Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke

BACKGROUND AND PURPOSE: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists' implementation of evidence-based practice (EBP) for people with stroke. SUBJECTS: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. METHODS: A cross-sectional mail survey was conducted. RESULTS: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. DISCUSSION AND CONCLUSION: Lack of education, negative perceptions about research and physical therapists' role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.     

Transformational leadership required to design and sustain evidence-based practice: a system exemplar

In a pay-for-performance environment, implementing and sustaining evidence-based practice (EBP) is no longer a luxury but a necessity. A critical driving force for EBP is that our communities-the people we serve-expect to receive care based on the best available evidence. Transformational nursing leadership is required to create an infrastructure that influences organizational factors, processes and expectations, thus enabling the sustainability of EBP. The American Nurses Credentialing Center and the American Organization of Nurse Executives provide a framework for nursing leaders to consider when designing EBP implementation structures. This exemplar illustrates nursing leadership competencies with regard to implementation and sustainability of EBP within a multihospital system.     

Perceived knowledge,skills, attitude and contextual factors affecting evidence‐based practice among nurse educators,clinical coaches and nurse specialists

Evidence‐based practice (EBP) in the clinical setting is recognized as an approach that leads to improved patient outcomes. Nurse educators (NEs), clinical coaches (CCs) and nurse specialists are in key positions to promote and facilitate EBP within clinical settings and have opportunities to advance practice. Therefore, it is important to understand their perceptions of factors promoting EBP and perceived barriers in facilitating EBP in clinical settings, before developing educational programmes. This paper reports findings from a study that aimed to explore NEs' , CCs' and nurse specialists' knowledge, skills and attitudes associated with EBP. This study used a questionnaire containing quantitative and a small number of qualitative questions to capture data collected from NEs, CCs and nurse specialists working at a tertiary health‐care facility in Victoria, Australia. The questionnaire was distributed to a total of 435 people, of whom 135 responded (31%). Findings revealed that the three senior nurse groups relied heavily on personal experience, organizational policies and protocols as formal sources of knowledge. Furthermore, they had positive attitudes towards EBP. However, participants demonstrated lack of knowledge and skills in appraising and utilizing evidence into practice. They indicated a desire to seek educational opportunities to upskill themselves in the process of EBP.     

Increasing nursing research capacity: The roles and contributions of nurse scientists within healthcare systems in the Greater Philadelphia region

PhD prepared nurse scientists within healthcare systems are uniquely positioned to advance nursing science through research and evidence-based practice (EBP) initiatives due to their ability to closely collaborate with nurses and other healthcare professionals in the clinical setting. The purpose of this paper is threefold: 1) to describe the roles and contributions of Nurse Scientists, from their perspectives, in four different health care systems in the Greater Philadelphia area, three of which are Magnet® designated hospitals; 2) to highlight organizational approaches to increase nursing research and EBP capacity; and 3) to explore strategies that Nurse Scientists used to overcome barriers to build nursing research capacity. Nurse Scientists employed in these healthcare systems share many of the same essential roles and contributions focused on developing nursing research and EBP initiatives through education and mentorship of clinical nurses, conduct and oversight of independent research, and dissemination activities. With supportive executive nurse leadership, the Nurse Scientists within each healthcare system employed different strategies to overcome barriers in building nursing research and EBP capacity. Nurse scientists within healthcare settings have potentially powerful positions to generate and apply new knowledge to guide nursing practice and improve outcomes.     

Development of an evidence-based practice questionnaire for nurses

AIM: The aim of this paper is to report the development and validation of a self-report measure of knowledge, practice and attitudes towards evidence-based practice (EBP). BACKGROUND: Evidence-based practice has become increasingly important in health care since the mid-1990s as it provides a framework for clinical problem-solving. However, to date no means exist to quantify the extent to which barriers, such as lack of time in the working day, lack of appropriate skills and negative attitudes, may prevent greater uptake of EBP. METHODS: Questionnaire development was based on established psychometric methods. Principal component factor analysis was used to uncover the underlying dimensions of the scale. Internal consistency of the scale was assessed by Cronbach's alpha. Finally, construct validity was assessed via convergent and discriminant validity. RESULTS: The final questionnaire comprised three distinct scales (EBP, attitudes towards EBP and knowledge of EBP), which had robust validity and internal reliability. CONCLUSION: This tool can be used to measure the implementation of EBP.     

Work-based learning: a leadership development example from an action research study of shared governance implementation

AIM: An empowering action research study was undertaken to evaluate and strengthen the implementation of shared governance. One aim was to identify factors that acted as aids or barriers to effective decision-making by clinical leaders. As a work-based learning approach, action research was expected to lead to integration of learning into practice by researcher and participants alike. BACKGROUND: Shared governance replaces traditional hierarchies and requires and develops clinical leaders. Strategies are needed to maximize learning from introduction of such initiatives at the individual, group and organizational level. METHODS: Participant-observations and interviews were undertaken with shared governance council members from one model in north-west England. RESULTS: Leadership skills and knowledge and shared governance practices were significantly enhanced. Preparation for council roles was considered inadequate. Increased structured time for reflection and action planning was indicated. CONCLUSIONS: Implementation of shared governance has succeeded in developing leadership capacity. Evaluation findings have led to improvements in the overall shared governance model. Action research has been found to have great utility at optimizing work-based learning. Nurse Managers need to develop their coaching and facilitating skills and recognize there is no "quick fix" for developing clinical leaders. Implications include the need to support learners in identifying and implementing changes arising from work-based learning activities, the significant resource implications and the need to optimize the organizational climate if work-based learning approaches to leadership and management development are to succeed.     

Growing leaders in a professional membership organization

shekleton m .e ., preston j .c . & good l .e . (2010) Journal of Nursing Management  18, 662–668
Growing leaders in a professional membership organization Aims This study describes the background, development and delivery of an innovative approach to prepare elected state association leaders for their new leadership roles in their respective state organizations. Background State-based professional associations face unprecedented threats to scope of practice in the current volatile healthcare environment. In 2009 the American Association of Nurse Anesthetists (AANA) began offering a Leadership Development ‘Boot Camp’ for all nurse anesthetist state association presidents-elect designed with the intent of providing the participants with information, resources and tools they need in their new role. Methods An organizational assessment examined the philosophy of and need for leadership development across the entire organizational structure. Results Recommendations from the assessment included the need for intensive leadership development at the state level. A 3-day intensive workshop was designed and implemented. Adult learning theory was used for its development. Conclusions The success of this programme has lead to its implementation as part of leadership development of the AANA. Implications for nursing management Nurse managers and elected volunteer leaders in state-based professional associations face similar challenges requiring sound leadership ability. Principles applied to the development of the AANA programme can be applied to leadership development for new nurse managers.     

Making evidence based practice a reality for mental health nursing

In recent years, efforts have been directed towards making mental health nursing more evidence-based. Making evidence based practice (EBP) a reality in modern health services requires due attention to service planning and management. It is acknowledged that there are many challenges and barriers to implementing EBP as outlined in this article. However, by using an example from our mental health service and drawing upon the literature, we show that a variety of techniques can be used to incorporate EBP into everyday practice. A combination of approaches is recommended, including education and training, leadership programs, research units, dissemination of research findings and structural changes to draw upon the expertise of key clinical, education, management and research staff.     

Building foundations for the future: the NHS Scotland advanced practice succession planning development pathway

currie k. & grundy m. (2011) Journal of Nursing Management 19, 933–942 Building foundations for the future: the NHS Scotland advanced practice succession planning development pathway Aim To highlight implications for managers from the implementation of a national advanced practice succession planning development pathway within Scotland. Background Internationally, advanced practice posts have often developed in an ad-hoc manner, with little organizational attention to succession planning. Evaluation of a pilot national succession planning development pathway identified mechanisms which facilitate or hamper effective planning for advanced practice roles. Methods A responsive evaluation design incorporating semi-structured questionnaires to pathway participants (n = 15) and semi-structured telephone interviews with case-site pathway participants (n = 7) and their line managers. Results Managers believed the development pathway was worthwhile; however, there was limited strategic planning to match individuals’ development to service need. Practitioners generally perceived managers as interested in their development, although levels of practical support varied. There is concern from both managers and practitioners regarding ongoing funding for advanced practice development. Conclusion The present evaluation study reiterates the need for organizational commitment to succession planning including robust service needs analysis mechanisms and adequate funding for development processes. Implications for nursing management Nurse managers are viewed as the ‘gatekeepers’ to opportunities for developing advanced nurse practitioners; scare resources must be targeted effectively to support succession planning through the development of selected individuals for future advanced practice posts, justified by service need.     

Nurses' attitudes to and perceptions of knowledge and skills regarding evidence-based practice

The study evaluated the effect of an evidence-based practice (EBP) educational programme on attitudes and perceptions of knowledge and skills, of registered nurses, towards EBP. The study was conducted using a quasiexperimental interrupted time series design. Participants were clinical nurses in educational and leadership roles within a Health Service District in south-east Queensland. The data were collected using a self-administered questionnaire at three points. Nurses' belief in the value of EBP for practice was high prior to the programme and did not change subsequently. There was an improvement following the intervention in nurses' attitudes to organizational support for EBP and their perceptions of their knowledge and skills in locating and evaluating research reports. Providing educational courses in a clinical setting is useful in improving clinicians' attitudes to and perceptions of knowledge and skills related to EBP.     

Organizational factors that support the implementation of a nursing best practice guideline

BACKGROUND: The context of the healthcare setting may play a crucial role in influencing the implementation of best practice guidelines in nursing. Further study is required to understand these organizational factors. Two variables, organizational culture and leadership, are thought to influence the adoption of best practice guidelines. AIM: A discussion of organizational factors that influence best practice guideline adoption is presented. A small pilot study is provided as an example of methods for further research. METHODS: A quantitative survey of nursing staff was conducted. RESULTS: Results from the pilot study reveal variability in best practice guideline implementation despite the presence of a culture of organizational learning and transformational leadership. CONCLUSIONS: There is beginning evidence in the literature that culture and leadership are key elements influencing guideline implementation. In this pilot work on two inpatient units where a nursing best practice guideline was implemented, a supportive organizational culture and key people leading change were present. Implications for further studies are offered. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leaders interested in promoting the use of best practice guidelines must pay attention to the organizational context in which nursing care occurs. A supportive culture where learning is valued coupled with transformational leadership may be key factors in the implementation and the sustainability of best practice guidelines.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

Evidence-Based Practice in physiotherapy: a systematic review of barriers,enablers and interventions

Background

Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake within physiotherapy has been inconsistent.

Objectives

Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of enhancing adoption and implementation.

Data sources

Literature concerning physiotherapists’ practice between 2000 and 2012 was systematically searched using: Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological Association databases, Medline, Journal Storage, and Science Direct. Reference lists were searched to identify additional studies.

Study selection

Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions in physiotherapy were included.

Data extraction and synthesis

One author undertook all data extraction and a second author reviewed to ensure consistency and rigour. Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions.

Results

Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP.

Limitations

Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication bias. Furthermore, narrative synthesis may be subject to greater confirmation bias.

Conclusion and implications

There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most effective methods of supporting physiotherapists’ adoption of EBP.     

Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project

Purpose: To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers. Methods: The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the “local facilitator” to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters. Results: A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians. Conclusions: Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers.

Implications for Rehabiliation

• Despite increasingly strong evidence for stroke rehabilitation, there are delays in implementation into clinical practice.

• This study showed that lack of time, staffing issues, staff education, therapy selection or prioritization, lack of equipment and team functioning were the main barriers to implementation.

• Managers and stakeholders should consider these barriers and prioritize evidence when implementing.

     

A survey of the uptake and implementation of research evidence by South Australian acupuncturists in clinical practice: attitudes and associated predictive factors

OBJECTIVE: To examine South Australian acupuncturists' attitudes towards the use of research evidence and concurrently identify predicative factors associated with the uptake and implementation of research evidence. METHODS: Questionnaires were mailed out to the entire South Australian acupuncturist population (n=94). The population was divided into two groups, medical acupuncturists (general practitioners or other medical specialists) and non-medical acupuncturists, as previous studies have suggested that clinicians' attitudes to EBP are particular to the clinical setting. RESULTS: The total response rate to the survey was 76.6% (n=72). The difference in response rates between non-medical acupuncturists (90.9%, n=60) and medical acupuncturists (42%, n=12) was significant (p<0.0001). Over half of all respondents had both prior research training and previous research experience. Both groups held positive attitudes to research utilization, the use of research information was considered to be an important component of their professional practice, although they prioritized patient care over both reading research evidence and undertaking primary research. There was no significant difference in research interest between groups. The only predicative factor that influenced research utilization was related to the non-medical acupuncturists period of time in practice; non-medical acupuncturists interest in research (rho=-0.29, p=0.036) declined as they accrued clinical experience. No predictive factors were identified for the medical acupuncturist group. CONCLUSION: South Australian acupuncturists hold favorable views towards research utilization and consider the integration of research evidence into clinical practice as an important component of professional development. Professional associations should implement strategies which capitalize on the respondents' positive attitudes in order to ensure high quality evidence-based care for patients seeking acupuncture.