healthcare-related professional groups [9‐17]. Overall, most healthcare professionals hold positive attitudes toward EBP but lack sufficient knowledge and skills for implementation. A number of personal and organizational barriers impede EBP implementation [9, 16‐22]. To date, investigations of how health professionals implement EBP in clinical decision-making are still lacking [23, 24].

In regional hospitals of Taiwan, the majority of disease patterns are more complex than in primary-care settings. Health providers in regional hospitals devote most of their time to patient care. Therefore, it is essential to promote EBP among regional hospitals in order to improve the quality of healthcare. Since the beginning of 2007, the National Health Research Institutes (NHRI) has provided EBP-related information resources and promotional activities for healthcare professionals of regional hospitals in Taiwan [25]. Despite the NHRI’s considerable ongoing efforts to encourage implementation of EBP, diffusion into regional hospitals is not yet widespread.

The backgrounds of physicians, nurses, pharmacists, and allied healthcare professionals naturally differ. Little research has focused on comparing the use of EBP among different healthcare professions. For EBP to be fully implemented, it is essential to clarify possible differences among professions. In this survey, we systematically assessed how EBP is perceived among all groups of healthcare professionals. This nationwide study allowed us to compare and contrast various levels of awareness, beliefs, attitudes, knowledge, skills, barriers, and implementation among various professions. The data provide critical evidence that can be used to guide strategies for improving the effectiveness of EBP dissemination.

In this study, we describe perceptions of EBP implementation among medical, nursing, pharmacological, and allied healthcare professionals in Taiwan. Our results demonstrate that a majority of healthcare personnel have favorable beliefs in and attitudes toward EBP. However, their knowledge of and skills in EBP are limited. These findings are in accordance with previous studies of a variety of professional healthcare groups [10, 13‐17, 27‐29]. In addition, our data showed that EBP has not yet widely diffused into all groups of healthcare professionals in Taiwan. The results of this study have clinical implications for healthcare organization leaders and policymakers who wish to disseminate and implement EBP more broadly.

There were important differences related to EBP across the professional groups. Discrepancies among the groups in awareness of, beliefs in, attitudes toward, knowledge of, skills in, barriers to, and behavior regarding EBP were wide. First, physicians and pharmacists were the most aware of EBP. This is likely due to a long history of exposure to and efforts to influence the use of EBP [16]. In contrast, technicians were the least aware of EBP. A similar report from Upton et al. showed that technicians have poor awareness of EBP [12]. In addition, our results identified a number of factors related to an awareness of EBP, such as age and gender. Nevertheless, these factors were exclusively associated with the demographic characteristics of the professions [30]. Second, physicians and pharmacists were more likely to recognize the value of EBP. These findings are generally consistent with results of previous studies [13, 17, 27]. Burkiewicz et al. reported positive views toward EBP in as many as 90% of pharmacists [13]. Furthermore, nurses held the most unfavorable beliefs and attitudes toward EBP; this may have been due to unfamiliarity with EBP [16]. Third, physicians had more sufficient knowledge and skills than the other groups. This may be because EBP is a part of the initial educational training for physicians. Similar studies supported our findings in showing that physicians possess greater capability to implement EBP than nurses and allied healthcare personnel [16, 17]. Fourth, physicians reported implementing EBP the most, whereas nurses and technicians implemented EBP the least. It is possible that clinical roles of physicians, nurses, and technicians are divergent. Physicians need to find evidence based on the best quality and make clinical decisions for the most effective healthcare. In contrast, hospital-based nurses and technicians may rely more on clear directions rather and may have less discretion in medical decision-making.

In addition to examining EBP-related differences among those in different professions, our study highlighted several factors in relation to implementing EBP. First, positive perceptions and high self-efficacy appear to be primary influences on implementation. Other studies similarly indicated that EBP users have more-favorable attitudes toward, knowledge of, and skills in EBP than non-users [23, 31, 32]. Second, a faculty position, educational training, and academic degree are important factors affecting implementation of EBP. Our previous study identified being a faculty member as a significant position from which to search for evidence-based information [33]. Furthermore, our data showed that healthcare professionals with a high academic degree or with educational training more often implemented EBP than those without either of these. Third, deficient knowledge and skills were negative predictors of EBP implementation. Taken together, our data support the importance of providing advanced education and training courses to facilitate the implementation of EBP. Our findings concur with other available literature showing that effective teaching programs can increase behaviors that support EBP implementation [2, 34].

In terms of barriers to implementing EBP, the results of this study are similar to findings in other countries [15, 20, 35, 36]. A lack of time is the most commonly reported personal barrier for healthcare professionals around the world [14, 37‐39]. In addition, insufficient knowledge and skills are significant barriers to EBP [37, 40]. Nevertheless, our data indicated that a number of barriers were unique to organizational settings. In particular, our survey found that language barriers were a significant barrier to our participants. This is supported by our previous survey showing that nurses preferred evidence-based resources to be available in Chinese [26].

There are some limitations to this study. First, this was a self-administered survey, not an audit of actual practice; the results might not reflect the realities of practice under routine clinical care [22]. Second, inaccuracies may have occurred in the questionnaire survey; however, there is no other reliable method for collecting such data on a nationwide basis. Third, the return rate of this questionnaire survey was 59.1%; however, we believe our respondents are a representative sample because their backgrounds were similar to those in our previous surveys [16, 26, 30]. In spite of these limitations, our survey presents several potentially useful findings. Our study differs from previous studies examining information-searching patterns in that we evaluated self-reported EBP-related behaviors in the context of clinical decision-making, which is a vital component in implementing research evidence into clinical practice [22]. To our knowledge, this study is the first survey to systematically assess EBP implementation across physicians, nurses, pharmacists, and allied healthcare professionals.

The significance of the present study stems from its focus on evaluating implementation of EBP in daily clinical practice. We used a large-scale questionnaire survey to compare various levels of perceptions toward EBP among all groups of healthcare professionals. Our data showed that healthcare professionals more often integrate evidence into clinical decision-making when the following characteristics are present: positive perceptions toward EBP, high self-efficacy to perform EBP, educational training for EBP, and having a faculty position and a high academic degree. To the extent possible, education and training that support these factors may help to increase positive beliefs and attitudes regarding EBP, and ultimately, EBP use in practice.