write fron 4 to 8 – Slides 4 – 8 Assessment, Diagnosis, and SMART goal.
Improving
Hand-off
Report
Student Names
Team Name and First/Last Names of Participants
Problem
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Our task is to propose a change that will address these issues.
Report (timing and hand off errors: Unit managers observed that there was miscommunication between staff during shift report. Often times leaving out important patient information as well as taking a significant amount of time to relay the information. Our goal it to offer a change that will address these issues.
Now here is our SWOT analysis starting off with Derrick talking about the strengths.
Majka
“Communication failures compromise patient treatment, care quality, and safety. It also leads to medical errors, the third leading cause of deaths in the United States” (Ghosh, et all., 2015)
“The varying parties and large amount of complex information included in patient handoff reports frequently contribute to informational gaps and omissions in the handoff report that can lead to sentinel events and patient hard” (Staggers & Blaz, 2013)
“Research has identifed handovers as a risky time in the care process, when information may be lost, distorted or misinterpreted (Borowitz et al 2008, Owen et al. 2009, Philibert 2009)
Report (timing and hand off errors): The unit manager of a medical surgical unit has observed that change of shift report takes greater than 45 minutes. In addition, staff has complained that their peers do not include vital data (IV sites, dressing sites, DVT prevention measures….) in report leading to errors, leave patients in disarray, and leave tasks incomplete. Your task is to propose a change that will address these issues.
Increase of errors during patient hand-off report leading to missed information and incomplete tasks
Hand-off report time is taking a greater deal of time
Our task is to implement the use of SBAR as the standard hand-off report between shifts in order to reduce errors and decrease the time spent giving report.
2
SWOT
Strengths:
Multidepartment focus addressing handoff report problems(Robins et al., 2017)
Solutions shorten time taken in report while increasing quantity of pertinent information. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Proven error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness
Use of the tool requires education to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on giving report (Ghosh et al., 2018)
Some staff are unreceptive to change (Robins & Dai, 2017).
Evaluating execution of report can be affected by observer bias (Robins & Dai, 2017)
Opportunities
SBAR is inexpensive as a tool and will earn its cost in education by the reduction of sentinel events (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in SBAR format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018). Threats
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
Some staff are unreceptive to change (Robins et al., 2017).
Evaluating execution of report is subject to observer bias (Drach-Zahavy, 2014)
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017)
Strengths:
Multidepartment focus on addressing problems with handoff report (Robins et al., 2017)
Solutions manage to shorten time taken to give report while increasing the amount of pertinent information given in that time frame. (Stewart & Hand, 2017)
SBAR is supported by the Joint Commision (Stewart & Hand, 2017)
Error reduction due to use of SBAR tool. (Stewart & Hand, 2017)
SBAR is an evidence-based hand-off tool (Eberhardt, 2014)
Weakness (Wendy)
Use of the tool requires education for all staff to reduce user error (Stacey Eberhardt 2014)
Medical personnel have personal bias on how they want to give report (Ghosh et al., 2018)
Healthcare worker disinterest in changing how they give report. (Robins et al., 2017).
Subjective approach to measuring a handover’s strategies might be subject to bias, as participants may behave differently in the presence of an observer.
Opportunities (ashley)
SBAR is inexpensive as a tool and will earn its cost in education by providers by the reduction of sentinel events (each of which carries a high expense). (Stewart, 2017)
Improve patient handoff by implementing an evidence-based handoff tool in Situation Background Assessment Recommendation (SBAR) format (Eberhardt, 2014)
For continued nursing education in standardizing hand-off report (Ghosh et al., 2018).
Threats (Alma)
Due to the variety of the change-of-shift reporting process, the findings of the study may not be applicable across similar settings (Ghosh et at., 2018).
The acuity of patient injury and medical history can increase the amount of time for patient hand-off (Robins, 2017).
Small sample sizes from 2 studies: only one randomized control study (Stewart, 2017) and sample size of 200 handovers in 5 wards in another study(Drach-Zahavy, 2014)
3
Assessment
Inefficient communication during hand off report is a challenge to patient care. (Ghosh, et al., 2018)
Communication error given during report increases risk of poor patient outcomes. (Stewart, 2017)
Hand off communication between medical personnel leads to an increase in medication errors, incomplete tasks, disorder, and eventually poor patient outcomes (Robins et al., 2015)
According to The Joint Commission, communication errors have been among the top three leading root causes of reported sentinel events every year since 2004. (Stewart, 2017)
The information we had gathered from our assessment on giving report overall was –
1. Poor communication leads to poor patient outcome
2. The Joint Commission has stated communication errors has been the top 3 leading root causes of unanticipated major events in the healthcare setting that results in death or serious physical or psychological injury to a client which require immediate investigation by the health care facility since 2004
3. And now we will be talking about our Diagnosis.
Goal should comes from assessments (SMART (MEASURABLE))
Assessment will be bullet points of why is this a problem
Specific, measurable, attainable, realistic, timely
All RNs and assistive personnel will attend 1 or more in-services on the use of SBAR handoff report within three weeks.
During the same three week period, charge nurses and nursing management will include SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
Following the three week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of 1 month with the goal of receiving ideas of how we can improve it from the staff at the end of the 1 month period.
At the end of the one month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas they have to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the 1 month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinal events, falls, nosocomial infections, et al will be compared between the two systems.
Majka
4
Diagnosis
Lack of standardization in report
Communication Barriers (Stewart & Hand, 2017)
Communication practices learned by various career stages of nurses (promise, momentum, harvest)
Different individual communication styles
Gaps in knowledge regarding lack of standardized reporting
A lack of standardization in report increases risk of error and poor patient outcomes
5
S.M.A.R.T. Goal
Use an evidence-based standardized hand-off report tool to reduce report times to less than 45 minutes while reducing report-based errors by 20% within 6-month period.
Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.
Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it.
Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.
Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system.
Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.
Alma
6
Full-Range Leadership Model/Theory
Definition: Focuses on the behavior of leaders towards the workforce in different work situations. (Marquis & Huston, 2011)
Three sub-types
Transactional
Transactions between leaders and followers
Leaders promote compliance to standard SBAR method through rewards and punishments
Transformational
Identifies needed change, inspires, and executes change
Emphasize the importance of reducing errors in patient hand-off through application of SBAR. Our goal is to enhance quality of care and thorough communication.
Laissez-faire
No standard rules
Used when nursing staff and PCTs are efficient with and advocating use of SBAR
Full Range Leadership: Promise, Momentum, Harvest
Wendy
Transactional: Promoting buy-in from nurses and PCTs through encouragement of ideas and discussion while also increasing of stakeholder support of the SBAR method
Theory should apply to what we are trying to accomplish
“this is how we plan to use this leadership style because….”
Why is this theory important for our outcome?
Using more then one theory, where is it applicable?
7
Plan
Following the three-week introduction of SBAR to the staff, SBAR will be implemented on the unit for a trial period of one-month with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
At the end of the one-month period, staff nurses and assistive personnel will be invited to discuss their experiences with SBAR, as well as any ideas to improve it, during pre-shift meetings, down-time during their shift, or via email with the nurse manager.
15 days into the trial month, as well as at the end of the trial month, the nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
At the end of the one-month trial period, metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
During the second month, a new SBAR form that includes select suggestions from staff will be used by those staff members while other staff members continue to use the known SBAR report. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial.
8
3 Weeks
RNs and assistive personnel to attend 1 or more in-services on SBAR handoff report
Following in-service, SBAR teaching in pre-shift meetings, encouraging staff to begin to practice using the SBAR template during report.
1-month trial
SBAR will be implemented on the unit for a trial period with the goal of receiving ideas of how we can improve it from the staff at the end of the one-month period.
15 days into the trial month/ after the trial month
Nurse manager will personally solicit input regarding SBAR from harvest nurses on the unit.
Post 1-month trail
Staff invited to discuss their experiences with SBAR, to share ideas to improve it
Second trial(1 – 3 months)
New SBAR form that includes select suggestions from staff will be used. Communication errors, sentinel events, falls, nosocomial infections, et al will be compared between the two SBAR report templates at the end of a one-month trial. Then again at the end of three months.
Metrics on sentinel events, falls, nosocomial infections, and other communication errors will be compared with the month prior to SBAR implementation and to the same month in the previous year.
References
Drach-Zahavy A ; Hadid N. Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift. J Adv Nurs. 2015; 71: 1135-1145
Ghosh, K., Curl, E., Goodwin, M., Morrell, P., & Guidroz, P. (2018). An Exploratory Study on how to Improve Bedside Change-of-Shift Process: Evidence from One Hospital Using Technology to Support Verbal Reporting. HICSS.
Marquis, B.L., & Huston, C. (2011). Leadership roles and management functions in nursing: Theory and application (9th ed). Lippincott, Williams, Wilkins. ISBN: 978-1-4963-4979-8
Robins, H., & Dai, F. (2015). Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care. AANA journal, 83 4, 264-8.
Stewart, Kathryn R., “SBAR, communication, and patient safety: an integrated literature review” (2016). Honors Theses. https://scholar.utc.edu/honors-theses/66
RESEARCH ARTICLE
Implementation of evidence-based practice:
The experience of nurses and midwives
Asrat Hailu DagneID*, Mekonnen Haile Beshah
Department of Midwifery, Debre Tabor University, Debre Tabor, Amhara Region, Ethiopia
* 1221Asrat@gmail.com, asrahail@dtu.edu.et
Abstract
Background
Implementation of evidence-based practice in clinical practice is crucial. Nurses and mid-
wives play a vital role in using updated evidence. However, limited support and barriers to
implementing evidence-based practice hamper the use of up-to-date evidence in clinical
decision-making practice. Therefore, this study aimed to explore the implementation of evi-
dence-based practice of nurses and midwives working in public hospitals.
Methods
A qualitative descriptive study was conducted to explore the experience of implementing
evidence-based practice among nurses and midwives working in public hospitals. A total of
86 participants, of which, 25 in-depth interviews, 5 FGDs having 47 participants and 14 par-
ticipants were involved during observations, were considered in Amhara Region public hos-
pitals from November 17, 2019 to April 25, 2020. The observational data, interview and
FGD transcripts were imported into NVivo 12 plus to manage and analyze the data using
the Computer-Assisted Data Analysis Software Program (CAQDAS). The data were ana-
lyzed through thematic content analysis.
Results
Nurses and midwives perceived that implementation of evidence-based practice is the use
of research findings, guidelines, hospital protocols, books, and expert experience in clinical
decision-making practice. However, there was limited support for the implementation of evi-
dence-based practice by nurses and midwives. The lack of knowledge and skill to use evi-
dence like research findings, time mismanagement, the lack of motivation, the lack of
resources and training were the perceived barriers to the implementation of evidence-based
practice. Stick to the traditional practice due to lack of incentive and unclear job description
between diploma and BSc nurses and midwives were the perceived causes of the lack of
motivation.
Conclusions
The experience of evidence-based practice of nurses and midwives indicated that there was
limited support for the implementation of evidence-based practice. However, research
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OPEN ACCESS
Citation: Dagne AH, Beshah MH (2021)
Implementation of evidence-based practice: The
experience of nurses and midwives. PLoS ONE
16(8): e0256600. https://doi.org/10.1371/journal.
pone.0256600
Editor: Tareq Mukattash, Jordan University of
Science and Technology, JORDAN
Received: February 25, 2021
Accepted: August 10, 2021
Published: August 27, 2021
Copyright: © 2021 Dagne, Beshah. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its S1 and S2 Files.
Funding: This study was funded by the Center for
International Reproductive Health Training
(CIRHT). The funder is not listed in the FundRef
Registry and there is no award number/grant
number. The funding body had no role in the study
design and collection, analysis, and interpretation
of data and in writing the manuscript.
Competing interests: The authors declare that they
have no competing interests.
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findings were rarely used in clinical decision-making practice The Knowledge, attitude
towards implementing evidence-based practice, lack of resources and training, time mis-
management and lack of motivation were the barriers to the implementation of evidence-
based practice. Therefore, the promotion of adopting the implementation of evidence-based
practice and training on the identified barriers are mandatory.
Background
Implementation of evidence-based practice (IEBP) refers to the use of best, valid, currently
available and relevant research findings, expert opinion, standard guidelines and books in clin-
ical decision-making practice [1]. IEBP improved quality healthcare and client outcomes in
the care setting like reducing patient pain, hospital stay and ulcers due to pressure [2]. There-
fore, future research needs to explore ways to foster the documentation of evidence-based
practice (EBP) interventions more effectively. Nurses and midwives who have higher educa-
tional status, and management and service provision experience can reduce barriers to the
IEBP. Thus, IEBP achieves quality health care through knowledge, skill, the experience of
health service providers, collaborative decision making and good time management [3].
The best, valid, currently available, and relevant research findings were rarely used in
healthcare and clinical decision-making practice [4]. Nurses and midwives use experienced-
based knowledge, and their observations, colleague and other collaborators’ support in prac-
tice without considering best and current evidence [4]. International and national organiza-
tions have enhanced IEBP for the standard of quality health care service. IEBP is essential to
meet patient safety and quality health services. It is also vital to increase formal and informal
health information, treatment expectation, and patient role related to clinical decision-making
practice [5]. Several standard guidelines, books, primary research and systematic review results
are produced continually [6].
The uptake of EBP by updating knowledge, skill and attitude of nurses and midwives
improved the advanced practice of nurses and midwives through role modeling, training,
problem-solving and facilitating change [7]. However, nurses’ and midwives’ education for
master’s and Ph.D. holders is not common even in European countries like France to imple-
ment evidence-based in clinical and healthcare practice, and research is conducted and is well
known to use it for clinical decision-making practice in higher educational institutions [8].
Worldwide, the quality of research and standard guidelines engaging in evidence-based behav-
ior is low. In addition to this, most factors influencing IEBP are not well identified and there is
a call for further research to be done globally [9]. The study conducted in South Africa indi-
cates that the use of evidence like research, standard guidelines and books require time and
perseverance from international researchers and stakeholders together with a readiness by
local researchers and stakeholders to take and actively promote IEBP in clinical and healthcare
practice [10].
IEBP involves solving complex problems that are basic in healthcare [11]. Nurses and mid-
wives have to address IEBP gaps through the insertion of the evidence into clinical practice,
i.e., research findings, currently updated experts opinions, standard guidelines, and books. To
fulfill this proposed role, they have to prepare their clinical expertise [12]. Studies suggested
that IEBP is intervened by an interplay between the individuals, the new knowledge, and the
actual context in which the sources of evidence are to be organized and utilized in daily prac-
tice [13, 14]. In addition to this, IEBP should be locally evaluated and the evaluation results
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must be made actionable and usable, and adapted to the local situations to get the best-needed
outcomes [15–17].
There is a paucity of literature that explores nurses’ and midwives’ experiences towards bar-
riers and supporting factors of IEBP in Ethiopia. The study’s findings will serve as a baseline
for measuring and monitoring change in IEBP readiness following a tailored educational and
organizational intervention. Therefore, this study was designed to explore the IEBP of nurses
and midwives, barriers and supporting factors that affect the implementation of evidence-
based practice among nurses and midwives.
Methods
Study design and setting
A qualitative descriptive study was engaged from November 17, 2019 to April 25, 2020 to
explore the experience of IEDBP among nurses and midwives working in Amhara Region
Public Hospitals. Three specialized hospitals (Debre Birhan, FelegeHiwot, and Gondar), four
general hospitals (MehalMeda, Motta, Debark, and FinoteSelam) and eighteen primary hospi-
tals (Dembia, Durbetie, Deneba, Debre Sina, ShoaRobit, Feres Bet, Ataye, Adet, Addis Alem,
MekaneEyesus, Addis Zemen, Merawi, Burie, Wogera, Delgi, Nefas Mewcha, Wogeda,
andMetema) were involved in the study.
Participants, sampling and recruitment
A total of 86 participants were considered for the in-depth interview (8 key informants and 17
interviewees), five FGDs (47 participants) and fourteen observations were conducted. The key
informants included three hospital managers, two medical directors and three case managers
(masters in emergency surgery and obstetrics). Each focus group discussion (FGD) consisted
of eight to twelve participants. A checklist was employed to observe nurses’ and midwives’
roles, and the availability of resources/materials used for EBP in the fourteen hospitals. Nurses,
midwives, doctors and masters in the emergency surgeon and obstetric participated in the in-
depth interview. Nurses and midwives participated in FGDs. Name of nurses, midwives, doc-
tors and masters in the emergency surgeon and obstetric was coded for the participants of the
interview (101–125), FGD1 (FGD1-01 to 9), FGD2 (FGD2-01 to 10), FGD3 (FGD3-01 to 10),
FGD4 (FGD4-01 to 08), FGD5 (FGD5-01 to 10) and observation (H101- H114) (see S1 File).
A purposeful sampling strategy was used to select hospital managers, medical directors and
case managers who have leadership roles as key informants. A similar strategy was used to
select nurses and midwives for participation in the interview, FGD and observation. Partici-
pants who give optimal insight into the implementation of evidence-based practice were
recruited through the hospital managers and the heads of department, and their contact details
were obtained. Due to the busy schedule of participants, a pragmatic approach was favored to
get them for the interview and FGD. A calendar invitation was subsequently sent out inviting
the professionals to participate, and all agreed.
Data collection
The theoretical framework of Klein and Knight was used as the basis of the FGD and interview
guide [18]. The in-depth interview and FGD guides and checklist for observation were devel-
oped by reviewing literature and feedback of experts in IEBP. The theoretical framework con-
sisted of factors enhancing and challenging the IEBP. IEBPs established by an organization,
shared perceptions of the IEBP, a supportive organization to IEBP, the availability of resources
and a learning organizational knowledge and skill development were enhancing factors.
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However, unreliable evidence, lack of knowledge and skill, time mismanagement, lack of moti-
vation, the decision to adopt and implement an innovation made by higher up in the hierarchy
than the innovation’s target users and lack of commitment are the challenges of implementa-
tion of evidence-
based practice.
The interview and FGD guide were divided into four sections i.e. Socio-demographic vari-
ables, perceptions towards IEBP, perceived barriers of IEBP and supporting factors for I
EBP.
The in-depth interview and FGD guide were also prepared first in English then translated to
Amharic and retranslated back to English for consistency. Eight data collectors (research assis-
tance) who had the educational status of master and Ph.D. with previous qualitative data col-
lection experience were selected. They were trained to be familiar with the objective and the
methodology of the research. Data were collected via FGD and face-to-face interview tech-
niques using semi-structured questionnaires. Good communication started with the greeting
and the ground rule had been set before the focus group discussion started. The interviews and
FGDs took place in separate rooms at hospitals that guarantee good communication. The
interview duration was between 45 minutes and 60 minutes and the FGD duration was 90
minutes to 120 minutes. Moreover, the data collectors were engaged in participatory observa-
tion using a checklist. The participants’ emotions and non-verbal communication were
recorded as field notes. The interviews and FGDs were audio-recorded and then later tran-
scribed for analysis. Saturation was determined when there were multiple overlapping
responses across participants.
Data analysis
Interview and FGDs data were captured using voice recorders, and each day field notes
were transcribed verbatim first in Amharic and then translated into English and retrans-
lated back to Amharic by interviewers and FGD data collectors each day to check for consis-
tency. The transcripts were read repeatedly and checked independently by investigators for
confirmation. Initially, the observational data, and interview and FGD transcripts were
imported into NVivo 12 plus to manage and analyze the data using the Computer-Assisted
Data Analysis Software Program (CAQDAS). The data were analyzed through content anal-
ysis. First, a list of codes was created and described. Then after adding and defining the con-
cept, categories were developed. The number of categories was reduced by” collapsing those
that are similar or dissimilar into broader higher-order categories” [19]. Finally, the codes
were ordered into essential categories, and the main contents and categories were identified.
Moreover, essential quotations were clustered. The quotations were used to elaborate on the
context that affects the participants’ experience and how the participants experienced the
events.
Trustworthiness
The investigators, research facilitators, nurses and midwives expert were invited to review
the study’s findings and the right idea that represents their point of view was taken for the
study to maintain credibility. Dependability was addressed by analyzing all the observational
data, and interview and FGD transcripts by at least two researchers with a third “checker” to
ensure consistency across the data analysis process. Moreover, the investigators and research
facilitators discussed the emerging categories from the dataset and resolve any different per-
spectives by foraging consensus on interpretation. The decision of transferability of the find-
ings to a new set of situations depend on the contextual information provided by the
investigators.
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Ethics approval and consent to participate
Ethical approval was obtained from the Ethical Committee of Debre Tabor University, health
Science College and we communicated it to Amhara Region Ethical Review Board. A formal
letter of cooperation was written for Amhara Region Public Hospitals and permission to con-
duct the study was obtained from the hospital and the unit managers. Participants were
informed that they had the right to withdraw from the study at any time. Moreover, we
informed the purpose, procedures, advantages and disadvantages. Finally, informed written
consent was obtained from each study participant.
Results
The participant’s ages ranged from 21 to 50 years, and their mean age was 31 years. Thirty-
eight participants were married and thirty of them were single. Sixty male and twenty-six
female participants have participated in the study. The work experience of the participants ran-
ged from 1 year to 34 years and its mean was seven years. Of the total 86 participants, 46
(53.5%), 32(37.2%), 8 (9.3%) were nurses, midwives and key informants respectively. Five MSc
nurses, forty-one BSc nurses, three MSc midwives and twenty-nine BSc midwives participated
in the study. In terms of participants’ positions, six head nurses and three head midwives par-
ticipated in the study. Two medical directors, three hospital managers, three quality health
care cordinators, and three case managers also participated in the study.
The data analysis of observation, FGD, and interview produced four themes. These four
themes were the perceptions towards implementing EBPe, the nurses’ and midwives’ attributes
the supporting of nurses and midwives for the IEBP and the perceived barriers to implement-
ing EBP. The four themes were further subdivided into eleven subthemes. Of which, four sub-
themes were included under the nurses’ and midwives’ attributes, three subthemes were
included under the supporting of nurses and midwives for IEBP and four subthemes were
included under the perceived barriers to implementing EBP.
The perceptions towards the IEBP
This is the theme defined as the awareness of participants towards the IEBP. The interviewees
and FGD participants perceived that IEBP is using research findings, guidelines, hospital pro-
tocols, books, and experts’ experience during health services, particularly in clinical decision-
making. One of the interviewees describes the perception towards the IEBPe like this:
“First of all, evidence-based practice is the use of hospital protocols, guidelines and training
manual for health care service especially when we give patient care and do procedures. It is a
matter of reading books and search for research findings. It is also to get updated information
during morning sessions and seminar presentations from experts’ experience (119).”
Another focused group discussion participant expressed his perception as follows:
“I understand that EBP is the use of scientifically proved evidence in the health service. It is a
means of clinical practice based on rules and follows the scientific procedure (FGD5-02).”
The nurses’ and midwives’ attributes
The nurses’ and midwives’ attributes are personal attributes that affect the ability to implement
EBP. The nurses’ and midwives’ attributes include knowledge, skill, attitude and experience in
IEBP. Knowledge, skill and attitude indicate the credibility of nurses’ and midwives’ expertise
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in implementing EBP. However, nurses and midwives felt that they did not have the knowl-
edge, the skill and the attitude to implement EBP. Further, they could not differentiate quality
research. This was described by one of the interviewees:
“I am working in all wards and my colleagues too. . .. I do not expect knowledge and skill at
the competency level to use evidence like standard guidelines, books and research findings. I
do not think that we have the knowledge and the skill to perform every procedure using evi-
dence particularly quality research. Some of the nurses and midwives may not be positive to
read the evidence. They are negligent in using evidence (121).”
The observation of BSc midwife using a checklist revealed that there were challenges to per-
form tasks without difficulty. Skilled delivery was attended without the steps of procedures.
The skill and getting ready to perform the procedure were the practical challenges (H111).
Experience in IEBP
Experience in IEBP is the subcategory of nurses’ and midwives’ attributes. It is participants’
experience in using evidence such as standard guidelines, hospital protocols, experts’ opinions,
books and research findings. Nurses and midwives use guidelines and hospital protocol for
their day-to-day activities. Sometimes, they read books to increase their confidence in clinical
decision-making practice. However, they use research findings to provide health services
rarely. The experience of nurses and midwives in IEBP was stated by one of the FGD
participants:
“You see, implementation of evidence-based practice is beneficial. Medicine is updated every
time. Evidence that we use today may not work for tomorrow. Most of the time, I use guide-
lines and hospital protocols. However, I didn’t use a research article. Even if, there is an off
library in our hospital, we refer to some books. We know our job is teamwork and there is sup-
porting and sharing ideas between team members (FGD4-03).”
The supporting of nurses and midwives for IEBP
The theme ‘the supporting of nurses and midwives for IEBP’ included the subthemes ‘the sup-
portive organization to implement EBP’, ‘the support from Non-governmental Organizations
(NGOs) and other stakeholders to implement EBP’ and ‘the supportive supervision, monitor-
ing and evaluation of IEBP’. The support for nurses and midwives to implement evidence-
based practice and managers’ role in supporting organizations affect the ability to implement
EBP.
Supportive organization to implement EBP
Nurses and midwives’ managers and ward heads experienced that they did not support organi-
zations to implement EBP. However, they understand that supportive organizational resources
like electronic journals, work-based libraries, books and research findings had an impact upon
IEBP. This was described by one of the interviewees:
“I ask chief manager, “how to implement evidence- based practice through training and fulfill
resources in the hospital?” I did nothing beyond this. I cannot communicate with higher offi-
cials and other stakeholders outside this hospital. The chief manager can do this. I understand
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using guidelines, books, hospital protocols, training manuals and experts’ opinions to improve
quality health care. (124).”
There should be a strong supportive organization for the existence of the IEBP. However,
nurses and midwives felt no support and commitment in using updated guidelines, journals
and protocols. This was described by one of the FGD participants:
“Updated evidence like guidelines, hospital protocols, books and journals should be available
to apply the evidence-based practice. I do not think that we are using updated guidelines and
hospital protocols. As a nurse and midwife, commitment is essential. We have to support each
other and get support. I do not remember this was done practically (FGD3-06).”
NGOs’ and other stakeholders’ support for IEBP
One cannot expect the IEBP without the support of both local and international stakeholders.
Non-governmental organizations like the world health organization, the health bureau and the
Ethiopian ministry of health support hospitals by providing training for nurses and midwives,
distribution of guidelines and training manuals. However, the NGOs’ and other stakeholders’
support for implementing EBP is still inadequate. There is no training considering research
findings to use in clinical decision-making practice and healthcare. One of the labor and deliv-
ery ward head midwife describe the stakeholders’ support as follow:
“There are NGOs like CDC, World Vision and Gender Health Ethiopia that provide short-
term training and different guidelines. These organizations did well but it is not adequate sup-
port. We use these updated guidelines. Nevertheless, there is a big gap in using research articles
and there are no supporters to use it (105).”
The supportive supervision, monitoring and evaluation of IEBP
Mentoring and supportive supervision, control and evaluation were identified in all FGD and
interview participants to change IEBP. One of the interviewees stated his experience:
”What do you mean? How could we change without the mentoring and supervision of the
IEBP? I understand that it is important. However, there is no direct mentoring and supportive
supervision, control and evaluation of nurses’ and midwives’ use of guidelines, books and
manuals. We do it indirectly. I do not expect something good towards the use of research in
our clinical settings (112).”
The perceived barriers to IEBP
The theme ‘the perceived barriers to IEBP’ involved the subthemes ‘knowledge and skill’,
‘insufficient time’, ‘lack of resource and training’, and ‘lack of motivation’. The data analysis of
interview, FGD, field note and observation identified the barriers of IEBP.
Insufficient time
All the study participants described that shortage of time was a barrier to implement EBP. One
of the emergency ward head nurses described this barrier as follow:
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“We do not have any plan of implementation of evidence-based practice because of emergency
activities. We work for 24 hours. We are too busy. We can get different pieces of evidence from
the library. However, we cannot go to the library due to a lack of time in this emergency ward.
Nurses are few compared to emergency activities. Nurses are working continuously. They are
strong. Nurses do not use evidence because of the workload. As I told you, we have a shortage
of time. I have no time to read books. There is tiredness. We sleep, when we get time. We can-
not consider anything rather than this because of a shortage of time (111).”
Lack of resources and training
The data from FGD, interview, field note and observation indicated that participants did not
implement EBP because of a lack of guidelines, hospital protocols, books, research articles and
training. One of the key informants described the condition:
“Nurses and midwives use guidelines, books and hospital protocols. However, it is not easy to
get books, guidelines and recent research. Nurses and midwives do not understand the best
research findings. They do not have the skill to use it and we need training. We cannot get
updated guidelines and manuals for most of the procedures (122).”
During the hospital visit, the observation revealed that most of the procedures did not have
guidelines and hospital protocols and there were no books and literature in the ward. More-
over, most of the hospitals had no library, computers and internet access in the wards. The
nurse claimed the nonuse of these resources (H105).
Lack of motivation
The majority of interviewees and FGD participants believed that motivation is one of the driv-
ing forces of implementing EBP. They describe personal derive and motivation to change the
IEBP. It is impossible to change the existing EBP of health care and clinical decision-making
without personal drive and motivation. This was described by one of the key informants:
”Let me tell you the real history of an educated patient and doctor. The doctor has been a long
time in the hospital. He was frustrated and he was as he had been graduated from college.
There was no incentive for him to do his job and negligence is his habit which does not lead to
a good attitude. The patient knows the doctor very well. The patient got this doctor during the
examination, and the patient said that no. . .he did not read anything about his profession
after he had been graduated. The patient went to another doctor who was working in the uni-
versity thinking that he read many books and articles. Similarly, nurses and midwives were
not motivated to update themselves through reading books, guidelines and research articles.
They stick to traditional practice (108).”
Nurses and midwives blamed that having unclear job descriptions decrease their interest
and motivation in doing their job. One of the participants stated that an unclear job descrip-
tion decreases motivation to implement EBP.
“There are no job descriptions of MSc, BSc and diploma nurses and midwives. There is no
clear demarcation of job descriptions among nurses and midwives based on the level of educa-
tion. You see here, this is a matter of morals. I feel less interested when I am always doing the
same job of diploma (101).”
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Discussion
This study presented that the participants’ perception towards IEBP, the nurses’ and midwives’
attributes, the supporting of nurses and midwives for IEBP, and the perceived barriers of IEBP
were the main themes of analysis. The participants had an understanding of how to implement
EBP. The supporting of nurses and midwives to implement EBP indicates quality healthcare
and working for safe patient care [2, 20]. Barriers to IEBP of nurses and midwives were the pri-
mary concern in the experience of IEBP [21, 22].
In this study, participants were seen to perceive the concept of IEBP. They understood that
IEBP was using different types of evidence as a source of knowledge and skill in clinical deci-
sion-making practice and healthcare service. They know which types of evidence they used fre-
quently. Commonly, participants use guidelines, hospital protocols and training manuals for
clinical decision-making practice in our study conducted among nurses and midwives work-
ing in Amhara Region public hospitals. The studies conducted in Ghana and England were in
line with this finding which indicated participants’ understanding of IEBP [7, 20]. However,
our study findings showed that research was rarely used. This is because of a lack of under-
standing to use research and participants’ trust to use it for IEBP.
This study conducted in Amhara region public hospitals revealed that there was little sup-
port for nurses and midwives to implement EBP, and managers’ and ward heads’ commitment
to support nurses’ and midwives’ IEBP was not successful. Moreover, nurses and midwives use
guidelines and protocols without concern for the update. This finding let us understand the
support for IEBP consisted of all the management team that provided mentorship, delivering
resources and commitment to collaborative activities. This finding agrees with the studies that
reported that barriers and facilitators to EBP occurred at the organization and individual level
[21–24]. The reason could be less support of staff to decrease barriers of IEBP due to lack of
managers’ commitment, poor access of resources and lack of expertise to share updated infor-
mation in all studies with the same finding. Therefore, there should be support where there
were barriers to the IEBP.
This study identified that the barriers to implementing EBP were time mismanagement,
lack of knowledge, negative attitude, lack of motivation, lack of resources and training. These
barriers could be categorized under individual and institution level barriers. Studies conducted
in Canada, Ghana, Germany, Iran, China and Jordan presented these barriers to implementing
EBP [20, 22, 23, 25–27]. However, the perceived causes of these barriers to use guidelines, hos-
pital protocols, books, experts’ opinions and research in our study were different from causes
of barriers to IEBP in other studies. In our study, participants perceived that barriers to imple-
menting EBP stem from the lack of incentive and unclear job descriptions between diploma
and MSc nurses and midwives. Diploma and MSc nurses and midwives were seen to have the
same clinical practice activities because of unclear job descriptions between diploma and MSc
nurses and midwives. Participants had no interest in implementing EBP. Our study findings
also indicated that nurses and midwives did not read books, guidelines and research in clinical
decision-making practice due to negligence in doing the same thing. Otherwise, the USA’s
study revealed that the lack of motivation was common among nurses working for long years
in one health facility which resulted in the loss of interest due to the length of time between
formal academic training and current employment [28].
Denmark’s study also revealed that lack of motivation of nurses presented and the perceived
cause of lack of motivation was failed IEBP due to nobody taking action on the agreed plan
[29]. Otherwise, our study also presented that the participants were inclined to traditional clin-
ical practice. Our study participants think that the use of updated evidence added the burden
or workload to their day-to-date activities. They were negligent and they were not interested.
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They were not motivated. They also wanted incentives and support to implement evidence-
based practice.
Our study revealed a lack of supportive organizational resources to get electronic journals,
a work-based library, and access to books and research. Otherwise, the lack of support pre-
sented in the study of Denmark was non-formalized at the organizational level. Denmark’s
study had no problem of sharing new sources of evidence and consensus decision to use the
new evidence [29]. The possible reason for this difference in this lack of support for both stud-
ies could be better promotion of implementing EBP in Denmark.
One of the outcomes identified as subthemes was “the lack of resources and training.” The
participants had difficulty of getting updated guidelines, books and research findings. They
had a knowledge gap even if they got journals and they wanted training to use research. As far
as our search for other similar studies, no other studies reported this finding.
The strengths and limitations
The study’s major strength is the use of interviews, FGDs and observation data collection tech-
niques that contributed to providing insight into the complexity of IEBP in the health care sys-
tem. The risk of bias was restricted by ensuring privacy for the interviewee and a quiet room to
conduct FGD. This study addresses that IEBP in this study is typically underpinned through
addressing supporting factors for IEBP, perceived barriers of IEBP and the experience IEBP.
The first limitation of this study was the possibility for social desirability bias as the study
was conducted using interview and FGD methods, while nurses and midwives were working
in the hospitals. Moreover, the response of the participants might be inflated or underesti-
mated due to individuals with some interests. Second, this study was conducted in hospitals
where a more advanced human resource dynamic, quality medical service and well-organized
structure were available. Hence, transferability is difficult for health centers and health posts.
Conclusions
The experience of IEBP indicated that there was limited support for IEBP. Nurses and mid-
wives used guidelines, hospital protocol and training manuals in the clinical decision-making
practice. However, the research was rarely used in clinical practice. The knowledge, attitude
towards IEBP, lack of training, time mismanagement and lack of motivation were the barriers
to implementing EBP. The study’s findings will serve as a baseline for measuring and monitor-
ing change in IEBP readiness following a tailored educational and organizational intervention.
To implement EBP and to provide high-quality healthcare, organizational and individual level
support for the IEBP is crucial. Moreover, the promotion of adopting EBP and training on the
identified barriers are mandatory. Future research should be conducted to see the impact of
IEBP on the quality health care.
Supporting information
S1 File. Availability of data and materials. The data set necessary to replicate our study find-
ings as supporting information files.
(DOCX)
S2 File. Tools. The interview, FGD and observation guides used in the study were both
Amharic and English language.
(DOCX)
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http://www.plosone.org/article/fetchSingleRepresentation.action?uri=info:doi/10.1371/journal.pone.0256600.s002
https://doi.org/10.1371/journal.pone.0256600
Acknowledgments
We are thankful to data collectors and all nurses and midwives working in Amhara region
public hospitals for their willingness to participate in the study. We would also like to thank
Debre Tabor University College of health science department of midwifery for the facilitation
of activities of the Center for International Reproductive Health Training and Amhara Region
Health Bureau for giving information on the study population.
Author Contributions
Conceptualization: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Data curation: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Formal analysis: Asrat Hailu Dagne.
Investigation: Asrat Hailu Dagne.
Methodology: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Project administration: Asrat Hailu Dagne.
Software: Asrat Hailu Dagne.
Supervision: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Validation: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Visualization: Asrat Hailu Dagne, Mekonnen Haile Beshah.
Writing – original draft: Asrat Hailu Dagne.
Writing – review & editing: Asrat Hailu Dagne, Mekonnen Haile Beshah.
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