Identifying barriers to evidence-based practice adoption: A focus group study

www.sciedu.ca/cns Clinical Nursing Studies 2015, Vol. 3, No. 2
ORIGINAL ARTICLE
Identifying barriers to evidence-based practice
adoption: A focus group study
Leilani Tacia ∗1, Karen Biskupski1, Alfred Pheley1, Rebecca H. Lehto2
1Allegiance Health System, Jackson, MI, United States
2Michigan State University College of Nursing, East Lansing, MI, United States
Received: January 3, 2015 Accepted: January 28, 2015 Online Published: February 4, 2015
DOI: 10.5430/cns.v3n2p90 URL: http://dx.doi.org/10.5430/cns.v3n2p90
Abstract
Objectives: The promotion of evidence-based practice (EBP) to ensure that the best scientific evidence, clinician expertise, and
patient advocacy are used in health care delivery is an important leadership role of advanced practice nurses. While there has
been much progress in advancing EBP, there are many hospital systems in the United States and other parts of the world that
have yet to integrate an EBP framework. A focus group study was conducted to examine nurse’s views relative to the adoption
of EBP in a specific community hospital setting.
Methods: Design: A focus group design was used. Setting: A Midwestern United States rural community hospital. Sample:
Four nurse practitioners, three nurse administrators/managers, and eleven inpatient direct care nurses. Three focus groups were
conducted. Data were analyzed using qualitative methodology.
Results: Themes identified included institutional and/or cultural barriers, lack of knowledge, lack of motivation, time manage-
ment, physician and patient factors, and limited access to up-to-date user-friendly technology and computer systems.
Conclusions: Engaging a participatory approach, findings provide strategy to consider when developing programs to expose
nurses to EBP and for the translation of current standards into clinical practice. Building infrastructure to sustain and support
EBP via leadership; time provision; access and support for continuing education; and collaborative integration of team members
will guide the development of clinical environments that promote EBP.
Key Words: Clinical nurse specialist, Evidence-based practice, Community hospital
1 Introduction
Use of evidence-based practices ensures the best scientific
evidence, clinician expertise, and patient advocacy are used
in health care delivery. Promotion of evidence-based prac-
tice (EBP) is an important leadership role of clinical nurse
specialists.[1–3] Practicing nurses must be prepared to for-
mulate questions, critically assess practice, and evaluate re-
search, clinical guidelines, and levels of evidence.[4] De-
spite substantive development and systems in place to pro-
mote EBP, many hospital systems internationally have yet
to integrate an evidence-based model of care.[1, 5] Barriers
to successful implementation arise from multiple factors in-
cluding varying education and clinical experiences of nurs-
ing staff, and a lack of understanding about its’ importance
to optimal high quality patient care.[3, 6, 7]
Focus group research allows researchers to generate data
that provides insight into the unique personal experiences
and views of participants.[8–10] Such data can be used by
∗Correspondence: Leilani Tacia; Email: [e-mail]; Address: Allegiance Health System, Jackson, MI, United States.
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www.sciedu.ca/cns Clinical Nursing Studies 2015, Vol. 3, No. 2
clinical nurse specialists in the development of targeted
strategies to respond to particular problems that challenge
specific clinical settings.[8, 9] This focus group study exam-
ined nursing staff perceptions, attitudes, and beliefs regard-
ing the adoption of EBP in a community hospital system
recognized to be early in its transition to evidenced based
care.
1.1 Background and significance
Wider adoption of EBP is yet needed to improve quality,
safety, and promote effective care that can positively im-
pact patient outcomes.[2, 11–13] Sparked by several Institute
of Medicine reports published since 2001 focusing broadly
on healthcare quality and redesigning systems to ensure pa-
tients receive safe, effective, patient centered, timely, effi-
cient and equitable care, much progress has been made in
developing systems to support EBP.[13] However, only in the
past decade has EBP been incorporated into nursing curric-
ula, and many practicing nurses still lack knowledge about
implementation.[3] As a result, patients across the United
States and other parts of the world may still receive care that
is not based on current scientific evidence, including health
care that may be unnecessary or have negative effects.[14]
While there have been advancements, translation of re-
search into practice settings, incorporation of clinical prac-
tice guidelines to promote high quality care, and system-
atically changing institutional culture remain serious pub-
lic health issues for some hospital systems.[5, 15] It is rec-
ognized that lag time from translating evidence to practice
can take anywhere from eight to thirty years.[16, 17] Several
well-accepted inpatient practice guidelines exist for pain,
diabetes care, wound healing, and heart failure manage-
ment, and have been incorporated into the medical record
and into patient care. Patients experiencing these condi-
tions, however, may still experience preventable adverse
outcomes.[2, 11]
Previous reports of attitudes and knowledge of nurses to-
wards EBP demonstrates a wide range of awareness, re-
sources, and implementation.[17] While nurses may be pos-
itive about EBP, this does not translate into implementa-
tion.[18, 19] Studies suggest that consistent educational pro-
grams may help build positive attitudes and knowledge, and
nursing leadership is critical to promoting a positive EBP
climate.[7, 12, 17, 20]
The application of EBP can be challenging and requires col-
laboration and teamwork among nurses practicing in various
roles.[13, 19] While organizational culture is critical to ensur-
ing that a best practice climate is fostered, successful EBP
requires more than positive leadership.[21] At the foundation
is a well-prepared workforce that moves the institution for-
ward.[17] Nurses in advanced roles are recognized as critical
to leading a cultural shift that promotes EBP in the hospi-
tal environment and across the scope of health care inter-
nationally.[7] A recognized participatory approach to facili-
tate change and buy-in is to involve the stakeholders such as
practicing nurses in the early development of a project.[19]
Therefore, the focus group methodology was considered a
possible tool for better understanding the challenges of EBP
implementation in a specific practice environment.
1.2 Theoretical framework
The Advancing Research and Clinical Practice through
Close Collaboration (ARCC) Model was developed to im-
prove integration of research and clinical practices in acute
and community health care settings.[22] The AARC model
was conceptualized as a broad systematic strategy incorpo-
rating EBP mentorship, reliable information, and support to
overcome institutional barriers.[22] The model further em-
phasizes the importance of change. An important step to
EBP adoption is to conduct an organizational assessment
of implementation readiness for personal and institutional
change.[23]
The purpose of the study was to examine nurses’ per-
ceptions, attitudes, and beliefs about EBP using focus
groups. While limited clinical research has used focus group
methodology, the established approach permits participants
with shared background to discuss perspectives in a format
where they can exchange meaningful information that leads
to common themes.[8, 24, 25] Study objectives included to:
1) gain an understanding of EBP perceptions based on prac-
tice environments and educational backgrounds; 2) explore
specific barriers to EBP implementation unique to the spe-
cific cultural paradigm; and 3) elicit recommendations to
enhance promotion of EBP. Such appraisal of nurse percep-
tions and experiences will be instrumental in guiding tar-
geted strategies to promote best practice in the respective
hospital culture. Further, the approach may be applicable to
clinical nurse specialists promoting such progress in other
unique practice settings.
2 Methods
The hospital Institutional Review Board approved all study
procedures prior to the beginning of participant recruitment
and study implementation.
2.1 Setting and sample
Three focus groups were conducted, coordinated by a site
clinical nurse specialist with support from an academic part-
nership with a local university that has strong community
involvement. The aim of the academic partnership was to
assist with promotion and adoption of an evidenced-based
practice culture and to foster nurse-led clinical research.
Study participants were recruited from a community hos-
pital located in the Mid-western region of the United States.
Aiming to maximize variation in perspectives and views, in-
cluded in the study were registered nursing staff with ad-
Published by Sciedu Press 91

www.sciedu.ca/cns Clinical Nursing Studies 2015, Vol. 3, No. 2
vanced practice roles (such as nurse practitioners, clinical
nurse specialists), administrative managerial roles, and in-
patient direct care providers. Participants in each focus
group coincided with the proportion of associated numbers
of registered nursing personnel in the respective practice
categories at the identified institution. Thus, there were
fewer advanced practice nurses and management nurses
who were included compared to numbers of nurses who
provided direct bedside care. The three focus groups con-
sisted of registered nurses in the following roles: advanced
practice nurses (APN) (n = 4), nursing managers and/or ad-
ministrators (n = 3), and inpatient direct care nurses (n =
11). The APN’s were masters’ degree prepared, the admin-
istrator/managers group were bachelors’ degree prepared,
and 9 of the 11 inpatient direct care nurses (82%) were as-
sociate degree prepared. Table 1 provides sample demo-
graphic data.
Table 1: Focus group nurse participant characteristicsAdvanced practice nurses (N = 4) Administrators/Managers (N = 3) Staff nurses (N = 11)
Age range (Median; Range) M = 50; 37-62 years M = 45; 27-57 years M = 36; 20-55 years
Years of nursing experience (Mean
± Standard deviation; Range) 26.75 ± 10.69; 16-41 years 18.0 ± 19.16; 5-40 years 6.45 ± 5.57; 1-19 years
Sex N (%) Female = 3 (75%) Female = 3 (100%) Female = 9 (82%)
Work Environment N (%)
Inpatient N = 0 N = 3 (100%) N = 11 (100%)
Outpatient N = 3 (75%) N = 0 N = 0
Both N = 1 (25%) N = 0 N = 0
Shift Worked N (%)
Days N = 3 (75%) N = 3 (100%) N = 6 (55%)
Nights N = 0 N = 0 N = 5 (45%)
Variable (Days/evenings) N = 1 (25%) N = 0 N = 0
Education Background N (%)
Associates N = 0 N = 0 N = 9 (82%)
Bachelor of Science N = 0 N = 3 (100%) N = 2 (18%)
Master of Science N = 4 (100%) N = 0 N = 0
2.2 Data collection
Nurses were recruited for specific groups based on job title
and work roles via email and flyer distribution. Established
focus group rules included the voluntary nature of participa-
tion and use of audio recording. In addition, group conduct
rules including the importance of strict confidentiality, re-
spect for alternative viewpoints, the need to ensure that all
participants had the chance to share perspectives, and use
of first names only during discussions were incorporated.
Each focus group was conducted in the same conference
room and informed consent was obtained from all partici-
pants. Each focus group was completed within a two-hour
time frame. Refreshments were provided and participants
were free to leave early, as needed. A doctoral prepared
nurse scientist familiar with focus group methodology who
was aligned with the academic partnership institution mod-
erated each session using the pre-established questions and
probes (see Table 2). Also participating in focus group co-
ordination and conduct were the site principal investigators,
a master’s degree prepared clinical nurse specialist and a
bachelor’s prepared nurse manager. While the nurse scien-
tist who moderated the focus groups did not know the partic-
ipants, the site principal investigators had previous personal
interactions with some participants working in the same or-
ganization. It is understood in qualitative methodology that
researchers bring inherent bias based on their personal view-
points and background into the study dynamic. In this line,
site investigators worked to facilitate a nonthreatening sup-
portive atmosphere and reflective dialogue among the fo-
cus group participants while avoiding interjecting personal
opinions and interpretation.
92 ISSN 2324-7940 E-ISSN 2324-7959