BARRIERS TO IMPLEMENTATION OF EVIDENCE-BASED PRACTICES IN A

CRITICAL CARE UNIT

BY

CANDICE ANDREA BOWERS

Submitted in partial fulfilment of the requirements for the degree

Magister Curationis

in the
Faculty of Health Sciences

at the
Nelson Mandela Metropolitan University

Supervisor: Dr PJ Jordan

2013
 DEDICATION

Research without practice is like building castles in the air

Practice without research is like treading on slippery ground
Author: Unknown

I dedicate this research study to those who have awakened and inspired my passion
for critical care nursing.

To the critically ill patients in a critical care unit, my sincerest hope for you is that
you receive care that is based on the latest evidence-based practices by
professional nurses who strive for excellence by conscientiously delivering the best
care possible to you consistently.
PROOF OF EDITING

i
DECLARATION

ii
 ACKNOWLEDGEMENTS

First and foremost I thank God, the Almighty, for providing me with this
opportunity and granting me the capability to complete this research study. I
thank HIM for the guidance, perseverance and wisdom HE has given me
throughout this endeavour.
Nothing is impossible with GOD Luke 1:37

I should like to express my immense gratitude to the following people for their
support, assistance, encouragement and caring during the process of completing
my research study:
 Dolores Bowers (my mother) - words will not describe how indebted and
eternally grateful I am for your constant love, caring, support and
encouragement in all my endeavours. Without you, I would never have
been able to achieve my goals.
 Preston Bowers (my father) - for the encouragement.
 Earl and Lyle Bowers (my brothers) - for your support.
 Anne Daniels (my grandmother) - I appreciate all your love and support.
 Dennis Daniels (my late grandfather) - for always having faith in me.
 Dr. Portia Jordan (my mentor) - my most sincere gratitude for all your
invaluable honesty, insight, wisdom, guidance and motivation throughout
this journey. Thank you for being an inspiration and for always believing in
me and my potential.
 Mrs Erica Wagenaar (my formatter) - for your help throughout this whole
process. For your invaluable assistance, patience and perseverance.
 Mr Danie Venter (my statistician) - for your input with the data analysis
process.
 Mrs Rosemary Batchelor (my language editor) - I appreciate your advice
and suggestions.
 Professional nurses in the critical care unit (my participants) - for your
willingness and enthusiasm to participate in my research study.
 And to the rest of my family, friends and colleagues - I thank you for all your
interest in my research study and unwavering support throughout this
journey.

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 ABSTRACT

Over the last three decades there has been a greater need for health care
practitioners to base their decision on the best available in order to optimise
quality and cost-effective patient care. Evidence-based practice necessitates
guideline development, education and review in order to achieve improved patient
outcomes. However, initiatives that endeavour to disseminate and implement
evidence-based practice have faced barriers and opposition. Barriers that might
hamper the implementation of evidence-based practice include characteristics of
the evidence itself, personal, institutional or organizational factors.
The research study explored and described the barriers to implementation of
evidence-based practices in a critical care unit. Based on the data analysis,
recommendations were made to enhance the implementation of evidence-based
practices in the critical care unit. A quantitative, explorative, descriptive and
contextual research design was used to operationalize the research objectives.
The target population comprised professional nurses in the critical care unit. Non-
probability sampling was used to obtain data by means of a structured self-
administered questionnaire. Descriptive data analysis was applied, using a
statistical programme and the aid of a statistician. The results are graphically
displayed using bar graphs and tables. Recommendations for nursing practice,
education and research were made. Ethical principles have been maintained
throughout the study.

Keywords:
Evidence-based practice, Critical care unit, Barriers, Translation of evidence,
Professional nurses, Implementation.

iv
 TABLE OF CONTENTS

PROOF OF EDITING .................................................................................................. I

DECLARATION ........................................................................................................... II
ACKNOWLEDGEMENTS............................................................................................ III
ABSTRACT ................................................................................................................. IV
LIST OF FIGURES ...................................................................................................... XV
LIST OF TABLES ....................................................................................................... XVIII
LIST OF TEXTBOXES ................................................................................................ XVIII

CHAPTER ONE OVERVIEW OF THE STUDY

1.1 INTRODUCTION ............................................................................................ 1
1.2 PROBLEM STATEMENT .............................................................................. 6
1.3 PURPOSE OF THE STUDY .......................................................................... 8
1.4 RESEARCH QUESTION ............................................................................... 8
1.5 RESEARCH OBJECTIVES ............................................................................ 8
1.6 CONCEPT CLARIFICATION ......................................................................... 8
1.6.1 Professional nurse........................................................................................... 8
1.6.2 Critical care unit ............................................................................................... 9
1.6.3 Best-practice guidelines ................................................................................. 9
1.6.4 Evidence-based practice ................................................................................ 9
1.6.5 Barriers ........................................................................................................... 10
1.6..6 Knowledge translation ………………………………………………….....10

1.7 RESEARCH DESIGN .................................................................................... 10

1.7.1 Quantitative research ...................................................................................... 10
1.7.2 Exploratory study ............................................................................................ 11
1.7.3 Descriptive study ............................................................................................ 11
1.7.4 Contextual study ............................................................................................. 11

1.8 RESEARCH METHOD .................................................................................. 12

1.8.1 Target population ........................................................................................... 12
1.8.2 Sampling Method ........................................................................................... 12
1.8.3 Data-collection Instrument ............................................................................. 12

v
1.8.4 Data-collection method .................................................................................. 13
1.8.5 Pilot study ....................................................................................................... 13
1.8.6 Data analysis .................................................................................................. 13

1.9 QUALITY OF THE RESEARCH STUDY ...................................................... 14

1.10 ETHICAL CONSIDERATIONS ...................................................................... 14
1.11 DISSEMINATION OF RESULTS .................................................................. 14
1.12 DELINEATION OF THE STUDY ................................................................... 15
1.13 SUMMARY OF THE CHAPTER .................................................................... 15

CHAPTER TWO LITERATURE REVIEW

2.1 INTRODUCTION ............................................................................................ 16
2.2 LITERATURE SEARCHING PROCESS ...................................................... 16
2.3 IMPLEMENTATION OF EVIDENCE-BASED PRACTICES ........................ 18
2.3.1 Historical overview of evidence-based practice ............................................ 19
2.3.2 Familiarity with evidence-based practice ....................................................... 20
2.3.3 The concept “evidence-based practice” ........................................................ 22
2.3.4 Clinical decision-making in related to evidence-based practices ................. 23
2.3.5 Nursing practice and clinical decision-making .............................................. 25
2.3.6 Accessing online evidence-based sources ................................................... 26
2.3.7 Hierarchy of evidence .................................................................................... 28
2.3.8 Factors influencing the implementation of evidence-based practices ........... 30
2.3.9 Summary of the section .................................................................................. 31

2.4 BARRIERS RELATED TO KNOWLEDGE OF THE NURSE WITH

REGARD TO EVIDENCE-BASED PRACTICE ............................................ 32
2.4.1 Insufficient time to change to evidence-based practice ................................ 33
2.4.2 Clinical decisions are based on information gained during training as a
professional nurse .......................................................................................... 34
2.4.3 Intuition and clinical decision-making ............................................................ 35
2.4.4 Benefits related to implementing evidence-based practices in the critical
care unit .......................................................................................................... 36
2.4.5 Conducting independent literature reviews ................................................... 36

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2.4.6 Critical reflection in the care of the critically ill patient .................................. 37
2.4.7 The value of implementing evidence-based practice .................................... 37
2.4.8 The rewards of using research findings in the care of the critically
ill ..................................................................................................................... 38
2.4.9 Resistance to implementing evidence-based practices ................................ 38
2.4.10 Tradition/ritual practices outweigh evidence-based practices ...................... 39
2.4.11 Evidence-based practices and the improvement of the quality of patient
care ................................................................................................................. 39
2.4.12 Evidence-based practices and daily practice in the critical care unit ........... 40
2.4.13 Heavy workload related to evidence-based practice implementation ........... 40
2.4.14 Lack of evidence translation into clinical practice ......................................... 41
2.4.15 Summary of the section ................................................................................. 41

2.5 BARRIERS TO FINDING AND REVIEWING EVIDENCE ............................ 42

2.5.1 Locating evidence to guide clinical decision-making .................................... 43
2.5.2 Insufficient time to find and read research reports ........................................ 45
2.5.3 Undertanding research reports ..................................................................... 46
2.5.4 Critical appraisal of journal articles or guidelines .......................................... 46
2.5.5 Implications of research findings for practice ................................................. 47
2.5.6 Access to evidence ........................................................................................ 48
2.5.8 The amount of literature pertaining to critical care is overwhelming ............ 49
2.5.9 Publication of research reports related to critical care ................................... 50
2.5.10 The interpretation of best-practice guidelines .............................................. 50
2.5.11 Summary of section ....................................................................................... 50

2.6 BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICES

BASED ON THE RELEVANT RESOURCES ............................................... 51
2.6.1 Changing to evidence-based practice in the critical care unit ...................... 52
2.6.2 Lack of authority in the critical care unit related to evidence-based practice
………………………………………………………………………………………….53
2.6.3 Severity of the critically ill patient and the implementation of evidence-
based practices ............................................................................................... 54
2.6.4 Insufficient resources in the critical care unit to change practice .................. 54

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2.6.5 Insufficient time to implement evidence-based practices in the critical care
unit .................................................................................................................. 55
2.6.6 Summary of the section ................................................................................. 57

2.7 BARRIERS RELATED TO FACILITATION AND SUPPORT

STRUCTURES REQUIRED FOR EVIDENCE-BASED PRACTICE
IMPLEMENTATION ....................................................................................... 57
2.7.1 Support for initiatives to change to evidence-based practices in the critical
care unit ........................................................................................................... 58
2.7.2 Nurse managers are supportive of implementing evidence-based practices
in the critical care unit ..................................................................................... 60
2.7.3 Physicians are supportive of implementing evidence-based practices in
the critical care unit ........................................................................................ 62
2.7.4 Receptiveness to the use of best-practice guidelines in the care of the
critically ill patient ........................................................................................... 62
2.7.5 Organizational support for best-practice guideline development and
implementation ................................................................................................ 63
2.7.6 Institutional management and evidence uptake............................................ 64
2.7.7 Promotion of adherence to evidence-based practices................................... 64
2.7.8 An EBP champion/mentor for implementation of evidence-based
practices ......................................................................................................... 65
2.7.9 Best-practice guidelines and evidence uptake 666
2.7.10 Facilitating agents of evidence-based practice .............................................. 67
2.7.11 Summary of section ....................................................................................... 68
2.8 SUMMARY OF CHAPTER ............................................................................ 68

CHAPTER THREE RESEARCH DESIGN AND METHOD

3.1 INTRODUCTION ............................................................................................ 70
3.2 RESEARCH OBJECTIVES ........................................................................... 70
3.3 RESEARCH DESIGN .................................................................................... 70
3.3.1 Quantitative Research .................................................................................... 71

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3.3.2 Exploratory Research ..................................................................................... 72
3.3.3 Descriptive Research ..................................................................................... 72
3.3.4 Contextual research ....................................................................................... 73

3.4 RESEARCH METHOD .................................................................................. 74

3.4.1 Target Population ........................................................................................... 74
3.4.2 Sampling method ........................................................................................... 75
3.4.3 Data-collection Instrument ............................................................................. 75
3.4.4 Data-collection method ................................................................................... 78
3.4.5 Pilot study ....................................................................................................... 79
3.4.6 Data Analysis .................................................................................................. 81
3.4.7 Quality control of the research study ............................................................. 83
3.4.8 Reliability ......................................................................................................... 83
3.4.9 Validity ............................................................................................................ 84
3.4.10 Ethical considerations ..................................................................................... 85
3.4.11 Informed Consent ........................................................................................... 85
3.4.12 Anonymity and Confidentiality ....................................................................... 86
3.4.13 Privacy ............................................................................................................ 87

3.5 SUMMARY OF CHAPTER ............................................................................ 87

CHAPTER FOUR DATA ANALYSIS AND DISCUSSION OF FINDINGS

4.1 INTRODUCTION ............................................................................................ 89
4.2 TARGET POPULATION OF PROFESSIONAL NURSES ........................... 89
4.3 DATA ANALYSIS APPROACH .................................................................... 90
4.4 DEMOGRAPHIC DATA ................................................................................. 91
4.4.1 Results ............................................................................................................. 91
4.4.1.1 Gender ............................................................................................................ 93
4.4.1.2 Age in years .................................................................................................... 93
4.4.1.3 Indicate the years you have been working in a critical care unit .................. 93
4.4.1.4 Current position within the critical care unit ................................................... 94
4.4.1.5 Additional qualifications with the South African Nursing Council ................. 94
4.4.1.6 Specific additional qualification ...................................................................... 94

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4.4.2 DISCUSSION PERTAINING TO THE DEMOGRAPHIC PROFILE .............. 95
4.4.3 Summary of demographic data ...................................................................... 96

4.5 IMPLEMENTATION OF EVIDENCE-BASED PRACTICES ........................ 97

4.5.1 RESULTS ....................................................................................................... 98
4.5.1.1 Degree of familiarity with evidence-based practices ...................................... 98
4.5.1.2 The concept known as “evidence-based practice”......................................... 98
4.5.1.3 Frequency of consulting evidence to support clinical decision-making and
nursing practice in the critical care unit ......................................................... 99
4.5.1.4 Frequency of accessing best-practice guidelines in the critical care
unit ................................................................................................................... 100
4.5.1.5 Information sources that are consulted to guide clinical
decision-making ............................................................................................. 100
4.5.1.6 Information sources that are used on which to base clinical decision-
making ............................................................................................................ 101
4.5.1.7 Frequency of accessing online evidence-based sources ............................. 102
4.5.1.8 Source to consult when weaning the patient from the mechanical
ventilator ......................................................................................................... 103
4.5.1.9 Source of reference for the prevention of ventilator-associated pneumonia
(VAP) .............................................................................................................. 103
4.5.2 Discussion pertaining to implementation of evidence-based practices ......... 104

4.6 BARRIERS RELATED TO KNOWLEDGE OF THE NURSE WITH

REGARD TO IMPLEMENTATION OF EVIDENCE-BASED
PRACTICE ..................................................................................................... 107
4.6.1 Results ............................................................................................................ 108
4.6.1.1 Insufficient time to change to evidence-based practice ................................ 109
4.6.1.2 Clinical decisions are based on information gained during training as a
professional nurse .......................................................................................... 109
4.6.1.3 Intuition about what seems "right" for the critically ill patient guides
decision-making ............................................................................................. 110
4.6.1.4 Minimal benefits for the nurse or patient when implementing evidence-

x
 based practice in the critical care unit ........................................................... 111
4.6.1.5 Nurses in critical care units should not be responsible for conducting their
own literature reviews .................................................................................... 111
4.6.1.6 Critical reflection is not necessary when new treatments and medications
are prescribed for the critically ill patient ....................................................... 112
4.6.1.7 Implementing evidence-based practices is a waste of time ......................... 112
4.6.1.8 Minimal rewards for using research findings ................................................. 113
4.6.1.9 Resistance to implementing evidence-based practice .................................. 114
4.6.1.10 Traditional/ritual practices outweigh evidence-based practices ................... 114
4.6.1.11 Evidence-based practices do not improve the quality of patient care .......... 115
4.6.1.12 Evidence-based practice are not necessary for daily practice within the
critical care unit .............................................................................................. 115
4.6.1.13 Heavy workload............................................................................................... 116
4.6.1.14 Lack of efficient evidence translation into clinical practice ........................... 116
4.6.2 Discussion pertaining to barriers related to knowledge of the nurse with
regards to evidence-based practicE .............................................................. 117

4.7 BARRIERS TO FINDING AND REVIEWING EVIDENCE IN THE

CRITICAL CARE UNIT .................................................................................. 122
4.7.1 RESULTS ....................................................................................................... 123
4.7.1.1 Difficulty in locating evidence to guide clinical decision-making ................... 123
4.7.1.2 Insufficient time in the critical care unit to find and read research
reports ............................................................................................................ 124
4.7.1.3 Research reports are difficult to understand ................................................. 124
4.7.1.4 Difficulty in critical appraisal of journal articles or guidelines ........................ 125
4.7.1.5 Implications of research findings for clinical practice are unclear ................ 126
4.7.1.6 Access to research evidence is poor (slow or no computers in the critical
care unit) ......................................................................................................... 126
4.7.1.7 Research reports are not readily available in the critical care unit ............... 127
4.7.1.8 The amount of literature related to critical care is overwhelming ................. 128
4.7.1.9 Research reports related to issues in the critical care are not published
fast enough 128
4.7.1.10 Best-practice guidelines are difficult to interpret ........................................... 129

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4.7.2 Discussion pertaining to barriers to finding and reviewing evidence ............ 129

4.8 BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICE

BASED ON RELEVANT RESOURCES ....................................................... 134
4.8.1 Results ............................................................................................................ 135
4.8.1.1 Lack of confidence about changing to evidence-based practices in the
critical care unit 135
4.8.1.2 Lack of authority in the critical care unit to change to evidence-based
practice ........................................................................................................... 135
4.8.1.3 Severity of the critically ill patient influences implementation of evidence-
based practices .............................................................................................. 136
4.8.1.4 Insufficient resources to change practice in the critical care unit ................. 137
4.8.1.5 Insufficient time to implement evidence-based practices in the critical care
unit .................................................................................................................. 137
4.8.2 Discussion pertaining to the barriers to implementingevidence-based
practice based on relevant resources ........................................................... 138

4.9 BARRIERS RELATED TO FACILITATION AND SUPPORT

STRUCTURES REQUIRED FOR EVIDENCE-BASED PRACTICE
IMPLEMENTATION ....................................................................................... 140
4.9.1 Results ............................................................................................................ 141
4.9.1.1 Nursing colleagues are supportive of initiatives to change to evidence-
based practices in the critical care unit ......................................................... 142
4.9.1.2 Nurse managers are supportive of implementing evidence-based practice
in the critical care unit .................................................................................... 142
4.9.1.3 Physicians are supportive of implementing evidence-based practices in
the critical care unit ........................................................................................ 143
4.9.1.4 Professional nurses are open and receptive to the use of best-practice
guidelines in the care of the critically ill patient ............................................. 144
4.9.1.5 The organization will be able to support best-practice guideline
development and implementation .................................................................. 144
4.9.1.6 The institutional management is open and willing to participate in evidence

xii
 uptake ............................................................................................................. 145
4.9.1.7 In-service training will promote your understanding of, and adherence to,
evidence-based practices .............................................................................. 146
4.9.1.8 An evidence-based practice mentor or champion is needed for
implementation of evidence-based practices ................................................ 146
4.9.1.9 Best-practice guidelines will promote evidence-based practices ................. 147
4.9.2 Discussion pertaining to facilitation and support structures required for
evidence-based practice implementation ...................................................... 147
4.10 SUMMARY OF THE CHAPTER .................................................................... 151

CHAPTER FIVE CONCLUSIONS, LIMITATIONS AND

RECOMMENDATIONS
5.1 INTRODUCTION ............................................................................................ 153
5.2 CONCLUSIONS OF THE RESEARCH STUDY ........................................... 153
5.3 RECOMMENDATIONS RELATED TO NURSING RESEARCH,
NURSING EDUCATION, NURSING PRACTICES AND DATA ANALYSIS
................................................................................................................... 154
5.3.1 Recommendations related to nursing research ............................................ 155
5.3.2 Recommendations related to nursing education ........................................... 155
5.3.3 Recommendations related to nursing practice .............................................. 155
5.3.4 Recommendations related to data analysis of this research study .............. 156
5.3.4.1 Section B: Implementation of evidence-based practices .............................. 157
5.3.4.2 Section C: Barriers related to the knowledge of the nurse with regard to
evidence-based practice ................................................................................ 159
5.3.4.3 Section D: Barriers to finding and reviewing evidence ................................. 161
5.3.4.4 Section E: Barriers to implementing evidence-based practice based on the
relevant resources .......................................................................................... 163
5.3.4.5 Section F: Barriers related to facilitation and support structures required
for implementation of evidence-based practice ............................................ 165
5.4 STUDY LIMITATIONS ................................................................................... 166
5.5 SUMMARY OF THE CHAPTER .................................................................... 166
REFERENCES ............................................................................................................ 168

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 ANNEXURES

ANNEXURE A: QUESTIONNAIRE ........................................................................... 181

ANNEXURE B: PARTICIPANT LETTER .................................................................. 190
ANNEXURE C: INFORMED CONSENT LETTER ................................................... 191
ANNEXURE D: HOSPITAL MANAGEMENT PERMISSION LETTER ................... 194
ANNEXURE E: UNIT MANAGER REQUEST FOR PERMISSION TO CONDUCT
RESEARCH ................................................................................................... 196
ANNEXURE F: PERMISSION TO UNDERTAKE A RESEARCH STUDY IN THE
CRITICAL CARE UNIT .................................................................................. 197

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 LIST OF FIGURES

Figure 2.1: Model of evidence-based practice ........................................................ 23

Figure 2.2: Evidence-based clinical decision making model .................................. 24
Figure 2.3: Pyramid of evidence .............................................................................. 29
Figure 2.4: Factors influencing implementation of evidence-based practices ....... 31
Figure 4.1: The sampling process ........................................................................... 90
Figure 4.2: Degree of familiarity with evidence-based practices ............................ 98
Figure 4.3: The concept known as “evidence-based practice” ................................ 99
Figure 4.4: Frequency of consulting evidence to support clinical decision-making
and nursing practice in the critical care unit .......................................... 99
Figure 4.5: Frequency of accessing best-practice guidelines in the critical care
unit .......................................................................................................... 100
Figure 4.6: Information sources that are consulted to guide clinical decision-
making..................................................................................................... 101
Figure 4.7: Information sources that are used on which to base clinical decision-
making..................................................................................................... 101
Figure 4.8: Source to consult when weaning the patient from the mechanical
ventilator ................................................................................................. 103
Figure 4.9: Source of reference for the prevention of ventilator associated
pneumonia (VAP) ................................................................................... 104
Figure 4.10: Insufficient time to change to evidence-based practices ...................... 109
Figure 4.11: Clinical decisions are based on information gained during training as
a professional nurse ............................................................................... 110
Figure 4.12: Intuition about what seems to be „right‟ for the critically ill patient
guides decision-making .......................................................................... 110
Figure 4.13: Minimal benefits for the patient or nurse when implementing
evidence-based practice in the critical care unit ................................... 111
Figure 4.14: Nurses in the critical care unit should not be responsible for
conducting their own literature reviews ................................................. 112
Figure 4.15: Critical reflection is not necessary when new medicines and
treatments are prescribed for the critically ill patient ............................. 112
Figure 4.16: Implementing evidence-based practices is a waste of time.................. 113
Figure 4.17: Minimal rewards for using research findings ......................................... 113

xv
Figure 4.18: Resistance to implementing evidence-based practice .......................... 114
Figure 4.19: Traditional/ritual practices outweigh evidence-based practices ........... 115
Figure 4.20: Evidence-based practices do not improve the quality of patient care .. 115
Figure 4.21: Evidence-based practices are not necessary for daily practice within
the critical care unit................................................................................. 116
Figure 4.22: Heavy workload ...................................................................................... 116
Figure 4.23: Lack of efficient evidence translation into clinical practice .................... 117
Figure 4.24: Difficulty in locating evidence to guide clinical decision-making ........... 124
Figure 4.25 Insufficient time in the critical care unit to find and read research
reports ..................................................................................................... 124
Figure 4.26 Research reports are difficult to understand ......................................... 125
Figure 4.27 Difficulty in critical appraisal of journal articles or guidelines ................ 126
Figure 4.28: The implications of research findings for clinical practice are unclear . 126
Figure 4.29: Access to research evidence is poor (slow or no computers are
available in the critical care unit) ............................................................ 127
Figure 4.30: Research reports are not readily available in the critical care unit ....... 128
Figure 4.31: The amount of literature related to critical care is overwhelming ......... 128
Figure 4.32 Research reports related to issues in critical care are not published
fast enough ............................................................................................. 129
Figure 4.33: Best-practice guidelines are difficult to interpret ................................... 129
Figure 4.34: Lack of confidence about changing to evidence-based practices in
the critical care unit................................................................................. 135
Figure 4.35: Lack of authority in the critical care unit to change to evidence-
practice ................................................................................................... 136
Figure 4.36: Severity of the critically ill patient influences implementation of
evidence-based practices ...................................................................... 136
Figure 4.37: Insufficient resources to change practice in the critical care unit ......... 137
Figure 4.38: Insufficient time to implement evidence-based practice in the critical
care unit .................................................................................................. 138
Figure 4.39: Nursing colleagues are supportive of initiatives to change to
evidence-based practices in the critical care unit.................................. 142
Figure 4.40: Nurse managers are supportive of implementing evidence-based
practice in the critical care unit ............................................................... 143
Figure 4.41: Physicians are supportive of implementing evidence-based practices

xvi
 in the critical care unit ............................................................................. 143
Figure 4.42: Professional nurses are open and receptive to the use of best
practice guidelines in the care of the critically ill patient ....................... 144
Figure 4.43 The organization will be able to support best-practice guideline
development and implementation .......................................................... 145
Figure 4.44: The institutional management is open and willing to participate in
evidence uptake ..................................................................................... 145
Figure 4.45: In-service training will promote your understanding of and adherence
to evidence-based practices .................................................................. 146
Figure 4.46: An evidence-based practice mentor or champion is needed for
implementation of evidence-based practice .......................................... 147
Figure 4.47: Best-practice guidelines will promote evidence-based practices ......... 147

xvii
 LIST OF TABLES

Table 2.1: Nursing roles in implementation of evidence-based practices ............. 60

Table 4.1: Demographic data .................................................................................. 92
Table 4.2: Frequency of accessing online evidence-based sources ..................... 102

LIST OF TEXTBOXES

Textbox 2.1: Items for discussion on implementation of evidence-based practices . 19

Textbox 2.2: Barriers related to knowledge of the nurse with regard to
implementing evidence-based practice ................................................. 33
Textbox 2.3: Barriers to finding and reviewing evidence ........................................... 43
Textbox 2.4: Barriers to implementing evidence-based practices based on
resources ................................................................................................ 52
Textbox 2.5: Barriers related to facilitation and support structures required for
evidence-based practice implementation .............................................. 58
Textbox 4.1: Demographic data .................................................................................. 91
Textbox 4.2: Implementation of evidence-based practices ........................................ 97
Textbox 4.3: Barriers related to knowledge of the nurse with regard to
implementation of evidence-based practice .......................................... 108
Textbox 4.4: Barriers to finding and reviewing evidence in the critical care unit ....... 123
Textbox 4.5: Barriers to implementing evidence-based practice based on relevant
resources ................................................................................................ 134
Textbox 4.6: Barriers related to facilitation and support structures required for
evidence-based practice implementation .............................................. 141

xviii
Overview of the study Chapter One

CHAPTER ONE

OVERVIEW OF THE STUDY

1.1 INTRODUCTION

Critical care nursing as a specialty has been established by means of an

awareness that patients with life-threatening illnesses or injuries require vigilant
hemodynamic monitoring provided by nurses with in-depth advanced theoretical
and practical skills (Urden, Stacy & Lough, 2008:3). The cultivation of critical care
nursing as a specialty has demanded harmonious relations between nurses and
technology which is constantly becoming more sophisticated. To address
physiological, spiritual and psychosocial needs of patients, evidence-based
interventions are required from clinicians that are empowered with expertise,
knowledge and skill (Morton & Fontaine, 2009:12).

Evidence-based practice is not a new method as one would like to believe but has
been a topic in medical literature for the past thirty years, when there was a
movement away from ritualistic practices. In the mid-1990s there was a shift
towards evidence-based medicine specifically, with a greater awareness for
rendering quality patient care (Smith, James, Lorentzon & Pope, 2004:1).
According to Sackett, Richardson, Richardson, Rosenberg and Haynes (2000:10),
evidence-based medicine can be defined as a means of integrating the best
available extrinsic clinical evidence from systematic research incorporating an
individual‟s clinical expertise. As time passed the realization arose that evidence
should be implemented in healthcare to improve patient outcomes and to provide
value-laden care to patients (Clancy, Slutsky & Patton, 2004:15).

In the 1970s there was awareness that nursing practice could not rest with
tradition, ritual, assumptions or trial and error. To improve the quality of patient
care, practice delivered by nurses had to be guided by evidence (Gerrish,
Ashworth, Lacey & Bailey, 2008: 62). Integration and implementation of evidence-
based practice play an active role in the restoration or improvement of patient
health. DiCenso, Guyatt and Ciliskia (2005:4) state that the nursing interventions

1
Overview of the study Chapter One

which have proved to be relevant and effective are derived from best research
evidence. The evidence aims to increase precision, relevanc e and accuracy of
nursing practice. The ultimate purpose of using best-evidence practices is to
improve patient outcomes.

Within the healthcare environment emphasis is placed on the adherence to

evidence-based practices. According to Pearson, Field and Jordan (2007:16),
evidence-based practice relies on accessing the best available evidence for
clinical decision-making, with the purpose of achieving global health. Hoffman,
Bennet and Del Mar (2010:3) state that the best research evidence is vital but
other facets are also to be considered, namely: clinical expertise, patient values or
circumstances and lastly the context of the working environment. Evidence-based
clinical decision-making implies that various dimensions are taken into
consideration when making decisions regarding patient care. Best-evidence that
has been validated by rigorous research studies assists in decision-making
processes. Expertise that clinicians possess also assists in decision-making and
the patient has an active role because their preferences or circumstances are also
taken into account (Melnyk & Fineout-Overholt, 2010:242). Evidence-based
clinical decision-making is the basis for daily decisions that are influenced by best-
practice guidelines that uphold good standards of care whilst remaining cost-
effective (Mallik, Hall & Howard, 2009:8).

Since the nursing profession is not static, it is vital for clinicians to have access to
the best research evidence with relevant rationale applied as nurses are usually
the primary caregivers in rendering patient care. Since out-dated practices result
in prolonged hospitalisation, increased morbidity or even mortality, nurse
practitioners should use critical thinking and reflective practice skills during nursing
interventions to improve practice. Insight into rationale for interventions carried out
in a specific way will also ensure that evidence-based practices are sustained.

According to Craig and Smyth (2007:238), best-practice guidelines may also be

helpful to professional nurses to assist in decisions about the healthcare for
specific clinical conditions. Best-practice guidelines are in existence within some

2
Overview of the study Chapter One

hospitals to ensure congruency in implementation of nursing skills and to ensure

high standards of patient care delivery. In doing so, variances in practice are
eliminated but the reality is that actual evidence or research rarely enters the
clinical practice realm. Glasgow and Emmons (2007:427) state that a gap between
practice and evidence still exists as there is lack of clarity in what constitutes
evidence or which aspects should be implemented in practice. There should not
be a reliance on randomized controlled trials only. In most randomized control
trials it is not mentioned how patients could benefit from practices or what the
financial implications would be for organizations in adopting evidence-based
practices. Lang, Wyer and Haynes (2007:355) add that even though these
challenges exist, measures should be taken to ensure that all research is
disseminated and translated into clinical practice for the well being of the patients.

Clinical practitioners should be aware that certain barriers will prevent translation
of evidence into the clinical practice domain. Evidence-based nursing is founded
on translating research findings into clinical practice with multiple intentions,
namely, to improve patient outcomes, decrease hospitals stays and improve the
quality of nursing care rendered to patients. However, the translation of findings
into actual practice remains a constant battle due to barriers to implementing
evidence-based practices but through recognition and overcoming barriers,
evidence-based practices can be realized (Kajermo, Bostrom, Thompson,
Hutchinson, Estabrooks & Wallin, 2010:2). According to Grol and Grimshaw
(2003:1225), inappropriate care is rendered in some instances due to tradition,
ritual or trial and error. The characteristics of evidence itself may be responsible
for practitioners being resistant to modify practices. When research advocates
practices that are complex or require multidisciplinary collaboration then
compliance tends to decrease. Attributes of evidence that encourage compliance
may be: fewer new skills, concrete description of procedures, rationale for the
recommendations and less impact to organizations. Barriers to implementing
evidence-based practices may occur at various levels in the healthcare system: at
that of the patient, the individual professional, the healthcare team, the healthcare
organization or the wider environment.

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Overview of the study Chapter One

In a systematic review done by Squires, Estabrooks, Gustavsson and Wallin

(2011:15), an explicit link between research utilisation and individual
characteristics was highlighted which may promote or hinder evidence translation.
Trends that emerged reported that an individual‟s positive attitude towards
research was a factor that would increase implementation of evidence-based
practices. Positive reinforcement by attending conferences or in-service training
improved the likelihood that evidence-based practices would be sustained. On an
educational level an individual in possession of a graduate degree who has been
exposed to research during training has an appreciation of the benefits of
research. Furthermore, it was highlighted that individuals experiencing job
satisfaction were more likely to adhere to evidence-based practices (Squires et al,
2011:15).

The above-mentioned individual characteristics have a positive influence that

increases the tendency to carry over research findings into clinical practice.
However, deficiencies in the characteristics may be considered to be a barrier that
hinders actualisation of research recommendations. Koehn and Lehman
(2007:209) imply that barriers to implementing evidence-based practices do not
rest solely with an individual, as external factors may also be influential. An
individual may be optimistic toward research, yet time constraints and lack of
access to journal articles or best-practice guidelines present a major obstacle.
Negative attitudes to evidence-based practice arise as a result of minimal
exposure to evidence-based practices. Knowledge deficits of staff may include
definition of evidence-based practices and difficulty in interpreting research reports
or statistical analyses. Quite often nurses have difficulty in accessing journal
articles, and even after gaining access there is difficulty understanding the
implications for practice. Heavy workloads may prevent staff from reading journal
articles during work hours and lack of support from management in promoting
evidence- based practices has also proved non-conducive to implementation of
evidence-based practices.

Grol and Grimshaw (2003:1226) add that patients may directly refuse treatment
which is part of the patients‟ charter of rights, and this tends to be a barrier to

4
Overview of the study Chapter One

beneficial practices that may be evidence-based. With regard to the professional

nurse, uncertainty and lack of competence in skills will impede research
implementation; but the barrier can be overcome through in-service training
programmes. On a larger scale, a barrier to implementing evidence-based
practices may be the political and/or the economic climate of a country which does
not have the financial resources to apply evidence-based practices to clinical
settings.

A study measuring barriers to implementing EBP among 253 nurses in Finland

revealed that the top barriers included were lack of awareness of evidence-based
practices or the value thereof. Another factor is physicians‟ non-compliance with
practice implementation or most research articles are published in English which is
considered to be a major setback that prevents research from entering clinical
practice. Language is possibly a huge barrier in countries where English is not the
first official language (Oranta, Routasalo & Hupli, 2002:205). Similarly McInerney
and Suleman (2009:90) conducted a study among health professionals. The 23
participants listed time constraints, inadequate resources, knowledge deficits and
inadequate training on evidence-based practices were as the main barriers in the
study. Lack of accesses to online journals was also identified. The study has
prompted universities to re-evaluate educational programmes and incorporate
evidence-based practices within the nursing curriculum at under- and post-
graduate levels.

Strategies should be put into place to overcome barriers to implementing

evidence-based practices which might include placing emphasis on the
importance of evidence-based practices, stimulating positive attitudes towards
evidence-based practices, encouraging the use of best-practice guidelines,
creating an organisational culture that endorses change and providing adequate
resources and teamwork within organizations (Melnyk, Fineout-Overholt,
Fischbeck, Feinstein, Hong, Small, Wilcox & Kraus, 2004:190). Facilitation of
evidence-based practices includes collaboration between institutions and
professional associations such as the Registered Nurses‟ Association of Ontario
(Ploeg, Davies, Edwards, Gifford & Elliot-Miller, 2007:215).

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Overview of the study Chapter One

Barriers to the implementation of evidence-based practices may exist in a

multitude of clinical settings such as the critical care unit. To date there are various
best-practice guidelines, clinical algorithms and care bundles available in the
critical care unit that pertain to the care of the critically ill patient. However, in a
critical care unit in which specialised nursing care is rendered, the implementation
of evidence-based practices might be hampered. The focus of this research study
will thus be to explore the barriers to the implementation of evidence-based
practices in a critical care unit.

1.2 PROBLEM STATEMENT

The critical care unit is dynamic and constantly evolving. On a global scale
researchers are continually carrying out research studies regarding diagnosing
conditions or investigating various treatment modalities. Through research studies,
best-practice guidelines have been developed and are available within critical care
units.

The setting in which the research study will be conducted is a 23-bed critical care
unit in the private sector within the Nelson Mandela Metropole where medical,
surgical, cardiothoracic or even paediatric patients may be admitted. Patients are
critically ill and it is indisputable that the latest best-practice guidelines should be
applied in the care of patients to reduce complications, facilitate the healing
process and reduce mortality and morbidity. Within the unit there are best-practice
guidelines based on evidence, for example, the Nesibopho Best-Practice
guidelines (Anon, 2010) which are endorsed by the Critical Care Society of
Southern Africa. The aims of the guidelines were developed to assist critical care
nurses in caring for the critically ill.

The invaluable and indispensable evidence is readily available and accessible; yet
professional nurses are not using the evidence to its full potential. The researcher
has observed that best-practice guidelines are not consulted or are infrequently
used by professional nurses in the critical care unit, indicating that the nursing
care being rendered is according to ritual or tradition. Informal discussions with
professional nurses in the critical care unit revealed lack of, or infrequent use of,

6
Overview of the study Chapter One

available best-practice guidelines. When asked how often they consulted the
guidelines within the critical care unit a large proportion of the professional nurses
acknowledged that they did not consult the Nesibopho Best-practice Guidelines
(Anon, 2010), Best Care Always Guidelines (Anon) or journal articles. The small
amount of professional nurses who did access the guidelines acknowledged that
they did so infrequently. Online sources that consist of high-level evidence, such
as the Joanna Briggs Institute (JBI) or Worldviews on Evidence-Based Nursing,
are not accessed by the professional nurses within the unit.

The researcher noticed that professional nurses were not cognisant of the impact
of non-adherence to evidence-based practices. To illustrate another example, the
instillation of saline during suctioning is not recommended as per evidence‟, yet it
is still practised by professional nurses in the critical care unit in accordance with
ritual practices. A study done by Jordan, van Rooyen and Venter (2012:13) in the
critical care units of the public and private health-care sector in the Nelson
Mandela Metropole revealed that the majority of the professional nurses (80-85%)
based their clinical decision-making on tradition, what they had been taught in the
unit or ritualistic practices. In a similar study done by Gerrish, Ashworth, Lacey
and Bailey (2008:66) among 528 nurses most of them indicated that they refer to:
their own personal experience when caring for patients, they will also seek
information from colleagues, use information that they gained from their training or
even information from textbooks. Consulting best-practice guidelines or journal
articles were the least accessed sources by participants.

The study therefore highlights the lack of evidence-based practice implementation

in clinical practice. The researcher observed that professional nurses in the unit
also referred to textbooks, expert opinion or used their previous experience in
caring for the critically ill. The fact that best-practice guidelines are available, but
not accessed, that research reports are not read or that professional nurses in a
critical care unit use traditional or ritualistic practices is of concern to the
researcher. The conclusion has prompted the researcher to explore the barriers to
implementation of evidence-based practices in a critical care unit.

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Overview of the study Chapter One

1.3 PURPOSE OF THE STUDY

The purpose of the intended study is to explore and describe the barriers to
implementation of evidence-based practices and make recommendations to
enhance the implementation of evidence-based practices in a critical care unit.

1.4 RESEARCH QUESTION

The research question is as follows:

“What are the barriers to the implementation of evidence-based practices in a
critical care unit?”

1.5 RESEARCH OBJECTIVES

The objectives of the study are as follows:

 to explore and describe the barriers to the implementation of evidence-
based practices in a critical care unit, and
 to make recommendations to enhance the implementation of evidence-
based practices in the critical care unit.

1.6 CONCEPT CLARIFICATION

The following is a description of the core concepts applicable to the research

study.

1.6.1 PROFESSIONAL NURSE

A professional nurse is a person who is registered with the South African Nursing
Council as a nurse/or midwife who has acquired specific qualifications and has the
capacity to deliver holistic nursing care independently and competently (The
Nursing Act, No. 33 of 2005:39). The research population will comprise
professional nurses who either have experience or hold an additional qualification
in critical care nursing.

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Overview of the study Chapter One

1.6.2 CRITICAL CARE UNIT

A critical care unit is a dynamic, unique and constantly evolving environment, a

fundamental aspect of which is preservation of life by means of life-sustaining
equipment, medication and the rendering of essential nursing care. Jacoby and
Youngson (2005:440) state that a critical care unit is a specialized and highly
technological environment in which care is rendered to patients with life-
threatening emergencies, injuries or illnesses. The research study will be
conducted in a critical care unit with a diverse patient population, comprising
medical and surgical cases, with both adult and paediatric patients.

1.6.3 BEST-PRACTICE GUIDELINES

Best-practice guidelines assist healthcare professionals and patients in decision-

making about appropriate healthcare with the guidance of systematically
developed statements in caring for patients (Jo Brown, 2009:230). The critical care
unit where the study will take place has best-practice guidelines pertaining to the
care of the critically ill patient such as the Nesibopho best-practice guidelines
(Anon, 2010) or the Best Care Always guidelines (Anon).

1.6.4 EVIDENCE-BASED PRACTICE

Evidence-based practices (EBP) imply usage of the best research evidence to

support decisions in clinical practice, therefore improving patient outcomes (Burns
& Grove, 2009:26). Courtney and McCutcheon (2010:4) add that the most quoted
definition of evidence-based practice that has been derived from Sackett et al
(2000:10) which states that evidence-based practice incorporates the integration
of the best research evidence while taking patients‟ preferences into account as
well as the clinical expertise of the practitioner. The practice differs from traditional
views as it relies on substantiated proof which highlights why a particular practice
is deemed the best. An example of a best-practice guideline, for instance, is the
application of a guideline such as the Surviving Sepsis Campaign Guidelines by
Dellinger, Levy, Carlet, Bion, Parker, Jaescke, Reinhart, Angus, Brun-Buisson,
Beale, Dhainaut, Gerlach, Harvey, Marini, Marshall, Ranieri, Ramsay, Sevransky,
Thompson, Townsend, Vender, Zimmerman and Vincent (2008:20) based on

9
Overview of the study Chapter One

high-level evidence from randomized control trials that highlight recommendations

and the rationale for managing patients with sepsis or septic shock.

1.6.5 BARRIERS

A barrier is defined as an obstacle, fence and/or prevention of access (Trayler,

2007:73). Barriers to implementation of evidence-based practices include: lack of
knowledge or skills, absence of organisational support, language barriers, lack of
physician support or lack of time (Morton & Fontaine, 2009:5). The intended
research study will explore various barriers to the implementation of evidence-
based practices in the critical care unit.

1.6.6 KNOWLEDGE TRANSLATION

Knowledge translation involves transferring high quality evidence from research

into clinical practice (Lang, Wyer & Haynes, 2007:355). The intended research
study will explore what the barriers are preventing transference of evidence to
practice within the critical care unit.

1.7 RESEARCH DESIGN

The research design is a blueprint of how the research study will be carried out
(Stommel & Willis, 2004:33). According to Creswell and Plano Clark (2007:58),
research designs are techniques for collecting, analysing and interpreting data in
research studies. The research design for this study will be quantitative,
explorative, descriptive and contextual in nature.

1.7.1 QUANTITATIVE RESEARCH

The emphasis of quantitative research is on statistics, variables, and relationships

between variables. Qualitative research, on the other hand, is focused on
experiences and emotions of participants. Neuman in (De Vos, Strydom, Fouché
& Delport, 2005:133) explain that quantitative research encompasses experiments
and surveys. Walsh (2001:7) argues that quantitative research involves an inquiry
into numerical patterns and relationships. Phelps, Fisher and Ellis (2007:217) add
that quantifiable data can be measured in numerical terms. Therefore in essence

10
Overview of the study Chapter One

quantitative research is unique in its measuring aspect. The research study will be
quantitative as it will be numerical in nature to explore variables related to the
barriers to implementation of evidence-based practices in the critical care unit.

1.7.2 EXPLORATORY STUDY

Kraemer and Thiemann (in Burns & Grove, 2009:359) explain that an exploratory
study aims to improve the knowledge base of a particular study and is not meant
to generalize to populations. Walsh (2001:6) adds that an explorative research
study aims to investigate the possibilities of undertaking a research study. The
researcher intends to explore the barriers to the implementation of evidence-
based practices within the critical care unit.

1.7.3 DESCRIPTIVE STUDY

A descriptive study has a primary function which is to describe a specific research

area. Other possible reasons to pursue descriptive studies may be to identify
shortcomings within current practice, theory and development or to determine
what others are doing in similar situations (Burns & Grove, 2009:237). According
to Kumar (in Walsh, 2001:5), descriptive research provides a graphical
representation of a problem, situation or practical dilemma. The study will aim to
describe the barriers to the implementation of evidence-based practices in a
critical care unit.

1.7.4 CONTEXTUAL STUDY

Information which describes a situation and is closely affiliated to the research

question is contextual (Tappen, 2011:94). Comprehension of individuals can be
achieved by exploring their context which is body, world and the environment
(Burns & Grove, 2009:732). According to Holloway and Wheeler (2010:41), the
context includes the environment and the conditions in which the study takes
place. The study will take place in a critical care unit consisting of a twenty-three-
bedded unit.

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Overview of the study Chapter One

1.8 RESEARCH METHOD

Research methods are strategies utilized by researcher‟s to structure the research

study and to gather, analyse and interpret information that is linked to the research
objectives (Burns & Grove, 2009:13). In this section the researcher will elaborate
on the method that will be used systematically for the intended research study.

1.8.1 TARGET POPULATION

Arkava and Lane (in de Vos et al, 2005:194) suggest that the population refers to
individuals with specific characteristics. Bruce, Pope and Stanistreet (2008:133)
define the population as a group of people who are of interest to the research
study and to whom we wish the results of the study to be applied. Myatt (2007:54)
mentions that the population refers to all possible outcomes, measurements or
values about which inferences will be made. In terms of the research study the
research population will encompass seventy professional nurses (N=70) within the
critical care unit.

1.8.2 SAMPLING METHOD

A sampling method include constituents from the population, namely, people,

behaviours and/or events that are chosen according to their ability to represent the
intended research study accurately (Burns & Grove, 2009:42). A non-probability
sampling method will be used in this research study.

1.8.3 DATA-COLLECTION INSTRUMENT

The data-collection instrument, which varies with each research study, is reliant on
the research design that is chosen (Burns & Grove, 2009:293). The researcher will
use a self-administered structured questionnaire to explore barriers to the
implementation of evidence-based practices. The researcher consulted previously
validated questionnaires which were then contextualized to the critical care unit.
Bruce et al (2008:165), mention that a self-completed questionnaire avoids
interviewer bias, so participants can express their opinions whilst remaining
anonymous.

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Overview of the study Chapter One

1.8.4 DATA-COLLECTION METHOD

Burns and Grove (2009:43) state that data-collection is a specific, systematic way
of acquiring information pertaining to objectives of the research study. Data will be
collected by means of a structured questionnaire. Prior to data-collection,
permission will be obtained from hospital management where the research study
will be conducted. All participants will be obliged to sign a written consent form.

1.8.5 PILOT STUDY

The goal of a pilot study is to test the research approach and to recognize
potential difficulties that may affect the validity of research findings (Blessing &
Chakrabarti, 2009:114). It is essential that a pilot study be conducted before any
attempt is made to initiate the main study. When a pilot study is undertaken it is
crucial that the research design is adhered to. A pilot study provides a testing
ground for data-collection instruments, sample and method of data analysis so
that any potential pitfalls will be corrected or modified (Offready & Vickers,
2010:85).

A pilot study, using two participants within the critical care unit of the chosen
hospital, will be done before the main study is carried out. The participants will be
given a questionnaire which they will be able to complete before the end of their
shift.

1.8.6 DATA ANALYSIS

Data analysis is a systematic method of making sense of data. In quantitative

research data is usually numerical; therefore responses have to be analysed with
the assistance of a statistician (Walsh, 2001:79). Data preparation and data
cleaning is one of the most important constituents in the data-analysis process.

According to Hek, Judd, Moule and Goodman (2003:91), descriptive statistics can
be applied to describe the results whereas with inferential statistics the researcher
attempts to link the relationship between two variables. A statistician employed at
the Nelson Mandela Metropolitan University will assist with the data capturing and

13
Overview of the study Chapter One

analysis. Each potential answer will be coded through a statistical programme,

namely, Statistica version 10 to draw conclusions about research. Once data is
analysed and interpreted, it may be represented graphically via bar charts,
histograms, frequency polygon, pie charts, and pictograms (de Vos et al,
2005:222).

1.9 QUALITY OF THE RESEARCH STUDY

The quality of the research study is of utmost importance or research findings may
be rendered worthless. Reliability and validity are two tools that are crucial for any
research study.

1.10 ETHICAL CONSIDERATIONS

Babbie (2001:470) states that ethics are based on principles that deal with what is
right or wrong and to serve as guidance for the researcher. The ethical principles
in this research study include informed consent, anonymity, confidentiality and
privacy.

1.11 DISSEMINATION OF RESULTS

Dissemination of nursing research is crucial to developing the use of science in

nursing (Burns & Grove, 2009:338). A goal of research is to improve clinical
practice and to enlighten clinical practitioners of findings. Once the study is
completed and research findings are obtained a copy will be kept in the library at
the Nelson Mandela Metropolitan University. The unit manager of the critical care
unit will also be given a copy. Results of findings will be disseminated to
professional nurses through in-service training, workshops, conferences and a
peer-reviewed journal manuscript.

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Overview of the study Chapter One

1.12 DELINEATION OF THE STUDY

The research study will be divided into the following chapters.

Chapter One: Overview of the study

An introduction to the study, research question, problem statement, research
design and methodology will be clearly stated.

Chapter Two: Literature Review

The literature review consists of factual information pertaining to the research
question and questionnaire.

Chapter Three: Research design and method

The research design and method will be discussed in the chapter.

Chapter Four: Data analysis and discussion of findings

Data will be collected via a questionnaire and data analysis will be presented and
discussed in this chapter.
Chapter Five: Conclusions, limitations and recommendations
A conclusion of the research study and possible recommendations, research and
education opportunities will be discussed.

1.13 SUMMARY OF THE CHAPTER

Evidence-based practices are imperative in providing rationale and

recommendations of the best possible treatment for patients resulting in improved
patient outcomes and decreased complications. Evidence is substantiated through
concrete research findings from studies that comply with standards of validity and
reliability. Recognition of the barriers to implementing evidence-based practices is
crucial within any health institution. Identifying barriers can assist in determining
which facilitators may encourage implementing and sustaining evidence-based
practices. This study will explore and describe the barriers to implementation of
evidence-based practices in a critical care unit. The following chapter consists of a
narrative literature review pertaining to the topic.

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Literature Review Chapter Two

CHAPTER TWO

LITERATURE REVIEW

2.1 INTRODUCTION

Chapter One provided an introduction and overview of the study. Ritualistic practices
are frequently based on out-dated interventions that do not enhance the goal of
achieving optimal health. Evidence-based practices on the other hand use the
integration of the best research evidence in the care of patients. This research study
therefore aims to identify the barriers to the implementation of evidence-based
practices in a critical care unit. A literature review encompasses reading, analysing,
writing and synthesis of scientific literature about a specific topic that is being
reviewed (Garrard, 2011:4). The three main intentions of a literature review include:

 discovering what is already known about the topic;

 identifying gaps in established knowledge, and
 determining how a proposed study will contribute to knowledge (Oerman &
Hays, 2010:47).

The literature review of the research study will explore the concept known as
evidence-based practice, as well as the barriers to implementation of evidence-
based practice.

2.2 LITERATURE SEARCHING PROCESS

The section comprises methods applied to access scientific and high-quality

literature. Searching for literature should not be haphazard but should be
systematic and thorough to ensure that the various dimensions of a topic are
unravelled. As a point of departure, the Nelson Mandela Metropolitan University
library was consulted for textbooks on evidence-based practices. Several
textbooks have proved to be useful in shedding light on the topic. However,
textbooks have the limitation of not being current as they are written a while before
being published; therefore journals are a preferred source as they are constantly

16
Literature Review Chapter Two

being updated.

Search engines such as EBSCO host, EMBASE, CINAHL, PubMed, MEDLINE,

Sage and Biomed Central that are available on the Nelson Mandela Metropolitan
University library database were accessed. Journals that were accessed included,
World-views on Evidence-based Nursing, International Journal of Evidence-based
Healthcare and Evidence-based Nursing that are specific to the topic of evidence-
based practices. Google Scholar, which consists of scientific articles, was also
utilized by the researcher. Nursing organizations such as the Registered Nurses
Association of Ontario (RNAO) and Joanna Briggs Institute (JBI) that have local or
global incentives to steer evidence-based practices were also explored in this
section.

In relation to the research topic, namely barriers to the implementation of

evidence-based practices in a critical care unit, certain search strategies were
used. Inclusion criteria were that only articles written in English were included in
the research study.

Search terms that were used in the research study during the literature review
process are as follows:
 Boolean logic operators: linking words that are used were AND, OR,
NOT. For example,” Barriers” “OR” “facilitators” of “evidence-based
practices” or “facilitators” “NOT” “barriers of evidence-based practices” or
“Nurses” “AND” “evidence-based practices” were used to seek information.
 Truncation: is a short-cut device to save time, so that all the different
variations of a word do not have to be typed as part of the search strategy.
It works by finding the beginning of a word with a different ending on it. A “*”
or”$” is usually used. For example, evide* or Faclitat* evidence-based
practices.
 Phrase searching: will search for phrases. For example, “evidence-based
practices in the critical care unit” will yield more results than if “evidence”
and “practices” were searched separately.
 Free text searching: words and phrases are typed in and the database will

17
Literature Review Chapter Two

search the abstract, title or author that matches the word. For example,
“Time as a barrier to implementation of evidence-based practice” was a
search strategy that was used.
 Pearl grow technique: At the end of a journal article the reference list can
be advantageous by clicking on the author or title allowing the researcher
access to the original article (Craig & Smyth, 2007:56). The technique was
used in the research study whereby the reference list at the end of a journal
article was checked, references that were underlined with links and
pertained to the research study was accessed by clicking on the reference
which led to the original article.

2.3 IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

According to Van Achterberg, Schoonhoven and Grol (2008:302), implementation

refers to the introduction of innovations into daily routines. In the healthcare
industry emphasis is on rendering nursing care that is evidence-based. In some
nursing units best-practice guidelines are readily available; but the question arises
whether they are being fully implemented. Evidence-based practices emerged as
a global initiative within the healthcare sector in since 1970 onwards. The concept
implies that the best evidence is supplemented by clinical expertise and patient
preferences and is then applied within clinical settings. According to the Institute of
Medicine (IOM), evidence-based practices are vital in clinical decision-making
processes and are estimated to support 90% of clinical decisions by the year 2020
(Smith & Donze, 2010:61).

Spear (2006:52) adds that evidence-based practices promote quality care through
integrating the latest and best research evidence. However, regardless of the vast
amount of available research evidence worldwide, the gap between research and
practice is evident resulting in a failure of knowledge translation. Knowledge
translation involves translating evidence into practice. Failure in knowledge
translation results in health care workers basing care on non-scientific practices,
such as ritual or tradition which may be harmful to patients (Kent, Hutchinson,
Bioeth, Fineout-Overholt & Williamson, 2009:246). Statistically, there is a 15-to-20
year lag before new evidence is integrated into routine nursing care due to various

18
Literature Review Chapter Two

barriers that may be present in clinical practice (Helfrich, Blevins, Smith, Sales,
2011:76).

Textbox 2.1 illustrates items for discussion in the section with regard to
implementation of evidence-based practices.

Textbox 2.1: Items for discussion on implementation of evidence-based

practices
2.3 IMPLEMENTATION OF EVIDENCE-BASED PRACTICES
2.3.1 Historical overview of evidence-based practice
2.3.2 Familiarity with evidence-based practices
2.3.3 The concept “ evidence-based practice”
2.3.4 Clinical decision related to evidence-based practice
2.3.5 Nursing practice and clinical decision making
2.3.6 Accessing online evidence-based resources
2.3.7 Hierarchy of evidence
2.3.8 Factors influencing implementation of evidence-based practices
2.3.9 Summary of the section

2.3.1 HISTORICAL OVERVIEW OF EVIDENCE-BASED PRACTICE

The evidence-based movement arose in the 1970's when Professor Archie

Cochrane, a British epidemiologist, criticized the medical profession for not using
evidence to guide practice. He believed that the only valid form of evidence was
based on randomized control trials (RCTs), which he considered as the gold
standard for guiding practice. Randomized control trials refer to using
experimental designs to test the effectiveness of interventions. The medical
profession supported Professor Cochrane's beliefs by the promulgation of the
Cochrane Collaboration which was established in 1993, producing systematic
reviews on a wide array of topics within clinical practice (Barker, 2010:6).

Concurrently, nursing innovators realized that nursing practice needed to be

substantiated through evidence that would improve patient outcomes. There was
also an awareness that a research-practice gap existed within the nursing

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profession and practices were ritualistic or based on tradition. Attempts to bridge

the gap occurred, and then in 1993 the National Institute of Nursing Research
(NINR) was established to enable professional nurses to conduct research.
Electronic databases such as CINAHL were founded in 1995 allowing professional
nurses access to nursing studies that were conducted globally. In the 1990's
research utilisation incorporated models such as the Iowa Model of nursing
utilisation and the Stetler model for research utilisation that translated research
into practice. Currently, challenges still exist due to barriers to the implementation
of evidence-based practices (Schmidt & Brown, 2009:22).

From the above inferences it may be concluded that the nursing profession has
evolved tremendously from that point onwards with establishment of organizations
such as the Registered Nurses Association of Ontario (RNAO), the Joanna Briggs
Institute (JBI), the Cochrane Collaboration, the National Guideline Clearinghouse
have best-practice guidelines specifically developed for guiding professional
nurses in rendering patient care.

2.3.2 FAMILIARITY WITH EVIDENCE-BASED PRACTICE

The integration of evidence into practice is endorsed globally, yet the reality
hindering translation into clinical practice may be due to professional nurses being
unfamiliar with the concept of evidence-based practices. Contributing factors
responsible for the unfamiliarity may arise from nursing colleges or tertiary
institutions omitting evidence-based practices in the curriculum. An aspect which
may be daunting for professional nurses is the lingering confusion between
terminology such as research, evidence or evidence-based practices; and the
perplexity increases when professional nurses work in an organization that does
not value evidence-based practices (Spear, 2006:52).

A survey conducted in 2004 in a 436-bed hospital in Chicago explored nurses'

familiarity with evidence-based practices. A sample of 162 professional nurses
participated in the research study. A total of 58% indicated that they subscribed to
nursing journals. Of the participants 30% revealed that they had previous
experience with participating in research projects. A large proportion of

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participants were familiar with evidence-based practices through previous

exposure to the terminology and research-driven projects (Bevan & Pelosi-Kelly,
2006:72). In a survey that was conducted by Koehn and Lehman (2007:214), 24%
of participants had never heard the term “evidence-based practice”. A cross-
sectional survey was conducted in Spain with a sample of 917 nurses to explore
barriers to research implementation. Findings from the survey described 75% of
participants as not having the skills to judge the quality of research articles. In
relation to this, 73% of the participants agreed that they had not been granted the
authority to change practices in the clinical setting. Perhaps the rationale for the
perceptions is because 70% of participants stated that they were unaware of
evidence-based practices (Moreno-Casbas, Fuentelsaz-Gallego, de Miguel,
Gonzales-Maria & Clarke, 2011:1936).

Many critical care nurses are unaware of current evidence-based practices

guidelines for specific disease processes which lead to professional nurses
rendering care based on intuition and tradition (Chester, 2007:106). In an
American study 121 nurses participated in a cross-sectional survey to assess
readiness of implementing evidence-based practices. The data-collection
instrument was a 64-item Nurses‟ Readiness for Evidence-based Practice Survey.
Findings of the study indicated that recently graduated nurses or those with post-
graduate qualifications were more aware of the concept evidence-based practice
in comparison to their colleagues who worked in clinical practice (Thiel, 2008:182).
From the above one may deduce that evidence-based practice is not yet a global
phenomenon. Inconsistencies in familiarity with evidence-based practices may
directly relate to the context which should be taken into account as nursing
curriculum and organizations may be diverse across continents, not providing
some professional nurses with exposure to evidence-based practice. In critical
care units where the critically ill are compromised, it is imperative that professional
nurses are aware of evidence-based practice so as to provide the best care
possible.

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2.3.3 THE CONCEPT “EVIDENCE-BASED PRACTICE”

An escalation in health expenditure coupled with variations in practices and a vast

amount of literature have promulgated the development of evidence-based
practices (Salmond, 2007:114). Evidence is defined as a systematic body of
knowledge that supports actions or beliefs (Barker, 2010:143). The definition of
evidence-based practice by Sackett et al (2000:10) is consistently described and
referred to throughout evidence-based practice literature. Evidence-based practice
refers to the integration of the best research evidence that is incorporated with
clinical expertise of the practitioner whilst taking patients‟ preferences and values
into account. The best research evidence implies rigorous high-quality study
findings: quantitative, qualitative, intervention or outcomes-based research is used
to address a clinical problem. Clinical expertise is the practical skills and
theoretical knowledge that a professional nurse has acquired through experience
in caring for patients, formal training, or through literature that has been accessed.
Patients' preferences or values are the cultural preferences, values, beliefs that
make an individual unique (Craig & Smyth, 2007:9).

In Figure 2.1 terms known as “evidence-based practice” have three constituents:

namely, clinical expertise, patients‟ needs and values and the best research
evidence. Evidence-based practice is invaluable as it does not rest or rely solely
on the best research evidence, but takes patients values and preferences into
account. For implementation and sustainability of evidence-based practice to be
successful the patient‟s co-operation is a crucial facet that needs to be
considered. Respect is also given to the clinical expertise of the professional
nurse, who can use previous experience obtained from caring for patients,
knowledge and skills obtained during training (Burns & Grove, 2009:11).

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Literature Review Chapter Two

Figure 2.1: Model of evidence-based practice

Source: (Burns and Grove, 2009:11)

An inference made from the above is that the integration of these components will
ensure that the critically ill patient receives care according to the best and latest
evidence. The clinical expertise of professional nurses is also a component of
evidence-based practice that is taken into consideration in caring for the critically
ill. The preferences of patients are also respected.

2.3.4 CLINICAL DECISION-MAKING RELATED TO EVIDENCE-BASED

PRACTICES

Kent et al (2009:246) observed that professional nurses usually based clinical

decision-making on sources not founded on evidence. Decisions are frequently
based on knowledge from textbooks, information learned during training, personal
experience or intuition (Penz & Bassendowski, 2006:251). According to DiCenso
et al (2005:4) clinical decision-making should be evidence-based which is only
possible when the best research evidence is integrated with contextualization of
the clinical state, clinical setting and circumstances at that time.

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In Figure 2.2 the evidence-based clinical decision-making model comprises four

constituents, namely the clinical setting, the patient preferences, research
evidence, healthcare resources and clinical expertise. The evidence-based clinical
decision-making incorporates the best research when making clinical decisions
about the care of patients.

Figure 2.2: Evidence-based clinical decision making model

Source: (DiCenso et al, 2005:4)

It is quite evident that the model diverges from the typical traditional views which
use knowledge from textbooks, intuition, personal experience, gut feeling, trial and
error in making decisions. The evidence-based clinical decision-making model
does not disregard clinical expertise but uses it in conjunction with the best
evidence to make an informed decision. However, the patient‟s input in decision-
making is vital as the patients‟ culture, preferences and beliefs are respected. An
important aspect of the model is the realization that resources and the clinical
setting also have influence upon decisions (DiCenso et al, 2005:4).

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From the above conclusions it can be observed that the model can be applied in
the critical care unit. For instance, the research evidence may refer to a best-
practice guideline such as the Registered Nurses‟ Association of Ontario (RNAO).
The clinical setting may refer to the critical care unit where the evidence-based
practices are being implemented. If critically ill patients are alert and oriented, they
can play an active role in decision making processes. The clinical expertise refers
to the skills of the professional nurse in the critical care unit. The healthcare
resources imply all the equipment or supplies needed in the critical care unit to
enable implementation of evidence-based practices.

2.3.5 NURSING PRACTICE AND CLINICAL DECISION-MAKING

Rolfe, Segrott and Jordan (2008:440) performed a survey to ascertain nurses‟

understanding of evidence-based practices. A cross-sectional survey was done
with a sample of 218 participants from a National Health Services (NHS) trust
hospital in the UK. The findings were as follows: 69% stated that using their own
personal experience in caring for patients; 49% indicated that they consulted best-
practice guidelines occasionally; 82% participants stated they would use their
intuition to guide them and of the 218 participants 43% stated that they never used
the Cochrane database.

Thiel (2008:186) conducted a survey to determine professional nurses‟ readiness

for evidence-based practice. A descriptive cross-sectional survey design was
used, with a sample of 121 professional nurses in an acute care hospital in
Midwestern United States. Results from the study that were significant revealed
that 39% accessed information on a weekly basis to guide decision making whilst
25% accessed information several times a week to assist them in caring for
patients. Of the participants 60% stated that they frequently asked their colleagues
or peers when seeking information.

A similar survey was conducted by Pravikoff, Tanner and Pierce (2005: 41) in a
descriptive, exploratory survey with a sample of 1097 professional nurses who
completed a questionnaire. In response to the frequency in searching for
information 27% accessed information occasionally; and 12% accessed

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information less frequently than once a month. When seeking information 52%
indicated that they frequently referred to their colleagues versus 43% who
indicated they frequently referred to journal articles when seeking information.
From the above conclusions it can be observed that intuition and personal
experience are ranked higher than evidence-based practices to guide clinical
decision-making processes in the above-mentioned studies. This is concerning as
intuition and personal experience are not scientific. In the critical care unit it is
preferable to use evidence-based practices.

2.3.6 ACCESSING ONLINE EVIDENCE-BASED SOURCES

There are available online resources that contain peer-review journal articles or
best practice guidelines that will be mentioned in this section.

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) database
contains 1200 journals that are regularly indexed and also provide access to
theses, books, conference proceedings or educational software (Booth & Brice,
2004:36).

The Evidence-based Nursing journal which is published on a quarterly basis has

articles that are critically appraised with abstracts, commentaries or editorials that
give the full text of the original article.

The Cochrane Collaboration is an international organization that has high-quality

systematic reviews on an array of healthcare interventions. One of the sub-
sections is The Cochrane Library that contains systematic reviews of randomized
control trials that is updated quarterly and assists clinicians in addressing clinical
questions. PubMed is an online bibliographic database which contains an
advanced search engine that assists the user with search terms. Other features
include a clinical queries section that enables users to locate studies that have a
robust research methodology. An added benefit consists of a systematic review
filter that has the ability to retrieve systematic review not only in the PubMed
database but also in the Cochrane database. MEDLINE is a very large database
that has 12 million citations from 4600 life sciences journals. To obtain the highest

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level of evidence methodology filters to subject terms have to be applied (DiCenso

et al, 2005:34).

Worldviews on Evidence-based Nursing, which is published quarterly, focuses on

bridging the research practice gap. Journal articles focus on knowledge synthesis,
education and management .Emphasis is given to current evidence-based nursing
issues.

International Journal of Evidence-based Healthcare publishes systematic reviews,

and journal articles focus on evidence translation, evidence synthesis and
utilisation from the Joanna Briggs Institute (Salmond, 2007:120).

The Joanna Briggs Institute was established in 1996, currently has an

international collaboration of 500 researchers in 31 countries and provides a
database of evidence summaries on healthcare interventions. The summaries
consist of care bundles that propose recommendations for practice that are
intended for nurses. Another component is best-practice information sheets that
are summaries of systematic reviews.

The National Guideline Clearinghouse is a database with an array of best-practice

guidelines on various healthcare topics. The guidelines may be helpful but should
be assessed for suitability to the local context.

Google and Wikipedia are popular search engines that should be avoided when
searching for scientific literature or evidence based-practices, because they lack
quality control; information may be derived from unreliable or irrelevant sources
and should therefore not be used at all (Courtney & McCutcheon, 2010:7).

Sigma Theta Tau International (STTI) is an international organization which

develops and disseminates evidence-based practices through research and
education. The organization also recognizes and awards nurses for excellence in
evidence-based practices (Schmidt & Brown, 2009:41).

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The Registered Nurses Association of Ontario (RNAO) can be accessed on the

site (www.rnao.org). The organization, which is funded by the government of
Ontario, has 30 000 members. The main purpose of the organization is to create,
monitor and disseminate best-practice guidelines. Currently the 38 best-practice
guidelines are an array of topics ranging from oral care to a healthy work
environment, topics that are aimed toward empowering nurses. The guidelines are
structured to reduce variations in practice and to bridge the research-practice gap.
The RNAO developed an implementation toolkit to identify factors influencing
evidence uptake, to assess organisational readiness and to identify stakeholders
who could be influential in adoption of evidence-based practices. The organization
created an implementation plan that describes potential barriers and facilitators
with a core focus on sustainability of evidence-based practices.

From the above one may conclude that there may be some online resources that
are not of high quality. Critical care nurses who search for information should
receive training which should involve recognition of scientific, valid and reliable
journal articles or best-practice guidelines.

2.3.7 HIERARCHY OF EVIDENCE

Salmond (2007:119) emphasizes that not all research should be regarded as

evidence. Professional nurses in clinical practice must have the ability to grade
evidence according to the level of quality.

Figure 2.3 illustrates the hierarchy of evidence. Bias from the researcher increases
as each level descends. The most robust forms of evidence are in the form of
evidence-based guidelines or systematic reviews which are at the peak of the
pyramid. The hierarchy of evidence decreases with single randomized controls,
cohort studies, case controlled studies and qualitative studies (Salmond,
2007:119).

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Figure 2.3: Pyramid of evidence

Source: (Salmond, 2007:119)

Best-practice guidelines which are based on scientific literature, document

processes of how information was obtained and grade quality of evidence in
guiding clinical recommendations. The National Guideline Clearinghouse and the
U.S. Preventative Task Force have a host of guidelines on their database that fall
into this category according to the hierarchy of evidence (Salmond, 2007:119).

Systematic reviews encompass a review of primary studies on a topic. A

researcher searches for applicable articles to a topic, then only high-quality
articles are selected after an appraisal process whereby findings are interpreted
and summaries of the best available evidence is supplied. Internationally
recognized databases are The Cochrane Databases of Systematic Reviews or
(TRIP) Turning Research into Practice (Salmond, 2007:119).

Randomized Controlled Trials (RCT's) is the most scientific form of evidence for
intervention studies. Bias is obliterated in RCT's as treatments are allocated in a
random method to subjects (Salmond, 2007:119).

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With Cohort studies two groups of patients are formed and studies are
observational and longitudinal. Segregation comes into place when one group
receives a treatment and the other group forfeits the treatment. The groups are
then monitored over a time period to determine the outcomes (Salmond,
2007:119).

Case control studies are concerned with patients who have a specific condition
and are compared with a group without the pre-existing condition. The risk for bias
increases as there is no anonymity and documentation is accessed (Salmond,
2007:119).

Qualitative studies explore perceptions through interviews, observation, focus

groups or document analysis (Salmond, 2007:121).

2.3.8 FACTORS INFLUENCING THE IMPLEMENTATION OF EVIDENCE-

BASED PRACTICES

Barriers and facilitators to evidence-based practices may occur at the individual,

organisational or environmental level. Factors determining implementation at an
individual level are the attitudes towards evidence-based practices. For instance, if
staff has a positive attitudes toward evidence-based practice then this will promote
implementation. Negative attitudes towards evidence-based practices on the other
hand will result in staff being resistant to implementing evidence-based practices.
The implementation of evidence-based practices is influenced by the
organisational culture which is dependent on leadership, evidence-based
practices, champions and teamwork. Another factor that determines adoption of
evidence-based practices is the support from the larger scale environment (Ploeg
et al, 2007:213)

Figure 2.4 indicates the factors that influence implementation of evidence-based

practices within nursing units that may occur at the individual, organisational or
environmental level. The figure clearly highlights which whether certain elements
will promote or hinder evidence-based practice.

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Figure 2.4: Factors influencing implementation of evidence-based

practices

Source: (Ploeg et al, 2007:213)

From the above it may be concluded that there are factors which may be a barrier
or promote evidence-based practices in the critical care unit. In the following
sections barriers and facilitators that may inhibit implementation of evidence-
based practices will be discussed. Organizations must take cognisance of these
factors to develop strategies to enhance evidence uptake.

2.3.9 SUMMARY OF THE SECTION

Patients who enter healthcare facilities are under the assumption that they will
receive the best care possible. The assumption is that practices are relevant,
supported by the best evidence and will improve their outcomes. It is imperative
that the latest evidence is accessed to improve patient outcomes, especially with
regard to the critically ill population.

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2.4 BARRIERS RELATED TO KNOWLEDGE OF THE NURSE WITH

REGARD TO EVIDENCE-BASED PRACTICE

Globally nurses are the largest professional healthcare group. Their primary
function is to provide the best possible care to patients by creating a safe,
therapeutic environment (Parahoo 2006:12). Traditionally nursing has evolved
from ritualistic practices such as folklore, gut instinct, personal error or personal
preference. But over the past 30 years emphasis has been on performing
interventions that are evidence-based (Urden et al, 2006:4). However there are
barriers preventing evidence uptake that include lack of knowledge, lack of
commitment by professional nurses, limited resources or resistance from within
organizations (Morton & Fontaine, 2009:4). Certain predisposing conditions will
create an environment that makes implementation of evidence-based practices a
challenge.

Textbox 2.2 is a list of items in relation to the knowledge of the nurse with regards
to evidence-based practice.

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Textbox 2.2: Barriers related to knowledge of the nurse with regard to

implementing evidence-based practice

2.4.1 Insufficient time to change to evidence-based practice

2.4.2 Clinical decisions are based on information gained during training as a
professional nurse
2.4.3 Intuition and clinical decision-making
2.4.4 Benefits related to implementing evidence-based practices in the critical
care unit
2.4.5 Conducting independent literature reviews
2.4.6 Critical reflection in the care of the critically ill patient
2.4.7 The value of implementing evidence-based practice
2.4.8 The rewards of using research findings in the care of the critically ill
2.4.9 Resistance to implementing evidence-based practices
2.4.10 Tradition/ritual outweighs evidence-based practices.
2.4.11 Evidence-based practices and the improvement of the quality of patient
care
2.4.12 Evidence-based practice and daily practice in the critical care unit
2.4.13 Heavy workload related to evidence-based practice implementation
2.4.14 Lack of evidence translation into clinical practice
2.4.15 Summary of section

2.4.1 INSUFFICIENT TIME TO CHANGE TO EVIDENCE-BASED PRACTICE

In 2006, Sigma Theta Tau International (STTI), the Honour Society of Nursing
performed an online survey with 565 professional nurses to determine barriers to
implementation of evidence-based practices in the United States. The survey
revealed that 69% had a low to moderate understanding of the concept “evidence-
based practices”. From the participants 27% indicated that accessibility to
resources was inadequate .The largest barrier to evidence-based practices that
66% of participants chose was not having time at work to search for or to analyse
evidence (Alspach, 2006:11). Lai, Teng and Lee (2010:279) examined
implementation of evidence-based practices by doing cross-sectional surveys
using a self-administered questionnaire. The questionnaire focused on three

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domains namely, confidence and understanding, attitudes and barriers to practice.

The survey was completed by 144 participants of which, 92 doctors and 52 nurses
from two Malaysian hospitals. Of the participants 71% of doctors stated they had
done frequent searches regarding evidence-based practices in comparison to the
nurses who had done almost no searches at all. Findings from the study revealed
that 63% of doctors and 68% of nurses indicated that they had insufficient time to
perform searches or read research reports.

From the above one may conclude that time constraints within organizations may
contribute be a barrier to the implementation of evidence-based practice.
Allocating time to access best-practice guidelines or searches for evidence should
be granted to professional nurses in critical care units.

2.4.2 CLINICAL DECISIONS ARE BASED ON INFORMATION GAINED

DURING TRAINING AS A PROFESSIONAL NURSE

Gerrish et al (2007:334) mention that professional nurses base their practice on

information that may not be relevant; and some rely on knowledge that they
received during their training as a professional nurse. According to DiCenso et al
(2005:15), traditionally there was reliance on textbooks during training as a
professional nurse. However, the limitations of textbooks are that they run the risk
of promoting outdated practices within a period of time. A survey was carried out
by Squires, Moralejo and LeFort (2007:17) to explore research utilisation amongst
professional nurses in a Canadian Hospital with a sample of 248 professional
nurses. One of the sections in the self-administered questionnaire explored the
frequency in accessing sources. From the list of sources 76% of the participants
revealed that they frequently used knowledge obtained from training as a
professional nurse to assist them in caring for patients.

From the above one may conclude that professional nurses in the critical care unit
may rely on information that they used during their training to obtain patient
information and literature data. They may also apply techniques and skills that
they were taught during training as a professional nurse which may be out-dated.

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2.4.3 INTUITION AND CLINICAL DECISION-MAKING

Intuition is a process of arriving at a conclusion without following an analytical

process (Barker, 2010:19). Traditional practices, also known as ritualistic
practices, are knowledge that has been passed through the generations and is
derived from books, observation or experience (Moule & Goodman, 2009:18).
Schmidt and Brown (2009:5) identified trial and error as another source of practice
adopted by nurses. In this instance, various approaches are applied to obtain a
desired result which may in fact be hazardous to patients. Historically, the nurse's
role was passive and subservient to physicians because orders were carried out
without question or challenges. Currently, over the past decades nursing has
grown as a profession with certification and training programmes. Nursing as the
caring profession has been female dominated up till now; so the way of knowing
and intuition traditionally guides practice. Adoption of evidence-based practices
has not been fully embraced thus far as it is based on 'pure science' (Wall
2008:37).

Parahoo (2006:444) proposed that the purpose of evidence-based practices is to

improve patient outcomes by reducing unnecessary or variations in practice, which
may be the case with intuition or tradition. Practices not based on science or best
evidence can be harmful towards patients or even costly. A study was conducted
in Ireland by Flynn and Sinclair (2005:143) in a critical care unit with a sample of
19 professional nurses to determine if practices were followed as stipulated in
evidence-based guidelines. The guideline that was implemented was
endotracheal tube suctioning. Data was collected via semi-structured interviews
and was transcribed verbatim. Findings indicated that professional nurses
deviated from the recommendations that were clearly outlined in the guideline.
One of the recommendations was that saline was no longer to be instilled into the
suction catheter as it had no beneficial effect; and in fact caused complications.
Despite the evidence, a large proportion of participants stated they still instilled
saline for suctioning when they deemed it necessary. Their argument was that the
patient secretions were thick or dry; therefore saline was necessary. Interviewees
suggested that their intuition should not be dismissed when caring for patients.
From the above one may conclude that when seeking medical care, patients

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assume that they will receive the best quality of care. Nurses have a role act as an
advocate for the best interests of the patient by providing up-to-date and relevant
best practice. In the critical care unit nurses need to incorporate the best clinical
evidence when making decisions regarding the vulnerable critically ill patients.
Using tradition and ritualistic practices in caring for the critically ill should be
avoided.

2.4.4 BENEFITS RELATED TO IMPLEMENTING EVIDENCE-BASED

PRACTICES IN THE CRITICAL CARE UNIT

Kocaman, Seren, Lash, Kurt, Bhengu and Yumrumezoglu (2010:1909) performed

a descriptive, cross-sectional survey involving 329 professional nurses in a
Turkish Hospital to explore barriers to research utilisation. Findings from the study
revealed that 72% indicated that there were minimal benefits for themselves or for
patients in implementing evidence-based practices. In a study done by Brown,
Wickline, Ecoff and Glaser (2009:371) to explore evidence-based practices, a
descriptive, cross-sectional survey was done involving 458 nurses at a hospital in
California. The data-collection instrument was a self- administered questionnaire.
The findings revealed that 34% felt that there were minimal benefits for
themselves or patients in implementing evidence-based practices.

2.4.5 CONDUCTING INDEPENDENT LITERATURE REVIEWS

Generally nurses do not possess the ability to search for evidence effectively. This
may be a consequence of training as a professional nurse when emphasis was on
rendering patient care as described in textbooks, not journal articles or best-
practice guidelines. The cultures of certain organizations do not encourage
professional nurses to perform literature searches, access libraries or even
discuss evidence-based practices (DiCenso, et al, 2005:15). A cross-sectional
survey to explore professional nurses‟ implementation of evidence-based
practices was conducted with a sample of 422 professional nurses where the
data-collection instrument was a self-administered questionnaire that participants
had to complete. Participants had the option to add any additional comments to
the questionnaire. About 25% of the professional nurses indicated that the survey
prompted them to conduct literature reviews which they had not done beforehand

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and critically reflect on whether best-evidence practices could be integrated into

their nursing care (Koehn & Lehman, 2007:213). In a similar study by Sherriff
Wallis and Chaboyer (2007: 364) where only 52% of the participants indicated that
they were encouraged to perform independent literature reviews in the
organization.

2.4.6 CRITICAL REFLECTION IN THE CARE OF THE CRITICALLY ILL

PATIENT

Reflective practice is a process whereby an individual actively evaluates an

experience and decides to modify behaviour to achieve practice that is desirable.
The objectives of reflective practice are to diminish ritualistic practices, fill research
practice gaps and create an awareness of patient care delivered (Barker,
2010:122). However, professional nurses are hesitant to reflect critically on their
care delivered to patients (Parahoo, 2006:8).

Reflective practice should be utilized by professional nurses within the critical care
unit to analyse care delivered conscientiously and strive toward rendering the best
care, which can only happen with the integration of the best research evidence.

2.4.7 THE VALUE OF IMPLEMENTING EVIDENCE-BASED PRACTICE

An Iranian survey was done to understand the level of research utilisation by

nurses. Data was collected from a sample of 15 nurses via one-to-one interviews.
Several themes emerged from the research study that indicated nurses were
pessimistic towards evidence-based practices. Professional nurses were of the
opinion their practice was task oriented and evidence-based practices belonged to
nursing academia, as they could not fathom the link between research and
practice. The general attitudes toward evidence-based practices are that it has no
value in clinical practice nor does it improve the quality of patient care (Salsali &
Mehrad, 2009:8).

A similar survey was conducted by Oranta et al (2002:211) involving 253

professional nurses. Findings from the study indicated that 40% of the participants
did not see the value of evidence-based practice. From the professional 458

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professional nurses that participated in a survey in an academic centre in

California 20% of the participants were of the opinion that evidence-based
practices were a waste of time.

From the above one may conclude that participants in these studies do not see
the value of evidence-based practices at all which is concerning. The implication
of these views is that the best research evidence will not be incorporated in the
care of patients.

2.4.8 THE REWARDS OF USING RESEARCH FINDINGS IN THE CARE OF

THE CRITICALLY ILL

In a survey that was conducted by Oranta et al (2002:211) 31% of the participants

revealed that there were minimal rewards for using research findings in caring for
patients. A systematic review of 53 studies exploring barriers to the
implementation of evidence-based practice was conducted by Kajermo et al
(2010:35). A total of 50% of the participants from 6 out of the 53 studies indicated
that the rewards for using research findings in caring for patients were minimal.

2.4.9 RESISTANCE TO IMPLEMENTING EVIDENCE-BASED PRACTICES

Brown et al (2009:371) carried out a cross sectional survey to explore evidence-

based practices involving 458 nurses in a hospital in California. The data-
collection-instrument was a self-administered questionnaire. From the results
yielded 38% indicated that professional nurses were resistant to change practice
or try new ideas.

In a survey done by Caldwell, Coleman, Copp, Bell and Ghazi (2007:524) a cross
sectional postal questionnaire was completed by 200 participants to explore the
level of engagement with evidence-based practices. The findings revealed that
48% of the participants revealed were professional nurses are resistant to
implementation of evidence-based practices as a result of insufficient time. In a
similar survey done by Kocaman et al (2010:1912) 71% of the participants
indicated that professional nurses were resistant to change to implementing
evidence-based practices.

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2.4.10 TRADITION/RITUAL PRACTICES OUTWEIGH EVIDENCE-BASED

PRACTICES

A descriptive, cross-sectional survey that was conducted by Brown et al (2009:

381) revealed that of the 458 professional nurses that participated in the study,
30% indicated that they preferred to performing practices in a manner that is
comfortable or familiar to them, rather than changing whilst 25% resented
questioning about their clinical practice and 20% indicated they viewed evidence-
based practice as a waste of time.

Majid, Foo, Luyt, Zhang, Theng, Chang, Moktar (2011:232) conducted a survey in
Singapore with 1486 professional nurses participating in the research study to
evaluate adoption of evidence-based practices. Of the participants 28% indicated
that they had a neutral stance about whether they preferred tradition to evidence-
based practice. In a similar survey done by Squires et al (2007:21), 81% of the
participants indicated they frequently used their personal experience to guide
them in caring for patients, 32% indicated they frequently used tradition or ritual;
47% revealed they frequently relied on their intuition; 52% indicated they
frequently used practice that had worked for years; and 48% indicated they
frequently accessed information from their fellow nurses.

2.4.11 EVIDENCE-BASED PRACTICES AND THE IMPROVEMENT OF THE

QUALITY OF PATIENT CARE

A survey was performed by Sherriff et al (2007:366) to explore nurses‟ attitudes,

knowledge and skills of evidence-based practices with 43 professional nurses who
participated in the research study. The findings of the research study revealed that
82% were of the opinion that evidence-based practice improved the quality of
patient care. However, in a study done by Kocaman et al (2010:1912) 68% of the
participants indicated that research was not relevant to nursing practice while 71%
indicated that patient care did not improve with evidence-based practice. Oranta et
al (2002:211) concur by stating that 31% of the participants do not see the need
for incorporating evidence-based practice into patient care.

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2.4.12 EVIDENCE-BASED PRACTICES AND DAILY PRACTICE IN THE

CRITICAL CARE UNIT

A descriptive and exploratory survey was conducted in an Austrian University

involving 1825 professional nurses who had to complete a self-administered
questionnaire. The results indicated that 32% agreed that evidence-based practice
was not necessary for daily nursing practice; 53% revealed that research findings
had no value in clinical practice; 55% indicated that nurses rarely used research
findings in clinical practice (Breimaier, Halfens & Lohrmann, 2011:1744)

2.4.13 HEAVY WORKLOAD RELATED TO EVIDENCE-BASED PRACTICE

IMPLEMENTATION
Thompson, O'Leary, Jensen, Scott-Findlay, O'Brien-Pallas and Estabrooks
(2008:539) performed a research study to explore the relationship of busyness
and research utilisation. “Busyness” may be defined as the individual's perception
that there is a shortage of time to complete tasks. The survey was conducted in
two Canadian cities using methods such as individual interviews, focus group
interviews and observation. A sample of 235 nurses participated in the research
study. Findings accumulated from the interviews suggested that tasks such as
transfers or admissions, and shortage of professional nurses contributed to an
increasingly heavy workload. Interestingly, professional nurses also commented
that sitting and reading evidence-based practices would be perceived by peers,
other health professionals or patients as lazy. Professional nurses indicated that
management did not value activities other than giving direct patient care. An
interviewee mentioned that time constraints and a heavy workload prevented
nurses from rendering even essential care practices, which is a priority. Walsh
(2010:26) conducted a study to determine perception of issues that affected
implementation of evidence-based practices. The target sample included 88
professional nurses who participated in semi-structured interviews which revealed
that most participants felt that time were the greatest barrier as well as an
increased workload for nurses. Factors increasing the workload are: high acuity of
patients depleted professional nurse‟s levels, paperwork and lack of time.
Participants commented that performing searches or reading articles in relation to
evidence-based practice was not a priority.

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From the above one may conclude that time is closely associated to the workload
as various activities have to be completed within a twelve-hour shift. Nurses who
view themselves as having a heavy workload will rank implementing evidence-
based practice as a low priority.

2.4.14 LACK OF EVIDENCE TRANSLATION INTO CLINICAL PRACTICE

There may be a lack of evidence translation as barriers on various levels, namely

the individual, the organization or the environment (Barker, 2010:7). From the
above one may conclude that each critical care unit has barriers that may hinder
evidence uptake. Strategies that will increase evidence uptake have to be
assessed and will be discussed later in this chapter.

Currently the challenge still exists for critical care nurses to implement research
findings into clinical practice. The gap is in existence as a result of variables that
have come into play, namely, a lack of awareness of evidence-based practices,
poor literature searching skills and pessimistic attitudes (Sherriff et al, 2007:363).
According to Basford and Slevin (2003:329) the gap is expanding because what is
taught at nursing colleges or universities is divergent from clinical practice. The
healthcare industry cannot keep up with the pace of research-generated knowledge
either. Risjord (2011:264) argues that nurses contribute to the widening gap as they
do not update their knowledge on a continual basis which they are professionally
obliged to do. Research articles are not user-friendly because of its presentation and
jargon which appears complex to readers, therefore the implications for clinical
practice may be unclear for professional nurses.

2.4.15 SUMMARY OF THE SECTION

Nurses with a heavy workload will rank evidence-based practice as a low priority.
Lack of appropriate searching skills will prompt nurses to use less scientific
method for accessing information such as asking colleagues, reading out-dated
textbooks or searching sites such as Google. Practice based on tradition, ritual,
folklore or trial and error should be minimized and discouraged.

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2.5 BARRIERS TO FINDING AND REVIEWING EVIDENCE

One of the barriers to implementation of evidence-based practice may arise from

difficulty in finding and reviewing evidence. In Textbox 2.3 there is a list of items
that will be discussed in this section.

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Textbox 2.3: Barriers to finding and reviewing evidence

2.5.1 Locating evidence to guide clinical decision-making

2.5.2 Insufficient time to find and read research reports
2.5.3 Understanding research reports
2.5.4 Critical appraisal of journal articles or guidelines
2.5.5 Implications of research findings for practice
2.5.6 Access to evidence
2.5.7 The amount of literature pertaining to critical care is overwhelming
2.5.8 Publication of research reports related to critical care
2.5.9 The interpretation of best practice guidelines
2.5.10 Summary of the section

2.5.1 LOCATING EVIDENCE TO GUIDE CLINICAL DECISION-MAKING

DiCenso et al (2005:21) stated that the work setting might be an obstacle

preventing nurses from accessing evidence. Medical libraries may be available
within some organizations, whereas in others they may be non-existent. Another
problem is that access to computers may not be available in some institutions. But
the most reported barrier throughout literature on the barriers to the
implementation of evidence-based practice is lack of time to locate or read
evidence during work hours. There is an overwhelmingly large amount of research
data available on online databases, journals, in conference papers, workshops or
textbooks. Therefore professional nurses may find the task of searching for the
latest evidence daunting. Professional nurses with inadequate searching skills
may encounter information that is not credible, trustworthy or relevant to clinical
practice. Research articles on search engines such as Google, Wikipedia or
Yahoo are not regarded as scientifically sound (Courtney & McCutcheon,
2010:79).

Using abbreviations can prove to be troublesome at times. For instance; BNF may
refer to the British National Foundation or the British National Formulary. Using an
abbreviation as a search term can yield a multitude of information that is not
relevant to the search topic. When using truncation in a search term, care must be

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taken where it is allocated. For example, pat$ would yield, patients, patience,
patent, patio, and patch. The example demonstrates how unrelated items may
appear if incorrect search techniques are applied. If search terms are not specific
enough, too many articles will be produced for instance "evidence-based
practices" may produce more articles than specific terms, for instance, "Facilitators
of evidence-based practices within organizations"(Craig & Smyth, 2007:52).

Rosenbaum, Glenton and Cracknell (2008:1472) performed a study in the United

Kingdom and Norway to explore nurses' experiences of accessing an online
resource. The online resource site was the Cochrane Library which has
international recognition and respect throughout the world. Thirty-two participants
were selected to participate in the study. Each participant was then taken to a
private, quiet room and given one hour to search for specific content on the
Cochrane Library whilst all movement on the computer was being monitored.

Findings from the study proved that participants struggled to find the specific site.
They attempted to access the site through Google which led to useless links.
However, once the site was found, participants used the basic and not the
advanced search option which made the task difficult for ascertaining relevant
content. From the participants 75% could not differentiate between systematic
reviews versus randomized control trials. The presentation of information on the
site was not in a user-friendly form; and so most participants indicated that the site
should be simplified to make searches easier and research jargon should be
avoided. The opinion of participants was that the site was aimed at researchers
and physicians; and the implications for practice would be difficult to determine.

Caldwell, et al (2007:518) conducted a cross-sectional quantitative study with a

sample of 200 nurses using a structured anonymous postal questionnaire.
Findings from the study indicated that 40% of participants never accessed
databases such as MEDLINE and they had never received any formal training on
how to conduct literature searches. In a survey done by Sherriff, et al (2007:366)
57 participants completed a questionnaire. Findings from the survey revealed that
only 40% indicated that they had the necessary skills to perform effective literature

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searches.
In a survey done by Brown et al (2009:371) to explore evidence-based practices a
descriptive, cross-sectional survey was done involving 458 nurses at a hospital in
California. The data-collection instrument was a self-administered questionnaire.
The findings of the survey revealed that 48% were of the opinion that research
reports were not readily available in critical care nursing units.
From the above one may deduce that professional nurses have difficulty in
locating evidence. If no formal training is given on how to perform literature
searches professional nurses could spend vast amounts of time yielding fruitless
results.

2.5.2 INSUFFICIENT TIME TO FIND AND READ RESEARCH REPORTS

Ubbink, Vermeulen, Knops, Legemate, Rengerink, o Heineman, Roos,

Fijnvandraadt, Heymans, Simons and Levi (2011:87) performed a cross-sectional
survey involving 305 doctors and 396 professional nurses to explore
implementation of evidence-based practices within a hospital. The results of the
study revealed that 77% of nurses indicated that they had insufficient time to read
research reports. Furthermore, 70% revealed that they have insufficient time in the
workplace to implement evidence-based practice. In a similar study conducted by
Kocaman, et al (2010:1912) a descriptive cross-sectional study was conducted
involving 329-professional nurses who completed a questionnaire to explore
barriers to research utilisation in a Turkish Hospital. Findings from the survey
revealed that 85% indicated that there was insufficient time to change to evidence-
based practice whilst 79% stipulated that there was insufficient time to read
research reports. Oranata et al (2002:207) administered a questionnaire to 316
professional nurses in two Finnish Hospitals. Data derived from the participants
indicated that 71% revealed that there was inadequate time to perform searches
or even change to evidence-based practice.

From the above one may deduce that that time is the most noted consistent
barrier to implementation of evidence-based practice.

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2.5.3 UNDERSTANDING RESEARCH REPORTS

A descriptive, cross-sectional study that was conducted in a Turkish University

hospital explored barriers to research utilisation involving 329 nurses.
Questionnaires were the data-collection instrument. A staggering 83% of
participants indicated that most of research articles were written in English, which
was not their first language; therefore they had difficulty in comprehending
research articles. Once again, as in most of the literature, participants mentioned
that time constraints prevented them from accessing evidence. Participants also
struggled to comprehend implications for clinical practice. There were 58% who
indicated that the presentation of research articles was not user-friendly; statistical
analyses were unfamiliar and the implications for practice were vague. From the
sample 68% mentioned that research was not relevant to clinical practic e. A total
of 78% stated that best practice guidelines were not compiled in one place which
just compounded the problem (Kocaman, et al, 2010:1909). In a similar study
conducted by Majid, et al (2011:233), 1486 professional nurses in Singapore
participated in the survey to determine adoption of evidence-based practices to
assist with clinical decision-making. Findings from the survey revealed that 48%
had difficulty in understanding statistical analyses of research reports while 46%
had difficulty in understanding the terminology of research reports.

From the above it may be concluded that nurses who have no previous
experience in reading journal articles or best-practice guidelines may find it difficult
to determine implications for clinical practice; therefore professional nurses in the
critical care unit should be exposed to read

2.5.4 CRITICAL APPRAISAL OF JOURNAL ARTICLES OR GUIDELINES

Critical appraisal is a careful assessment of the value and quality of evidence

(Barker, 2010:54). Three important constituents are weighed up in evaluating
evidence, namely, validity, applicability and reliability. Validity implies that results
are accurate and free from bias which could affect research outcomes. Reliability
represents the ability of research to be duplicated yielding the same findings.
Applicability refers to the level to which evidence can be transferred to practice
(Booth & Brice, 2004:106). According to Courtney and McCutcheon (2010:84)

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critical appraisal is a skill that requires patience in comprehension of the design

and methods of an individual study. Critical appraisal tools have been formulated
to allow easier appraisal of articles. Numerous tools are available online and the
UK Critical Appraisal Skills Programme and the Johanna Briggs Institute are just
two that are frequently used. The Agree II instrument is used to appraise critically
best-practice guidelines.

Implementation of evidence-based practices requires that professional nurses

appraise evidence according to its validity and presentation. In a survey done by
Coomarasamy, Latthe, Papaioannou and Publicover, Gee and Khan (2001:573) a
total of 55 appraisals were done and each article was evaluated on predetermined
criteria, which were16-item checklist with 6 domains to assess relevance, validity,
and usability, attribution, currency and contact details. A score was given for each
domain to determine quality of an article. Findings indicated that 22% of
appraisals missed relevant articles to answer clinical questions. A randomized
control trial was conducted by Taylor, Reeves, Ewings and Taylor (2004:1) to
determine if critical appraisal training would improve skills. A sample of 145
participants was further divided into two groups. Seventy-eight participants
received training on critical-appraisal skills whilst the other group received no form
of training. About six months after the training both groups were required to do
critical appraisal. However, there was not a significant difference in the skills
between either group as results were similar indicating that critical appraisal
training could be helpful, but if not applied regularly the information gained might
be forgotten.

2.5.5 IMPLICATIONS OF RESEARCH FINDINGS FOR PRACTICE

Research reports will describe studies applied in patient populations, clinical

settings and the results of studies. Quite often recommendations will be made; but
what is not indicated in most research reports is how the findings should be
applied in clinical practice (Burns & Grove, 2009:617). In a survey conducted by
Brown et al (2009:380) 458 professional nurses from California participated in a
cross-sectional study to explore possible barriers to the implementation of
evidence-based practices. From the participants 41% indicated that the

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implications of research findings were unclear for application in clinical practice. In

a similar survey conducted by Oranta et al (2002:208) 67% of the participants
reported that research reports did not elaborate on implications of research
findings for clinical practice.

From the above one may conclude that research findings may be stipulated, but
there are no indications about how those results should be applied in clinical
practice.

2.5.6 ACCESS TO EVIDENCE

A descriptive exploratory survey was conducted in the United States to explore

evidence-based practice in relation to information resources. A target sample of
987 participants were involved in the study and a structured self-administered
questionnaire was the data-collection instrumented that was distributed through e-
mails. The study focused on 760 participants who worked as professional nurses
in the hospital. Findings from the study are as follows: only 67% had a vague
awareness of the term “evidence based practice”. When participants‟ sought
information 67% indicated they would ask a colleague instead of accessing journal
or guidelines. Of the participants 58% indicated they had never read a research
report. An obstacle that was apparent was that 82% never accessed a hospital
library. A large proportion of participants revealed that they never accessed
MEDLINE or CINAHL. Only 36% stated they had access to computers at work and
46% were of the opinion that they had inadequate resources for evidence-based
practice implementation (Pravikoff, et al, 2005:40).

Mohide and King (2003:100) conducted a survey in an 1157-bed tertiary hospital

in Canada. The purpose of the survey was to evaluate the evidence-based
practices committee that emerged and evaluate application of models in relation to
the application of one best-practice guideline. One of the barriers nurses
encountered was limited access to online resources as computers were not
available in the workplace. During the study a definite barrier identified was poor
access to e-mail which resulted in communication breakdown. Therefore the
committee communicated with leaders and managers telephonically or personally

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to ensure that the care practice of using chlorhexidine as an antiseptic agent

before venipuncture to prevent infection was graded as level I evidence. There
were 324 participants of whom only 42% adhered to the evidence-based
practices.

2.5.7 THE AMOUNT OF LITERATURE PERTAINING TO CRITICAL CARE IS

OVERWHELMING

In an era of technological advancement there is an explosion of information on the

internet. The plethora of information creates a scenario where professional nurses
do not have the ability to distinguish which information is of high quality or value
(Hall & Walton, 2004:103). Rosseauw (2012:34) adds that there are too many
research articles published on a yearly basis, about 3600 articles pertaining to the
subject of coronary artery disease alone. Salmond (2007:114) concurs that it has
become an insurmountable task to keep updated with the latest evidence as 1500
new articles are published daily and 55 new clinical trials are performed per day.
Barker (2010:1) further states that on the CINAHL database there are 3011
articles in response to the search term 'evidence-based practice". Brown et al
(2009:371) conducted a study to explore evidence-based practices in a
descriptive, cross-sectional survey involving 458 nurses at a hospital in California.
The data-collection instrument was a self-administered questionnaire. The findings
revealed that 53% of the participants indicated that the amount of information
pertaining to patient care was overwhelming.

A conclusion that may be drawn from the above is that wealth of information may
have been created by a lack of quality control of research studies. Over the past
few years there has been the creation of a multitude of journals and databases
causing a dual effect of variety but also confusion, as readers will be unsure which
sources are trustworthy. There may be an overload of literature pertaining to
critical care; however, with educational programmes that include search strategies
and critical appraisal skills, professional nurses should be able to identify evidence
of high quality.

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2.5.8 PUBLICATION OF RESEARCH REPORTS RELATED TO CRITICAL

CARE

In a survey by Kocaman et al (2010:1908), a descriptive, cross-sectional study

with a sample of 329 professional nurses was conducted to identify barriers to
research utilisation in a Turkish Hospital. The purpose of the study was to
ascertain barriers to research utilisation within the hospital. Findings from the
study revealed that 60% of participants indicated that research reports were not
published fast enough. In a similar study by Brown et al (2009:381) of the 458
professional nurses who participated in the descriptive cross-sectional survey,
34% indicated that research reports were not published fast enough, as
information was available in nursing units much later after it was published.

2.5.9 THE INTERPRETATION OF BEST-PRACTICE GUIDELINES

According to Courtney and McCutcheon (2010:59) best practice guidelines may

be difficult to interpret as they may not be at the level of the target audience.
Guidelines that are vague, complex and containing excessive medical jargon may
not be appealing to potential users of the guideline. A descriptive, cross-sectional
survey done by Brown et al (2009:371) involving 458 nurses at a hospital in
California explored evidence-based practices. The data-collection instrument was
a self-administered questionnaire and findings from the survey revealed that 41%
of participants were of the opinion that research was not presented with clarity; so
they had difficulty interpreting results and the implications for practice.

2.5.10 SUMMARY OF SECTION

It is imperative that critical care nurses have the ability to search for evidence as
practices are continually evolving. Critical appraisal skills are crucial in determining
the validity of research articles and best-practice guidelines. Therefore, the more
those professional nurses in the critical care unit interact with guidelines or journal
articles the more familiar they will become with interpreting statistical
presentations, research jargon and implications for practice. Globally research
studies are conducted and best-practice guidelines are developed for one
purpose, which is to ensure that the best care is rendered to patients.

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2.6 BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICES

BASED ON THE RELEVANT RESOURCES

Some healthcare institutions are being criticized for not having the capacity to
provide professional nurses with resources to carry out evidence-based practices.
Inaccessibility to computers in nursing units makes it challenging to search for the
evidence which can be found through online resources. Accessibility to written
guidelines is a scarce commodity in some critical care units. To adopt evidence-
based practices intensive educational training sessions have to be provided to
create awareness, assist professional nurses with search strategies and provide
insight on how to grade levels of evidence. Managers of organizations should also
attend educational programmes to appreciate the value that evidence-based
practice has on patient outcomes. The reality is that some institutions are not
willing to invest the time or money on training at all. Professional nurses are
resistant to initiating changes based on evidence with threats of litigation, lack of
support from the organization or not having the confidence to take initiatives.
Adopting practices based on evidence might have implications for financial
resources of institutions as a change in practice might influence increase the need
for professional nurses or purchasing new expensive equipment or consumables
(Burns & Grove, 2009:618).

Textbox 2.4 indicates items for discussion which are barriers to implementing
evidence-based practices based on resources. Without resources in organizations
implementing evidence-based practices will prove to be challenging.

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Textbox 2.4: Barriers to implementing evidence-based practices based on

resources

2.6.1 Changing to evidence-based practices in the critical care unit

2.6.2 Lack of authority in the critical care unit related to evidence-based practice
2.6.3 Severity of the critically ill patient and the implementation of evidence-
based practices
2.6.4 Insufficient resources in the critical care unit to change practice
2.6.5 Insufficient time to implement evidence-based practices in the critical care
unit
2.6.6 Summary of the section

2.6.1 CHANGING TO EVIDENCE-BASED PRACTICE IN THE CRITICAL

CARE UNIT

There is escalating scepticism amongst nurses about applying evidence-based

practices in critical care units, a fear of applying unfamiliar nursing techniques or
knowledge as well as concern about litigation. With the magnitude of journal
articles published, nurses are also uncertain which articles qualify as 'evidence'
(Smith et al, 2004:26). Unfamiliarity with evidence-based practices predisposes
nurses to rely on knowledge from nurse specialists, peers, previous experience or
in-service training. They are not comfortable about seeking knowledge themselves
due to a lack of confidence in their own abilities or fear of the unknown (Barker,
2010:109).

Kalassian, Dremisizov and Angus (2002:11) note that nurses do not have the skills
or confidence to appraise peer-reviewed literature critically. Even though
guidelines may be available professional nurses may hesitate to use them without
formal training or may even apply them incorrectly as they may not be suitable in a
patient situation or techniques described can be incorrectly interpreted. Nurses
may also be hesitant to apply practices in organizations which are profit-driven as
most guidelines do not elaborate on financial implications for adopting evidence-
based practices. Upton and Upton (2005:454) performed a research study to
determine implementation of evidence-based practices. A self-administered

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questionnaire was administered to 751 healthcare workers in Wales. Data

obtained from the questionnaire that was statistically significant indicated that
nurses consequently did not implement evidence-based practices due to lack of
searching skills and an inability to translate research findings into clinical practice.
From the above one may conclude that there may be apprehension in adopting
evidence-based practices. A combination of unfamiliarity with evidence-based
practices, coupled together with inadequate searching or critical appraisal skills
may be the reasons why nurses may be hesitant to apply practices in the critical
care unit. Resistance too may also be a result of having to incorporate unfamiliar
nursing techniques in the care of the critically ill patient. Traditionally in the nursing
profession nurses followed physicians‟ orders and information was sought in
textbooks whereas the evidence-based practice movement relies on professional
nurses accessing evidence themselves for clinical decision-making.

2.6.2 LACK OF AUTHORITY IN THE CRITICAL CARE UNIT RELATED TO

EVIDENCE-BASED PRACTICE

A barrier to the implementation of evidence-based practices is that nurses

perceive themselves as not having the authority to initiate practices based on
evidence, particularly novices and lower category nurses, a view which may
originate from nurses not having support from management or physicians within
critical care units (Parahoo, 2006:422). A survey was conducted by Kocaman et al
(2010:1909) involving 329 professional nurses working in a Turkish University
Hospital using a self-administered questionnaire. Information derived from the
data analysis indicated that 70% of the participants said that they lacked the
authority to change to evidence-based practice within their nursing units. A
descriptive cross-sectional survey conducted by Brown et al (2009:379) involving
458 professional nurses using a self-administered questionnaire. Findings from
the survey revealed that 60% of the participants indicated that they lacked the
authority to change to evidence-based practice.

From the above one may conclude that professional nurses may be of the opinion
that they do not have the authority to change to evidence-based practice, which
may be concerning as they may continue with tradition or ritualistic practices.

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2.6.3 SEVERITY OF THE CRITICALLY ILL PATIENT AND THE

IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

Lawless, Wan and Zeng (2010:16) performed a survey in New Zealand involving
1003 nurses who participated in the research study through completing a self-
administered questionnaire. Findings from the study indicated that professional
nurses experienced high stress levels due to increasing heavy workloads. Derived
from the data analysis showed 56% indicated a high patient acuity, 52% stated a
high level of patient dependence; and 38% indicated the professional nurse-to-
patient ratio was unsatisfactory which would influence implementation of evidence-
based practices. Walsh (2010:26) conducted a mixed-methodology survey which
revealed in structured interviews that participants found it challenging to
implement evidence-based practices due to the high patient acuity. In a survey
conducted by Majid et al (2011:232) 1486 professional nurses in a hospital in
Singapore took part in the research study to identify the degree of adoption of
evidence-based practices. Findings from the survey indicated that 40% of the
participants had difficulty incorporating evidence-based practice into their nursing
care because of a high patient acuity and heavy workloads, which hindered time
spent reading journal articles or adapting to best-practice guidelines.

2.6.4 INSUFFICIENT RESOURCES IN THE CRITICAL CARE UNIT TO

CHANGE PRACTICE

Resources may refer to professional nurses, funding, equipment or education.

Without any of these evidence-based practices would be challenging (Barker,
2010:118). Therefore organizations should empower professional nurses with
access to computers, journal articles or libraries to create an organization that
embraces evidence-based practices (Gerrish & Lacey, 2010:496). Allocation of
resources is dependent on management, physicians and medical aids. Therefore
there are many stakeholders that may hinder the implementation or sustainability
of evidence-based practices (Moule & Goodman, 2009:378).

Research studies indicate recommendations for practices; but they omit the
impact on cost and nursing time which is in f act influential on whether practices
will be adopted in organizations. For instance, blood glucose checking and

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glycaemic control in the critically ill patients may require 2-hourly glucose
monitoring. The time taken to perform the action, document the result and carry
out the action accounts for nearly 2 hours in a 24-hour period. One evidence-
based intervention has a calculated cost that amounts to 250 000 US dollars per
year in four critical care units (Dracup & Bryan-Brown, 2006:356).

Resources are scarce in developing countries where supplies, professional nurses

and equipment are barely enough to serve the population. The dilemma of
implementing evidence-based practices in such an environment is impractical
when financial resources are unavailable. On average in developing countries
there are 76 doctors to a population of 100 000 compared to 253 doctors to 100
000 people in developed countries. In developing countries there are only 85
nurses to 100 000 people compared to developed countries where there are 900
nurses on average to a population of 100 000. Infrastructures such as clean water,
electricity, transport, communication systems and fridges for medicines are non-
existent in some developing countries. Best-practice guidelines are available
through online sites which require internet connectivity, which may be non-existent
in developing countries. These conditions pose a huge barrier to implementation
of evidence-based practices where healthcare providers in those countries strive
to ensure that communities survive only because basic needs met and essential
medication is administered (Pearson & Jordan, 2010:97).

It thus appears that implementing a new practice in any critical care unit will
require manpower or even perhaps new equipment, which might prove to be
challenging especially in a developing country.

2.6.5 INSUFFICIENT TIME TO IMPLEMENT EVIDENCE-BASED PRACTICES

IN THE CRITICAL CARE UNIT

In numerous research studies that have been conducted on barriers to the

implementation of evidence-based practice, a lack of time has been one of the
highest-ranked barriers noted consistently throughout the literature. Time is
required to search for evidence and then read information which is sometimes not
possible during working hours of professional nurses, who are burdened with

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many tasks to perform and the focus which is, after all, on rendering patient care.
Evidence-based practices have been met with resistance in some healthcare
institutions. For instance, antimicrobial dressings may be recommended according
to the highest level of evidence in best-practice guidelines. However, institutions
may not adopt the practices as they may require time to train professional nurses
on how to use the dressing, for instance, without realizing that the new product or
technique could save time in the longer term and may be more cost-effective
(Parahoo, 2006:421).

Breimaier, et al (2010:1744) performed a study to identify barriers and facilitators

to research utilisation. The descriptive and exploratory cross-sectional survey was
conducted in an Austrian university hospital with a target population of 1023
professional nurses. Data was collected from a structured questionnaire. Of the
1023 professional nurses, 70% stated that the lack of time to read best-practice
guidelines or journal articles was a major obstacle to implementation of evidence-
based practices.

In 2007 a similar Canadian survey was done by Squires et al (2007:17) to

evaluate the role of the organisational research policies and procedures to
promote research utilisation by professional nurses. Within the policy and
procedure file eight practices were evaluated to check for consistency in
accessing information regarding practices. The method of data-collection was a
self-administered questionnaire that was given to professional nurses in 8 regions
working in acute services. A sample of 248 nurses participated in the research
study. A statistically significant barrier identified by 43% of participants was
insufficient time to read or even search for evidence.

Inferences that can be made from the above are that insufficient time may be a
barrier to implementation of evidence-based practices. In the critical care unit
professional nurses are responsible for patients who are critically ill. Patients are
mostly mechanically ventilated and on life-sustaining medication, various
diagnostic tests need to be carried out and need assistance with essential care
practices. Families may also require support from these professional nurses, and

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doctors write orders that have to be carried out. The perplexity of the situation
increases when caring for a haemodymically unstable patient. These activities are
just a few that require time and dedication from professional nurses in critical care
units. Therefore an allocation of sufficient time for performing literature searches
and accessing best-practice guidelines is crucial to ensure that the critically ill
receive care that is founded on evidence.

2.6.6 SUMMARY OF THE SECTION

Strategies to bridge the chasm between research and practice are dependent to a
large extent on the organization. Critical care nurses must have the freedom to
perform searches or read latest evidence in an environment that is conducive to
embracing evidence-based practices. The nursing profession must also reclaim
the independent role in initiating evidence-based practices that is substantiated by
a high level of recommendations.

2.7 BARRIERS RELATED TO FACILITATION AND SUPPORT

STRUCTURES REQUIRED FOR EVIDENCE-BASED PRACTICE
IMPLEMENTATION

To gain an understanding of the concept known as “facilitation” two definitions

have been referred to consistently. The first definition by Kitson, Harvey and
McCormack (1998:152) states that facilitation is a technique used by one person
to make things easier for others, whether it be change in attitudes, behaviour, skill,
thinking or action. The second definition by Harvey, Loftus-Hills, Rycroft-Malone,
Seers (2002:579) define facilitation rather as a process of enabling the
implementation of evidence into clinical practice.

Therefore facilitation bridges the gap between research and clinical practice by
interplay of factors which promote implementation of evidence-based practices.
The factors may be at various levels: the individual, organization, or characteristics
of the evidence itself. Organizations must also take into account that facilitators
are dependent on the local context of the critical care environment. In Textbox 2.5
a list of items which may facilitate evidence uptake in critical care units is
presented.

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Textbox 2.5: Barriers related to facilitation and support structures required

for evidence-based practice implementation
2.7.1 Support for initiatives to change to evidence-based practices in the critical
care unit
2.7.2 Nurse Managers are supportive of implementing evidence-based practices
in the critical care unit
2.7.3 Physicians are supportive of implementing evidence-based practices in the
critical care unit
2.7.4 Receptiveness to the use of best-practice guidelines in the care of the
critically ill patient
2.7.5 Organizational support for best-practice guideline development and
implementation
2.7.6 Institutional management and evidence uptake
2.7.7 Promotion of adherence to evidence-based practices
2.7.8 An evidence-based practice champion/mentor for the implementation of
evidence-based practices
2.7.9 Best-practice guidelines and evidence uptake
2.7.10 Facilitating agents of evidence-based practice
2.7.11 Summary of section

2.7.1 SUPPORT FOR INITIATIVES TO CHANGE TO EVIDENCE-BASED

PRACTICES IN THE CRITICAL CARE UNIT

LoBiondo-Wood and Haber (2010:420) indicate that the nursing profession plays
an integral role in facilitation of evidence-based practices as they are direct
providers of patient care. The goal of healthcare institutions should be to stimulate
nurses to use evidence-based practices through various strategies, which may
include: in-service training of all professional nurses on evidence-based practices;
offering professional nurses opportunities to attend workshops that have
interventions based on the latest evidence; and initiating best-practice guidelines
that are part of quality improvement programmes within nursing units. Participation
in evidence-based practices should form part of employees' yearly performance
evaluations to assess active involvement in evidence-based practices in the
critical care unit.

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Schmidt and Brown (2009:43) add that the nurse‟s role should use a team
approach and each nurse should have a clearly demarcated role. In Table 2.6 the
nursing roles for facilitation of evidence-based practice is described. Pertaining to
the critical care unit the level of the nurse executive may refer to support from the
matron on duty responsible for the critical care unit. The advanced practice nurse
pertaining to the critical care unit may refer to an evidence-based practices mentor
or champion who searches and disseminates evidence to the rest of the
professional nurses within the critical care unit. The nurse manager in the South
African context refers to the unit manager of a nursing unit who encourages
professional nurses to incorporate evidence-based practice in their nursing care.
The nurse manager should also ensure that best-practice guidelines are used in
the critical care unit. The professional nurse in the critical care unit is directly
responsible for rendering evidence-based care to the critically ill population.

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Table 2.1: Nursing roles in implementation of evidence-based practices

Professional Nurse Manager Advanced Nurse executive

Nurse practice nurse
Challenge Ensures governance
Questions practice professional nurses Serves as a coach reflects evidence-
to seek evidence and mentor based practices
Participates in and resolve clinical
evidence-based issues and improve Locates evidence Assures
practices care organisational
Synthesizes commitment to
Participates as Role model for evidence evidence-based
team member in evidence-based practices
evidence-based practices Uses evidence in
practices practice Ensures resources
Uses performance are available
Suggest criteria about Facilitate system
resolutions for evidence-based change to
clinical issues practices when evidence-based
based on evidence evaluating practices
professional nurses

Source: (Schmidt and Brown, 2009:35)

Ring, Malcolm, Coull, Murphy-Back and Watterson (2005:1048) performed a

descriptive study to explore adoption of evidence-based practices where 15
professional nurses participated in the qualitative research study which collected
data through semi-structured interviews, fourteen participants were optimistic that
evidence-based practices improved patient outcomes. Data obtained from
interviews revealed that participants were of the opinion that in-service training
and presence of an EBP champion would promote implementation of evidence-
based practice into clinical practice.

2.7.2 NURSE MANAGERS ARE SUPPORTIVE OF IMPLEMENTING

EVIDENCE-BASED PRACTICES IN THE CRITICAL CARE UNIT

Promotion of evidence-based practices is promulgated through the assistance of

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management and strong leadership as a steering force (DiCenso et al, 2005:182).

An exploratory study to identify research utilisation and facilitation was carried out
on three bibliographic databases namely CINAHL, MEDLINE AND EMBASE. A
total of 39 articles were used. Upon content analysis, several commonalities were
found in articles that were identified as strongly ranked facilitators. Two facilitators
that emerged as effective throughout peer-reviewed journal articles are strong
leadership and support by nursing management. The presence of strong leaders
who implement evidence-based practice in an organization has the potential to
infiltrate enthusiasm for evidence-based practice amongst the rest of the team
members. The role of nursing management may include organizing logistics such
as meetings or disseminating the latest best-practice guidelines (Dogherty,
Harrison & Graham, 2010:76).

Robinson, Driedger, Elliot and Eyles (2006: 467) performed a parallel case study
in 5 provinces in Canada that were involved in disseminating heart health
promotion guidelines, using a mixed method approach. Data was drawn from 53
provincial project reports and interviews as well. Participants identified facilitators
that encouraged evidence uptake. There were 29% of the participants that
indicated that support from nursing management was crucial for successful
implementation of best-practice guidelines. Aarons, Sommerfield and Walrath-
Greene (2008:83) conducted a survey across 17 communities in 16 states to
ascertain if an organisational context had a role in implementing evidence-based
practices. Participants from both the private and public sector took part in the
research study. The survey was done via e-mail with a sample of 174 participants.
Results from the study indicated that leadership and encouragement from all
levels of nursing management verified adoption of evidence-based practices.

One may draw inferences from the above that consistent feedback from all levels
of nursing managers, from top to middle management and to clinicians, will create
an environment within the critical care unit that endorses evidence-based
practices. Leaders can serve as role models to the rest of the healthcare team by
adhering to best-practice guidelines. In the critical care unit leaders may refer to
senior nurses or clinical nurse specialists who can serve as role models to

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encourage other professional nurses to implement evidence-based practices.

2.7.3 PHYSICIANS ARE SUPPORTIVE OF IMPLEMENTING EVIDENCE-

BASED PRACTICES IN THE CRITICAL CARE UNIT

Ubbink et al (2011:91) state that support from physicians is an important

component in the successful implementation of evidence-based practices.
Physicians need to be cooperative about new techniques being applied in caring
for patients. Innovations or medication may also be beneficial for patients;
therefore support from physicians is important. Ploeg et al (2007:210) conducted
semi-structured telephonic interviews with 125 participants to identify which factors
influenced best-practice guideline implementation. From the themes that emerged
participants indicated that support from physicians encouraged them to implement
evidence-based practices. From the above one may conclude that support from
physicians is important for evidence uptake.

2.7.4 RECEPTIVENESS TO THE USE OF BEST-PRACTICE GUIDELINES IN

THE CARE OF THE CRITICALLY ILL PATIENT

An exploratory study was done in Canada by Estabrooks, Scott, Squires, Stevens,

O‟Brien Pallas, Watt-Watson, Profetto-McGrath, McGilton, Golden-Biddle, Lander,
Donner, Boschma, Humphrey and Williams (2008:391) with the purpose of
investigating determinants of research use amongst professional nurses in nursing
units. Professional nurses from seven nursing units participated over a period of
six months with both qualitative and quantitative approaches being applied in the
study. Results from the study revealed that professional nurses were optimistic
about the implementation of evidence-based practices. Results also indicated that
participants with postgraduate qualifications tended to appreciate the value of
research, whilst younger nurses were more flexible in adopting practices based on
evidence.

In a survey conducted by Caldwell et al (2007:518) a sample of 200 health care

professionals participated in a cross-sectional quantitative survey by completing a
structured postal questionnaire. Findings from the study revealed that 60%
indicated that their colleagues would be supportive in implementing best-practice

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guidelines. Sherriff et al (2007:363) conducted a study in Queensland with a

sample of 57 professional nurses to explore their views on evidence-based
practice. From the findings 87% of the participants indicated that they were willing
to incorporate best-practice into their practice.

Conclusions from the above are that professional nurses will be open and
receptive to implementing best-practice guidelines in the care of their patients. By
following recommendations according to best-practice guidelines the critically ill
patients can have improved outcomes.

2.7.5 ORGANIZATIONAL SUPPORT FOR BEST-PRACTICE GUIDELINE

DEVELOPMENT AND IMPLEMENTATION

Before implementing any evidence-based practices the environment has to be

assessed for readiness. Environmental readiness refers to how the environment
will respond to the introduction of changes and implementation processes that will
improve patient outcomes. Organisational readiness is a state of preparedness
within an organization in response to change and has three dimensions:
organisational culture, organization infrastructure and organisational resources.

Organisational culture
The organisational culture determines the norms, values and morals of an
organization. Other aspects which are included are relationships amongst
employees and the employer, the vision and mission statement of the
organization, leadership styles and resources available. The interaction between
these components may determine if an organization is indeed ready for adopting
evidence-based practices. (Smith & Donze, 2010:62).

Organisational infrastructure
The organisational infrastructure refers to the goals, people, process, structure
and results within an organization. An organization that is planning to adopt
evidence-based practices must incorporate it as part of the goals of the
organization. People that are committed to carrying out evidence-based practices
are crucial (Smith & Donze, 2010:62)

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Organisational resources
Human resources such as EBP champions are needed to dedicate time to search
for evidence and disseminate it to others. Physical resources are the workforce
using evidence-based practices directly for patients inclusive of the
multidisciplinary team. Financial resources for new requisitions need to be
allocated as part of the budget. Information resources can refer to accessibility to
computers, libraries, textbooks and conferences (Smith & Donze, 2010:62).

A conclusion that may be drawn from the above is that an organization that
embraces change is goal oriented and has the infrastructure and the resources
that will cultivate a culture of evidence-based practices that thrives through
leadership.

2.7.6 INSTITUTIONAL MANAGEMENT AND EVIDENCE UPTAKE

Ploeg et al (2007:214) mention that support from all levels of institutional

management is crucial within organizations to promote implementation of
evidence-based practices. Administrators within organizations should incorporate
“striving to provide care that is evidence-based” in their mission statement.
Implementing best-practice guidelines should be supported by institutional
management. With regard to education, programmers on evidence-based practice
management from all levels should attend to grasp the value that evidence-based
practice can achieve in the healthcare environment. In a survey by Breimaier et al
(2011:1750) of the 1825 professional nurses that participated in the survey 14%
indicated that support from the human resource department and institutional
management would promote evidence uptake.

2.7.7 PROMOTION OF AND ADHERENCE TO EVIDENCE-BASED

PRACTICES

A professional nurse who aims to implement evidence-based practices should

have a sufficient knowledge base which can only be achieved through educational
programmes. Educational outreach programmes require an expert who provides
on-the-spot training to others and is seen as an effective teaching strategy.
Educational workshops that include interaction and discussion are one way of

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successfully translating research into practice (DiCenso et al, 2005:192).

A cross-sectional survey was conducted by Ubbink et al (2011:87) to establish

determinants of evidence-based practices in 5 departments in a hospital in
Amsterdam in the Netherlands. A total of 305 doctors and 396 nurses participated
in the study. The data-collection method was self-administered questionnaires.
Results from the study indicated that participants ranked educational programmes
as the third-highest-ranked facilitator of the implementation of evidence-based
practices. A study conducted by Breimaier et al (2011:1751) indicated that 49%
were of the opinion that educational programmes with adequate information on
evidence-based practices would promote evidence uptake.

From the above one may deduce that adequate training programmes at colleges,
universities or within organizations will empower critical care nurses with the skills
needed to perform literature searches, accessing best-practice guidelines and
thus ensuring that patients in critical care units are given the best possible care.

2.7.8 AN EVIDENCE-BASED PRACTICE CHAMPION / MENTOR FOR THE

IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

An intervention to promote evidence-based practices that has been mentioned

throughout literature is the presence of EBP champions, also known as mentors
(Mortaine & Fontaine, 2009:5). EBP champions are usually professional nurses
within the clinical setting who are experts on evidence-based practice. They
embrace innovation, are passionate to improve standards of care and
communicate well with team players. Their function is to disseminate the latest
evidence to peers; to remain updated regarding the latest research and
technology; and then relay that information to all members of the multidisciplinary
team. One or two EBP champions within a nursing unit that can perform these
functions should be identified (LoBiondo-Wood & Haber, 2010:410).

In a quantitative study that was done in Singapore, a target population of 1486

professional nurses from two public hospitals participated in the study. Data was
collected in the form of self-administered questionnaires to explore adoption,

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attitudes, knowledge and barriers to implementing evidence-based practices.

Results obtained from participants indicated that the presence of an EBP
champion dedicating time to evidence-based practice within a nursing unit would
stimulate evidence uptake (Majid, et al, 2011:235).

From the above observations inferences may be drawn that an EBP champion within
a critical care unit who can dedicate time in searching for latest evidence and
disseminating that to the rest of the nursing team could alleviate the workload of
nurses who are still expected to perform individual searches. Best-practice guideline
adherence can also dramatically improve as critical care nurses will be aware of the
latest evidence and the EBP champion will ensure the team remains updated.

2.7.9 BEST-PRACTICE GUIDELINES AND EVIDENCE UPTAKE

Best-practice guidelines provide statements based on evidence to assist

practitioners in making decisions in clinical circumstances with the ultimate goal of
facilitating evidence-based practices. Characteristics of the best-practice
guidelines that increase compliance are a user-friendly format and
comprehensible information relevant to practice will ensure that the guideline is
implemented (Cahill, Suurdt, Quellette-Kuntz & Heyland, 2010:616).

During the development of best-practice guidelines nine principles have to be

adhered to:
 Guideline development should be outcome-based;
 Guidelines should be based on best available evidence and describe the
strength of recommendations;
 Guideline evidence should be the strongest method available to determine
effect on clinical outcomes;
 Guidelines should be formulated by the multidisciplinary team;
 Guidelines should be adapted to the local context;
 Guidelines should be developed bearing resources in mind;
 Guidelines should be evaluated for effect, value, validity and usage;
 Guidelines should be reviewed and modified regularly to incorporate new
evidence;

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 Guidelines should be developed with consideration for the target audience

(Courtney & McCutcheon, 2010:64).

Over the past few years best-practice guidelines (BPGs) have been developed on
an international scale as well, with expert opinions and international peer-review
articles as a solid foundation for ensuring robustness of these guidelines. In the
United Kingdom, the National Institute for Clinical and Health Excellence (NICE),
the Scottish Intercollegiate Guidelines Network (SIGN), and the Royal College of
Nursing have developed guidelines which are recognized globally. In Australia the
Johanna Briggs Institute has formulated best-practice guidelines that professional
nurses can access. The Appraisal of Guideline Research and Evaluation (AGREE)
instrument assesses the quality of a guideline by measuring six domains. Best-
practice guidelines can also be developed at a local level as high-quality evidence
is readily available in the form of systematic reviews (Gerrish & Lacey, 2010:504).
In a study conducted by Walsh (2010:29) one of the themes that emerged from
semi-structured interviews was that best-practice guidelines would ensure that
there was consistency in the nursing care delivered to patients as it would be
based on the best research evidence.

From the above one may conclude that the presence of best-practice guidelines in
critical care units will ensure that consist care based on evidence will be rendered
to critically ill patients.

2.7.10 FACILITATING AGENTS OF EVIDENCE-BASED PRACTICE

Other approaches which may be helpful in the facilitation processes have not
been discussed thus far. Clinical audits and feedback sessions in nursing units are
also processes that might be helpful in sustaining evidence-based practices.
Reminders in the manual or electronic format and are effective in sustaining
evidence-based practices (Craig & Smyth, 2007:324).

Courtney and McCutcheon (2010:114) add that a clinical audit is an instrument to

evaluate practice and compare patient outcomes with quality standards, evidence-
based practice and best practice guidelines. The overall intention of a clinical audit

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is to improve the quality of care rendered to patients. Simpson and Doig

(2007:709) conducted a survey in 14 critical care units in New Zealand and
Australia to ascertain which interventions were effective in practice changes from
the 18 evidence-based practices which were implemented. Participants were then
required to rank interventions from “highly effective” to “least effective” which they
perceived as helpful. A response rate of 100% was achieved. Active reminders
(short friendly chats) were ranked as the highest amongst all 14 critical care units.
According to Ubbink et al (2011:92) journal clubs may be established in
organizations where professional nurses can search for evidence or best-practice
guidelines; and once evidence is found discussions may follow to discuss the
evidence.

From the above conclusions may be drawn that within the critical care units
interventions such as clinical audits may easily be adapted to evaluate the
effectiveness of adoption of best-practice guidelines.

2.7.11 SUMMARY OF SECTION

Adoption of evidence-based practice requires careful planning within organizations

to guarantee successful endeavours in adoption of evidence uptake. An
assessment of facilitators that will promote facilitation according to the context of a
critical care unit will ensure that practices are sustained. In-service training is a
crucial component to ensure that professional nurses are aware of the importance
of implementing evidence-based practices and will provide a platform to ensure
that professional nurses grasp the value of evidence. Strong leadership and the
presence of an EBP champion is are integral components in shaping an evidence-
based practice culture in the critical care unit.

2.8 SUMMARY OF CHAPTER

Implementing evidence-based practices in the critical care unit may prove to be an

intricate process with many facets hindering success or sustainability. Barriers to
implementing evidence-based practices may exist on diverse levels: the
characteristics of evidence, the individual or the organization. Therefore before
any practices are adopted a careful evaluation of the local context should be

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considered. An evaluation of adequacy of staff, equipment, technology and

financial resources should be undertaken. Ultimately, regardless of the barriers
that lie on the path of evidence-based practices professional nurses should
conscientiously strive toward delivering care that is based on evidence; therefore
care that is founded on ritual or tradition will be minimized. Within Chapter Two
studies have been carried in various contexts within different countries, and similar
barriers have been identified. In Chapter Two a comprehensive literature review
on evidence-based practice has been discussed in the following Chapter Three
the research design and methods will be discussed.

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CHAPTER THREE

RESEARCH DESIGN AND METHOD

3.1 INTRODUCTION

Two chapters have been explored thus far. Chapter One provided a brief overview
of the research topic, the research problem was identified and research objectives
were highlighted, the research design and method were listed and ethical
principles which would be maintained during the research study were given.
Chapter Two elaborated on a narrative literature review to enhance the readers'
comprehension on the research topic: barriers to implementation of evidence-
based practice within a critical care unit.

The purpose of Chapter Three is to explain the research design that was chosen
by the researcher and the research methods that were applied in relation to the
research study. The research design and methods signify the foundation of what
steps are to be followed after identifying a research problem and determining what
research objectives should be achieved. Without these crucial steps any research
study may not be deemed reliable or robust. Before delving into the research
methodology processes, the objectives of the research study that were stated in
Chapter One are once again revisited.

3.2 RESEARCH OBJECTIVES

The objectives of the study were as follows:

 to explore and describe barriers to implementation of evidence-based
practices within a critical care unit, and
 to make recommendations to enhance the implementation of evidence-
based practices within a critical care unit.

3.3 RESEARCH DESIGN

A research design is the overall plan or guideline which provides structure in

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addressing research questions (Jo Brown, 2009:19). The definition is supported

by Rebar, Gersch, Macnee and McCabe (2011:175) stating that the research
design is chosen according to which approach is best suited to answer the
research question and ensure that results are valid. LoBiondo-Wood and Haber
(2010:159) further state that the research design has three functions:
 to give rise to the blueprint or plan for the research study;
 to test research questions and hypotheses and
 to involve structure and strategy.

The overall goal of the research design is to assist the researcher in developing
the research questions, then conducting the study and lastly, analysing data whilst
using a systematic design. The multidimensional role of the research design
encompasses constituents such as sampling, ethical principles, pilot studies, data-
collection processes and extends to data analysis. The researcher has
implemented a quantitative design that is descriptive, exploratory and contextual
in nature for the research study which is to investigate barriers to the
implementation of evidence-based practices within a critical care unit.

3.3.1 QUANTITATIVE RESEARCH

Quantitative research aims to produce numerical data by seeking to measure the

correlation between different phenomena, to describe phenomena that are not
extensively researched or to measure cause and effect relationships. The
approach is formal, systematic and objective (Moule & Goodman, 2009:178).
Leedy and Ormrod (2005:94) concur that quantitative research addresses
relationships amongst variables through controlling, explaining or predicting
phenomena.

Quantitative research has unique characteristics, as illustrated in Barker

(2010:17):
 Research is based on scientific principles.
 Theory is converted into numerical data which is represented as statistics.
 Causal relationships exist amongst data.
 Processes are highly structured.

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 The researcher is objective.

 The study usually involves large numbers of participants.

A quantitative approach was ideal in its measuring aspect which was suitable for
answering the research question formulated in Chapter One. The systematic and
structured format of the quantitative research design was stringently adhered to
throughout the research study. The role of the researcher was objective, as input
during data-collection processes was gleaned from participants only. Data was
collected through a structured questionnaire which was then converted into
statistics with the aid of a statistician using the Statistica version 10 Programme.
Data will be presented according to graphs and percentages in Chapter Four.

3.3.2 EXPLORATORY RESEARCH

Exploratory research in quantitative studies incorporates an inquiry into a

phenomenon of interest from manifestation to the impact of underlying factors
which are related to the phenomenon (Polit & Beck, 2008:20). Exploratory
research may investigate a phenomenon that is perhaps unfamiliar or new.
Neuman (2006:33) mentions a research topic with a paucity of literature or none
whatsoever in existence may be referred to as exploratory research. Definitive
answers are seldom reached with exploratory research since the focus addresses
the "what" question. Conducting this type of study can require researchers to be
flexible and creative as there are few guidelines to follow.

An exploratory design was selected with the intention to explore the barriers to
implementation of evidence-based practices in a private critical care unit within the
Nelson Mandela Metropole. Data was collected from professional nurses working
in the critical care unit.

3.3.3 DESCRIPTIVE RESEARCH

Polit and Beck (2008:274) maintain that descriptive research tends to describe,
observe and document a situation. Therefore, in essence the purpose of
descriptive research is to explain the relationships between variables of a research

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study. As noted in Boswell and Cannon (2007:148), descriptive research serves

as an investigation into the characteristics of one sample population. Instances
when descriptive research is typically used are for clinical decision making,
rationale for current practice or for theory development. Descriptive research
dissects a problem and then establishes a description of variables being studied.
A distinguishing characteristic of descriptive research is that variables are not
manipulated and a situation is examined as it unfolds naturally, but the intention of
the research type is not to explain cause-and-effect relationships. Descriptive
research is often used in quantitative studies, with questionnaires being the
chosen method for data-collection (Schmidt & Brown, 2009:149). A descriptive
design was particularly selected to describe barriers to the implementation of
evidence-based practices amongst professional nurses in the critical care unit,
within the Nelson Mandela Metropole.

3.3.4 CONTEXTUAL RESEARCH

Contextualization relates to the time and place of an event. A context may be

altered by the chronological sequence of events or the conditions of a setting
(Johnson & Christensen, 2008:432). Social phenomena may be interpreted
differently by individuals who base their context upon experience, perceptions and
behaviour and this is referred to as contextual grounding (Saks & Allsop,
2007:82). According to Neuman (2006:158), when conducting a study emphasis
should be given to the social context by being aware of events and surroundings.
However, there might be divergence within the consistency of context. Within
various cultures or historical eras the context or meaning can be interpreted
differently; therefore that should be taken into account when conducting a
research study.
This research study was conducted in the context of a critical care unit in a private
hospital within the Nelson Mandela Metropole. The critical care unit consists of a
twenty-three beds into which the adult and paediatric population are admitted. The
critical care unit is a dynamic, fast-paced unit with a diverse patient population.
Patient disease profiles may range from respiratory diseases such as pulmonary
embolism, pulmonary oedema, Acute Respiratory Distress Syndrome (ARDS),
pneumonia or respiratory distress. Other conditions may be post-surgical

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conditions e.g. post-laparotomy, post-coronary artery bypass grafts, post-

craniotomies etc. Other complex diseases may extend to septic shock,
pancreatitis, diabetic keto acidosis (DKA) or polytrauma. Most of the patients
admitted to the critical care unit are mechanically ventilated with various
pharmacological agents as a mode of treatment. Professional nurses within the
unit should have a comprehensive knowledge base when dealing with these
patients. The latest technological advances or equipment such as cardiac
monitors, cardiac output monitors, syringe/feeding or intravenous pumps are
available in the critical care unit. Therefore it is imperative that patients receive
nursing care that is based on the latest available evidence.

3.4 RESEARCH METHOD

Research methods encompass techniques used to structure a research study and

information is accumulated and then evaluated in a systematic manner (Polit &
Beck, 2008:765).

3.4.1 TARGET POPULATION

In research studies information is usually acquired from a particular population

who meet certain criteria (Moule & Goodman, 2009:265). Parahoo (2006:256)
concurs that the target population is defined as the population of interest from
whom data can potentially be collected. Neuman (2006:224) adds that the target
population is a concrete and specific large group of cases that the researcher
identifies and from which he or she chooses a sample.

At the time of data-collection a total of seventy (n=70) professional nurses in

critical care units at a private hospital within the Nelson Mandela Metropole
participated in the research study. From the total of seventy participants, positions
held within the critical care units comprised fifty-eight permanently employed
professional nurses. From the fifty-eight professional nurses who worked in the
critical care unit thirty five worked on a shift basis, nineteen were shift leaders and
four were unit managers. The other twelve participants were agency workers who
worked through a nursing agency. Therefore the majority of participants comprised
participants who were permanently employed in the critical care unit.

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3.4.2 SAMPLING METHOD

A sample is a set of elements taken from a larger population according to specific

criteria. An element is a basic unit of the population, which may be an individual or
a group. Sampling is the process of choosing a sample from the chosen
population (Johnson & Christensen, 2008: 222). In quantitative studies the
sampling approach focuses on subjects who match the population of interest. To
eliminate bias, a sampling plan is adhered to once the sample is identified and
recruited. Only then will data be analysed, which differs from the sampling process
in qualitative studies (Rebar et al, 2011:119).

Researchers can select a sample by using either of two methods. The two
categories of sampling are divided into probability and non-probability sampling.
With probability sampling every element in the population has an equal chance for
inclusion in the research study. However, with non-probability sampling the
researcher has no way of predicting that every element will be represented in the
sample. There is no randomization so some members of the population will not
have a chance of being included in the sample (Schmidt & Brown, 2009:217).
Brink (2006:132) adds that with non-probability sampling, the researcher selects
subjects that will best describe a population. Professional nurses working in the
critical care unit who volunteered to participate in the research study was included
in the sample. Those who were on sick or study leave or those who refused to
participate were excluded from the sample. There were no inclusion criteria, as all
professional nurses working in the critical care unit were included in the sample
owing to the limited number of professional nurses in the critical care unit at the
private hospital; therefore non-probability sampling was the most appropriate
method for this research study.

3.4.3 DATA-COLLECTION INSTRUMENT

In research data-collection instruments or tools often measure characteristics,

performance, ideas, feelings or performance. A questionnaire is often the data-
collection instrument that is used in quantitative studies to uncover what a
participant thinks about a certain topic (Boswell & Cannon, 2007:191).

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Research design and method Chapter Three

A questionnaire is a self-report data-collection instrument filled out by participants,

in which they can express their beliefs, values, attitudes and perceptions. The
researcher has to follow certain principles when constructing a questionnaire
which are the following.
 The questionnaire items meets research objectives;
 Participants must comprehend questions being asked;
 Language used should be at the level of the participant‟s;
 Questions should not be leading;
 Double-barrelled questions are to be avoided;
 When to use open or close-ended questions must be determined;
 Different response categories should be available in closed- ended
questions;
 Multiple items are to be used to measure abstract constructs;
 The questionnaire should be easy to complete;
 The questionnaire must be pilot tested (Johnson & Christensen, 2008:172).

For this research study the measuring instrument chosen by the researcher was a
structured questionnaire. The researcher consulted previously validated
questionnaires during the development of the questionnaire. However, due to the
specific nature of the critical care context, a structured questionnaire was created.
A thorough literature review was done on barriers to the implementation of
evidence-based practices to serve as a guideline for which questions on the
questionnaire should be asked. Various questions were presented in the
questionnaire to yield data that would be congruent with the research objectives.
Dichotomous questions were given to limit responses to a “Yes” or “No”. Forced-
choice questions compelled the participant to allocate one answer from a list of
possible answers. There were a few open ended questions which prompted
participants to write answers in an allocated space. Within the research study
there were only a few filter questions which forced the participant to respond to a
follow-up question. Apart from questions, scales also formed part of the
questionnaire content. The Likert scale was created to assess the strength of a
participant's opinion to about a statement provided.

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Researchers determine the content of questionnaires based on the topic chosen.

Usually, it is standardized; therefore all participants will receive the same
questionnaire and will complete it themselves without any interference from the
researcher (Moule & Goodman, 2009:300). Administration of questionnaires may
range from posting them or the researcher hand-delivering them to participants.
Response rates may vary and can be affected by factors such as the length of a
questionnaire. Questions should be kept to as few as necessary to improve
response rates. The questionnaire should also flow and be logical in the way the
sections follow one other. A covering letter may increase response rates, therefore
information such as confidentiality, purpose of the study, what will be done with
the results and contact information should be stated in case the participant has
any queries (Moore, 2006:127). Advantages of questionnaires are as follows: they
are inexpensive, easy to use, confidentiality and anonymity may be maintained,
abstract concepts may be measured and large amounts of data may be collected
in a short space of time (Parahoo, 2006:285).

The questionnaire (Annexure A) was checked by the statistician to ensure the flow
and sections were relevant to extract the data that was required. The
questionnaire was subdivided into specific sections as outlined below:
 Section A: Demographic data;
 Section B: Implementation of evidence-based practices;
 Section C: Barriers related to knowledge of the nurse with regard to
evidence-based practices;
 Section D: Barriers to finding and reviewing evidence;
 Section E: Barriers to implementing evidence-based practice based on
relevant resources;
 Section F: Barriers related to facilitation and support structures required for
evidence-based practice implementation.

Section A contains 6 items to explore the demographic data of participants. In

section B there are 9 items to explore implementation of evidence-based
practices. Section C comprises 14 items which explores the knowledge of a nurse
with regard to evidence-based practices. Section D consists of 10 items which

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ascertain barriers to finding and reviewing evidence. Section E contains 5 items to

explore barriers to implementing evidence-based practices on the relevant
resources. Section F contains 9 items which explores barriers related to facilitation
and support structures required for evidence-based practice implementation.

3.4.4 DATA-COLLECTION METHOD

In quantitative research data-collection methods may range from interviews,

questionnaires, observational schedules, self-reporting schedules to bio-
physiological measures. The data-collecting instrument should also be appropriate
in addressing the research question (Barker, 2010:71). Gerrish and Lacey
(2010:23) add that data-collection methods often involve interaction with patients,
staff or the public, depending on the method chosen. According to Polit and Beck
(2008:381), data-collection protocols which may guide researchers describe the
following:
 conditions when data is collected;
 recruitment of participants;
 rules that must be followed during data-collection;
 procedures for collecting data and
 management and storage of data.

Before commencement of the main study consent was granted by internal and
external stakeholders. The unit manager was informed beforehand when the main
study would be conducted. The study took place over approximately one week at
the critical care unit at a private hospital in the Nelson Mandela Metropole as
participants rotated from day and night shifts. Therefore participants from all shifts
were involved in the research study. Participants were approached outside of
peak times in the unit such as doctors‟ rounds, rendering of basic care or
administering medication.

The researcher handed out questionnaires to participants and remained in the unit
for at least 20 minutes to clarify any uncertainties about the questionnaire.
Instructions were given to participants to enable that data retrieved would be
easily analysed and not compromised in any way. Participants were told that the

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questionnaire had to be completed before the end of their shift. At no point could
they consult textbooks, the internet or their peers in answering questions. Each
aspect of the participant letter (Annexure B) and informed consent (Annexure C)
was explained to the participants. Once a participant decided to participate, the
informed consent form was filled in with all the particulars of a participant. The
questionnaire was handed to the participant and each section was explained. The
researcher emphasized that each question had to be answered and instructions
on how to answer the question had to be followed to allow the researcher to use
that questionnaire. The consent form did not have to be attached to the
questionnaire. The questionnaire was in no way marked. Participants could
contact the researcher by telephone if there were any queries. Participants were
reassured that anonymity and confidentiality would be adhered to throughout the
research process.

Upon completion of the questionnaire participants were instructed to place the

questionnaire into a sealed box at the central nursing station. The researcher
returned to the unit to collect the sealed box and then replaced it with another
empty sealed box. The researcher was the only person to access the sealed box.
A total of 75 questionnaires were handed out and 70 were returned achieving a
response rate of 93%. Five participants were excluded from the study as they
changed their minds about participating in the study and others did not return the
questionnaire before the end of their shift.

3.4.5 PILOT STUDY

A pilot study is conducted before the main study to test out a data-collection
instrument. In quantitative studies a few participants with characteristics similar to
those of main study will be given questionnaires; therefore the researcher can
ascertain if questions are interpreted correctly. Any modifications to the
questionnaire can be made after the pilot study. Results of the pilot study from
quantitative studies are not published or included in the main study (Gerrish &
Lacey, 2010:23). As noted in Polit and Beck (2008:213), a pilot study is described
as a trial run designed to test methods to be used in the parent study, which is
also known as the main study. Essential functions of pilot studies are:

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 to evaluate the study methods and procedures;

 to determine involvement of participants;
 to check the effectiveness of instruments;
 to identify which variables need to be controlled and;
 to explore possible problems that could be encountered in the main study.

Pilot testing of the questionnaire will enlighten the researcher to whether

participants understand the questionnaire in the same way. The suitability,
structure and format of questions can also be tested according to responses of
participants. Researchers will also be able to establish if questionnaires are of an
appropriate length. Therefore by pilot testing the questionnaire strengths and
weaknesses can be determined, and then modified before the main study
(Parahoo, 2006:309).

Prior to conducting the main study, a pilot study was performed to test the
questionnaire under similar conditions to the main study. Firstly, the researcher
chose the exact location where the main study would be conducted. Consent was
obtained in advance from hospital management and the unit manager of the
critical care unit at the private hospital within the Nelson Mandela Metropole. On
the day of the pilot study, the researcher liaised with the unit manager to avoid
peak periods such as doctors' rounds, rendering of basic nursing care or
administering medication. During a quiet period of the day, two participants agreed
to participate in the pilot study. The researcher elaborated upon all aspects of the
research study and answered all questions asked by the two participants. The two
participants signed the informed consent. Afterwards, each participant received a
questionnaire whilst the researcher remained in the critical care unit to address
any issues pertaining to the questionnaire. Both participants completed the
questionnaire before the end of their shift.

When the researcher evaluated the completed questionnaire the responses

elicited were not as desired, therefore with the aid of the statistician six questions
were added to the questionnaire. Questions that were added were to determine
the comprehension of the concept of evidence-based practices and frequency in

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accessing online evidence-based sources. The two participants were excluded

from the main study to prevent any bias as they had exposure to the questionnaire
in the pilot study. All data extracted from the pilot study will be kept in a safe place
for a period of five years and will be discarded thereafter.

3.4.6 DATA ANALYSIS

When research questions are addressed through completion of questionnaires,

any data collected has to undergo a process called data analysis. In quantitative
studies the process only commences once all data is collected from participants
(Parahoo, 2006:375). Computers enable data to be transformed into
comprehensible results, therefore producing recommendations in accordance with
research objectives. Software on computers to analyse data may range from a
standard spread sheet to statistical analyses packages, such as Quantum or
SPSS depending on the complexity of the research (Moore, 2006:133). The
statistician who assisted with the data analysis process used Statistica Version 10.
Neuman (2006: 344) describes the systematic processes related to data analysis
when handling data that has been outlined below.

Coding data
Coding implies that data is converted into a form that a computer will be able to
analyse. The researcher codes the data by assigning a number to a variable. For
example: Males as 2 and females as 1. A codebook is a document that the
researcher may implement to describe how each variable was coded. Once each
variable is coded the data may be captured on the computer. With regard to the
research study carried out before commencing with the coding procedure, each
questionnaire was checked by the researcher for completeness. Questionnaires
that were incomplete marked incorrectly or left blank were to be discarded but
each question that was answered according to the instructions given, and included
into the main study. A reference number was then allocated to each questionnaire.
Once all raw data was acquired the researcher consulted the statistician on how
each response should be coded. The statistician took a blank questionnaire and
coded the question and responses by giving each one a code which was in
numerical form. The data was then captured onto a Microsoft Excel graphical chart

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which was constructed by the statistician. The coding process was conducted in a
way that would allow data to be analysed.

Entering data
The data is entered into the computer onto a grid format and each row represents
one participant with a column representing the variable. Therefore the researcher
should be able to match the row and column to the questionnaire. For example,
participant 5 will be on row 5 with question 2 being represented as variable
number 2. The research study conducted required the researcher to enter the
information onto the grid format. Across the horizontal plane each line represented
data from the 70 participants and was labelled as P01 to P70. Each vertical row
symbolized a variable that was being measured. In each vertical row responses
elicited from participants were recorded. Once completed by the researcher the
data cleaning processes followed to check that all data entered onto the spread
sheet was indeed correct.

Cleaning the data

The researcher checked that data entered was correct by ensuring that there were
no coding errors, a process known as data cleaning. Code cleaning checks
variables for codes that are incorrect. For example, a variable with a code of 1 to 5
that, when checked has a code of 8, has a coding error. The other method is
contingency cleaning which means that two variables are compared for impossible
combinations. With regard to the research study that was carried out, the
researcher checked data entered into the spread sheet was compared to and
verified with the questionnaire to ensure the data captured was correct. The data
cleaning process is the responsibility of the researcher and is an absolute vital
step in data analysis, as omitting this step would skew results.

Data presentation
Hek, et al (2003:91) concur that descriptive statistics are used to describe results
whereas with inferential statistics the researcher attempts to link a relationship
between variables. According to Saks and Allsop (2007:198) data may be
presented via descriptive or inferential statistics.

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Descriptive statistics involves the graphs, tables or numerical representation of

data as outlined below:
 Graphs: represents a variable through a pie, bar or histogram;
 Tables: The variable is represented according to frequency distribution;
 Numerical: Features of a distribution is represented in a single number.

Inferential statistics are defined as the numerical techniques for making

conclusions about a population based upon information obtained from a random
sample drawn from that population. Therefore inferential statistics test hypotheses
to ascertain whether descriptive results are random or whether there is a relation
between variables. In the study conducted data was represented in the graphical
and numerical format, which is illustrated in Chapter Four.

3.4.7 QUALITY CONTROL OF THE RESEARCH STUDY

In order to achieve a research study of high quality reliance on a reliable and valid
measuring instrument is critical. Through testing a measuring instrument for
validity and reliability the soundness of a questionnaire can be established; for
without the presence of the two concepts a research study may be deemed
insignificant.

3.4.8 RELIABILITY

The term is concerned with investigating if a research study is replicable and

dependable is known as reliability (Barker, 2010:145), which is quite often used in
quantitative research to measure research variables (Polit & Beck, 2008:196). A
study has reliability if the same results are yielded each time a particular technique
is applied to the same object (Babbie, 2010:150).There are three types of
reliability: stability reliability, representative reliability and equivalence reliability.
Stability reliability assesses reliability over a period of time (which is whether the
same results will be achieved at any point in time), representative reliability
identifies reliability across various groups of people so results should be
consistent; and equivalence reliability measures reliability across indicators.
Therefore reliability suggests that the same results will be achieved in very similar

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situations (Neuman, 2006:190).

To ensure that the measuring instrument was reliable, responses in the pilot study
were compared to that of the main study. Responses elicited were very similar
indicating that the measuring instrument had a high threshold of reliability. With
the aid of a statistician it was concluded that responses were in alignment to
concepts being measured. The researcher established reliability by seeking expert
opinion in relation to the content of the questionnaire from the supervisor of the
research study, the unit manager and the clinical facilitator of the critical care unit.

3.4.9 VALIDITY

The validity of a measurement instrument is the extent to which an instrument

measures what it is supposed to (Leedy & Ormrod, 2005:28). According to Polit
and Beck (2008:196), validity is a crucial concept for evaluating methods to
measure research variables. Validity measures the soundness of a research study
and ensures that results are unbiased and well grounded. An instrument is
regarded as valid if it reflects characteristics that are being measured. There are
also three types of validity that exist: content validity, criterion-related validity and
construct validity. However, two types of validity pertain to this research study:
namely, content and face validity.

Content Validity is obtained when researchers are sure that the instrument
measures what it is supposed to and when researchers try to obtain face validity
by allowing others to examine the measuring instrument and try to establish if the
instrument measures what it intends to. Another method involves giving the
measuring instrument to a panel of experts who then score the instrument
according to the degree that the concept being measured is reflected in the
instrument (Polit and Beck, 2008:196). To determine content validity the
researcher aimed to prove that the content presented in a questionnaire actually
measures what it is supposed to. When constructing the questionnaire, a thorough
comprehensive background of literature guided the researcher in ensuring
relevance of content in the questionnaire. The questionnaire was discussed with
experts in the field such as the research supervisor, the statistician, the clinical

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facilitator and physicians.

Face validity implies that the data-measuring instrument appears to measure the
content that it is supposed to measure. Participants are also more compliant about
filling out a questionnaire if they perceive the content of the questionnaire to be in
line with the title of the research study (Burns & Grove, 2009:381). The statistician
assisted with this type of validity as part of the content was related to barriers to
implementing evidence-based practices in a critical care unit. Validity of the study
was assured by discussing the content of the questionnaire with various experts in
the field, including the clinical facilitator, the supervisor and professional nurses in
the critical care unit.

3.4.10 ETHICAL CONSIDERATIONS

Ethics is defined as moral values that are concerned with the degree to which
research procedures adhere to the professional, legal and social obligations to the
research study participants (Polit & Beck, 2008:753). The American Nurses‟
Association (ANA) 2001 code of ethics states that five human rights should be
protected when conducting research, namely:
 the right to anonymity;
 the right to self-determination;
 the right to privacy;
 the right to fair treatment and
 the right to protection from harm (Schmidt & Brown 2009:229)

Ethical considerations have to be taken into account when conducting research.

The researcher will discuss the following ethical principles: informed consent,
anonymity, confidentiality and privacy that were relevant to the study.

3.4.11 INFORMED CONSENT

The legal principle is based on an individual's decision to participate in a research

study after all relevant information pertaining to the study is provided within a
reasonable amount of time. Informed consent is usually provided in a written form

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and is considered a legal document (Rebar et al, 2011:133). The purpose of the
study, procedures, risks, benefits, and the duration of the study are elements to be
mentioned in an informed consent (LoBiondo-Wood & Haber, 2010:255). As noted
in Moule and Goodman (2009:60) emphasis should also be on the technical
aspects of how information is provided. The informed consent form should be
easily understood, unambiguous and easy to read. The tone of the information
should be invitational and not coercive. All forms provided should also be dated
with headings that are clear. Ruane (2005:19) adds that informed consent also
implies that a participant may withdraw from the study at any time.

Before the main study was conducted, the research proposal had to be approved
by various structures such as the DRC (Departmental Research Committee) and
the FRTI (Faculty of Research, Technology and Innovation) at the Nelson
Mandela Metropolitan University. The research study was approved at the FRTI
(Faculty of Research, Technology and Innovation) level with the allocation of the
reference number: HII-HEA-NUR-008. A participant letter (Annexure B) and an
informed consent form was constructed before the main research study (Annexure
C). Before the pilot and main studies were conducted consent was granted from
hospital management (Annexure D) and the unit manager (Annexure E). In
(Annexure F) written consent was granted from the nursing manager where the
study was conducted.

During the research study each section of the form was thoroughly explained to
participants so that they could also pose any questions or state sections that
needed clarification. Once participants gave written consent they could participate
in the research study. However, they were aware that they could withdraw from
the study at any point in time if they wished to.

3.4.12 ANONYMITY AND CONFIDENTIALITY

Anonymity implies that the participant's identity cannot be linked to individual

responses. Confidentiality exists when identities and information provided by
participants are kept private and not divulged (LoBiondo-Wood & Haber,
2010:253). Johnson and Christensen (2008:119) concur and elaborate by stating

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that anonymity means that not even the researcher can uncover the participant's
identity. The context of confidentiality in a research study refers to the participants'
identity not being revealed to the researcher. Wood and Ross-Kerr (2011:37) adds
that confidentiality ensures that all records are kept closed and only the researcher
will have access to the records.

In the research study that was performed the questionnaires (Annexure A) handed
out to participants were not marked and names were not required as the
researcher allocated a reference number to each questionnaire after the data-
collection process. Participants were also instructed to sign the informed consent
form (Annexure C) with the assurance that information collected would be kept
strictly private. Therefore participants' anonymity was assured through these
measures. During the study confidentiality was asserted as the researcher
exclusively handled the completed questionnaires. Upon completion of the
questionnaire participants were instructed to deposit it into a sealed box that was
kept within the unit. When the boxes were collected from the unit, only the
researcher opened the sealed boxes with the data. Each questionnaire was given
a reference number and all of them will be kept in safe storage for a period of five
years for audit purposes, after which all data will be destroyed.

3.4.13 PRIVACY

Privacy is maintained when the behaviour or responses of participants are in no

way divulged to anyone except the researcher (Leedy & Ormrod, 2005:102).
When the research study was conducted there were no factors that existed that
could threaten privacy as data obtained were only accessed by the researcher. All
data is stored in a safe place and will be kept for a period of 5 years. Participants
did not disclose their names on questionnaires as a reference number was
allocated to each questionnaire.

3.5 SUMMARY OF CHAPTER

This chapter comprehensively explained the research design and method

employed when conducting the research study. The systematic application of a
research design and methods are imperative when conducting any research

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study. A quantitative, descriptive, exploratory and contextual design was adopted

to ascertain barriers to the implementation of evidence-based practices within a
critical care unit. In the following chapter a description of the results extracted and
data analysis will be discussed.

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CHAPTER FOUR

DATA ANALYSIS AND DISCUSSION OF FINDINGS

4.1 INTRODUCTION

Three chapters have been discussed thus far. Chapter One introduced the reader to
the method known as evidence-based practices. Chapter Two delved into a literature
review on the topic, whereas Chapter Three focused on the research methodology
that was applied when conducting the research study to identify barriers to the
implementation of evidence-based practices within a critical care unit.
This chapter will describe:
 the sample of professional nurses used in the study and
 a discussion of all results obtained from the distribution of self-
administered questionnaires to professional nurses in a critical care unit at
a private hospital within the Nelson Mandela Metropole
The goal of this section is to address the research objectives which are as
follows:
 to explore and describe barriers to the implementation of evidence-based
practices in a critical care unit and
 to make recommendations to enhance implementation of evidence-based
practices in a critical care unit

4.2 TARGET POPULATION OF PROFESSIONAL NURSES

A sample of seventy professional nurses (n=70) working in a private hospital

within the Nelson Mandela Metropole participated in the research study. The
sample included fifty-eight permanently employed professional nurses and twelve
professional nurses working through a nursing agency. In Figure 4.1 the sampling
process of the research study is outlined. Seventy-five questionnaires were
handed out to participants at the commencement of the data- collection phase.
However, some questionnaires were not returned before the end of the shift and
one participant decided not to participate anymore; therefore

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seventy questionnaires were returned. The response rate was 93%.

Assessed for
inclusion
n=75

Excluded n=5

Reasons for
exclusion n=5

Refused to Did not return

participate questionnaire before end
n=1 of shift
n=4

Number of participants
n=70

Permanent Nurses Analysis n=70 Agency nurses n=12

n=58

Response rate= 93%

Figure 4.1: The sampling process

4.3 DATA ANALYSIS APPROACH

The data analysis approach was comprehensively described in Chapter Three.

Data was analysed with the aid of a statistician; the programme used was
Statistica version 10 and all data was entered using a spread sheet and frequency
distributions were established. Descriptive statistics in this section will be
displayed through tables and bar-graph charts.

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Data analysis and discussion of findings Chapter Four

All results presented in this chapter are from the research study: barriers to
implementation of evidence-based practices within a critical care unit and are from
the following:
 Section A: Demographic data
 Section B: Implementation of evidence-based practices
 Section C: Barriers related to knowledge of the nurse with regard to evidence-
based practice
 Section D: Barriers to finding and reviewing evidence
 Section E: Barriers to implementing evidence-based practices based on the
relevant resources
 Section F: Barriers related to facilitation and support required for evidence-
based practice implementation

4.4 DEMOGRAPHIC DATA

The demographic profile of participants who participated in the research study will
be elaborated upon in this section. A list of all items that will be discussed will be
presented in the Textbox 4.1.

Textbox 4.1: Demographic data

4.4.1 Results
4.4.1.1 Gender
4.4.1.2 Age in years
4.4.1.3 Years of employment in the critical care unit
4.4.1.4 Current position in the critical care unit
4.4.1.5 Additional qualification with SANC
4.4.1.6 Specific additional qualification
4.4.2 Discussion pertaining to demographic profile
4.4.3 Summary of demographic profile

4.4.1 RESULTS

The results of the demographic data obtained from participants where the study
took place will be displayed in Table 4.1.

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Data analysis and discussion of findings Chapter Four

Table 4.1: Demographic data

1. Indicate your gender No: %
Male 7 10%
Female 63 90%
2. Indicate your age in Years
<25 years 2 3%
25-29 years 9 13%
30-39 years 18 26%
40-49 years 31 44%
>50 years 10 14%
3. Indicate the years you have been working in a critical care unit
<1 year 5 7%
1-4 years 23 33%
5-9 years 10 14%
10-14 years 16 23%
>15 years 16 23%
4. As a professional nurse what position do you hold in a critical care
unit?
Permanently employed professional nurse on shift 35 50%
Agency worker 12 17%
Shift leader 19 27%
Clinical facilitator 0 0%
Unit manager 4 6%
5. As a professional nurse do you hold an additional qualification with
SANC
Yes 23 33%
No 47 67%
6. * If yes, please specify
Master‟s degree in Critical Care nursing 2 3%
Honours degree in Critical Care nursing 6 9%
Diploma in Critical Care nursing 6 9%
Neonatal critical care nursing 1 1%
Nursing education 1 1%

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Data analysis and discussion of findings Chapter Four

Nursing administration 5 7%
Infection control nursing 2 3%
Paediatric nursing 2 3%
Occupational nursing 2 3
*Please note that some participants were in the
possession of more than one additional qualification

4.4.1.1 Gender

From the 70 participants who participated in the research study: barriers to the
implementation of evidence-based practices in a critical care unit n=7(10%) were
male and n=63 (90%) were female.

4.4.1.2 Age in years

Participants were required to stipulate their age in Section A of the self-

administered questionnaire. There were n=31(44%) who were between 40 and 49
years age. A proportion of participants n=18(26%) participants were between the
ages of 30 and 39 years while n=10(14%) were 50 years and older. There were
some participants, n=9(13%) were between 25 to 29 years of age whilst there
were n=2(3%) who were younger than 25 years of age.

4.4.1.3 Indicate the years you have been working in a critical care unit

The purpose of the section was to ascertain the time periods that participants
worked in the critical care unit. Of the seventy participants there were n=23(33%)
who had worked in the critical care unit for a period of 1 to 4 years. The study
findings indicated there were n=16(23%) who had worked in the critical care unit
for 10 to 14 years whilst there were n=16(23%) who had worked for a period of 15
years or more. There was a proportion of participants, n= 10(14%), who had
worked in the critical care unit for a period of 5 to 9 years. Lastly, n=5(7%)
indicated that they had been working in the critical care unit for less than one year.

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4.4.1.4 Current position within the critical care unit

From the seventy participants that participated in the study there 58 professional
nurses that were permanently employed. From the 58 professional nurses there
were n=35(50%) that rotated from dayshift to nightshift; n=19(27%) who were shift
leaders that were responsible for taking charge of the shift; and n=4(6%) who
were unit managers. The remaining participants, n=12(17%), were professional
nurses working through a nursing agency.

4.4.1.5 Additional qualifications with the South African Nursing Council

Results obtained from the demographic profile that is presented in Table 4.1
indicate that n=47(67%) do not hold an additional qualification with the South
African Nursing Council. From the remaining participants n=23(33%) possess an
additional qualification other than the basic four-year nursing diploma or degree
for registration as a professional nurse.

4.4.1.6 Specific additional qualification

Of the seventy participants only 23% have additional post-basic qualifications. In

Table 4.1, Question 6, there were also participants who had more than one
additional qualification; therefore the percentages and numbers do not correlate
with Question 5. Derived from the data analysis n=2 possessed two additional
qualifications whilst n=1 possessed three additional qualifications with the South
African Nursing Council.

With regard to an additional qualification n=6(9) have an Honours degree in

Critical Care Cursing and n=6(9%) have their Diploma in Critical Care Nursing.
The results indicate that n=5(7%) have a Diploma in Nursing Administration. A
proportion of participants, n=2(3%), who have their Masters degree in Critical Care
Nursing. Of the seventy participants n=2(3%) have an additional Diploma in
Infection Control Nursing; n=2(3%) have a qualification in Paediatric Nursing whilst
n=2(3%) have an additional qualification in Occupational Nursing. A proportion of
participants, n=1(1%), have Neonatal Nursing and n=1(1%) have a Diploma in
Nursing Education.

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4.4.2 DISCUSSION PERTAINING TO THE DEMOGRAPHIC PROFILE

The South African population comprises 47.9 million people. The patient
population in critical care units in South Africa differs vastly from the rest of the
world. Patients are admitted to critical care units nationally, for instance, due to
increased prevalence of trauma such as gunshot wounds, stabbings, falls and
motor vehicle accidents (De Beer, Brysiewicz & Bhengu, 2011:6). In a national
audit to establish the availability of critical care resources it was found that there
was a total of 4168 critical care beds in South African hospitals (Bhagwanjee &
Scribante, 2008:4).

Gender was discussed under section A of the self-administered questionnaire.

According to the South Africa Nursing Council (SANC), statistics were obtained by
following the link (http:www.sanc.co.za). The SANC 2011 geographical statistics
reflect that there are 118 262 professional nurses in South Africa. In the Eastern
Cape Province there are 13 017 female professional nurses and 1101 male
professional nurses yielding a total of 14 118. The estimated population-to nurse
ratio in the Eastern Cape is 484:1. The findings of this research study indicated
participants comprised 90% females and 10% males. The nursing profession is
traditionally known for being a female-dominated profession, and the demographic
profile from the research study is congruent with statistics from the South African
Nursing Council.

The target population that took part in the research study varied in age.
Participants had to indicate their age group in the self-administered questionnaire
under the demographic data section. The South African Nursing Council (SANC)
2011 age statistics determined that, of the professional nurses 30% were between
the ages of 40 and 49 years; 30% were between 50 and 59%; and 19% were 30-
39 years of age. According to SANC the minority of prof essional nurses were
younger than 30 years old. The data suggests that professional nurses registered
with the South African Nursing Council are an ageing population. The findings of
this research study revealed that of the participants 44% were between the ages
of 40 and 49 years of age. The research findings are congruent with statistics from
the South African Nursing Council.

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Data analysis and discussion of findings Chapter Four

Years that participants have worked in a critical care unit will be discussed in
this section. Bhagwanjee and Scribante (2008:5) who performed a national audit
ascertained that 43% of professional nurses working in critical care units in South
Africa had between 0-5 years of critical care experience. Findings of this research
study indicate that 33% of the professional nurses have 1 to 4 years of experience
working in a critical care unit. The research findings are congruent with the
statistics from the national audit that was conducted.

Position in the critical care unit was in the demographic data section.
De Beer, et al (2011:6) comment that professional nurses emigrating to other
countries, coupled together with few entering the profession, has created a
dilemma which has been solved by allowing agency workers to alleviate staff
shortages. Challenges have arisen from sourcing agency workers though,
because standards of care have been lowered and medico-legal risks have
increased. Another reality is that agency workers may be permanently employed
at one institution and work extra hours elsewhere; therefore level of functioning
deteriorates as they do not get sufficient rest. Findings of this research study
indicate that 83% of the professional nurses who participated in the study were
permanently employed whilst 17% worked through a nursing agency.

Additional qualifications in the critical care unit.

In the national audit done in 2004-2005, it was estimated that 25.6% of nurses
working within a critical care unit were ICU trained. The ideal should be 75% of
professional nurses within any critical care unit. Statistically there was a shortage
reported of 7 920 critical care nurses in South Africa (Scribante & Bhagwanjee,
2007:1317). In an ideal critical care unit there should be an intensivist that makes
major decisions and collaborates with the rest of the team. Statistics have
deduced that an intensivist is present in only in 4% of the critical care units in
South Africa (Bhagwanjee & Scribante, 2008:5). Findings of this research study
indicated that 33% of the participants had an additional qualification. Of those
participants only 21% have an additional qualification that pertains to critical care
nursing.

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4.4.3 SUMMARY OF THE DEMOGRAPHIC PROFILE

The following results from the demographic data section were of significance. Of
the seventy participants there were n=63(90%) who were female. With regard to
the age group the predominant age group was n=31(44%) who were between 40
and 49 years of age. A proportion of participants, n=23(33%), had worked in a
critical care unit for a period of 1 to 4 years. Of the seventy participants,
n=58(83%), were permanent employees in the critical care unit. There were
n=47(67%) of participants who did not possess an additional qualification with the
South African Nursing Council.

4.5 IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

This section comprised sections to explore how often nurses accessed evidence-
based practices, their understanding of evidence-based practice and which online
resources they accessed. For this section dichotomous, forced choice, open-and
closed-ended questions were used in the questionnaire to yield relevant data.

Textbox 4.2: Implementation of evidence-based practices

4.5.1 Results
4.5.1.1 Degree of familiarity with evidence-based practices
4.5.1.2 The concept known as “evidence-based practice”
4.5.1.3 Frequency of consulting evidence or to support clinical decision-making
and nursing practice in the critical care unit
4.5.1.4 Frequency of accessing best-practice guidelines in the critical care unit
4.5.1.5 Information sources that are consulted to guide clinical decision-
making
4.5.1.6 Information sources that are used on which to base clinical decision-
making
4.5.1.7 Frequency of accessing online evidence-based sources
4.5.1.8 Source to consult when weaning the patient from the mechanical
ventilator
4.5.1.9 Source of reference for prevention of ventilator-associated pneumonia
4.5.2 Discussion pertaining to the implementation of evidence-based
practices.

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Data analysis and discussion of findings Chapter Four

4.5.1 RESULTS

The results were obtained from the seventy participants who completed the
questionnaire. The section explored familiarity of evidence-based practices. The
data derived will be schematically presented using bar graphs.

4.5.1.1 Degree of familiarity with evidence-based practices

Of the seventy participants n=24(34%) were to a moderate extent familiar with

evidence based practices while n=23(33%) were to a great extent familiar with
evidence-based practices. A proportion of participants, n=12(18%), were
completely familiar with evidence-based practices; n=8(11%) were to a little extent
familiar with the term evidence-based practice whilst n=3(4%) were not at all
familiar with evidence-based practice.

40
Percentage

30

20

10

0
Moderate
Completely Great extent Little extent Not at all
extent
Participants 12 23 24 8 3
Percentage 18 33 34 11 4

Figure 4.2: Degree of familiarity with evidence-based practices

4.5.1.2 The concept known as “evidence-based practice”

Figure 4.3 depicts the results from participants with regard to their understanding
of evidence-based practice. Of the seventy participants n=38(54%) identified the
correct answer, namely that evidence-based practice is the conscientious, explicit
and judicious use of the current best evidence in making decisions about the care
of patients. The other participants, n=24(34%), stated that their understanding of
evidence-based practices was skills taught during their training as a professional
nurse which is an incorrect answer whilst n=6(9%) were of the opinion that
evidence-based practices were skills that were taught in the unit, which was also
incorrect. The remaining participants, n=2(3%), thought that evidence-based
practice referred to any article that was in a medical or nursing journal, which is

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Data analysis and discussion of findings Chapter Four

also incorrect.

60
50

Percentage
40
30
20
10
0
Any Best evidence
Skills taught Practices
med/nurse in caring for
during training taught in unit
journal patients
Participants 24 2 38 6
Percentage 34 3 54 9

Figure 4.3: The concept known as “evidence-based practice”

4.5.1.3 Frequency of consulting evidence to support clinical decision-

making and nursing practice in the critical care unit

From the data analysis of the seventy participants, n=40(57%) indicated that they
only consulted evidence or research occasionally to support their clinical decision-
making in the critical care unit. Some participants, n=16(23%), stated that they
accessed evidence 1 to 3 times per month. There were some participants,
n=8(12%), that accessed evidence or research on a weekly basis to support their
clinical decision-making processes in the critical care unit. Of the seventy
participants, n=5(7%), stated that they accessed evidence or research 1 to 3 times
per year while n=1(1%) revealed that they never accessed evidence or research
to guide clinical decision-making.

60
50
40
Percentage

30
20
10
0
1-3 times a 1-3 times a Occa-
Weekly Never
month year sionally
Participants 8 16 5 40 1
Percentage 12 23 7 57 1

Figure 4.4: Frequency of consulting evidence to support clinical

decision-making and nursing practice in the critical care unit

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Data analysis and discussion of findings Chapter Four

4.5.1.4 Frequency of accessing best-practice guidelines in the critical care

unit

Figure 4.5 depicts the results of how often participants‟ access best-practice
guidelines in the critical care unit. A total of n=35(50%) revealed that they
accessed evidence-based guidelines on an occasional basis. There were some
participants, n=14(21%), who accessed guidelines 1 to 3 times per month.
However, n=10(14%) consulted the best- practice guidelines in the critical care
unit at least weekly. There were some participants who accessed the guidelines
less frequently; n=8(11%) did so 1 to 3 times a year whilst n=3(4%) never
accessed best-practice guidelines.

50

40
Percentage

30

20

10

0
1-3 times a 1-3 times a Occa-
Weekly Never
month year sionally
Participants 10 14 8 35 3
Percentage 14 21 11 50 4

Figure 4.5: Frequency of accessing best-practice guidelines in the

critical care unit

4.5.1.5 Information sources that are consulted to guide clinical decision-

making

The statement was aimed toward ascertaining where participants sought

information to guide them in decision-making processes. It is evident from Figure
4.6 that participants n=30(43%) ask their colleagues or peers when seeking
information to guide their decision-making. Of the seventy participants n=24(35%)
indicated that they preferred to search the internet when searching for information
to guide them in rendering nursing care to critically ill patients; n=8(11%) chose to
read textbooks in searching for information to guide them in clinical decision-
making and the remaining participants, n=8(11%), stated that they preferred to
access journal articles.

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Data analysis and discussion of findings Chapter Four

50
40

Percentage
30
20
10
0
Ask
Read journal Read text Search the
colleagues
articles books internet
and peers
Participants 8 8 24 30
Percentage 11 11 35 43

Figure 4.6: Information sources that are consulted to guide clinical

decision-making

4.5.1.6 Information sources that are used on which to base clinical

decision-making

The statement was aimed at determining from the participants on what sources
they based their clinical decisions. The responses are reflected in Figure 4.7. The
findings revealed that n=30(43%) based their clinical decisions on the latest
available evidence. However, n=27(39%) indicated that they relied on knowledge
and skills that they had been taught in the critical care unit. There was a
proportion of participants, n=12(17%), that preferred to ask their colleagues or
peers when making clinical decisions. The remaining participants, n=1(1%),
indicated that they based their decisions on ritualistic practices.

50
40
Percentage

30
20
10
0
On what I have On the latest
Ritualistic Ask colleagues
been taught in available
practices and peers
unit evidence
Participants 1 27 30 12
Percentage 1 39 43 17

Figure 4.7: Information sources that are used on which to base clinical
decision-making

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4.5.1.7 Frequency of accessing online evidence-based sources

Table 4.2 graphically displays the results for the frequency of accessing online
evidence-based sources from the list of twelve that were presented in the
questionnaire. In Table 4.2 the most frequently accessed online sources are
Google and Wikipedia. Participants also had the option to specify whether there
were other sources that they used. Of the seventy participants n=2(3%) indicated
that they accessed Medscape whilst n=1(1%) accessed Elsevier.

Table 4.2: Frequency of accessing online evidence-based sources

Never Seldom Frequent

Online evidence-based sources

Participants

Participants
Participants

%
EBSCO host 62 89 2 3 6 8
MEDLINE 50 72 10 14 10 14
Pubmed 58 82 6 9 6 9
The Cochrane Collaboration 64 91 4 6 2 3
National Guideline Clearinghouse 60 86 7 10 3 4
Registered Nurses Association of Ontario
61 87 5 7 4 6
(RNAO)
Johanna Briggs Institute (JBI) 61 87 5 7 4 6
World-Views on Evidence-based Nursing 52 74 10 14 8 12
The International Journal of Evidence-
49 70 12 17 9 13
based Healthcare
Google Scholar 45 65 10 14 15 21
Google 9 13 20 28 41 59
Wikipedia 32 46 12 17 26 37
Medscape 2 3
Elsevier 1 1

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Data analysis and discussion of findings Chapter Four

4.5.1.8 Source to consult when weaning the patient from the mechanical
ventilator

Of the seventy participants n=35(50%) indicated they would refer to information

taught in the critical care unit to assist them in weaning a patient from a
mechanical ventilator, which was the incorrect answer. The only recommended
answer that was identified by n=21(30%) indicated they would follow the latest
best-practice guideline. There was a proportion of participants, n=13(19%), who
stated that they would ask a colleague whilst n=1(1%) indicated they would
consult their critical care textbook. The results are illustrated in Figure 4.8.

50
40
Percentage

30
20
10
0
Consult Follow best
Ask a Follow what is
critical care practice
colleague taught in unit
textbooks guidelines
Participants 13 1 21 35
Percentage 19 1 30 50

Figure 4.8: Source to consult when weaning the patient from the
mechanical ventilator

4.5.1.9 Source of reference for the prevention of ventilator-associated

pneumonia (VAP)

The purpose of the question was to ascertain to which source participants would
refer a novice nurse for, the prevention of ventilator-associated pneumonia (VAP).
Of the participants n=39(56%) listed referring the novice nurse to the latest best-
practice guideline, which was the recommended answer. There was a percentage
of incorrect responses from, n=26(37%) who would refer her to the Standard of
Operating Practice (SOP) which is an institution‟s policy and procedure manual;
n=3(4%) participants that stated they would refer her to a critical care textbook
and the remaining participants, n=2(3%), revealed that they would tell her to
Google the term “ventilator-associated pneumonia”.

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Data analysis and discussion of findings Chapter Four

60
50
40

Percentage
30
20
10
0
Give best
Give latest
Refer her to Tell her to practice
critical care
SOP Google VAP guideline to
textbook
prevent VAP
Participants 26 3 2 39
Percentage 37 4 3 56

Figure 4.9 Source of reference for the prevention of ventilator associated

pneumonia (VAP)

4.5.2 DISCUSSION PERTAINING TO THE IMPLEMENTATION OF

EVIDENCE-BASED PRACTICES

A survey conducted by Koehn and Lehman (2007:213) revealed that the

utilisation of evidence-based practice might be unfamiliar to professional
nurses. According to Alspach (2006:11), findings from their study revealed that
31% of participants were completely familiar with the term known as evidence-
based practices; 45% were moderately familiar while 24% were unfamiliar with
evidence-based practice.

The findings of this research study revealed that 34% of the participants were
moderately familiar with the implementation of evidence-based practice. The study
findings are congruent with the above-mentioned studies.

Aveyard and Sharp (2011:6) highlight that the concept known as “evidence-
based practice” has been the most widely quoted by Sackett et al (2000) in 1996
who explained that evidence-based practice is the conscientious, explicit and
judicious use of the current best evidence in making decisions about the care of all
patients. Polit and Beck (2012:25) add that in the year 2000 Sackett et al (2000)
refined the definition of evidence-based practice by stating that evidence-based
practice was the integration of the best evidence while taking into account
patients‟ values and clinical expertise of practitioners. Craig and Smyth (2007:10)
state that nurses must access the latest evidence that has been critically

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appraised and then apply findings to a similar clinical situation, taking patient
preferences into account and the clinical expertise of professional nurses.
The findings of this research study revealed that 54% of the participants indicated
that evidence-based practice was the conscientious, explicit and judicious use of
the best evidence in making decisions about the care of critically patients, which
was the correct answer.

In a survey conducted by Pravikoff et al (2005:46), participants had to indicate

frequency of consulting information-based evidence or best-practice
guidelines. The survey revealed that 33% indicated they sought information on a
weekly basis; 29% accessed information several times a week; 27% did so an
occasional basis while 12% accessed information monthly. In a survey that was
conducted by Thiel (2008:186), 62% of the participants indicated that they read
journal articles on a monthly basis whilst 39% stated that they searched for
information on a weekly basis to guide them in caring for patients.

The findings of this research study revealed that 57% of the participants searched
for evidence or research on an occasional basis to support clinical decision-
making in caring for the critically ill patient. With regard to best-practice guidelines
findings from this research study indicated that 50% of the participants sought
best-practice guidelines on an occasional basis to assist them with clinical
decision-making. The findings from this research study are congruent with the
above- mentioned studies.

In a survey done by Pravikoff et al (2005:46) participants were asked which

information sources they consulted to guide clinical decision-making in the
care of patients. The results from that survey revealed that 56% of participants
never sought assistance from a librarian; 52% indicated that they frequently asked
colleagues or peers when seeking information; 42% stated that they never
accessed bibliographical databases; and 42% that read journals or textbooks
frequently. In a survey by Rolfe et al (2008:440) 89% of the participants indicated
they would ask their peers or colleagues when seeking information.

The findings of this study revealed that 43% of the participants would consult their

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Data analysis and discussion of findings Chapter Four

colleagues or peers when seeking information. The findings of this study are
congruent with the above-mentioned studies.

Range of information sources used by nurses on which to base clinical

decision-making. A survey was done by Gerrish et al (2008:66) with 598
participants who had to indicate which sources they frequently used. The highest-
ranked sources were tradition or ritual, intuition, information obtained from peers
or colleagues and information from policy/procedure manuals. However, 50% of
the participants indicated that they were novices at integrating research into
practice. In a survey done by Rolfe et al (2008:440), 69% of participants indicated
they used their intuition to guide them and 49% referred to best-practice
guidelines on which to base clinical decisions.

The findings of this research study revealed that 43% referred to the latest
evidence to guide them with clinical decision-making. The findings of this study are
congruent with the above-mentioned studies.

Evidence-based resources can be accessed via diverse sources, namely, the

Joanna Briggs Institute (JBI) which provides best practices in the form of
summaries on topics that pertain to nursing. The National Guideline
Clearinghouse provides good quality guidelines on various topics that comprise
the best evidence. The Cochrane Collaboration contains a list of systematic
reviews that have been formulated primarily from randomized control trials.
Bibliographic databases such as MEDLINE and Pubmed may be helpful as journal
articles are on these online resource sites. MEDLINE has a large medical
database that comprises journal articles. Pubmed is an online database that has
been created by the National Centre for Biotechnology Information at the US
National Library of Medicine (Craig & Smyth, 2007:61).

Jo Brown (2009:251) mentions that EBSCO host is a search engine that focuses
on a topic of interest. The Registered Nurses‟ Association of Ontario (RNAO)
disseminates best-practice guidelines which are aimed toward professional
nurses. Craig and Smyth (2007:320) further explain World-views on Evidence-
based Nursing and the International Journal of Evidence-based Healthcare

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Data analysis and discussion of findings Chapter Four

provides the best quality research evidence through commentaries or concise

summaries. Barker (2010:42) adds search engines such as Google or Wikipedia
which are useful but information on the site lacks quality control and in many
instances is not scientific. Courtney and McCutcheon (2010:82) state that Google
Scholar is a search engine that allows the researcher to search using specific
terms.

In a survey by Pravikoff et al (2005:49) findings indicate that 87% of the

participants never accessed databases such as CINAHL and 69% never used
MEDLINE. The findings of this research study which are illustrated in Table 4.2
indicate that 59% of the participants frequently use Google when searching for
information. The findings of this research study are congruent with the above-
mentioned study.

Best-practice guidelines are derived from systematic reviews that are from the
best research evidence and recommendations are graded according to the level of
evidence (Jo Brown, 2009:219). Courtney and McCutcheon (2010:60) describe
clinical guidelines as a mechanism that bridges the research practice gap.
Through using the best evidence that is graded according to the level of evidence
and recommendations, variances in practices can be eliminated.

In response to which source to consult when weaning the patient from the
mechanical ventilator, the findings from this research study indicated that 50% of
the participants would follow what was taught in the unit, which was incorrect. In
response to what reference to recommend for the prevention of ventilator-
associated pneumonia (VAP), the findings of this research study indicated that
56% of participants would refer to the latest best-practice guideline, which is the
correct response.

4.6 BARRIERS RELATED TO KNOWLEDGE OF THE NURSE WITH

REGARD TO IMPLEMENTATION OF EVIDENCE-BASED PRACTICE

Barriers to the implementation of evidence-based practice may occur at the

individual level of the professional nurse in the critical care unit. There were 14

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Data analysis and discussion of findings Chapter Four

statements that were presented to professional nurses. The section comprised a

5-point Likert scale. Participants had to choose one response to each statement
ranging from “strongly agree” to “strongly disagree”.

Textbox 4.3: Barriers related to knowledge of the nurse with regard to

implementation of evidence-based practice

4.6.1 Results
4.6.1.1 Insufficient time to change to evidence-based practice
4.6.1.2 Clinical decisions are based on information gained during training as
a professional nurse
4.6.1.3 Intuition about what seems to be “right” for the critically ill patient
guides decision-making.
4.6.1.4 Minimal benefits for the nurse or patient when implementing
evidence-based practice in the critical care unit.
4.6.1.5 Nurses in the critical care unit should not be responsible for
conducting their own literature reviews
4.6.1.6 Critical reflection is not necessary when new treatments and
medications are prescribed in the care of the critically ill patient.
4.6.1.7 Implementing evidence-based practices is a waste of time.
4.6.1.8 Minimal rewards for using research findings
4.6.1.9 Resistance to implementing evidence-based practice
4.6.1.10 Traditional/ritual practices outweigh evidence-based practices.
4.6.1.11 Evidence-based practices do not improve the quality of patient care.
4.6.1.12 Evidence-based practices are not necessary for daily
practice in the critical care unit
4.6.1.13 Heavy workload

4.6.1 RESULTS
4.6.1.14 Lack of efficient evidence translation into clinical practice.

4.6.2 DISCUSSION PERTAINING TO BARRIERS RELATED TO

KNOWLEDGE OF THE NURSE WITH REGARD TO
IMPLEMENTATION OF EVIDENCE-BASED PRACTICE

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The results that have been derived from data analysis will be discussed. The
purpose of the section was to explore barriers related to knowledge of the nurse
with regard to evidence-based practice.

4.6.1.1 Insufficient time to change to evidence-based practice

Of the seventy participants n=27(39%) disagreed whilst n=11(15%) strongly

disagreed that they lacked time or commitment to change to evidence-based
practice. However, n=12(16%) agreed while a further n=6(9%) strongly agreed
with the statement. The remaining participants, n=14(21%), had a neutral stance
toward the statement. Results are displayed in Figure 4.10.
40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 6 12 14 27 11
Percentage 9 16 21 39 15

Figure 4.10: Insufficient time to change to evidence-based practices

4.6.1.2 Clinical decisions are based on information gained during training

as a professional nurse

The statement was aimed at exploring if participants based their clinical decisions
on theoretical and practical skills they had obtained during training as a
professional nurse. Results indicate that n=41(59%) agreed while n=18(25%)
strongly agreed that they based their clinical decision making in caring for the
critically ill patient on information that they had been taught during their training as
a professional nurse. A proportion of participants, n=4(6%), disagreed with the
statement while n=1(1%) strongly disagreed that they based clinical decision-
making on information they had obtained during their training. There were
n=6(9%) who had a neutral opinion about the statement.

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Data analysis and discussion of findings Chapter Four

60
50
40

Percentage
30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 18 41 6 4 1
Percentage 25 59 9 6 1

Figure 4.11: Clinical decisions are based on information gained during

training as a professional nurse

4.6.1.3 Intuition about what seems "right" for the critically ill patient guides
decision-making

The purpose of the statement was to ascertain if participants used their intuition as
part of clinical decision-making in caring for the critically ill patient. Results are
graphically displayed in Figure 4.12. Of the seventy participants n=25(36%)
agreed while n=12(17%) strongly agreed that they used their intuition in decisions
concerning patient care in the critical care unit. There were n=14(20%) that
disagreed while n=12(17%) strongly disagreed that intuition guided their clinical
decision-making in caring for patients. The remaining participants, n=7(10), had a
neutral opinion about the statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 12 25 7 14 12
Percentage 17 36 10 20 17

Figure 4.12: Intuition about what seems to be „right‟ for the critically ill
patient guides decision-making

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Data analysis and discussion of findings Chapter Four

4.6.1.4 Minimal benefits for the nurse or patient when implementing

evidence-based practice in the critical care unit

As illustrated in Figure 4.13, of the seventy participants n=33(47%) disagreed

whilst n=26(37%) strongly disagreed that there were minimal benefits for the nurse
or patient when implementing evidence-based practices in the critical care unit.
There were some participants, n=6(9%), who had a neutral stance toward the
statement. A proportion of participants, n=3(4%), agreed with the statement while
n=2(3%) strongly agreed that there were minimal benefits with implementing
evidence-based practice in the critical care unit.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 2 3 6 33 26
Percentage 3 4 9 47 37

Figure 4.13: Minimal benefits for the patient or nurse when implementing
evidence-based practice in the critical care unit

4.6.1.5 Nurses in critical care units should not be responsible for

conducting their own literature reviews

In response to the statement n=22(31%) disagreed while n=8(11%) strongly

disagreed with the statement. There were n=16(23%) who agreed with the
statement while n=6(9%) strongly agreed with the statement. There were
n=18(26%) who had a neutral stance toward the statement. The results are
schematically represented in Figure 4.14.

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Data analysis and discussion of findings Chapter Four

35
30
25

Percentage
20
15
10
5
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 6 16 18 22 8
Percentage 9 23 26 31 11

Figure 4.14: Nurses in the critical care unit should not be responsible for
conducting their own literature reviews

4.6.1.6 Critical reflection is not necessary when new treatments and

medications are prescribed for the critically ill patient

As illustrated in Figure 4.15 there were n=42(60%) who disagreed while

n=11(15%) strongly disagreed with the statement. There were n=9(13%) who had
a neutral opinion about the statement. A proportion of participants, n=6(9%),
agreed whilst 2(3%) strongly agreed that critical reflection was not necessary in
caring for the critically ill.

70
60
50
Percentage

40
30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 2 6 9 42 11
Percentage 3 9 13 60 15

Figure 4.15: Critical reflection is not necessary when new medicines and
treatments are prescribed for the critically ill patient

4.6.1.7 Implementing evidence-based practices is a waste of time

Results reflected in Figure 4.16 indicate that n=32(46%) strongly disagreed while

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n=32(46%) disagreed that implementing evidence-based practice was a waste of

time. Of the participants n=2(3%) agreed whilst 1(1%) strongly agreed with the
statement. The remaining participants, n=3(4%), had a neutral opinion about the
statement.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 1 2 3 32 32
Percentage 1 3 4 46 46

Figure 4.16: Implementing evidence-based practices is a waste of time

4.6.1.8 Minimal rewards for using research findings

Of the seventy participants n=29(41%) disagreed whilst n=21(30%) strongly

disagreed that there were minimal rewards when using research findings and
applying it to clinical practice. There were some participants, n=13(19%), who
agreed whilst n=4(6%) strongly agreed that there were minimal rewards for using
research results. The remaining participants, n=3(4%), had a neutral opinion
toward the statement. Figure 4.17 depicts the results.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 4 13 3 29 21
Percentage 6 19 4 41 30

Figure 4.17: Minimal rewards for using research findings

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4.6.1.9 Resistance to implementing evidence-based practice

The purpose of the statement was to determine if professional nurses were

resistant to implementing evidence-based practice. There were n=34(49%) who
agreed whilst n=7(10%) strongly agreed with the statement. Of the seventy
participants n=13(19%) disagreed whilst n=9(12%) strongly disagreed with the
statement. A proportion of participants, n=7(10%), had a neutral stance toward the
statement. The results are schematically presented in figure 4.18.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 7 34 7 13 9
Percentage 10 49 10 19 12

Figure 4.18: Resistance to implementing evidence-based practice

4.6.1.10 Traditional/ritual practices outweigh evidence-based practices

Of the seventy participants there were n=17(25%) who disagreed whilst

n=14(20%) strongly disagreed with the statement. The remaining participants,
n=23(33%), agreed whilst n=8(11%) strongly agreed that tradition or ritual was
more significant than evidence-based practices. The remaining participants,
n=8(11%), have a neutral opinion about the statement. The results are illustrated
in Figure 4.19.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 8 23 8 17 14
Percentage 11 33 11 25 20

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Figure 4.19: Traditional/ritual practices outweigh evidence-based practices

4.6.1.11 Evidence-based practices do not improve the quality of patient care

A summary of the responses is graphically represented in Figure 4.20. Results

reflect that n=42(60%) strongly disagreed while n =21(30%) disagreed that
evidence-based practices did not improve the quality of patient care. Of the
seventy participants n=3(4%) agreed while n=2(3%) strongly agreed with the
statement. There were n=2(3%) that had a neutral stance about the statement.

70
60
50
Percentage

40
30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 2 3 2 21 42
Percentage 3 4 3 30 60

Figure 4.20: Evidence-based practices do not improve the quality of patient

care

4.6.1.12 Evidence-based practice are not necessary for daily practice within
the critical care unit

The purpose of the statement was to explore whether evidence-based practice

should be incorporated in daily practice. From the data analysis n=40(57%)
strongly disagreed while n=26(37%) disagreed that evidence-based practice was
not necessary for daily practice. A proportion of participants, n=2(3%), agreed
whilst n=0(0%) strongly agreed with the statement. There were n=2(3%) that had
a neutral opinion about the statement. Figure 4.21 depicts the results.

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60
50
40

Percentage
30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 0 2 2 26 40
Percentage 0 3 3 37 57

Figure 4.21: Evidence-based practices are not necessary for daily practice
within the critical care unit

4.6.1.13 Heavy workload

Figure 4.22 displays the responses to the statement. A proportion of the

participants, n=20(29%), agreed while n=19(27%) strongly agreed that the
workload of nurses was too heavy to keep up with evidence-based practices. Of
the seventy participants n=16(22%) disagreed whilst n=4(6%) strongly disagreed
with the statement. There were n=11(16%) who had a neutral opinion about the
statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 19 20 11 16 4
Percentage 27 29 16 22 6

Figure 4.22: Heavy workload

4.6.1.14 Lack of efficient evidence translation into clinical practice

As illustrated in Figure 4.23 the responses to lack of evidence translation into

clinical practice is displayed. Of the seventy participants n=30(43%) agreed while

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Data analysis and discussion of findings Chapter Four

n=13(19%) strongly agreed that there was lack of efficient evidence translation
into practice. There were n=14(20%) that had a neutral opinion toward the
statement. A proportion of participants, n=10(14%), disagreed whilst n=3(4%)
strongly disagreed with the statement.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 13 30 14 10 3
Percentage 19 43 20 14 4

Figure 4.23: Lack of efficient evidence translation into clinical practice

4.6.2 DISCUSSION PERTAINING TO BARRIERS RELATED TO

KNOWLEDGE OF THE NURSE WITH REGARDS TO EVIDENCE-
BASED PRACTICE

According to DiCenso et al (2005:15) changing practice requires long term

commitment and insufficient time to perform searches hinders evidence
uptake. Insufficient time to access or read evidence-based practices is one of the
main contributing factors to the chasm of research and practice (Gerrish & Lacey,
2010:512). In a survey by Kocaman et al (2010:1912), 85% of the participants
indicated they had insufficient time to carry out evidence-based practice. In a
survey by Koehn and Lehman (2008:213) 39% of the 422 participants stated they
had insufficient time to change to evidence-based practices.

The findings of this research study indicated that 39% disagreed while 15%
strongly disagreed that they lacked time or commitment to implement evidence-
based practice. The findings of this research study are incongruent with the
above-mentioned studies.

Quite often clinical decision-making pertaining to the care of the critically ill patient
is based on various sources. Nurses base clinical decisions on information

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that they were given through training. Nurses usually seek information from
authorities with clinical expertise in specific areas. But often authority figures base
decisions or actions on unscientific previous experiences. Trial and error is a
method that is applied in situations until a solution is achieved (Polit & Beck,
2012:10). Gerrish et al (2007:334) performed a survey in which one of the highest
ranked sources accessed by 524 participants was referring to knowledge they had
obtained during their training. In a survey by Brown et al (2009:381) 30% of
participants indicated use of knowledge they had acquired through training to
guide practice.

The findings of this research study indicated that 59% agreed while 25% strongly
agreed that they used information they had gained from training as a professional
nurse to guide clinical decision-making in the care of the critically ill. The findings
from this research study are congruent with the above-mentioned studies.

Intuition about what seems 'right' for a patient often guides decision-
making. However, this non-scientific method is founded on instinct or hunches
and should not be considered as a reliable source (Polit & Beck, 2012:10). In a
survey by Flynn and Sinclair (2005:143) involving nineteen professional nurses
through semi-structured interviews, participants used their intuition in caring for the
patient. They instilled saline when suctioning a patient‟s artificial airway, based on
intuition even though the best-practice guideline indicated such practice was not
recommended.

The findings of this research study indicated that 36% agreed while 17% strongly
agreed that they used their intuition to guide clinical decision-making in the care of
the critically ill. The findings of this research study are congruent with the above-
mentioned studies.

Nurses may perceive evidence-based practice as insignificant and having little

benefit for themselves or the patient in the critical care unit. The perception
may arise from lack of awareness or realizing the value of evidence-based
practices (Polit & Beck, 2012:29). In a survey by Majid et al (2011:232) 38% of the
participants disagreed that evidence-based practice had little benefit for self or the

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patient. In a survey by Kocaman et al (2010:1908) 71% were of the opinion that

evidence-based practice had no benefit for self or patient. In a survey by Brown et
al (2009:371)34% of the participants indicated that there were minimal benefits for
themselves or patients in adopting evidence-based practice.

The findings of this research study indicated that 47% disagreed while 37%
strongly disagreed that there were minimal benefits for self or patient in the care of
the critically ill. The findings of this research study are congruent with the above-
mentioned studies.

The nurse in the critical care unit should not be responsible for conducting
their own literature reviews to answer clinical questions. However, nurses
may not be equipped with skills to perform searches. Another challenge that exists
is that once evidence is found it may be difficult to interpret as the statistics and
medical jargon increases the complexity (Aveyard & Sharp, 2011:129). Evidence-
based practice has prompted the nursing profession to become aware of
evidence-based practice and realize that each nurse is responsible for accessing,
reading and appraising evidence (Moule & Goodman, 2009:374).

The findings of this research study indicated that 31% disagreed while 11%
strongly disagreed that the nurse in the critical care unit should not conduct
literature reviews.

Critical reflection on new treatment and medication when caring for the
critically ill patient will ensure that clinical practitioners strive to deliver the best
possible care to their patients. Craig and Smyth (2007:215) add that reflective
practice is a learning opportunity to analyse the clinical situation that occurred.
During this process professional nurses evaluate alternative methods that can
achieve desired outcomes and the effectiveness of an intervention is also
scrutinized.

The findings of this research study indicated that 60% disagreed while 15%
strongly disagreed that critical reflection on new treatment and medication was not
necessary. The findings from this research study are congruent with the above-

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mentioned studies.

Evidence-based practice is viewed as a waste of time by some practitioners.

They value information from colleagues, textbooks or their own experiences. The
view is supported by the belief that evidence-based practice does not address
patients as individuals who need unique care (Aveyard & Sharp, 2011:129). In a
systematic review by Kajermo et al (2010:3) a barrier noted was that nurses did
not value research in practice. In a survey by Breimaier et al (2011:1744) 52% of
the participants were of the opinion that research had no value in clinical practice.
In a survey by Oranta et al (2002:208) 52% of the participants indicated they did
not see the value of research for clinical practice.

The findings of this research study indicated that 46% disagreed while 46%
strongly disagreed that implementing evidence-based practice was a waste of
time. The findings are incongruent with the above-mentioned studies.

Professional nurses in the critical care unit are resistant to change and
trying new ideas. Barker (2010:109) mentions that most people are resistant to
change because they are trapped in their "comfort zones". In a study by Gerrish et
al (2008:67), participants indicated that they did not have a culture supporting
evidence-based practice. Oranta et al (2002:212) conducted a study in which
almost 50% of the participants indicated nurses did not want to change practice. In
a study done by Brown et al (2009:30) a barrier that was reported by 37% of
participants was that professional nurses were resistant to change.

The findings of this research study indicated that 49% agreed while 10% strongly
agreed that professional nurses were resistant to change. The findings of this
research study are congruent with the above-mentioned studies.

Traditional or ritualistic practices outweigh evidence-based practices in

organizations that do not have a culture of promoting evidence-based practices.
Individuals may use out-of-date practices and practitioners also do not challenge
those utilizing outdated practices (Aveyard & Sharp, 2011:129). Moule and
Goodman (2009:19) describe tradition as knowledge that is passed through

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generations and is based on traditional understanding. Intuition is a process that

incorporates an individual‟s "sixth sense" or previous experience to make a clinical
judgment.

The findings of this research study indicated that 25% disagreed while 20%
strongly disagreed that tradition or ritual outweighed evidence-based practice.
Evidence-based practice does not improves the quality of patient care by
ensuring that nurses use the best relevant evidence (Barker, 2010:4). According
to Burns and Grove (2009:618), not only does evidence-based practice improve
patient outcomes, but also impacts on the health institutions, families, nurses and
physicians as complications and hospital stays are decreased. Findings from a
survey done by McInerney and Suleman (2010:90) suggested that more than 75%
of participants believed that evidence-based practices improved patient care.
The findings of this research study indicated that 60% strongly disagreed while
30% disagreed with the statement. The findings from this research study are
congruent with the above-mentioned studies.

According to Moule and Goodman (2009:373) the application of evidence-based

practices is not necessary for daily practice within the nursing profession to
ensure that delivery of patient care is safe, relevant and effective. Results from a
survey done by McInerney and Suleman (2010:90) showed that the perception of
participants revealed that evidence-based practices should be part of daily nursing
practices. In a survey done by Breimaier et al (2011:1750) 55% of the participants
disagreed that evidence-based practice was not necessary for daily practice.
The findings of this research study indicated that 57% strongly disagreed while
37% disagreed with the statement. The findings from this research study are
congruent with the above-mentioned studies.

According to Gerrish and Lacey (2010:512), evidence-based practices have not

been embraced as nurses perceive it as increasing their workload. Pravikoff et
al (2005: 48) undertook a study in which participants stated that they had other
priorities and evidence-based practice was on a lower category of priorities. In a
survey by Koehn and Lehman (2007:212) findings ascertained that participants
regarded their workload as too great which hindered evidence uptake.

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The findings of this research study indicated that 29% agreed while 25% strongly
agreed that the workload was too heavy to keep up with evidence-based practice.
The findings of this research study are congruent with the above-mentioned
studies.

Barker (2010:107) highlights the fact, that even though people are aware of
evidence-based practice, there is no guarantee that they will adopt new practices.
There is lack of translation of evidence into practice as a result of barriers on
an individual, organisational, national level or due to the characteristics of
evidence itself.

The findings of this research study indicated that 43% agreed while 19% strongly
agreed that the workload was too heavy to keep up with evidence-based practice.
The findings of this research study are congruent with the above-mentioned
studies.

4.7 BARRIERS TO FINDING AND REVIEWING EVIDENCE IN THE

CRITICAL CARE UNIT

The section delves into barriers to finding and reviewing evidence in a critical care
unit. Professional nurses may have difficulty in locating evidence resulting in
evidence-based practices not being implemented effectively. Once evidence is
found, a further challenge that might exist is the inability to understand research
reports or the implications for clinical practice. The section comprised 10
statements that were presented to participants.

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Textbox 4.4: Barriers to finding and reviewing evidence in the critical care
unit
4.7.1 Results
4.7.1.1 Difficulty in locating evidence to guide clinical decision-making
4.7.1.2 Insufficient time to find and read research reports
4.7.1.3 Research reports are difficult to understand
4.7.1.4 Difficulty in critical appraisal of journal articles or guidelines
4.7.1.5 Implications of research findings for clinical practice are unclear
4.7.1.6 Access to evidence is poor (slow or no computers available in the
critical care unit)
4.7.1.7 Research reports are not readily available in the critical care unit
4.7.1.8 The amount of literature related to critical care is overwhelming
4.7.1.9 Research reports related to issues in the critical care unit are not
published fast enough
4.7.1.10 Best-practice guidelines are difficult to interpret

4.7.2. Discussion pertaining to the barriers to finding and reviewing

evidence

4.7.1 RESULTS

The following section is a compilation of results obtained from the data analysis.
The purpose of the section in the questionnaire was to identify if there were any
barriers to finding evidence in the critical care unit. The results for this section will
be illustrated using bar graphs.

4.7.1.1 Difficulty in locating evidence to guide clinical decision-making

The results are schematically presented in Figure 4.24. Of the seventy participants
n=24(34%) disagreed whilst n =20(29%) strongly disagreed that they had any
difficulty is accessing evidence which guided clinical decision-making. A proportion
of participants, n=16 (23%), agreed while n=3(4%) strongly agreed with the
statement which indicated that they did have difficulty in locating evidence. The
remaining participants, n=7 (10%), had a neutral stance toward the statement.

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40

30

Percentage
20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 3 16 7 24 20
Percentage 4 23 10 34 29

Figure 4.24: Difficulty in locating evidence to guide clinical decision-making

4.7.1.2 Insufficient time in the critical care unit to find and read research
reports

The intention of the statement was to determine if there was insufficient time in the
critical care unit to find and read research reports. As illustrated in Figure 4.25, the
results indicate that n=24(34%) agreed whilst n=19(28%) strongly agreed that
there was insufficient time in the critical care unit to find or read research reports.
A proportion of participants, n=12(17%), disagreed whilst n=5(7%) strongly
disagreed that time was an issue within the critical care unit. The remaining
participants, n=10(14%), had a neutral opinion about the statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 19 24 10 12 5
Percentage 28 34 14 17 7

Figure 4.25 Insufficient time in the critical care unit to find and read
research reports

4.7.1.3 Research reports are difficult to understand

The purpose of the statement was to ascertain if participants had difficulty in

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understanding research reports. Data analysis results reflected in Figure 4.26

indicated that n=39(56%) disagreed whilst n=7(10%) strongly disagreed that they
had any difficulty in understanding research reports. Of the seventy participants
n=14(20%) had a neutral opinion toward the statement. However, n=9(13%)
indicated that they agreed about having difficulty in understanding research
reports whilst 1(1%) strongly agree that they had difficulty in understanding
research reports.

60
50
40
Percentage

30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 1 9 14 39 7
Percentage 1 13 20 56 10

Figure 4.26 Research reports are difficult to understand

4.7.1.4 Difficulty in critical appraisal of journal articles or guidelines

The statement was intended to explore if participants encountered any difficulty in

critically appraising journal articles or guidelines. The study findings reflected in
Figure 4.27 indicated that n=21(30%) disagreed that they experienced any
difficulty in the critical appraisal process whilst n=9(13%) strongly disagreed with
the statement. A proportion of participants, n=25(36%), indicated that they agreed
and there were no participants that strongly agreed with the statement. The
remaining participants, n=15(21%), had a neutral stance toward the statement.

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40

30

Percentage
20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 0 25 15 21 9
Percentage 0 36 21 30 13

Figure 4.27 Difficulty in critical appraisal of journal articles or guidelines

4.7.1.5 Implications of research findings for clinical practice are unclear

The purpose of the statement was to explore if participants experienced difficulty

in applying research findings to clinical practice. Figure 4.28 graphically displays
the results indicating that n=25(36%) disagreed whilst n=9(13%) strongly
disagreed with the statement. Of the seventy participants n=18(26%) had a neutral
opinion toward whether the implications of research findings for clinical practice
were unclear. However, n=15(21%) agreed whilst n=3(4%) strongly agreed with
the statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 3 15 18 25 9
Percentage 4 21 26 36 13

Figure 4.28: The implications of research findings for clinical practice are
unclear

4.7.1.6 Access to research evidence is poor (slow or no computers in the

critical care unit)

The statement aimed to explore if a lack of access to computers played a role in

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influencing implementation of evidence-based practice as information was largely

available on various online resources. Of the seventy participants n=34(49%)
agreed while n=12(17%) strongly agreed that there is poor access to computers
within the critical care unit. A proportion of participants n=15(21%) indicated that
they disagreed with the statement while n=5(7%) strongly disagreed with the
statement. The remaining participants, n=4(6%) had a neutral stance toward the
statement. The results are schematically presented in Figure 4.29.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 12 34 4 15 5
Percentage 17 49 6 21 7

Figure 4.29: Access to research evidence is poor (slow or no computers are

available in the critical care unit)

4.7.1.7 Research reports are not readily available in the critical care unit

The results are schematically presented in Figure 4.30. Of the seventy participants
n=42(60%) agreed while n=9(13%) strongly agreed that research reports were not
readily available in the critical care unit. There were n=14(20%) that disagreed
with the statement while n=1(1%) strongly disagreed with the statement. Of the
remaining participants n=4(6%) had a neutral stance toward the statement.

60
50
40
Percentage

30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 9 42 4 14 1
Percentage 13 60 6 20 1

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Figure 4.30: Research reports are not readily available in the critical care
unit

4.7.1.8 The amount of literature related to critical care is overwhelming

In Figure 4.31 the results are depicted indicating that n=28(40%) agreed whilst
n=14(20%) strongly agreed that there was an overwhelming amount of literature
pertaining to critical care. There were n=12(17%) who disagreed while n=3(4%)
strongly disagreed that there was an overwhelming amount of literature pertaining
to the speciality of critical care. A total of n=13(19%) had a neutral opinion about
the statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 14 28 13 12 3
Percentage 20 40 19 17 4

Figure 4.31: The amount of literature related to critical care is overwhelming

4.7.1.9 Research reports related to issues in the critical care are not
published fast enough

The statement ascertained whether research reports within the critical care unit
were published at a slow rate. The results are reflected in Figure 4.32 indicating
that n=21(30%) agreed that research reports were not published fast enough while
5(7%) strongly disagreed with the statement. Of the seventy participants
n=23(33%) had a neutral opinion toward the statement. Derived from the data
analysis n=16(23%) disagreed while n=5(7%) strongly agreed with the statement.

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40

30

Percentage
20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 5 21 23 16 5
Percentage 7 30 33 23 7

Figure 4.32 Research reports related to issues in critical care are not
published fast enough

4.7.1.10 Best-practice guidelines are difficult to interpret

Of the seventy participants who participated in the study n=33(47%) disagreed

while n=12(17%) strongly disagreed that best practice guidelines were difficult to
interpret. However, n=11(14%) agreed while n=4(6%) strongly agreed with the
statement. There were n=10(14%) who had a neutral stance on whether best-
practice guidelines were difficult to interpret.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 4 11 10 33 12
Percentage 6 16 14 47 17

Figure 4.33: Best-practice guidelines are difficult to interpret

4.7.2 DISCUSSION PERTAINING TO BARRIERS TO FINDING AND

REVIEWING EVIDENCE

Nurses in the critical care unit have difficulty in locating evidence to guide
clinical decision-making due to the immense amount of literature published in

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the written or electronic format. A challenge that exists with online resources is the
lack of quality control of evidence or research studies due to the wealth of
literature available on the internet. Quite often evidence in the written format is not
located in one place in nursing units or accessibility to online resources remains a
problem as professional nurses do not have access to computers (Courtney &
McCutcheon, 2010:79). A survey done by Caldwell et al (2007:518) revealed that
40% of the participants had never accessed databases such as MEDLINE and
76% of the participants stated they have never received any formal training on
conducting literature searches. In a survey done by Rosebaum et al (2008:1472)
involving thirty two participants 75% of the participants had difficulty in locating
The Cochrane Library and struggled to search for specific information on the site.
The findings of this research study revealed that 34% disagreed whilst 29%
strongly disagreed that they had any difficulty in locating evidence. The findings of
this research study are incongruent with the above-mentioned studies.

In a study done by Gerrish et al (2007:67) insufficient time to search for or read

research reports was one of the main barriers stated by participants. Parahoo
(2006:421) adds lack of time as one of the main reasons for not accessing or
sustaining evidence-based practices. In a survey done by Brown et al (2009:378)
inadequate time during working hours was regarded as the highest-ranked barrier
by 67% of the participants. Factors such as shortage of staff, high patient acuities
and meeting deadlines were some of the main reasons for non-compliance with
evidence-based practices as stated by participants. In a systematic review done
by Kajermo et al (2010:3) from a total of 53 studies reviewed, in 49 of those
studies, inadequate time to read research or implement evidence-based practices
was one of highest ranked barriers by participants.

The findings of this research study indicated that 34% agreed whilst 28% strongly
agreed with that there was insufficient time to find or read research reports. The
findings of this research study are congruent with the above-mentioned studies.
One of the main constituents in the growing chasm in the research practice gap is
the inability to understand research reports (Barker 2010, 109). Aveyard and
Sharp (2011:129) add that certain aspects of research reports such as medical
jargon, language, statistics and presentation may make it more difficult to

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understand research reports. According to Oranta et al (2002:209), research

reports may be difficult to understand especially in countries where English is not
the first official language. There were 71% of participants who indicated that
research reports were not user-friendly due to the medical jargon and presentation
of statistical analysis.

The findings of this research study identified that 56% disagreed whilst 10%
strongly disagreed that they had any difficulty understanding research reports. The
findings are incongruent with the above-mentioned studies.

Courtney and McCutcheon (2010:84) propose that the research practice gap
exists due to nurses' lack of critical appraisal skills. Before evidence is applied
in the clinical setting, nurses must evaluate the validity and quality of the evidence.
Currently, there are online appraisal tools for the different types of research
articles. However, most nurses have never received any formal training on how to
proceed with the appraisal process which may contribute to hesitation in initiation
of evidence-based practices. Barker (2010:54) adds that a detrimental
misconception of nurses is that all published literature is of good quality. Therefore
critical appraisal of the evidence is a crucial step that must never be omitted
before research findings are adopted in clinical practice. In a survey done by
Brown et al (2009:371) 53% of the participants indicated that they experienced
difficulty in the critical appraisal of journal articles and guidelines.

The findings of this research study indicated that 30% disagreed while 13%
strongly disagreed that they had any difficulty with the critical appraisal process.
The findings of this research study are incongruent with the above-mentioned
studies.

Even though research studies describe patient populations and recommendations

for evidence-based practices, nurses may struggle on whether to apply these in
clinical practice (Burns & Grove, 2009:617). According to Mortaine and Fontaine
(2009:5) the implications of research findings for clinical practice may be
unclear for many nurses who read research reports. Gerrish and Lacey
(2010:496) concur by stating that even though research studies are carried out,

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issues in clinical practice are not being addressed. In a survey done by Majid et al
(2011:233) amongst 1486 professional nurses 41% indicated that they had
difficulty in determining the implications of research findings for clinical practice. In
a similar survey done by Oranata et al (2002: 208), 67% of the participants
indicated that the practical implications of research results were too vague for
application to clinical practice.

The findings from this research study revealed that 36% disagreed whilst 13%
strongly disagreed that implication of research findings for clinical practice was
unclear.

Perhaps one of the main barriers to the implementation of evidence-based

practices relates to inaccessibility to computers, as most of the latest and
relevant evidence is available online (Burns & Grove, 2009:618). In a survey done
by Pravikoff et al (2005:40), 46% of the participants indicated that access to
computers within the workplace was inadequate.

The findings of this research study revealed that 49% agreed and 17% strongly
agreed that inaccessibility to computers was a barrier to the implementation to
evidence-based practices. The findings of this research study are congruent with
the above-mentioned study.

One of the barriers to finding and reviewing evidence may be a result of research
reports not being readily available in nursing units. If research were readily
available staff could easily access and read reports. Professional nurses within the
critical care unit are expected to search for evidence themselves which may
present a barrier to the implementation of evidence-based practices (Gerrish et al,
2008:67). In a survey done by Kocaman et al (2010:1908) involving 329
professional nurses 58% indicated that one barrier to the implementation of
evidence-based practice was that research reports were not readily available. In a
survey done by Brown et al (2009:379) 48% of the participants indicated that
research reports were not readily available.

The findings of this research study identified that 60% agreed whilst 13% strongly

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agreed that research reports were not readily available in the critical care unit. The
findings of this research study are congruent with the above-mentioned studies.
The amount of literature related to critical care is overwhelming according to
Courtney and McCutcheon (2010:5) who state that it is an impossible task for
nurses to keep updated with literature In the specialty of surgical nursing for
instance, there are approximately one thousand publications on a yearly basis.

Aveyard and Sharp (2011:129) concur by adding that a barrier to implementation

of evidence-based practice may relate to too much published literature. Barker
(2010:1) mentioned that there were 3011 articles in response to the search term
“evidence-based practice”. Salmond (2007:114) adds that there are 1500 new
articles published daily. In a survey done by Kocaman et al (2010:1908), 58% of
the participants indicated that there was an overwhelming amount of literature that
pertained to patient care in the critical care unit.

The findings of this study revealed that 40% agreed while 20% strongly agreed
that the amount of literature pertaining to critical care was overwhelming. The
results of this study are congruent with the above-mentioned studies.

According to Brown et al (2009:380), one of the barriers that has been identified
by participants is that research reports are not published fast enough. In a
systematic review done by Kajermo et al (2010: 35) in 23 studies from a total of 53
studies, participants have ranked one of the barriers the fact that research reports
are not being published fast enough. In a survey done by Kocaman et al
(2010:1908) 60% of the participants indicated that research reports were not
published fast enough.

The findings of this research study revealed that 30% agreed while 7% strongly
agreed that research reports were not published fast enough. The results are
congruent with the above-mentioned studies.

Over the past couple of years clinical evidence has been presented in the form of
best-practice guidelines. There was a growing popularity for providing evidence
through this method of communication amongst healthcare professionals.

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However, best-practice guidelines may be difficult to interpret. A pitfall may be

that it is not at the level of the target audience, usually professional nurses who
have to apply the guidelines to patient care. Sometimes the medical jargon or
language used is complex and not user-friendly. Nursing interventions within the
guideline may sometimes be vague or complex which will decrease compliance in
application of the guidelines (Courtney & McCutcheon, 2010:59). The findings of
this research study indicate that 47% disagreed whilst 17% strongly disagreed that
best practice guidelines were difficult to interpret.

4.8 BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICE

BASED ON RELEVANT RESOURCES

Adequate resources are essential to ensure implementation of evidence-based

practices in the critical care unit. Resources may refer to human resources,
financial resources or consumables. The section comprised 5 statements
presented to participants who then had to allocate one response to each
statement. The purpose of the section was to explore if access to resources was a
barrier to evidence-based implementation in the critical care unit in the Nelson
Mandela Metropole where the study took place.

Textbox 4.5: Barriers to implementing evidence-based practice based on

relevant resources

4.8.1 Results
4.8.1.1 Lack of confidence about changing to evidence-based practices
in the critical care unit
4.8.1.2 Lack of authority in the critical care unit to change to evidence-
based practice
4.8.1.3 Severity of the critically ill patient influences implementation of
evidence-based practice
4.8.1.4 Insufficient resources to change practice in the critical care unit
4.8.1.5 Insufficient time to implement evidence-based practices in the
critical care unit
4.8.2 Discussion pertaining to barriers to implementing evidence-
based practice based on the relevant resources

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4.8.1 RESULTS

The results of the data analysis will be discussed in this section. The objective of
the section was to explore the impact of resource availability in the critical care
unit in relation to implementation of evidence-based practices.

4.8.1.1 Lack of confidence about changing to evidence-based practices in

the critical care unit

The purpose of the statement was to explore whether participants felt comfortable
about initiating evidence-based practices of their own accord in the critical care
unit. Of the seventy participants n=26(37%) disagreed, while n=9(13%) strongly
disagreed that they lacked the confidence to change to evidence-based in the
critical care unit. A proportion of participants, n=21(30%), agreed, while n=4(6%)
strongly agreed with the statement. The remaining participants, n=10(14%), had a
neutral opinion toward whether they would have the confidence to change to
evidence-based practice in the critical care unit.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 4 21 10 26 9
Percentage 6 30 14 37 13

Figure 4.34: Lack of confidence about changing to evidence-based

practices in the critical care unit

4.8.1.2 Lack of authority in the critical care unit to change to evidence-

based practice

The intention of the statement was to explore participants' level of authority within the
critical care unit to change practice to evidence-based practice. Derived from the data
analysis n=24(34%) agreed whilst n=16(23%) participants strongly agreed that they
lacked authority in the critical care unit to change practice. However, there were

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n=18(26%) who disagreed, whilst n=5(7%) strongly disagreed with the statement. Of
the remaining participants, n=7(10%), had a neutral stance toward the statement.
See Figure 4.35 for an illustration of the findings.

40

Percentage 30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 16 24 7 18 5
Percentage 23 34 10 26 7

Figure 4.35: Lack of authority in the critical care unit to change to evidence-
practice

4.8.1.3 Severity of the critically ill patient influences implementation of

evidence-based practices

Figure 4.36 depicts the results of whether the severity of the critically ill patient
influences implementation of evidence-based practice in the critical care unit. Of
the seventy participants n=24(34%) agreed whilst n=10(14%) strongly agreed that
a severe critically ill patient influenced evidence uptake. However, n=18(26%)
disagreed whilst 5(7%) strongly disagreed with the statement. The remaining
participants, n=13(19%), had a neutral opinion toward whether the severity of the
critically ill patient influenced implementation of evidence-based practices.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 10 24 13 18 5
Percentage 14 34 19 26 7

Figure 4.36: Severity of the critically ill patient influences implementation of

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evidence-based practices

4.8.1.4 Insufficient resources to change practice in the critical care unit

The response to this statement is schematically presented in Figure 4.37. Of the

seventy participants n=22(31%) disagreed while n=11(16%) strongly disagreed
with the statement. There were some participants, n=14(20%), who agreed whilst
n=7(10%) strongly agreed that there were insufficient resources in the critical care
unit. From the data analysis n=16(23%) had a neutral opinion on whether there
were sufficient resources within the critical care unit to change to evidence-based
practice.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 7 14 16 22 11
Percentage 10 20 23 31 16

Figure 4.37: Insufficient resources to change practice in the critical care

unit

4.8.1.5 Insufficient time to implement evidence-based practices in the

critical care unit

Of the seventy participants n=22(31%) agreed whilst n=15(21%) strongly agreed

that time was a barrier to the implementation of evidence-based practices within
the critical care unit. From the data analysis n=20(29%) disagreed whilst a total of
n=6(%) strongly disagreed with the statement. The remaining participants
n=7(10%) had a neutral opinion toward time as a barrier to the implementation of
evidence-based practices in the critical care unit.

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40

30

Percentage
20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 15 22 7 20 6
Percentage 21 31 10 29 9

Figure 4.38: Insufficient time to implement evidence-based practice in the

critical care unit

4.8.2 DISCUSSION PERTAINING TO THE BARRIERS TO

IMPLEMENTINGEVIDENCE-BASED PRACTICE BASED ON
RELEVANT RESOURCES

Lack of confidence about changing practice to evidence-based practices in

the critical care unit may stem from nurses‟ limited participation in research
studies, inexperience with critical appraisal or even insufficient searching skills
(Moule & Goodman, 2009:379). Since new evidence is not incorporated into
practice nurses lack confidence about changing practice to that which is evidence-
based. They tend to rely on nurse specialists instead of themselves for the
acquisition of new knowledge. This is also a temptation for nurses to continue with
traditional or ritualistic practices (Barker, 2010:109). The findings of this study
indicated that 37% disagreed whilst 13%strongly disagreed that they lacked
confidence about changing practice to that which was evidence-based.

One barrier to the implementation of evidence-based practice is the lack of

authority in the critical care unit to change practice, especially in an
organization that does not promote evidence-based practices (Burns & Grove,
2009:618). In a survey conducted by Gerrish et al (2008:67) the fourth highest-
ranked barrier that was statistically significant was the lack of authority in the
workplace to change practice. The findings of this study revealed that 34% of
participants agreed whilst 23% strongly agreed that they lacked the authority to

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change practice in the critical care unit where the study took place. The findings of
this study are congruent with the above-mentioned studies.

Severity of the critically ill patients may be influential in the uptake of evidence.
In a study done by Koehn and Lehman (2007:212), 40% of the participants
indicated that their heavy workload prevented implementation of evidence-based
practice as there was inadequate time. From the interviews that were conducted
another theme that emerged was inadequate staffing which influenced the quality
of patient care rendered, therefore searching for evidence was not perceived as a
high priority by participants. In a study done by Lawless et al (2010:16), 56% of
the participants indicated that a high patient acuity was one of the factors
contributing to non-compliance with evidence-based practices. Thompson et al
(2008:539) add that nurses are also not in control of their own time. Interruptions
within units arise from the multidisciplinary team, the pressure of families or from
managing alarms from the ventilators and pumps. Caring for a high-acuity patient
requires vigilance in monitoring and treating abnormalities with the ultimate goal of
stabilizing the patient.

The findings of this research study revealed that 34% of participants agreed whilst
a further 14% strongly agreed that the severity of the critically ill might influence
evidence uptake in the critical care unit. The findings of this research study are
congruent with the findings of the above-mentioned studies.

According to Schmidt and Brown (2009:9), resources are essential to promote and
sustain implementation of evidence-based practices. Insufficient resources in
the critical care unit will hinder translation of evidence into clinical practice.
Resources may refer to staffing, equipment, computers, journals or written
evidence-based guidelines. Without adequate resources the success rates in
implementation of evidence-based practices will dwindle. Brown et al (2009:15)
add that resources refer specifically to the support within organizations. Any
adoption of a new practice will require the manpower for in-service training, and
costs for purchasing new stock or equipment will be as per rec ommendations
within evidence-based guidelines. The reality is that some organizations are not
willing to invest in new practices because of these financial implications. In a

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survey that was conducted, 43% of the participants indicated that lack of access to
resources e.g. a computer, journals was considered a major barrier by participants
(Melnyk et al, 2004, 188).

The findings of this study indicated that 31% disagreed whilst 16% strongly
disagreed that there were insufficient resources in the critical care unit to
implement evidence-based practices. The findings of this study are incongruent
with the above-mentioned studies. However, the context of where the study took
place has to be considered, namely a critical care unit in a private hospital in the
Nelson Mandela Metropole. The latest equipment is available in the unit and there
are sufficient professional nurses to care for patients. However, there are no
written journal articles or computers for nursing staff which indicates that there are
insufficient resources in the critical care unit.

Aveyard and Sharp (2011:129) propose that insufficient time to implement

evidence-based practice in the critical unit is the main barrier identified by
nurses. In the work environment low staffing levels, high patient acuities, busyness
and meeting deadlines contribute to non-compliance with evidence-based
practices. Apart from the work environment nurses do not want to invest their
personal time in accessing evidence due to family or other commitments. In a
study done by Kocaman et al (2010:1909), 84% of a sample of 329 nurses stated
that they had inadequate time within the nursing unit to implement practices based
on evidence.

The findings of this research study were obtained from the 70 participants, of
whom 31% agreed whilst 21% strongly agreed that insufficient time was a barrier
preventing them from adopting evidence-based practices. The findings of this
research study are congruent with the above-mentioned studies.

4.9 BARRIERS RELATED TO FACILITATION AND SUPPORT

STRUCTURES REQUIRED FOR EVIDENCE-BASED PRACTICE
IMPLEMENTATION

The section comprises facilitators and support structures to promote

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implementation of evidence-based practice, namely, nine statements that were

listed to explore facilitators of evidence-based practice in the critical care unit.

Textbox 4.6: Barriers related to facilitation and support structures required

for evidence-based practice implementation

4.9.1 Results
4.9.1.1 Nursing colleagues are supportive of initiatives to change to
evidence-based practices in the critical care unit
4.9.1.2 Nurse managers are supportive of implementing evidence-based
practice in the critical care unit
4.9.1.3 Physicians are supportive of implementing evidence-based practices
in the critical care unit
4.9.1.4 Professional nurses are open and receptive to the use of best
practice guidelines in the care of the critically ill patient
4.9.1.5 The organisation will be able to support best-practice guideline
development and implementation
4.9.1.6 The institutional management is open and willing to participate in
evidence uptake
4.9.1.7 In-service training will promote understanding of, and adherence to,
evidence-based practices
4.9.1.8 An evidence-based mentor or champion is needed for implementation
of evidence-based practice
4.9.1.9 Best-practice guidelines will promote evidence based practices
4.9.2 Discussion pertaining to barriers related to facilitation and support
structures required for evidence-based practices

4.9.1 RESULTS

The section comprises all the results that have been derived from data analysis.
The results are presented graphically using bar graphs. The questionnaire
comprised nine statements that will be discussed in this section.

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4.9.1.1 Nursing colleagues are supportive of initiatives to change to

evidence-based practices in the critical care unit

Of the seventy participants n=24(34%) agreed whilst n=6(9%) strongly agreed that
their nursing colleagues were supportive of implementing evidence-based
practice. However, n=24(34%) disagreed whilst n=3(4%) strongly disagreed that
nursing colleagues were supportive of implementing evidence-based practices.
.As illustrated in Figure 4.39 there were a few participants, n=13(19%), that had a
neutral stance toward the statement.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 6 24 13 24 3
Percentage 9 34 19 34 4

Figure 4.39: Nursing colleagues are supportive of initiatives to change to

evidence-based practices in the critical care unit

4.9.1.2 Nurse managers are supportive of implementing evidence-based

practice in the critical care unit

The statement was aimed toward determining whether the participants were of the
opinion that nurse managers were supportive of the implementation of evidence-
based practice. Figure 4.40 depicts the results from the data analysis, which
indicate that n=33(47%) agreed whilst n=13(19%) strongly agreed that nurse
managers were supportive of implementing evidence-based practices. There were
n=16(23%) who disagreed while n=3(4%) strongly disagreed with the statement.
The remaining participants, n=5(7%), had a neutral opinion about the statement.

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Data analysis and discussion of findings Chapter Four

50

40

Percentage
30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 13 33 5 16 3
Percentage 19 47 7 23 4

Figure 4.40: Nurse managers are supportive of implementing evidence-

based practice in the critical care unit

4.9.1.3 Physicians are supportive of implementing evidence-based

practices in the critical care unit

The purpose of the statement was to ascertain whether physicians at the

institution were supportive of implementing evidence-based practices in the critical
care unit. A proportion of participants, n=19(27%), agreed whilst n=6(9%) strongly
agreed with the statement. Of the remaining participants n=18(26%) disagreed
while n=6(9%) strongly disagreed with the statement. Derived from the data
analysis n=21(29%) had a neutral stance toward the statement that physicians
were supportive of implementing evidence-based practices in the critical care unit.

40

30
Percentage

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 6 19 21 18 6
Percentage 9 27 29 26 9

Figure 4.41: Physicians are supportive of implementing evidence-based

practices in the critical care unit

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4.9.1.4 Professional nurses are open and receptive to the use of best-
practice guidelines in the care of the critically ill patient

Figure 4.42 provides a summary of responses on whether professional nurses are

open to using best-practice guidelines in the critical care unit. Of the seventy
participants n=34(49%) agreed whilst n=8(11%) strongly agreed that professional
nurses were open to using evidence-based guidelines. However, a total of
n=14(20%) disagreed whilst n=2(3%) strongly disagreed that professional nurses
were open to the use of evidence-based practice. A proportion of participants,
n=12(17%), had a neutral stance towards the statement
60
50
40
Percentage

30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 8 34 12 14 2
Percentage 11 49 17 20 3

Figure 4.42: Professional nurses are open and receptive to the use of best
practice guidelines in the care of the critically ill patient

4.9.1.5 The organization will be able to support best-practice guideline

development and implementation

The statement was posed to participants to obtain their opinion of whether the
organization would be supportive of implementing best-practice guidelines.
Results reflected in Figure 4.43 indicate that n=35(50%) agreed whilst n=5(7%)
strongly agreed with the statement. A proportion of participants, n=12(17%),
disagreed with the statement whilst none of the participants indicated that they
strongly disagreed with the statement. The remaining participants, n=18(26%),
had a neutral stance toward whether the organization would be able to support
best-practice guideline development and implementation.

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Data analysis and discussion of findings Chapter Four

60
50
40

Percentage 30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 5 35 18 12 0
Percentage 7 50 26 17 0

Figure 4.43 The organization will be able to support best-practice guideline

development and implementation

4.9.1.6 The institutional management is open and willing to participate in

evidence uptake

As illustrated in Figure 4.44 a proportion of participants n=22(31%) agreed whilst

n=6(9%) strongly agreed that the institution would be open to participating in
evidence uptake. There was a percentage, n=28(40%), who had a neutral opinion
toward whether the institutional management was open to adopting evidence-
based practices. However, n=13(19%) disagreed whilst n=1(1%) strongly
disagreed that the institution would participate in evidence translation.

50

40
Percentage

30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 6 22 28 13 1
Percentage 9 31 40 19 1

Figure 4.44: The institutional management is open and willing to participate

in evidence uptake

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4.9.1.7 In-service training will promote your understanding of, and

adherence to, evidence-based practices

The statement was presented to participants to determine whether in-service

education would promote their understanding of, and adherence to, evidence-
based practice in the critical care unit. The results are schematically presented in
Figure 4.45 indicating that n=35(50%) participants agreed whilst n=33(47%)
strongly agreed that in-service education would promote understanding of, and
adherence to, evidence-based practice. There were n=2(3%) who had a neutral
stance toward evidence uptake. None of the participants disagreed or strongly
disagreed with the statement.

60
50
40
Percentage

30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 33 35 2 0 0
Percentage 47 50 3 0 0

Figure 4.45: In-service training will promote your understanding of and

adherence to evidence-based practices

4.9.1.8 An evidence-based practice mentor or champion is needed for

implementation of evidence-based practices

Of the seventy participants n=33(47) agreed whilst n=31(44%) strongly agreed

that an EBP mentor would facilitate evidence uptake. A proportion of participants,
n=4(6%), had a neutral stance toward the statement. However, n=2(3%)
disagreed with the statement whilst none of the participants strongly disagreed
with the statement. The findings are illustrated in Figure 4.46.

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50

40

Percentage
30

20

10

0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 31 33 4 2 0
Percentage 44 47 6 3 0

Figure 4.46: An evidence-based practice mentor or champion is needed for

implementation of evidence-based practice

4.9.1.9 Best-practice guidelines will promote evidence-based practices

From the data analysis displayed in Figure 4.47 there were n=35(50%) who
strongly agreed while n=32(46%) agreed that best-practice guidelines could
promote evidence uptake. There were n=2(3%) who had a neutral stance toward
the statement. There were n=1(1%) who disagreed whilst there were no
participants who strongly disagreed with the statement.

60
50
40
Percentage

30
20
10
0
Strongly Strongly
Agree Neutral Disagree
Agree disagree
Participants 35 32 2 1 0
Percentage 50 46 3 1 0

Figure 4.47: Best-practice guidelines will promote evidence-based

practices

4.9.2 DISCUSSION PERTAINING TO FACILITATION AND SUPPORT

STRUCTURES REQUIRED FOR EVIDENCE-BASED PRACTICE
IMPLEMENTATION

Support of EBP by nursing colleagues within the critical care unit can occur

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Data analysis and discussion of findings Chapter Four

by encouraging teamwork. The workload can be equally divided when initiating

new practices. Management should allocate a time period to enable staff to
perform searches, read evidence-based guidelines and discuss findings with team
members (Schmidt & Brown, 2009:373). In a survey done by Gerrish et al
(2007:334) it was found that a facilitator of implementing evidence-based practice
was that nursing colleagues were supportive of one another during implementing
practices based on evidence. According to Ploeg et al (2007:214), 125
participants participated in the research study. A theme that was identified in the
semi-structured interviews was that teamwork was necessary for successful
implementation of evidence-based practice.

The findings of this research study revealed that there were 34% agreed whilst 9%
strongly agreed that support by nursing colleagues was important for successful
implementation of evidence-based practices. The findings of this study are
congruent with the above mentioned studies.

According to Schmidt and Brown (2009:35), the role of nurse managers is crucial
to the promotion of evidence-based practices. They should act as role models by
integrating evidence into their duties and encourage staff to base clinical decision-
making on evidence. Staff should also be evaluated according to EBP involvement
during yearly performance appraisal to ensure that practices based on evidence
are sustained. LoBiondo Wood and Haber (2010:415) concur that strong
leadership plays an integral role in adoption of evidence-based practices. In a
survey done by Breimaier et al (2011:1751), 39% of the participants indicated that
support from nurse managers was necessary for implementation of evidence-
based practice within an organization.

The findings from this study revealed that 47% agreed while 19% strongly agreed
that nurse managers were supportive of implementing evidence-based practice.
The findings of this study are congruent with the above-mentioned studies.

For implementation of evidence-based practices to be successful, support from

the multidisciplinary team is essential. That includes support from physicians
(Gerrish, et al, 2007:68). According to Lang et al (2007:359) physicians can be

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resistant to change, which may be the result of knowledge deficits or perhaps

comfort with traditional practices. A combination of interventions to promote
physicians implementing evidence-based practices in the critical care unit may
range from educational workshops and reminders to audits. In a survey done by
Kocaman et al (2010:1909), 78% of the participants stated that physicians within
their organization were resistant to change. In a systematic review 26 of 53
studies ranked lack of physician support as one of the top ten barriers to
evidence-based practices (Kajermo et al, 2010:32).

The findings of this research study indicated that 27% agreed while 9% strongly
agreed that physicians were supportive of implementing evidence-based practice.
The findings of this study are incongruent with the above-mentioned studies.
According to Craig and Smyth (2007:238), professional nurses implementing
best-practice guidelines can facilitate evidence uptake in clinical practice.
Guidelines may be developed at national or international level. Rigorous
guidelines based on the best research evidence are available on online sites such
as the National Institute of Clinical Health and Excellence (NICE), The Registered
Nurses Association of Ontario (RNAO) or The National Guideline Clearinghouse is
based on the latest clinical evidence. The guidelines on those sites, for instance,
stipulate the hierarchy of evidence used as well as the rationale for recommended
practices.

The findings from this research study revealed that 49% agreed while 11%
strongly agreed that professional nurses were open to using best practice
guidelines in the critical care unit.

Organizations that support implementation of evidence-based practices are

imperative to improve success of evidence uptake and sustainability (Mortaine &
Fontaine, 2009:5). An organisational culture that possesses strong leadership
support an all nursing levels, encourages teamwork and the presence of EBP
champion will facilitate implementation of evidence-based practices (Ploeg et al,
2007, 213). An organization must also possess the necessary infrastructure
needed to adopt new evidence-based practices. Staffing, policies and procedures
should all be aligned to encourage evidence-based practice (Smith & Donze,

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2010:61).

The findings of this research study indicated that 50% agreed whilst 7% strongly
agreed that the organization would be able to support initiatives to implement
evidence-based practices. The results of this study are congruent with the above-
mentioned studies.

Translation of evidence to practice is guaranteed with the support of the

institutional management. Administrators who value EBP should be recruited to
organizations. The institutions management vision and mission statements should
be congruent with providing care to patients based on the best evidence (Schmidt
& Brown, 2009:9). In a study done by Robinson et al (2006:471), 29% stated that
support from management within organizations would encourage them to
implement evidence-based practice.

The findings of this research study revealed that 31% agreed whilst 9% strongly
agreed that institutional management would be open to evidence uptake. The
findings of this study are congruent with the above-mentioned studies.

DiCenso et al (2005:17) propose that successful implementation of evidence-

based practices should encompass multifaceted interventions that use a variety of
strategies instead of a single intervention. In-service training within
organizations is one method that will enlighten staff about methods of providing
evidence-based practice when providing care to critically ill patients. During these
sessions learners can actively participate with experts on the topic. Empowering
staff with literature searching skills can also be included in these sessions.
Salmond (2007:117) adds that part of training should focus on enrichment of
computer skills, how to perform searches and how to appraise journal articles or
guidelines critically. In a survey by Breimaier et al (2011:1751) 49% indicated that
educational programmes would promote implementation of evidence-based
practice.

The findings of this research study revealed that 50% agreed while 47% strongly
agreed that in-service education on EBP would promote evidence uptake. The

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Data analysis and discussion of findings Chapter Four

findings of this study are congruent with the above-mentioned studies.

The presence of an EBP champion or mentor is one effective strategy that has
been described in literature to promote implementation of evidence-based practice
(Mortaine & Fontaine, 2009:5). An EBP champion is an expert clinician within the
nursing unit who searches for and disseminates evidence to the rest of the team
(LoBiondo-Wood & Haber, 2010:410). Organizations must provide EBP
champions who will have the time and skills dedicated to evidence-based
practices, and then inform the rest of the staff of the latest evidence. Therefore
nursing staff is not pressurized to perform individualized searches for evidence.
The strategy enables care rendered to be based on the latest updated evidence
(Smith & Donze, 2010:61).

The findings of this research study revealed that 47% agreed while 44% strongly
agreed that an EBP mentor was necessary in the critical care unit to perform
searches and disseminate that information to the rest of the staff. The findings of
this study are congruent with the above-mentioned recommendations.

Best-practice guidelines based on evidence can promote evidence-based

practices by ensuring safe practice and correct treatment. Variations in practice
will also be avoided (Craig & Smyth, 2007:260). In a study done by Sherriff et al
(2007:363), participants were optimistic toward developing guidelines or searching
for existing guidelines based on EBP. They indicated that they were willing to
search and appraise evidence as long as time was allocated during working
hours.

The findings of this research study revealed that 50%strongly agreed while 46%
agreed that best-practice guidelines implemented by professional nurses within
the critical care unit could facilitate evidence uptake. The findings of this research
study are congruent with the above mentioned recommendations.

4.10 SUMMARY OF THE CHAPTER

The chapter was a discussion of data that was analysed from the data-collection

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instrument, which was a structured questionnaire that explored the barriers to the
implementation of evidence-based practices. The data was extracted from 70
professional nurses working in a critical care unit in a private hospital within the
Nelson Mandela Metropole. Data has been presented using graphs. Descriptive
statistics have been used.

It is quite evident from the study findings that many barriers exist that are
congruent with information presented in research studies that explore barriers to
the implementation of evidence-based practice. The results are concerning as
patients who are in the critical care unit are already in a compromised state and
nurses using methods not based on scientific evidence can further contribute to
the patient developing complications. However, it is also evident that many
participants were optimistic about the integration of evidence into clinical practice
by stating the need for possible facilitators to implement evidence-based practice.
The following chapter will discuss recommendations to enhance the
implementation of evidence-based practice in the critical care unit.

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Conclusions, limitations and recommendations Chapter Five

CHAPTER FIVE

CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS

5.1 INTRODUCTION

The purpose of this research study was to identify barriers to the implementation
of evidence-based practices in a critical care unit. Derived from the data analysis
were all the research findings that were described in Chapter Four. Findings from
the research study highlighted that there were barriers to the implementation of
evidence-based practice in the critical care unit that will be discussed later in this
chapter. Conclusions, limitations and recommendations for the research study will
be discussed in this chapter. Recommendations will be presented in two parts
namely pertaining to various dimensions such as nursing research, nursing
education, nursing practice and recommendations for data analysis of this
research study.

5.2 CONCLUSIONS OF THE RESEARCH STUDY

There were two research objectives that were stipulated for the research study.
The research objectives that were listed in Chapter One are follows:
 to explore and describe barriers to the implementation of evidence-based
practices in the critical care unit, and
 to make recommendations to enhance implementation of evidence-based
practices in the critical care unit.

The findings of this research study revealed that there were barriers to the
implementation of evidence-based practice resulting in lack of efficient evidence
translation in the critical care unit. According to the data analysed certain
conclusions can be deduced that will be elaborated on in this section. Results
reflected that participants were not completely familiar with evidence-based
practices. Information from colleagues or peers was the most frequently accessed
sources by participants in the research study. Results of

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Conclusions, limitations and recommendations Chapter Five

this research study also revealed that professional nurses based their practices on
what they had been taught in the critical care unit when caring for critically ill
patients.

From the online sources that were listed in the questionnaire search engines such
as Google and Wikipedia were the most frequented by participants. These search
engines lack quality control and may contain information that lacks validity or
reliability. Another aspect which guided clinical decision-making in the care of the
critically ill patient was intuition. However, intuition is not based on scientific
principles or evidence at all. There is too much reliance on instinct or gut feeling.
Participants also stated that a barrier to the implementation of evidence-based
practice arose as a result of resistance to change, from professional nurses in the
critical care unit. A barrier that was identified for hindering evidence uptake was a
heavy workload experienced by professional nurses in the critical care unit. There
was general consensus that currently, a research-practice gap existed within the
critical care unit.

Furthermore, a conclusion drawn was that it was difficult to locate evidence. Even
though evidence was found insufficient time to read articles or best-practice
guidelines within the critical care unit posed a problem. Participants from the study
also revealed that inaccessibility to computers was a reality in the critical care unit.
A concern for participants was the amount of literature that pertains to critical care
nursing. An issue that has arisen from the research study is that participants
stated they lacked the authority to change to evidence-based practices in the
critical care unit.

5.3 RECOMMENDATIONS RELATED TO NURSING RESEARCH,

NURSING EDUCATION, NURSING PRACTICES AND DATA ANALYSIS

The aim of this section is to highlight the implications of this research study in the
nursing arena. Recommendations to enhance the implementation of evidence-
based practices in the critical care unit will be elaborated upon later in the chapter.

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Conclusions, limitations and recommendations Chapter Five

5.3.1 RECOMMENDATIONS RELATED TO NURSING RESEARCH

The research study has prompted future studies with regard to evidence-based
practices. Future descriptive studies can explore facilitators promoting and
sustaining evidence-uptake within critical care units. As the study was conducted
in a single critical care unit in the Nelson Mandela Metropole it is recommended
that forthcoming studies incorporate both the public and private sectors to provide
a true reflection of the barriers to evidence-based practices in critical care units.

Further research can be done to explore barriers to the implementation of

evidence-based practices in other clinical settings such as operating theatres,
nephrology units, trauma units or general wards. Research studies that can be
conducted in the future may explore an aspect of evidence-based practice from a
qualitative viewpoint. Qualitative studies exploring perceptions or attitudes toward
evidence-based practices can be explored through interviews or focus groups.
Furthermore, future research studies could explore the impact training on
literature-searching skills and critical appraisal has on evidence uptake within
critical care units.

5.3.2 RECOMMENDATIONS RELATED TO NURSING EDUCATION

With regard to evidence-based practices it is imperative that they are incorporated

at the under-graduate and post-graduate levels. Exposing nursing students to the
components of evidence-based, literature-searching skills, critical appraisal of
journal articles and implementing best-practice guidelines is crucial in an era when
nursing practice no longer relies on tradition. Professional nurses already working
in clinical practice should attend short learning programmes on evidence-based
practices.

5.3.3 RECOMMENDATIONS RELATED TO NURSING PRACTICE

Derived from the data analysis recommendations related to nursing practices can
be suggested. Strategies to promote evidence uptake in the critical care unit have
been explored and short learning programmes intended for professional nurses
working within critical care units may also overcome barriers. However, it is
imperative that stakeholders such as nursing and institutional management attend

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Conclusions, limitations and recommendations Chapter Five

these programmes to ensure that the organization embraces change. Programme

content may include the historical context of evidence-based practice, the
components of evidence-based practices, how to interpret research articles or
best-practice guidelines, how to access scientific online resource sites and
teaching skills such as literature searching and critical appraisal. Creating
awareness will prompt professional nurses to use critical thinking and reflective
practice with the purpose of providing the best research evidence to critically ill
patients.

Within organizations healthcare workers should be compelled to attend workshops

to remain abreast of the latest updated evidence-based practices. Another
strategy may be to incorporate professional nurses‟ contribution to evidence-
based practices within the critical care unit as part of their yearly performance
appraisal. Best-practice guidelines on specific clinical conditions can ensure that
evidence is rendered to critically ill patients according to the best research
evidence. Organizations should adopt best-practice guidelines in caring for
patients. The establishment of journal clubs within the critical care unit can ensure
that high-level evidence is accessed and by doing so professional nurses can
base their care on the latest evidence. For instance, if each professional nurse
reads a journal article on a specific topic during monthly meetings time can be
saved in comparison to an individual practitioner trying to keep up to date. Other
strategies that should be incorporated are reminders or audits that can be
developed in critical care units to ensure sustainability of evidence-based
practices.

5.3.4 RECOMMENDATIONS RELATED TO DATA ANALYSIS OF THIS

RESEARCH STUDY

For this section significant results extracted from this research study will be
presented and recommendations for the findings will be made. The
recommendations will be substantiated with literature. The findings presented in
this section have already been discussed in Chapter Four.

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Conclusions, limitations and recommendations Chapter Five

5.3.4.1 Section B: Implementation of evidence-based practices

Findings:
 34% of the participants were to a moderate extent familiar with evidence-
based practices
 54% of the participants indicated that “evidence-based practice is the
conscientious explicit and judicious use of the current best evidence in
making decisions about the care of patients”
 57% of the participants searched for evidence occasionally to support
clinical decisions
 50% of the participants accessed best-practice guidelines occasionally
 43% of the participants indicated they would ask their peers/ colleagues
when they need information to guide clinical decision-making
 59% of the participants frequently accessed Google
 50% of the participants would wean a patient from the mechanical ventilator
according to information that was taught in the unit

Recommendations:
According to Walsh et al (2010:30) a global initiative should be undertaken in the
nursing profession to highlight the importance of integrating evidence into clinical
practice. Education programmes intended for professional nurses on the topic of
evidence-based practice will raise awareness and enhance familiarity of evidence-
based practices. LoBiondo-Wood and Haber (2010:419) add that evidence-based
practice should be incorporated into an organization‟s mission, vision and strategic
plan to create a culture of evidence-based practice. In a survey done by Ubbink et
al (2011:91) involving 696 participants who revealed the highest-ranked facilitator
that would promote evidence-based practice was dedicated time to learn and
practice the translation of evidence into practice.

It is thus recommended that short learning programmes or workshops be

presented to professional nurses in the critical care units, which will enhance the
familiarity with evidence-based practices. The content of such courses may extend
from the concept known as evidence-based practice, accessing sources of
evidence, how to perform literature searches, how to conduct a critical appraisal

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Conclusions, limitations and recommendations Chapter Five

and how to interpret research reports. Stakeholders for instance unit managers
and other members of the multi-disciplinary team in the critical care unit should be
made more aware of evidence-based practice and the benefits thereof for the
critically ill patient.

Smith and Donze (2010:67) mention that available, recent and relevant evidence
should be accessed to ensure validity of evidence-based practices. According to
Burns and Grove (2009:618) best-practice guidelines provide a gold standard for
patient care resulting improved patient outcomes and in effect a decrease in
morbidity and mortality rates. Salmond (2007:117) state pre-appraised summaries
or best-practice guidelines on databases such as the Cochrane library can
enhance translation of recent evidence into practice as it is accessible.
Recommendations can thus be made that best-practice guidelines based on
evidence be accessed regularly to minimize variations in practice and bridge the
research-practice gap. Best research evidence should be consulted when seeking
information.

Relying on information from colleagues or peers may be unreliable as it may be

based on tradition, ritual or personal experience. In a survey done by Gerrish et al
(2008:66) the third highest-ranked source that was frequently used by participants
was the knowledge that their colleagues or peers shared. Parahoo (2006:8)
highlight accessing the best research evidence is the best recommended practice
as researchers collect and analyse data rigorously, then present findings and
recommendations and rationale. It is thus recommended that professional nurses
in the critical care unit do not rely on unscientific methods for information such as
asking colleagues or peers, tradition or ritual as it exposes patients to variations
and perhaps outdated practices.

According to Courtney and McCutcheon (2010:7) search engines such as Google

lack quality control as information may be extracted from untrustworthy sources
therefore should be avoided. The National Guideline Clearinghouse on the other
hand, provides an array of best-practice guidelines on various disease conditions.
Recommendations can be thus be made to critical care nurses through
educational programmes to avoid unscientific online sources such as Google

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Conclusions, limitations and recommendations Chapter Five

when seeking scientific answers. Databases such as the National Guideline

Clearinghouse, Joanna Briggs Institute (JBI), NICE or The Cochrane Collaboration
should rather be accessed.

Parahoo (2006:444) proposed that practices should be based on the best

research evidence as other information sources that are unscientific may be
harmful to patients. It is therefore recommended that information taught in the
critical care unit should not be the preferred source of reference when caring for
patients as there is a risk that the information might be based on personal
experience, out-dated textbooks or irrelevant practices.

5.3.4.2 Section C: Barriers related to the knowledge of the nurse with

regard to evidence-based practice

Findings:
 59% of the participants agreed whilst 25% strongly agreed that they based
clinical decisions on information that they gained from training as a
professional nurse
 36% of the participants agreed whilst 17% strongly agreed that they used
their intuition to guide them in caring for patients
 49% of the participants agreed whilst 10% strongly agreed that professional
nurses in the critical care unit were resistant to implementing evidence-
based practices
 29% of the participants agreed whilst 27% strongly agreed that the
workload of nurses were too heavy to keep up with evidence-based
practices.
 43% of the participants agreed whilst 19% strongly agreed that the efficient
translation of evidence into clinical practice was lacking

Recommendations:
Gerrish et al (2007:334) indicates that professional nurses often base their clinical
decisions on information that they have obtained during their training. Parahoo
(2006:8) states that there is a risk that relying on information obtained from

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Conclusions, limitations and recommendations Chapter Five

training as a professional nurse exposes patients to out-dated and harmful

practices. Aveyard and Sharp (2010:140) add professional nurses should adopt
an attitude whereby they question if their practice is based on the best integrated
evidence.

Due to the high percentage of professional nurses that agree that they base their
clinical decision-making on what they were taught in their training, it is thus
recommended that a greater awareness be created amongst professional nurses
to continuously update their knowledge. The importance of relying on the best
research evidence when making clinical decisions pertaining to the care of
critically ill patients and not information obtained during training as a professional
nurse should be emphasized.

Parahoo (2006:5) indicates intuition is not based on a rational reasoning but on

instinct or gut feeling. Schmidt and Brown (2009:9) suggest that the value
evidence-based practice improve standards of care and patient outcomes,
whereas with intuition there is no way of assessing if outcomes can be improved.
A comparison of the benefits of intuition versus the best research evidence should
be done, so that the value of evidenced-based practice can be realized.
Improvement in statistics and trends can be used to justify the rationale for
implementing evidence-based practices versus unscientific methods such as ritual
or tradition. Based on the study results, it is thus recommended that professional
nurses base their practice on evidence and not on intuition, as patient outcomes
will be improved. Traditional, ritualistic and intuitive practises amongst professional
nurses in the critical care unit should be discouraged.

Barker (2010:117) mentions that for successful implementation of evidence-based

practices to take place, staff must be flexible and committed to embracing change.
If best-practice guidelines are adopted in a nursing unit all professional nurses
should be compliant in adherence to ensure consistency in care rendered with the
ultimate benefit in improving patient care. Schmidt and Brown (2009:10) add that
when there is resistance to change reasons for the resistance should be explored
and resolved. In a survey done by Ubbink et al (2011:92) a major facilitating factor
identified was support from team members, physicians and management.

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Conclusions, limitations and recommendations Chapter Five

Based on the study results, it is recommended that professional nurses realize

that teamwork and support from colleagues is a facilitator to the implementation of
evidence-based practice. Collaborative relationships amongst members of the
multidisciplinary team members caring for the critically ill patient should be
encouraged.

DiCenso et al (2005:194) indicate there should be a suitable nurse-to-patient ratio

to ensure adherence to evidence-based practices. The roles and responsibilities
for professional nurses should be clearly defined with avoidance of unnecessary
tasks to ensure the workload of professional nurses are manageable. It is
therefore recommended that the workload of professional nurses are evaluated so
that unnecessary tasks are minimized and the core focus remains on delivering
nursing care based on the best research evidence.

Ubbink et al (2011:92) mentions the research practice gap can be bridged through
use of reminders, audits, journal clubs, regular research meeting and incorporating
discussions of evidence during handovers. Management can also ensure
sustainability through reviewing employees‟ participation in evidence-based
practices. Salmond (2007:117) adds that relations have to be forged between
nurse researchers and nurses in clinical practice for the successful implementation
of evidence-based practice. Based on the study results, it is recommended that
methods which will promote translation of evidence into practice are explored and
discussed amongst professional nurses in the critical care unit.

5.3.4.3 Section D: Barriers to finding and reviewing evidence

Findings:
 34% of the participants agreed whilst 28% strongly agreed that there was
insufficient time in the critical care unit to find and read research reports
 49% of the participants agreed whilst 17% strongly agreed that access to
research evidence was poor ( slow or no computers available) in the critical
care unit
 60% of the participants agreed whilst 13% strongly agreed that research
reports were not readily available in the critical care unit

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Conclusions, limitations and recommendations Chapter Five

 40% of the participants agreed whilst 20% strongly agreed that the amount
of literature pertaining to the critical care unit was overwhelming
 30% of the participants agreed whilst 7% strongly agreed that research
reports were not published fast enough

Recommendations:
Salmond (2007:117) indicates that organizations should provide adequate time in
which to search and find the best research evidence. Walsh (2010:30) adds that
time management skills should also be taught during short learning programmes
on evidence-based practice. Professional nurses should be taught how to manage
their time effectively in order to read and appraise evidence. In a survey
conducted by Ring et al (2005:1053) one of the main driving forces identified was
adequate time to find and read evidence. Recommendations will be made to
management that professional nurses in the critical care unit should be granted
allocated time on a daily basis in to perform searches or read research reports
therefore, the implementation of evidence-based practice in the care of the
critically ill patient will thus be enhanced.

Aveyard and Sharp (2010:128) suggests computers should be used to access

online sources based on evidence. Barker (2010:117) mentions that resources
such as computers will enhance the sustainability of evidence-based practices.
Schmidt and Brown (2009:9) indicate that even though organizations may not
have access to computers, innovative strategies such as applying for
sponsorships from pharmaceutical companies or writing a motivation letter to
managers stipulating the importance of computers for accessing evidence in their
organization. It is recommended there should be at least one dedicated computer
in critical care units that is available to perform searches to ensure that the latest
evidence is consulted.

Aveyard and Sharp (2010:130) suggests that articles and guidelines be kept in the
nursing unit so that it is easily accessible. Schmidt and Brown (2009:10) add that
through establishing journal clubs research reports can be discussed and shared
within nursing unit ensuring that the latest evidence is accessed. Based on the
study results, it is recommended that organizations subscribe to journals which

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Conclusions, limitations and recommendations Chapter Five

should be available in critical care units so that nursing staff can easily read
research reports. It would also be beneficial if journal clubs are established
amongst professional nurses in the critical care unit to discuss the latest evidence.
Ubbink et al (2011:91) indicate that organizations should incorporate methods that
such as accessing pre-appraised evidence or best-practice guidelines which can
reduce the workload of nurses. Walsh (2010:30) mentions that acquisition of skills
such as critical appraisal and literature-searching are facilitating agents to
evidence uptake. Salmond (2007:117) mentions that professional nurses should
be taught which online sources to access in order to avoid unscientific sources.
Educational sessions should also include how to interpret the statistical analysis
and to determine implications for clinical practice. Recommendations can be made
that critical appraisal and literature-searching skills be taught to professional
nurses, which will avoid the use of redundant information in making clinical care
decisions. In empowering professional nurses with these skills, they may no longer
feel that there is overwhelming literature pertaining to critical care nursing. It is
also recommended that pre-appraised journal articles or best practice guidelines
be available in the critical care unit.

Gerrish et al (2007:334) mentions that certain strategies can be implemented to

ensure that the latest best research evidence is accessed, namely: accessing the
library, and searching online evidence-based sources. It is recommended that
relevant research reports pertaining to the care of the critically ill patient are
available in nursing units.

5.3.4.4 Section E: Barriers to implementing evidence-based practice based

on the relevant resources

Findings:
 34% of the participants agreed whilst 23% strongly agreed that they lacked
the authority in the critical care unit to change to evidence-based practice
 34% of the participants agreed whilst 14% strongly agreed that the severity
of the critically ill patient influenced implementation of evidence-based
practices
 31% of the participants agreed whilst 21% strongly agreed that they had

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Conclusions, limitations and recommendations Chapter Five

insufficient time to implement evidence-based practices in the critical care

unit

Recommendations:
In a survey by Gerrish et al (2008:66) participants indicated that lack of support by
colleagues, managers and physicians are contributing factors to their view that
they do not have the authority to change to evidence-based practice. Barker
(2010:117) mentions an organization should provide positive reinforcement and
support for staff who implement evidence-based practices. Ploeg et al (2007:214)
conducted a survey whereby participants indicated the highest–ranked facilitator
for evidence-based practice was support from all levels of management and
stakeholders. It is therefore recommended that organizations create a culture that
embraces and encourages professional nurses to implement evidence-based
practices. In an organisational culture that is conducive to evidence-based
practice professional nurses will believe that they have the authority to implement
practices that are based on evidence.

Aveyard and Sharp (2010:130) state that time management is an integral

component therefore professional nurses should carry out tasks that are of priority,
unnecessary task should be minimized. In a survey conducted by Ring et al
(2005:1052) participants indicated that sufficient resources such as staffing will
enable implementation of evidence-based practice. Based on the study results, it
is recommended that professional nurses, caring for high acuity patients, have
relief sessions with the assistance from other staff members in the critical care
unit. Organizations must ensure that they have sufficient human resources to cope
with implementing new practices. Managers should be made aware that allocation
of sufficient time is an enhancer to the implementation of evidence-based practice
in the critical care unit.

Schmidt and Brown (2009:9) suggest there are certain strategies which may
overcome barriers to evidence-based practice. With regard to insufficient time
organizations can allocate 15 minutes per day to professional nurses to search for
evidence. A list of online resources that can be consulted will allow easier retrieval
of information and established best-practice guidelines can be adopted in nursing

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Conclusions, limitations and recommendations Chapter Five

units in order to save time. Barker (2010:117) highlight to ensure sustainability of

evidence-based practices sufficient time should be provided to enable the
integration of evidence into clinical practice. In a survey done by Breimaier et al
(2011:1751) 20% of the participants revealed that they need sufficient time to
implement evidence-based practices. Recommendations can be made to
management nurses should be allocated time to perform searches, read reports
and apply evidence-based practices.

5.3.4.5 Section F: Barriers related to facilitation and support structures

required for implementation of evidence-based practice

Findings:
 50% of the participants agreed whilst 47% strongly agreed that in-service
training would promote the understanding of, and adherence to, evidence-
based practices
 47% of the participants agreed whilst 44% strongly agreed that an EBP
mentor or champion was needed for the implementation of evidence-based
practices
 50% of the participants strongly agreed whilst 46% agreed that best-
practice guidelines could promote evidence-based practices

Recommendations:
DiCenso et al (2005:192) describes providing educational programmes intended
for professional nurses will enhance the translation of evidence into practice.
According to the Registered Nurses Association of Ontario (RNAO) accessed on
(www.rnao.org) active implementation strategies should incorporate educational
programmes. Craig and Smyth (2007:319) concurs that attendance of educational
programmes, workshops or conferences on evidence-based practice will promote
evidence uptake. It is thus recommended that educational programmes such as
in-service training must be done in the critical care unit, which will promote
understanding of and adherence to evidence-based practice amongst professional
nurses.

According to the Registered Nurses Association of Ontario (RNAO) EBP

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Conclusions, limitations and recommendations Chapter Five

champions may be professional nurses who are passionate about the improving
quality of patient care. In a survey conducted by Smith and Donze (2010:67) the
presence of an evidence-based practice champion was identified as a facilitator to
the implementation of evidence-based practices. Ploeg et al (2007:214) mentions
that the presence of an EBP champion is crucial to lead implementation and
supervise implementation of evidence-based practices. Based on the study
findings, it is recommended that an EBP mentor or champion within the critical
care unit be elected to dedicate time in searching and then disseminating
evidence. The role of an EBP mentor or champion might alleviate the workload of
individuals who are expected to conduct their own searches. Furthermore, the
EBP champion can be used to promote the implementation of evidence-based
practices in the critical care unit.

According to Polit and Beck (2012:31) best-practice guidelines is a method of

distilling evidence into a manageable form intended for professional nurses.
Variances in practice are minimized and the guidelines provide clinical guidance
when rendering patient care. It is thus recommended that best-practice guidelines
for the care of the critically ill patient are developed or adopted to ensure that
nursing practice is based on the best research evidence. Best-practice guidelines
based on evidence could reduce variances in the care delivered, and ensure that
consistent evidence-based care was delivered.

5.4 STUDY LIMITATIONS

Each research study is unique in its content and methodology with the ultimate
purpose of achieving perfection: however, it is inevitable that each study has
limitations. The study took place in one critical care unit at a private hospital within
the Nelson Mandela Metropole, therefore results cannot be generalized.

5.5 SUMMARY OF THE CHAPTER

The research study has been successful in attaining the research objectives and
identifying barriers to the implementation of evidence-based practices in a critical
care unit. The findings of this research study are congruent with findings of similar
research studies that were explained in Chapter Two. The context of this study

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Conclusions, limitations and recommendations Chapter Five

was to determine the barriers to implementation of evidence-based practices in a

critical care unit. The studies that were done in Chapter Two were within various
nursing units, not only critical care units and it is evident that the barriers are
similar regardless of the context of the nursing environment. In Chapter Two
various studies were performed in various countries, and it is evident that there
are similar barriers in the studies that were conducted within the various countries.

There is a chasm between research and practice which prompts the importance of
facilitation to promote evidence translation into critical care units. Findings from
the study revealed that some professional nurses in the critical care unit were
unfamiliar with the concept known as “evidence-based practices”. Derived from
the data analysis there is reliance on intuition, tradition and knowledge from
training to support the clinical decision-making process. The results of this study
also revealed that professional nurses were accessing unscientific online sources
which were an issue that persists in the critical care unit. The organisational
culture, such as resistance from management, resistance to change, poor access
to computers, and no time allocation to search for evidence are all aspects that
are barriers hindering evidence-uptake.

Critically ill patients are compromised due to disease processes; therefore it is

imperative that they receive care that is based on the best research evidence to
prevent complications, promote healing and facilitate rehabilitation. As advocates
for patients it is the responsibility of professional nurses to strive to provide
patients with evidence-based care. This implies that care based on the latest,
relevant and highest level of evidence will be consulted to guide care rendered
and assist in clinical decision-making. Facilitators promoting evidence-based
practices must be identified to ensure success and sustainability of evidence-
based practices within critical care units.

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References

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Annexures

ANNEXURE A: QUESTIONNAIRE

QUESTIONNAIRE: BARRIERS TO IMPLEMENTATION OF EVIDENCE-BASED

PRACTICES IN A CRITICAL CARE UNIT.

INSTRUCTIONS:
Please mark your response with an X where indicated.
For example:

Disagree

disagree
Strongly

Strongly
Neutral
Agree
agree
1. Participating in an exercise regime has a
1 2 3 4 5
role in promoting health.

A reference number will be allocated to the questionnaire; therefore your name will not
appear on the questionnaire and its contents will remain confidential.
Please answer all questions as honestly as possible.
Thank you for your time and co-operation!
With appreciation,
Candice Bowers

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Reference Number

SECTION A: DEMOGRAPHIC DATA

Please allocate one response for each item.

1. Indicate your gender.

Male Female

2. Indicate your age in years.

<25 years
25 – 29 years
30 – 39 years
40 – 49 years
>50 years

3. Indicate the years you have been working in a critical care unit.
< 1 year
1 – 4 years
5 – 9 years
10 – 14 years
>15 years

4. As a professional nurse what position do you hold in a critical care unit?

Permanently employed professional nurse on shift
Agency worker
Shift leader
Clinical facilitator
Unit manager

5. As a professional nurse do you hold an additional qualification with SANC?

Yes
No

6. If yes to question 5, please specify..........................................................

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Annexures

SECTION B: IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

For each item cross the box of the response that best represents your view.

7. Indicate how familiar you are with evidence-based practice (One answer please).
Completely familiar

To a great extent familiar

To a moderate extent familiar

To a little extent familiar

Not at all familiar

8. Indicate your understanding of the concept known as evidence-based practice (One

answer please).
Evidence-based practice consists of theoretical and practical skills you have
been taught during your training as a professional nurse

Any nursing or medical journal article is evidence-based

The conscientious, explicit and judicious use of the current best evidence in
making decisions about the care of patients

Practices that you have been taught in the critical care unit

9. How often do you consult information that is based on research or evidence to

support your nursing practice and clinical decision-making? (One answer please).
Weekly

1 – 3 times a month

1 – 3 times a year

Occasionally

Never

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Annexures

10. How often do you access the available best-practice guidelines in your critical care
unit? (One answer please).

Weekly
1 – 3 times a month
1 – 3 times a year

Occasionally
Never

11. When you need information to guide your clinical decision-making, where do you
usually find it? (One answer please)
I read journal articles
I read text books
I search the internet
I ask my colleagues and peers

12. On what do you typically base your clinical decision-making in caring for the critically
ill patient? (One answer please)

Ritualistic practices

On what I have been taught in the unit

On the latest available evidence

I ask my colleagues and peers

13. Which online evidence-based source do you Never Seldom Frequently

use? (Please give an answer for each
source)

13.1 EBSCO host

13.2 Medline

13.3 Pubmed

13.4 The Cochrane Collaboration

13.5 National Guideline Clearinghouse

13.6 Registered Nurses Association of Ontario

(RNAO)

13.7 Johanna Briggs Institute (JBI)

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Annexures

13. Which online evidence-based source do you Never Seldom Frequently

use? (Please give an answer for each
source)

13.8 World-Views on Evidence-based Nursing

13.9 The International Journal of Evidence-based

Healthcare

13.10 Google Scholar

13.11 Google

13.12 Wikipedia

13.13 Other: please specify

14. You have been allocated to care for a critically ill patient. The patient has been
mechanically ventilated for a period of 3 weeks. The physician has just assessed the
patient on morning rounds and has given the order to commence weaning from the
ventilator. Which source will you consult to initiate the weaning process? (One
answer please).
You will ask a colleague who has been within the unit for a period of time how to
go about the weaning process
You will consult a critical care textbook
You will consult the latest best-practice guideline on weaning a patient from the
mechanical ventilator
You will follow the weaning process that you have been taught in the unit

15. A novice nurse in your critical care unit enquires about prevention of ventilator
associated pneumonia (VAP). She states she has frequently heard about the
importance of preventing VAP. She enquires which source she should access to
learn more about the topic. You refer her to one of the following (One answer
please).

You refer her to the Standard Operating Procedure (SOP) on the prevention of
VAP.

You give her the latest critical care textbook to read on the topic.

You tell her to “Google” the term “Ventilator Associated Pneumonia”

You give her the latest best-practice guideline on prevention of VAP that is within
the critical care unit.

185
Annexures

SECTION C: BARRIERS RELATED TO KNOWLEDGE OF THE NURSE WITH REGARD TO

EVIDENCE-BASED PRACTICE

Please indicate to what extent you agree with each statement. Please give one
response for each statement.

Disagree

Disagree
Strongly

Strongly
Neutral
Agree
agree
16. Changing to practice based on evidence means
1 2 3 4 5
long-term commitment and I do not have time

17. I base clinical decisions pertaining to the care of

the critically ill patient on the information that I 1 2 3 4 5
have gained from my training

18. My intuition about what seems to be “right” for my

1 2 3 4 5
patient guides my decision-making

19. I see little benefit for self or patient care in

implementing evidence-based practice in the 1 2 3 4 5
critical care unit

20. The nurse in the critical care unit should not

conduct their own literature reviews to answer 1 2 3 4 5
clinical questions

21. I do not critically reflect on new treatments and

medications prescribed in the care of the critically 1 2 3 4 5
ill patient

22. I view evidence-based practices as a waste of

1 2 3 4 5
time

23. The rewards for using research results in the

clinical decision-making of critically ill patients are 1 2 3 4 5
minimal

24. The professional nurses in the critical care unit

1 2 3 4 5
are resistant to change and trying new ideas

25. Traditional / Ritual practices outweigh evidence-

1 2 3 4 5
based practices

26. Evidence-based practices do not improve the 1 2 3 4 5

186
Annexures

Disagree

Disagree
Strongly

Strongly
Neutral
Agree
agree
quality of patient care

27. The application of evidence-based practices is

not necessary for daily practice within the nursing 1 2 3 4 5
profession

28. The workload of nurses is too heavy to keep up

1 2 3 4 5
with evidence-based practices

29. There is lack of efficient translation of evidence

1 2 3 4 5
into clinical practice

SECTION D: BARRIERS TO FINDING AND REVIEWING EVIDENCE

Disagree

Disagree
Strongly

Strongly
Neutral
Agree
agree

30. I do not know where to find appropriate research

findings and other relevant pieces of evidence to 1 2 3 4 5
guide clinical decision making
31. There is insufficient time in the critical care unit to
1 2 3 4 5
find and read research reports
32. I find it difficult to understand research reports 1 2 3 4 5
33. I do not feel confident about appraising the quality
1 2 3 4 5
of research reports or other pieces of evidence
34. I find it difficult to identify the implications of
1 2 3 4 5
research findings for clinical practice
35. Access to research evidence is poor (slow or no
1 2 3 4 5
computers available)
36. Research reports are not readily available in the
1 2 3 4 5
critical care unit
37. The amount of literature related to critical care is 1 2 3 4 5

187
Annexures

Disagree

Disagree
Strongly

Strongly
Neutral
Agree
agree
overwhelming
38. Research reports related to issues in the critical
1 2 3 4 5
care are not published fast enough
39. Best-practice guidelines are difficult to interpret 1 2 3 4 5

SECTION E: BARRIERS TO IMPLEMENTING EVIDENCE-BASED PRACTICE BASED ON THE

RELEVANT RESOURCES

Disagree

disagree
Strongly

Strongly
Neutral
Agree
agree

40. I do not feel confident about changing practice

1 2 3 4 5
based on research findings or evidence
41. I lack the authority in the critical care unit to change
1 2 3 4 5
practice
42. The severity of the critically ill patient influences the
1 2 3 4 5
implementation of evidence based practices
43. There are insufficient resources to change practice
1 2 3 4 5
in the critical care unit
44. There is insufficient time to implement changes in
1 2 3 4 5
practice in the critical care unit

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SECTION F: BARRIERS RELATED TO FACILITATION AND SUPPORT STRUCTURES

REQUIRED FOR EVIDENCE-BASED PRACTICE IMPLEMENTATION

Disagree

disagree
Strongly

Strongly
Neutral
Agree
agree
45. Nursing colleagues are supportive of
implementation of evidence-based practices in the 1 2 3 4 5
critical care unit
46. Nurse Managers are supportive of initiatives to
1 2 3 4 5
change practice
47. Physicians are supportive of implementing
1 2 3 4 5
evidence-based practices in the critical care unit
48. Professional nurses are open and receptive to the
use of best-practice guidelines in the care of the 1 2 3 4 5
critically ill patient
49. The organization will be able to support initiatives
related to best-practice guideline development and 1 2 3 4 5
implementation
50. The institutional management is open and willing to
participate in translation of evidence into clinical 1 2 3 4 5
practice
51. In-service training on the concept of evidence-
based practice will promote your understanding of, 1 2 3 4 5
and adherence to, evidence-based practices
52. The presence of an EBP mentor or champion is
needed in the unit as the person will dedicate time
1 2 3 4 5
to search for the latest evidence-based practices
and disseminate information to the rest of the staff
53. Best-practice guidelines (BPG) based on evidence,
1 2 3 4 5
can promote evidence-based practices

Thank you for taking the time to complete this questionnaire.

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ANNEXURE B: PARTICIP ANT LETTER

Dear Participant
You are being asked to participate in a research study. I will provide you with the
necessary information to assist you to understand the study and explain what would
be expected of you (participant). These guidelines would include the risks, benefits,
and your rights as a study subject. Please feel free to ask the researcher to clarify
anything that is not clear to you.
To participate, it will be required of you to provide a written consent that will include
your signature, date and initials to verify that you understand and agree to the
conditions.
You have the right to query concerns regarding the study at any time. Immediately
report any new problems during the study, to the researcher. Telephone numbers of
the researcher are provided. Please feel free to call these numbers.
Furthermore, it is important that you are aware of the fact that the ethical integrity of
the study has been approved by the various departmental and faculty structures.
Participation in research is completely voluntary. You are not obliged to take part in
any research. If you do partake, you have the right to withdraw at any given time,
during the study without penalty or loss of benefits. However, if you do withdraw
from the study, you should return for a final discussion in order to terminate the
research in an orderly manner.
Although your identity will at all times remain confidential, the results of the research
study may be presented at scientific conferences or in specialist publications.
This informed consent statement has been prepared in compliance with current
statutory guidelines.
Yours sincerely

Candice Andrea Bowers

RESEARCHER

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ANNEXURE C: INFORMED CONSENT LETTER

NELSON MANDELA METROPOLITAN UNIVERSITY

INFORMATION AND INFORMED CONSENT FORM
RESEARCHER’S DETAILS
Title of the research project Barriers to implementation of evidence-based practices in the critical care unit.

Reference number

Principal investigator Candice Andrea Bowers

Address 43 Mowbray street, Newton Park ,Port Elizabeth

Postal Code 6045

Contact telephone number

041 3651445
(private numbers not advisable)

A. DECLARATION BY OR ON BEHALF OF PARTICIPANT INITIAL

I, the participant and the
undersigned

ID number

OR

I, in my capacity as (parent or guardian)

of the participant (full names)

ID number

Address (of participant)

A.1 HEREBY CONFIRM AS FOLLOWS: Initial

I, the participant, was invited to participate in the above-mentioned research project

that is being undertaken by Candice Bowers

from

of the Nelson Mandela Metropolitan University.

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THE FOLLOWING ASPECTS HAVE BEEN EXPLAINED TO ME, THE PARTICIPANT: Initial
The investigators are studying barriers to implementation of evidence-
2.1 Aim:
based practices

The information will be used to/for

2.2 Procedures: I understand that

2.3 Risks:

As a result of my participation in this study translation of evidence

2.4 Possible benefits:
into practice will be enhanced.
My identity will not be revealed in any discussion, description or
2.5 Confidentiality:
scientific publications by the investigators.
Any new information or benefit that develops during the course of the
2.6 Access to findings:
study will be shared as follows:

My participation is voluntary YES NO

Voluntary participation /
2.6 My decision whether or not to participate
refusal / discontinuation:
will in no way affect my present or future TRUE FALSE
care / employment / lifestyle

3. THE INFORMATION ABOVE WAS EXPLAINED TO ME/THE PARTICIPANT BY: Initial

Candice Bowers

in Afrikaans English Xhosa Other

and I am in command of this language, or it was satisfactorily translated to me by

(name of translator)

I was given the opportunity to ask questions and all these questions were answered satisfactorily.

No pressure was exerted on me to consent to participation and I understand that I may withdraw
4.
at any stage without penalisation.

5. Participation in this study will not result in any additional cost to myself.

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A.2 I HEREBY VOLUNTARILY CONSENT TO PARTICIPATE IN THE ABOVE-MENTIONED

PROJECT:
Signed/confirmed at on 20

Signature of witness:

Full name of witness:

Signature or right thumb print of participant

B. STATEMENT BY OR ON BEHALF OF INVESTIGATOR(S)

I, Candice Bowers declare that:
I have explained the information given in this document to (name of participant)
1.
and / or his / her representative (name of representative)

2. He / she was encouraged and given ample time to ask me any questions;

This conversation was conducted in Afrikaans English Xhosa Other

3. And no translator was used OR this conversation was translated into

(language) by (name of translator)

4. I have detached Section D and handed it to the participant YES NO

Signed/confirmed at on 20

Signature of witness:

Signature of interviewer Full name of witness:

C. IMPORTANT MESSAGE TO PATIENT/REPRESENTATIVE OF PARTICIPANT

Dear participant/representative of the participant

Thank you for your/the participant’s participation in this study. Should, at any time during the study:
- an emergency arise as a result of the research, or
- you require any further information with regard to the study, or
- the following occur

(indicate any circumstances which should be reported to the investigator)

Kindly contact Candice Bowers

at telephone number 072 152 1691 or 041 365 1445

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ANNEXURE D: HOSPITAL MANAGEMENT PERMISSION

LETTER

BARRIERS TO IMPLEMENTATION OF EVIDENCE-BASED PRACTICES

Letter of Permission to Hospital management
My name is Candice Bowers, and I am a Magister Curationis student at the Nelson
Mandela Metropolitan University (NMMU). I am conducting research on Barriers to
implementation of evidence-based practices under the supervision of Dr. Portia
Jordan of the Nelson Mandela Metropolitan University. A copy of their approval is
contained with this letter. I invite you to consider taking part in this research. This
study will meet the requirements of the Research Ethics Committee (Human) of the
NMMU.

AIMS OF THE RESEARCH

The research aims to:
 Explore barriers to implementation of evidence-based practices in a critical care
unit
 To make recommendations to enhance translation of evidence-based practices
amongst professional nurses in a critical care unit

SIGNIFICANCE OF THE RESEARCH PROJECT

The research is significant in three ways:
1. It will identify barriers to implementation of evidence-based practices in a critical
care unit.
2. It will make recommendations on how evidence-based practices can be
translated amongst professional nurses in a critical care unit.

BENEFITS OF THE RESEARCH TO HOSPITALS

1. Dissemination of results to professional nurses within the critical care unit,
throughout the hospital through in- service training, workshops and a copy to the
library Nelson Mandela Metropolitan University if required
2. Results will also be published in the format of an article in a peer- reviewed
journal.

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RESEARCH PLAN AND METHOD

Data will be collected from participants through a questionnaire. Permission will be
sought from professional nurses prior to their participation in the research. Only
those who consent will participate. The researcher will deliver the questionnaires to
the critical care unit, and be given to shift leaders or the unit manager who will serve
as gate keepers. All information collected will be treated in strictest confidence and
the hospital nor will participants be identifiable in any reports that are written.
Participants may withdraw from the study at any time without penalty. The role of the
hospital is voluntary and hospital management may decide to withdraw the hospitals
participation at any time without penalty.

Hospital Involvement
Once I have received your consent to approach professional nurses to participate in
the study, I will
 arrange for informed consent to be obtained from participants
 arrange a time with your hospital for data-collection to take place
 obtain informed consent from participants

Invitation to Participate
If you would like your hospital to participate in this research, please complete and
return the attached form. Thank you for taking the time to read this information.
Candice Bowers Dr. Portia Jordan
Researcher Supervisor
NMMU NMMU

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ANNEXURE E: UNIT MANAGER REQUEST FOR PERMISSION

TO CONDUCT RESEARCH

Unit Manager
Greenacres Hospital
Port Elizabeth
6001

REQUEST FOR PERMISSION TO CONDUCT RESEARCH IN CRITICAL CARE UNIT

Dear Madam/Sir

My name is Candice Andrea Bowers, and I am a Magister Curationis student at the Nelson
Mandela Metropolitan University in Port Elizabeth. The research I wish to conduct for my
Master‟s treatise involves Barriers to implementation of evidence-based practices in the
critical care unit. This project will be conducted under the supervision of Dr. Portia Jordan
(NMMU, South Africa).

I am hereby seeking your consent to access professional nurses to participate in my

research study. A structure questionnaire will be used as a data-collection instrument.

Ethical principles will be maintained throughout the study. Furthermore, the study will be not
be conducted unless approval has been granted by the various departmental and faculty
structures. Upon completion of the study, I undertake to provide the institution with a bound
copy of the research report if required. If you require any further information, please do not
hesitate to contact me on 072 152 1691 or 041 365 1445 or [email protected].

Thank you for your time and consideration in this matter.

Yours sincerely,
Candice Andrea Bowers
Nelson Mandela Metropolitan University

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ANNEXURE F: PERMISSION TO UNDERTAKE A RESEARCH

STUDY IN THE CRITICAL CARE UNIT

197