FACULTY KNOWLEDGE, ATTITUDES, AND PERCEIVED BARRIERS TO TEACHING EVIDENCE-BASED NURSING JAYNELLE F. STICHLER, DNSC, FACHE, FAAN,* WILLA FIELDS, DNSC, RN, FHIMSS, SON CHAE KIM, PHD, RN, AND CAROLINE E. BROWN, DED, CNS, WHNP This study measured the knowledge, attitudes, and perceived barriers to teaching evidencebased practice (EBP) among nursing faculty at two schools of nursing with baccalaureate and master's level programs in southwestern United States. Survey instruments included a demographic survey, the Evidence-Based Practice Questionnaire, and the BARRIERS to Research Utilization Scale. Descriptive statistics, Pearson's correlations, and hierarchical multiple regression procedures were employed to analyze the data. The results indicated that master's prepared faculty had significantly higher mean scores in the practice of EBP as compared with doctorally prepared faculty, and although faculty positively viewed EBP, their attitude toward EBP was more positive than their knowledge/skills and practice of EBP. One of the major findings in the study was that traditional research knowledge and skills among faculty does not necessarily translate to a supportive attitude or knowledge of the EBP process or skills in acquiring and appraising evidence. Understanding faculty's knowledge, attitudes, and practice of teaching EBP is a critical step to successfully transforming the school's culture to an evidence-based framework for teaching nursing practice, integrating of EBP content into curricula, and ensuring student mastery and appreciation of EBP. (Index words: Evidence-based practice; Faculty knowledge; Teaching strategies; Barriers to evidence-based practice) J Prof Nurs 27:92 100, 2011. 2011 Elsevier Inc. All rights reserved. EDUCATING THE FUTURE nurse is a daunting challenge, especially providing graduates with skills for lifelong learning. At best, nursing educators hope to graduate new nurses with beginning knowledge of the biological and psychosocial sciences, nursing theory, and patient care competencies; skills in critical thinking and professional judgment; and abilities to access clinical information to support practice. Because of the proliferation of clinical information in publications, Web sites, *Professor and Concentration Chair for Nurse Leadership in Health Systems, San Diego State University, San Diego, CA. Professor School of Nursing, San Diego State University, San Diego, CA. Professor, School of Nursing, Point Loma Nazarene University, San Diego, CA. Evidence Based Practice and Research Liaison, UCSD Medical Center, San Diego, CA. Address correspondence to Dr. Stichler: San Diego State University, 5500 Campanile Drive, San Diego, CA 92182-4158. E-mail: jstichler@aol.com 8755-7223/10/$ - see front matter journal articles, and the internet, the education of registered nurses has included an introduction to research as a part of the baccalaureate curricula. With the publication of several sentinel books such as To Err is Human (Kohn, Corrigan & Donaldson, 2000), Crossing the Quality Chasm (IOM, 2001), and Keeping Patients Safe Page, A. (Ed.) (2004), emphasis on the use of evidence to guide practice has become more commonplace. Responding to the call to improve health-care quality, the (Greiner & Knebel, Eds., 2003) described five core competencies for all health-care disciplines including the use of an evidence-based approach to care, informatics, patientcentered care, quality improvement processes, and interdisciplinary collaboration. Evidence-based process (EBP) has been defined as a decision-making process for patient care that uses the best evidence available combined with practice experience and the patient's own values and preferences to guide patient care (Melnyk & Fineout-Overholt, 2005; Sackett, Straus, Richardson, Rosenbergy, & Haynes, 2000). Evidence-based practice has been recognized by the health-care community as well as by regulatory 92 doi:10.1016/j.profnurs.2010.09.012 Journal of Professional Nursing, Vol 27, No. 2 (March April), 2011: pp 92 100 2011 Elsevier Inc. All rights reserved.
TEACHING EVIDENCE-BASED NURSING 93 agencies as being the gold standard for the provision of safe and compassionate health care to patients. The critical need for nurses to provide EBP has been cited by the Agency for Healthcare Research and Quality (Hughes, 2008) and the Joint Commission (2007) as a critical step in improving health-care quality. Nursing educators can no longer focus entirely on clinical skills mastery and content knowledge, but they must also prepare nurses to develop a spirit of inquiry and skills to search for evidence to support critical reasoning and thinking in their practice. Because faculty shape the future practice of nursing through education and role modeling, it is important that faculty include an evidence-based approach to nursing practice in their work with students (Flesner, Miller, McDaniel, & Rantz, 2006). The purpose of this study was to determine nursing faculty knowledge, attitudes, and perceived barriers to teaching EBP. The study is significant to nursing because there are few studies that have described nursing faculty's perceptions of EBP, and it is important to understand faculty's knowledge, attitudes, practice, and perceived barriers to teaching EBP if we can expect that they will impart an appreciation of EBP and the skills and competencies to engage in EBP by students. To be successful in moving evidence into nursing practice, teaching strategies must include an evidence-based approach across the curriculum in schools of nursing and tactics must address faculty and student perceived barriers and facilitators to the adoption of EBP (DeBourgh, 2001; Gosling, Westbrook & Spencer, 2004; Killeen & Barnfather, 2005). Research Questions This study addresses the following research questions: 1. What is the faculty's level of knowledge, attitudes, and practice of teaching EBP? 2. What do faculty identify as barriers to teaching EBP? 3. What are the relationships among demographic characteristics, perceived barriers, and faculty's level of knowledge, attitudes, and practice of teaching EBP? Conceptual Framework Two theoretical frameworks were used to guide this study: (1) diffusion of innovation theory (Rogers, 2003) and (2) adult learning theory (Knowles, 1978). The diffusion of innovation theory explains that the adoption of new behaviors by recipients of the innovation is affected by the complexity of the task to be learned. Evidence from the literature indicates that faculty and clinical nurses perceive the EBP process to be complex, likely reflecting their level of competence and confidence in acquiring evidence and appraising the findings. Barriers to EBP have included lack of knowledge about statistical analysis and immature skills in searching electronic databases for evidence. Rogers (2003) also postulated that the adoption of an innovation likely will be delayed unless the participants see the relative advantage of the change and its compatibility with existing values and current personal needs, which can be influenced by how the innovation is communicated to the participants. With more emphasis placed on EBP by service than in academia, faculty may not recognize the value of teaching an EBP approach in patient care to students. Knowles' (1978) adult learning theory was also used to guide the study. Knowles' stated that adults learn differently than children and that they are autonomous, self-directed learners who build new knowledge on a framework of life experiences and existing knowledge. Knowles indicated that adult learners must see the relevancy of the material to be learned, since they are goal-oriented and practical in how they will put the material to use in their work. This theory is relevant for this study because some faculty do not see a difference between research methods traditionally taught in schools as compared with teaching EBP and, therefore, do not see the relevance of including EBP content in student learning experiences and assignments. Knowles' theory of adult learning and the Rogers' theory of diffusion of innovation explained the relationships among the variables of interest in this study (Green and Ellis, 1997). The review of the literature focused on studies that demonstrated faculty knowledge, attitudes, practice, and perceived barriers to teaching evidence-based nursing practice and graduate nurses' acceptance and adoption of an EBP approach to their own nursing practice. Review of the Literature While most faculty members demonstrate knowledge and competencies in the traditional research process, many do not have the knowledge, attitudes, or competencies in EBP to include the content in their coursework or student assignments. Barriers and facilitators to the adoption of teaching and practice of EBP in nursing have been identified by researchers (Burke et al., 2005; Ciliska, 2005; DiCenso, Cullum, & Ciliska, 1998; DiCenso, Guyatt, Ciliska, 2005; Estabrooks, Floyd, Scott-Findlay, O'Leary, & Gushta, 2003; Fink, Thompson & Bonnes, 2005; Funk, Champagne, Tornquist, & Wiese, 1991; Melnyk, Fineout-Overholt, Feinstein, Li, Small, Wilcox, & Kraus, 2004). Misconceptions about teaching EBP; lack of philosophical framework for the curriculum, administrative support, mentorship, time, information literacy skills, or resources (financial, limited access to electronic data sources); poor understanding of statistics; and inconsistent basic knowledge and experience with research have been consistently reported as barriers. With a push from nursing service to meet regulatory requirements to constantly improve patient outcomes and Magnet's emphasis on professional nursing practice, faculty are challenged to use an evidence-based approach in their own educational practice and to teach students to appreciate and practice an evidence-based approach to nursing care.
94 STICHLER ET AL Importance of Including EBP in Nursing Curriculum Melnyk et al. (2004) reported that the extent to which clinical nurses (n = 160) implemented EBP was based on their knowledge of EBP (r =.42, P b.0001), involvement in EBP initiatives at work (r =.34, P b.001), and engagement with a mentor (r =.28, P b.003). This study emphasizes the importance of faculty teaching EBP as fundamental knowledge and skills in students' educational experiences. Similarly, an EBP curriculum based on adult learning theory has been correlated with improved skills and behaviors in EBP in nursing students (Chaboyer, Willman, Johnson, & Stockhausen, 2004). To be successful in moving evidence into nursing practice, teaching strategies must include an EBP approach across the curriculum, and school of nursing tactics must address known barriers and facilitators to the adoption of EBP by faculty and student nurses: For learners to grasp the need for integrating EBP principles and to evaluate the transfer of information effectively, the culture must be imbued with EBP (Fineout-Overholt, 2006, p. 145). Embedding EBP into the curriculum facilitates graduate nurses' use of EBP in practice (Chaboyer et al., 2004). Debate has focused on the appropriateness of teaching undergraduate students traditional research process as contrasted to an evidence-based approach of research analysis and critical appraisal skills (Chaboyer et al., 2004). Most agree that instilling basic informationseeking behaviors in students, teaching searching skills, and promoting research utilization are basic competencies for baccalaureate students (Burke et al., 2005; Burns & Foley, 2005; Ciliska, 2005; Feldman, 1996; Killeen & Barnfather, 2005). Not only must students develop an appreciation for the need to search the literature for evidence and examples of best practices to guide clinical decision making, but they must also be taught critical appraisal skills to analyze research methods and findings and to determine the applicability of the evidence to their own situation. Advancing students' knowledge and appreciation of EBP, ensuring competencies necessary to find the evidence, and applying it to practice require innovative teaching strategies beyond the traditional lecture format. Clinical nurses' practice reflects the influence of their education and training, and their appreciation for an evidence-based approach to patient care is often shaped by their faculty's influence and emphasis placed on EBP in their educational experience (Ferguson & Day, 2004). Faculty Attitudes about Teaching EBP Traditionally, faculty members have focused on teaching the research process to both undergraduates and graduate students with some application of research utilization (Stetler, 2001). Most faculty are supportive of teaching EBP, but some may not fully comprehend the differences between traditional research and an EBP approach. Traditional approaches to teaching research have often resulted in the students' lack of appreciation of the research process and an inability to integrate research into their practice to answer pressing clinical questions. The change in focus from traditional research to evaluating evidence for use in nursing practice has created challenges to change traditional teaching methods for clinical and leadership courses (Rosswurm and Larrabee, 1999). Faculty have been slow to adopt the paradigm shift to EBP and have related concerns about the time it takes to integrate these knowledge and skills in an already full curriculum or they indicate their own lack of knowledge and skill in the critical appraisal and statistical interpretation of data (Burke et al., 2005; Burns & Foley, 2005). In a National League of Nursing (NLN, 2006) Nursing Advisory Council's survey, faculty were queried about their perceptions that the NLN Hallmarks of Excellence in Nursing was reflected in their schools of nursing. Findings from the survey indicated that 88% of the faculty believed that their curricula provided experiences that taught students about EBP and prepared them to provide evidence-based nursing care. Seventy percent of the faculty reported implementing innovative strategies to teach EBP to students, and 78% indicated that those strategies were based on evidence. Themes identified in this study were consistent with earlier surveys indicating that technology has influenced the teaching/learning environment and that both students and faculty are continually learning new, innovative ways of implementing an evidence-based approach to patient care. The NLN and other professional organizations are advancing numerous strategies to support the preparation of students for EBP. The intent is to move the majority of schools to using evidence as their pedagogical framework (Ironside & Speziale, 2006). Strategies for Teaching EBP Several authors have outlined a number of strategies to teaching EBP including skills in asking focused clinical questions, searching electronic databases for evidence, critically analyzing the evidence, and determining if the published evidence fits with their clinical situations and justifies making a change in practice (Burnes & Foley, 2005; Killeen & Barnfather, 2005; Levin & Feldman, 2006). Schmidt and Brown (2007) described an innovationdecision process teaching strategy (I-DPTS) that was based on Roger's model of diffusion of innovation used in this study as well. The I-DPTS was a collaborative process between the school of nursing and community hospitals. The four phases consisted of (1) getting started (forming groups, collaborating with each other and the librarian, and identifying clinical problems), (2) implementation (advanced literature search, research article critique, and decisions about best practice), (3) dissemination (oral and poster presentation and preparation of manuscripts), and (4) appraisal of student assignments (peer evaluation of students' research grids, presentations, and an EBP nursing policy). In an evaluation of the I-DPTS, the faculty viewed the process
TEACHING EVIDENCE-BASED NURSING 95 positively and reported that the process facilitated development of students' leadership skills, critical thinking, communication (presentation, conflict resolution, collaboration), and overall professionalism. Student evaluation of the I-DPTS was not as positive as the faculty perspective. Students valued the real-life experience and saw direct application to their practice but struggled with managing group work when not all students' completed their assigned obligations. Although this was frustrating to students, faculty identified the learning opportunities in conflict resolution and problem solving. Overall, the I-DPTS was a useful strategy in teaching baccalaureate students about EBP and provided an experiential method for students to develop competencies to overcome perceived barriers to using research to guide clinical practice. Searching for evidence is a critical competency for EBP as is interpreting the key messages in the article and critically analyzing the articles applicability to clinical situation or current problem (Courey, Benson-Soros, Deemer & Zeller, 2006; Ciliska, 2005; Shorten, Wallace & Crookes, 2001). It has been demonstrated that integrating information literacy and evidence search assignments in the curriculum program enhanced students' competencies and confidence in searching databases and in assessing the usefulness of specific studies (Shorten et al., 2001). Expanding readings beyond the text and lecture materials and using an integrated search approach in class assignments has been viewed as a helpful strategy in advancing students' knowledge and skill in EBP (Burke et al., 2005). Having the students find articles pertinent to the clinical or seminar topic, critique the article, and determine its usefulness in answering a clinical question has been recommended by many (Burke et al., 2005; Burns & Foley, 2005; Ciliska, 2005; Melnyk et al., 2004) as a strategy to enhance undergraduate student skills. Most researchers and educators agree that undergraduate and master's level education should focus on research appraisal and research translation to practice with the doctoral levels focusing on knowledge generation. Building on this foundation, faculty teaching graduate students may expand the assignments to include the requirement for the student to use the information to develop clinical protocols or for leadership students to create an innovation or management change project. Most authors agree that including EBP in the curriculum at all levels of education for nurses is a paradigm shift that is long overdue (Burke et al., 2005, p. 359). Methodology This cross-sectional exploratory study determined faculty knowledge, attitudes, and perceived barriers to teaching EBP. The study was conducted at two schools of nursing (one public and one private) with baccalaureate and master's' level nursing education in the southwestern region of the United States. A convenience sample was recruited from a combined pool of approximately 125 faculty members. Eligible participants included all tenure and tenure track faculty, lecturers, and adjunct clinical faculty. All adjunct nonclinical faculty were excluded, since they only had occasional interaction with clinical classes. Study Instruments A 20-item demographic survey was designed to describe the sample and to control for possible extraneous variables. Two other instruments, the Evidence-Based Practice Questionnaire (EBPQ) and the BARRIERS to Research Utilization Scale, were used to operationalize the concepts of Knowledge, Attitudes, and Practice of EBP and Barriers to Use of EBP. The EBPQ is a 24- item self-report scale that is organized into three subscales with reported internal reliability of Cronbach's alphas of.87 for the total scale and.85 for the Practice of EBP subscale,.79 for the Attitudes subscale, and.91 for the Knowledge/Skills subscale (Upton & Upton, 2006). Construct validity was established by correlating the EBPQ scores using an independent measure of subjects' awareness of EBP, which yielded a moderate and positive relationship between scales (r =.30.40). Discriminant validity was demonstrated with significant differences in the scores between subjects who were involved in a local initiative to advance knowledge of EBP with those who did not participate in the initiative. The BARRIERS to Research Utilization Scale is a 29- item tool with four subscales: (1) Characteristics of the Adopter of Research, (2) Characteristics of the Organization, (3) Characteristics of the Innovation (qualities of the research), and (4) Characteristics of the Communication (presentation of the research). Internal reliability was established with Cronbach's alpha of.80,.80, and.72, respectively, for the first three subscales, and.65 for the last subscale (Funk et al., 1991). Fink, Thompson, and Bonnes (2005) described slightly higher Cronbach internal reliability coefficients in their study, with alphas ranging from.91 to.86. Permissions to use and modify the wording in the directions and items to make the questionnaires specific for this study for the BARRIERS scale and the EBPQ were obtained from both authors of the instruments prior to using them for data collection. For the EBPQ, words in the directions were changed from among health-care professionals to among faculty and from your practice to your teaching practice. For the BARRIERS scale, the words nurse, physician, and staff were change to faculty in each item where the words appeared. Data Collection. After IRB approvals were obtained from both universities, subjects were recruited by describing the study's purpose, design, and methods of data collection at the first faculty meetings of the fall semester at each respective school. The faculty were told that their participation was voluntary and that completion of the study instruments indicated their consent to participate in the study. The introductory/consent letter
96 STICHLER ET AL and the study instruments were distributed to each faculty member at each school with a return envelope attached with instructions to place the completed study instruments into the envelope and into the locked collection boxes located in each school's office. Data Analysis The data were analyzed using SPSS software (version 15.0, SPSS, Chicago, IL). Means, standard deviations, frequencies, and percentages were calculated for descriptive data analyses. To determine the relationship between predictor variables of evidence-based knowledge, attitudes, and practice, post hoc bivariate Pearson's correlational analyses were first performed among these dependent variables and the subjects' independent predictor variables. The level of significance was set at P.05. Subject independent variables included demographic characteristics and four BARRIERS subscales, Characteristics of the Adopter, Characteristics of the Organization, Characteristics of the Innovation, and Characteristics of the Communication. Dummy codes were assigned for categorical variables, such as the highest degree earned and current faculty position, as independent variables. The significant demographic characteristic variables from the bivariate correlational analyses (P.05) were entered into the first step of hierarchical multiple regression model. The four characteristics of BARRIERS subscales were entered into the second step of hierarchical multiple regression models. Hierarchical multiple regression model was employed to separately assess the influence of BARRIERS subscales and demographic variables. Hierarchical multiple regression analyses were performed for each of the three dependent variables. Results Demographic characteristics of the participants are shown in Table 1. A total of 40 faculty members participated in this study; 20 from each institution, for a 31% (40/125) response rate. The majority of the sample (97.5%) was female, between the ages of 28 and 68 years, White (87.5%), and earned their highest degree before 2000 (57.5%). Most of the participants had a master's degree (72.5%) as their highest educational degree and 25% had a doctoral degree. Years of experience as a registered nurse (RN) ranged from 5 to 47 years and as a teacher ranged from 0 to 34 years. Just over half of the participants (57.5%) held a full-time faculty position, and 35% reported that they had never attended an EBP class. Internal consistency reliability for the three EBPQ subscales and faculty mean scores for each subscale were similar to those reported by the original authors (Upton & Upton, 2006) and ranged from.74 to.92. Internal consistency reliability for the four BARRIERS subscales and faculty mean scores were similar to those reported by the original authors (Funk et al., 1991), with a range from.60 to.87. Table 1. Sample Characteristics (N = 40) Characteristic Value University Private 20 (50.0) Public 20 (50.0) Sex Male 1 (2.5) Female 39 (97.5) Age (years), mean (range) 49 (28 68) Ethnicity Black 2 (5.0) White (non-hispanic) 35 (87.5) Asian/Pacific Islander 2 (5.0) Other 1 (2.5) Year of highest degree 1970 1979 1 (2.5) 1980 1989 5 (12.5) 1990 1999 17 (42.5) 2000 2009 17 (42.5) Highest degree earned Baccalaureate (nursing) 1 (2.5) Master's (nursing) 27 (67.5) Master's (other field) 2 (5.0) Doctoral (nursing) 10 (25.0) RN experience (years), mean (range) 26 (5 47) Faculty teaching experience, mean (range), y 9.1 (0 34) Current faculty position Full-time 23 (57.5) Part-time 17 (42.5) No. of EBP None 14 (35.0) 1 4 19 (47.5) 5 9 2 (5.0) N10 2 (5.0) Note. Values are expressed as number (%), unless otherwise indicated. Research Questions Results What Is the Faculty's Level of Knowledge, Attitudes, and Practice of Teaching EBP? Faculty mean scores ranged from 4.86 to 5.64 on a scale of 1 to 7, with 7 being the optimal score (see Table 2). Although each of the subscales used a seven-point response set from a low of 1 to a high of 7, each response set was different. The Practice of EBP used a response set of never (1) to frequently (7), Attitude Toward EBP used a seven-point differential scale, and Knowledge/Skills of EBP used a response set of poor (1) to best (7). The Attitude Toward EBP subscale received the highest mean Table 2. Mean Scores (SDs) and Cronbach's Alpha for EBPQ (N = 40) Subscales Mean (SD) Cronbach's alpha Practice of EBP 4.86 (1.29).90 Attitude Toward EBP 5.64 (1.15).74 Knowledge/Skills Associated With EBP 4.93 (0.77).92 Note. Possible range 1 7, with 7 as the optimal response.
TEACHING EVIDENCE-BASED NURSING 97 Table 3. Mean Scores and Cronbach's Alpha for BARRIERS to Research Utilization Scale (N = 40) Subscales Mean (SD) Cronbach's alpha Characteristics of Adopter 1.91 (0.70).87 Characteristics of Organization 2.23 (0.65).82 Characteristics of Innovation 2.17 (0.47).60 Characteristics of Communication 2.40 (0.68).77 Note. Possible range 1 4, with 4 representing great extent. score, followed by Knowledge/Skills Associated with EBP, and then Practice of EBP. These results indicated that the faculty view EBP positively, although their Attitude Toward EBP tends to be more positive than their Knowledge/Skills and Practice of EBP. What Do Faculty Identify as Barriers to Teaching EBP? Faculty mean scores ranged from 1.91 to 2.40 on a scale of 1 to 4, with 4 being the optimal score (see Table 3). Among the four subscales, the Characteristics of Adopter had lowest mean barrier score (M = 1.91), followed by Characteristics of Innovation (M = 2.17), Characteristics of Organization (M = 2.23), and then Characteristics of Communication (M = 2.40). These results indicated that faculty perceived personal characteristics (Characteristics of Adopter) as relatively low barriers to practicing EBP, whereas the Characteristics of Innovation, Organization, and Communication were perceived as higher barriers to teaching EBP. The communication barriers addressed characteristics related to finding relevant research, understanding statistics, understanding the relevance, and implications for teaching EBP. The percentage of subjects' responses indicating to what extent each of the BARRIERS scale items were either a moderate or great barrier are shown in Table 4. The highest percentage of responses indicated that the Characteristics of Communication subscale was perceived as having the greatest barriers to EBP, followed by the subscales of Characteristics of the Organization and Characteristics of the Innovation. The subscale with the lowest percentage of responses indicating the lowest barrier to EBP was Characteristics of the Adopter. These results suggested that faculty do not see their personal characteristics such as being aware of relevant research, willingness to try new ideas, and value of research for teaching clinical practice as barriers, since fewer than 40% of the participants rated the items in this subscale as a moderate or great barrier. Table 4. BARRIERS Scale Item Responses Subscale Characteristics of the Adopter Characteristics of the Organization Characteristics of the Innovation Characteristics of the Communication Item % Moderate or great barrier Unaware of the research relevant to clinical practice areas 39.4 Isolated from knowledgeable colleagues with whom to discuss the research 38.4 Do not feel capable of evaluating the quality of the research 36.1 Feel that the benefits of changing their classes to EBP model will be minimal 32.4 Are unwilling to change/try new ideas 29.7 There is no documented need to change teaching practices 16.7 Does not see the value of research for teaching clinical practice 12.9 See little benefit for the student's learning 7.9 Does not have time to read research 51.2 There is insufficient time on the faculty role to implement new ideas 47.4 Physicians will not cooperate with nurses' implementation of EBP 46.9 Do not feel she/he has enough authority to change the focus of 45.7 clinical classes to EBP Do not feel that the results are not generalizable to own setting 40.0 The facilities are inadequate for teaching EBP 27.0 Other faculty are not supportive of implementation 22.2 University administration will not allow implementation of 3.2 EBP content into curriculum The research has not been replicated 53.3 The literature supports conflicting results 45.9 The research has methodological inadequacies 31.3 Research reports/articles are not published fast enough 29.7 Is uncertain whether to believe the results of the research 18.2 The conclusions drawn from the clinical research are not justified 5.9 The relevant research is not compiled in one place 62.9 Statistical analyses are not understandable 61.5 Implications for teaching that are not made clear 50.0 The research is not supported clearly and readably 39.4 Research reports/articles are not readily available 36.8 Research is not relevant to a student's learning 18.4
98 STICHLER ET AL Fifty percent or more of the participants rated the following items as moderate or great barriers to practicing/ teaching EBP: (1) access to research in one place, (2) understanding of statistical analyses, (3) generalizable results, (4) volume of available research, (5) lack of replication, (6) time to read research, and (7) lack of clear implications for teaching as barriers. These findings support Knowles' theory that adult learners focus on learning material that they believe to be of value to them, and since they do not see the research as generalizable or have clear implications for practice, learning about and teaching EBP to students may not be a high priority for faculty. The findings also support Rogers' theory, which states that the more complex the subject, the less likely there will be early adopters of the innovation. This study supports previous findings that faculty find searching for evidence and statistical interpretation complex, which may impede their rapid adoption of teaching EBP to students. Faculty indentified other barriers to teaching EBP as (1) insufficient time to read research, (2) lack of research replication to ensure the level of the evidence, (3) underdeveloped skills in finding evidence and interpreting statistics, and (4) lack of generalizability of research findings to their own specific clinical content as moderate to great barriers to EBP. Study participants also rated benefit to student's learning, university administration support for EBP content in the curriculum, and justifiable clinical research conclusions as low barriers to EBP, which supports that faculty have a positive attitude to EBP but may not actually implement teaching EBP to students. What Are the Relationships Among Demographic Characteristics, Perceived Barriers, and Faculty's Level of Knowledge, Attitudes, and Practice of Teaching EBP? Correlations among the demographic variables, EBPQ, and BARRIERS subscales are shown in Table 5. The only demographic variable with a statistically significant correlation to Attitude Toward EBP was the faculty members' highest degree with the master's degree positively correlated (r =.41, P b.05) with Attitude Toward EBP. Surprisingly, the doctoral degree was negatively correlated (r =.43, P b.01) with Attitude Toward EBP. It was assumed that doctorally prepared faculty would have more positive attitudes to teaching EBP, but the findings for this sample did not support that assumption. These findings likely occurred because faculty with master's degree typically work with students in the clinical service settings where EBP is emphasized. Doctoral faculty more often teach the theoretical aspects of the curriculum in the classroom setting. Other significant correlations included a positive correlation between EBP practice and Knowledge/Skills associated with EBP (r =.73, P b.01), suggesting that the more knowledge and skills faculty have about EBP, the more they practice EBP. Table 5 outlines the negative correlations between the BARRIERS subscales of Adopter, Innovation, and Communication and the EBPQ subscales Table 5. Bivariate Correlations Among Variables for EBP (N =40) Practice of EBP Attitude Toward EBP Knowledge/Skills Associated With EBP Age.11.06.24 Years of RN.11.01.23 Years of teaching.09.12.10 Master's degree.14.41.21 Doctoral degree.09.43.22 Part-time faculty.04.05.22 Full-time faculty.04.05.22 No. of EBP classes.22.19.21 attended BARRIER Adopter.60.10.46 BARRIER.40.20.35 Organization BARRIER.55.18.58 Innovation BARRIER.50.19.46 Communication P.05. P.01 of Practice of EBP and Knowledge/Skills associated with EBP, suggesting that the lower the barriers for EBP, the more faculty practice and know about EBP. Table 6 shows the hierarchical multiple regression analysis using the Practice of EBP as the first dependent variable. The doctoral degree explained 0.6% of the variance in Practice of EBP (R 2 =.006). The entry of four BARRIERS subscales in the second step changed the R 2 by.425 (P =.001), resulting in the total R 2 of.431. This indicates that the combination of all predictor variables explained a large fraction (43.1%) of the variance in Practice of EBP. Among the predictor variables, the BARRIER's Adopter subscale (beta =.54, P =.05) reached statistical significance. For the Attitude Toward EBP as the second dependent variable, the doctoral degree explained 15.8% of the variance in Attitude Toward EBP (R 2 =.158). The entry of four BARRIERS subscales in the second step changed the R 2 by.095 (P N.05), resulting in the total R 2 of.253. This indicates that the combination of all predictor variables explained a large fraction (25.3%) of the variance in Attitude Toward EBP. None of the predictor variables reached statistical significance (Table 6). For the Knowledge/Skills associated with EBP as the third dependent variable, the doctoral degree explained 4.5% of the variance (R 2 =.045). The entry of four BARRIERS subscales changed the R 2 by.283 (P.05), resulting in the total R 2 of.328. This indicates that the combination of all predictor variables explained a large fraction (32.8%) of the variance in Knowledge/Skills associated with EBP. None of the predictor variables reached statistical significance (Table 6). Therefore, the results from the hierarchical multiple regression analysis indicate that barriers to teaching EBP as measured by the BARRIERS scale effect the practice
TEACHING EVIDENCE-BASED NURSING 99 Table 6. Hierarchical Multiple Regression Models Predicting Subscales of EBPQ (N = 40) Predictors Practice of EBP Attitude Toward EBP Knowledge/Skills Associated With EBP B SE(B) Beta B SE(B) Beta B SE(B) Beta Step 1 Constant 4.81 0.25.08 5.89 0.20.40 4.84 0.14.21 Doctoral degree 0.22 0.48 1.01 0.39 0.37 0.28 Step 2 Constant 7.52 1.24.07 5.93 1.27.33 6.09 0.80.16 Doctoral degree 0.19 0.44.54 0.84 0.45.38 0.28 0.29.43 BARRIER Adopter 1.11 0.45.38 0.70 0.46.24 0.54 0.29.40 BARRIER Organization 1.02 0.55.15 0.58 0.57.12 0.65 0.36.23 BARRIER Innovation 0.51 0.61.34 0.39 0.63.19 0.49 0.40.19 BARRIER Communication 0.69 0.41 0.34 0.42 0.24 0.27 R 2 =.006 for step 1 R 2 =.158 for step 1 R 2 =.045 for step 1 ΔR 2 =.425 for step 2 ΔR 2 =.095 for step 2 ΔR 2 =.283 for step 2 ΔF(4, 31) = 5.778 ΔF(4, 32) = 1.013 ΔF(4, 33) = 3.471 P.05. P.001. of teaching EBP more than the Knowledge and Skills or Attitudes toward EBP. This is an important finding since it is the practice of teaching EBP to students that is most critical in their developing an appreciation for EBP and adopting an EBP approach to care in their nursing practice. Discussion and Recommendations The results of this study supported previous studies describing perceived faculty barriers to teaching EBP (Burke et al., 2005; Burns & Foley, 2005; Ciliska, 2005; Chaboyer et al., 2004). Although the faculty in this study had a positive attitude about EBP, they did not rate their knowledge and skills and practice of EBP as positively. Barriers cited by faculty to incorporating EBP in their practice included (1) characteristics of the organization (support, resources, and time), (2) the innovation itself (research methods, statistical analysis), and (3) communication of research findings. These findings suggest that continuing education for faculty on the EBP process is necessary to enhance faculty knowledge and skills in acquiring appropriate research relevant to the subjects they are teaching and in understanding statistical analysis. Specific EBP content should include developing a clinical question, information literacy skills to gather evidence that answers the questions, and statistical content such as odds ratios, relative risk, and number needed to treat. These EBP skills were not generally taught in academic programs prior to 2000, when most of the faculty received their highest academic degree. As faculty increase their knowledge and skills with EBP, they likely will see more opportunities to incorporate these practices in teaching their courses and student activities. Limitations Only two schools of nursing in the same geographic area were included in the study, and a convenience sampling technique that resulted in a small sample size limited the generalizability of the study. Neither of the schools of nursing have a doctoral program, although both schools have an undergraduate and master's degree programs, which may have also affected the findings. Feedback from participants indicated that the BARRIERS scale was difficult to understand, which may have affected their responses and the findings of the study. It is uncertain how other instruments measuring the same concepts in the study would have affected the findings. Conclusions This study adds new information about faculty knowledge, attitudes, and perceived barriers to teaching EBP to nursing students, and it cannot be assumed that faculty who know research will know how to teach EBP to students. Traditional research skills are not directly transferable to knowledge or teaching of EBP. Since regulatory agencies and professional practice settings support EBP in practice, it is incumbent on nursing faculty to attain these skills and integrate the concepts into clinical courses. Further research is needed to explore the effectiveness of faculty education on the faculty's integration of the EBP process into course content, assignments, and students' clinical learning experiences as well as into the faculty's professional practice. Acknowledgments This study was funded in part by Gamma Gamma Chapter, Sigma Theta Tau International. References Burke, L. E., Schlenk, E. A., Sereika, S. M., Cohen, S. M., Happ, M. B., & Dorman, J. S. (2005). Developing research competence to support evidence-based practice. Journal of Professional Nursing, 21, 348 363. Burns, H. K., & Foley, S. M. (2005). Building a foundation for an evidence-based approach to practice: Teaching basic
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