A scoping systematic review of factors influencing evidence-based practice implementation in nursing

Internationally, nurses are required to deliver care that is underpinned by sound evidence. However, available evidence suggests that the delivery of evidence-based practice is difficult due to multifaceted problems inherent in healthcare settings. This scoping review aimed to examine factors influencing evidence-based practice in nursing, to identify existing gaps requiring further inquiry. It is a scoping systematic literature search of major electronic databases, including CINAHL, MEDLINE, EbscoH, Embase, ASSIA, Science Direct, Nursing index, PsycINFO and Google Scholar. Fiftytwo studies met the inclusion criteria and were eligible for review. The PRISMA approach was utilised in retrieving articles which were critically appraised. Findings were qualitatively synthesised using constant comparative approach. Findings were collated and summarised thematically. Outcomes were categorised into four broad themes as well as four subthemes. The scoping review identified dearth of studies utilising qualitative approaches, particularly in the low and middle income countries. Consistent with previous findings, this review exposes the difficulties associated with implementing evidence-based practice. There is need to examine the influence of power dynamics on evidence-based practice implementation in nursing.


Introduction
Evidence-based practice (EBP) has gained the attention of researchers and health care professionals in the past few decades. It is widely acknowledged in modern healthcare and has instigated quality assurance initiatives in healthcare practice. The National Academy of Medicine's roundtable on Evidence based Medicine (EBM) set forth a goal requiring 90% of clinical decisions to be based on evidence by 2020 [1,2]. Indeed, several online databases, for example, the Cochrane Library and National Institute of Clinical Excellence (NICE) website, have been established to serve as sources of evidence for clinical practitioners [1,3,4]. In nursing practice, the delivery of evidence-based (EB) care to service users by adhering to standards is widely recommended [5,6] as nurses are required to justify the decisions they make for, and with patients in practice. However, having the knowledge and skills required to utilise evidence does not necessarily facilitate implementation process since wider organisational change is required to translate research into practice [7,8]. There are concerns that what is known to be best practice is not currently reflected in practice, which exposes service users and patients to potential harm.
Available evidence suggests that this is due to complex and multifaceted barriers within practice settings limiting nurses' efforts to implement EBP [7 9, 10]. Implementation of EBP can be largely impeded by a range of multilevel factors as several authors attribute this situation to circumstances related to the organisation, practice context, individual professionals as well as nature of evidence itself [6,11,12,14]. Others factors include lack of access to best evidence, lack of frontline nurse leaders leading implementation activities, inapplicability of clinical guidelines, lack of organisational readiness, obstructive organisational and professional cultures [9,11], lack of supportive workplace environment and inadequate resources for EBP [14].

Purpose
This review aimed to identify gaps in the literature regarding EBP in nursing by examining published literature in the field. It is intended to examine prevailing circumstances that influence implementation efforts in nursing practice, and to further critique methodologies utilised in investigating the field. Thus, the research question is; what is known from the qualitative, quantitative and mixed method studies about circumstances influencing implementation of EBP in nursing?

Design
This is a scoping review with a narrative synthesis. Scoping review is defined differently in the literature; however, researchers have made several efforts in seeking clarifications. The initial interpretation of a scoping study was laid in the Arksey and O'Malley's framework which refers to scoping study as the mapping of key sources and type of evidence available as well as main concepts underpinning a research area. Scoping review is a flexible and comprehensive approach to examining topics of interest [15]. It sets the scene for future research by discussing and reporting what is already known by critically analysing existing gaps in knowledge [16,17]. It is similar but also different from systematic reviews in that it can be used to answer broad research topics and studies of varying methodological designs as against systematic reviews that typically focus on addressing well defined questions with and attention to specific study designs that might have been defined in advance [16]. The review utilises the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [18].

Searching the literature
The literature research involves searching major electronic databases: CINAHL, Web of Science and MEDLINE, EbscoH, Embase, ASSIA, Science Direct, Nursing index, PsycINFO and Google Scholar using relevant key words/phrases. Initially, these databases were searched separately to retrieve literature related to implementation of EBP using key words: 'evidence-base practice' AND 'implementation' AND 'nursing*', employing use of '*' truncation to capture other relevant concepts, for example, research utilisation, knowledge implementation, barriers, facilitators, nursing, nurse managers using the Boolean operator word 'AND' to combine them. This initial search was basically undertaken to estimate the scope of literature in this topic and resulted in generation of large hits of >1500. Then, inclusion criteria were created and utilised to capture relevant studies via a more advanced search process.

Search results
Advanced searches yielded 351 citations and abstracts which were screened to identify appropriate studies. Out of these studies, 278 were excluded for failing to meet the inclusion criteria. Again, these 278 studies were screened by reading their abstracts and 21 was excluded in the end. Overall, 52 studies met the inclusion criteria and were eligible for the review. There would have been more studies meeting the inclusion criteria, but due to the volume of studies retrieved from the electronic search only studies considered relevant was included. The PRISMA flow chart in figure 1 below shows the search and article selection process.

Inclusion criteria
Essentially, years of publication, language, and type of study and review status were used to limit these advanced searches. Studies included in this review are scoping/systematic/integrative reviews, peer reviewed and primary studies utilising any form of methodology (e.g. quantitative, qualitative and mixed), focusing on nursing and healthcare practice. Additionally, articles from all over the world that were published in English language from 2005 to 2017 were included.

Assessment of quality
This scoping review have not utilised a specific critical appraisal tool in determining included and excluded studies as scoping studies do not typically have to include a screening or assessment of methodological quality. Besides, a scoping study aims to identify the breadth of the literature and so does not include formal quality assessment. However, an overall critical evaluation of the methodological qualities of the studies reviewed in the discussion to identify existing gaps.

Studies reviewed and their characteristics
As shown in appendix 1, these studies were selected from across continents, including America (15), Europe (12), Asia (12), and Africa (6) Australia/New Zealand (3) with the rest being reviews.  Key findings: Key factors include project leader, nature of evidence, nurses, patients and the system in which the projects were implemented. Managerial requirements, administrative power and influence from physicians were viewed as both barriers and facilitators. Clinical system might consider the administrative power as a facilitator of implementation of evidence when it is driven from the top level. However, it could be a barrier in a democratic organisation. Obedience to higher authority was also a barrier that prevented nurses who genuinely had the intention to implement EBP as they imbibed the culture of seeking harmony with the authority [32] UK Aim: To determine the extent to which clinical nursing practice has adopted research evidence. To identify barriers to the application of research findings in practice and to propose ways of overcoming these barrier  Key findings: Nurses who had bachelor's degree were better off in EBP than those who had diplomas. Availability of library and internet facilities in a workplace is associated with higher evidence-based nursing. Predictors of EBN include education, skills in locating and appraising research reports, knowledge sources based on colleagues and system procedures -inhibitors and knowledge sources based on reading professional literature, knowledge sources based on experience or intuition. There is need for research-based information, exposure to journals and organisational support for evidence-based nursing practice. Key findings: A reduction in the level of restraints was achieved as 27% initial level of restraint reduced to 7% after implementation of the strategy. This evidence-informed multicomponent strategy has the potential to reduce restraints in older mentally ill older adult patients [41] Canada Aim: To examine the determinants of research use among nurses working in acute care hospitals two Canadian hospitals

Identification
Design: Comparative ethnographic case study utilising quantitative and qualitative methods

Sample: 235 RNs
Key findings: High and moderate levels of research use was associated with high level of support from co-workers and organisation respectively while low level of research use was associated with lack of authority and support to use research in patient care. Research utilisation by nurses is significantly influenced by modifiable features of the organisational context at the patient care unit level. Thus, there is implication for patient care unit structures and so should be considered by future interventions aimed at enhancing research utilisation by nurses [42] USA Aim: To investigate the relationship between characteristics of the learning organisation to the registered nurses' beliefs regarding EBP Key findings: Nurses lacked previous training on EBP and were not familiar with the concept. Nurses' attitude towards EBP was poor and so is their self-efficacy of EBP. Facilitating factor for EBP was mentoring by nurses who were experienced while the strongest barrier was inability of the nurses to appraise research paper/reports. For nurses to improve nursing care quality and implement EBP, nurses will require relevant skills and knowledge for EBP. NMs should map out strategies that are appropriate for addressing these barriers and enable incorporation of EBP into clinical nursing practice. Key findings: Nurses prefer experiential knowledge and the knowledge they received from colleagues and patients to that which they retrieved from textbook and journals. Improvement in research utilisation in nursing was associated with membership of journal clubs. All respondents demonstrated confidence in accessing and using evidence for practice. Senior nurses were more confident in accessing all sources of evidence including published sources and the Internet and felt able to initiate change. Junior nurses perceived more barriers in implementing change and were less confident in accessing organizational evidence. Junior nurses perceived lack of time and resources as major barriers, whereas senior nurses felt empowered to overcome these constraints. However, the nursing culture seems to disempower junior nurses so that they are unable to develop autonomy in implementing evidence-based practice.
[47]   USA Aim: Tested an interdisciplinary, multifaceted translating research into practice (TRIP) intervention to promote adoption by nurses and physicians and to decrease barriers to its use in acute pain management of older hospitalised adults Design: Experimental design Sample: Nurses and physicians participated but sample was not stated The quality of acute pain care was significantly higher for experimental (10.1) than control (8.4). However, the TRIP enhanced quality of acute care pain management in older adults. Overall, nurses' knowledge levels regarding the subject did not improve. Additional research on the effectiveness of tailored educational intervention is required.

Data extraction
A pre-defined charting order was designed and utilised to gather information for each of the study included in this review. As shown in table 1 above, these orders include author, year and country of study, research focus, population, study design, and key findings. Data was qualitatively synthesised and analysed using the constant comparative methods to compare findings across studies [69]. Findings were collated summarised and reported in themes as well as subthemes.

Results
Findings of this review are presented in themes with a discussion about the study designs and identifiable gaps provided. Studies about EBP largely concentrate on investigating barriers and facilitators constituting major findings. These findings were organised as individual and organisational determinants, with organisational determinants being further reported in five subthemes. The five subthemes reported in organisational determinants include strategic, cultural, technical, structural and contextual factors. The facilitating strategies of knowledge implementation is discussed as a standalone theme.

Individual determinants
Seven of the studies report that higher educational qualifications were associated with positive attitudes towards EBP, and positive belief in ones' ability to synthesise and utilise evidence in patient care. Nurses who had lower academic qualifications were more likely to draw on their experiences and intuition whereas expert nurses and those who have higher educational qualification, for example, MSc and PhD were more skilful in synthesising evidence from various sources. Nurses who had requisite skills and knowledge were positive about the efficacy of implementing evidence in nursing practice while nurses who lacked relevant knowledge and were not familiar with EBP did not believe in its efficacy, and did not subsequently apply evidence in patient care. Overall, nurses generally held positive attitudes towards EBP, and were highly interested in improving their EBP knowledge and skills [19,21,28,34,38]. Additionally, a few nurses who utilised evidence in practice were considered as having increased knowledge which is associated with positive attitudes towards EBP [50,60].

Organisational determinants
These are factors relating to the healthcare setting or practice context. They are classified based on four aspects of the organisation as enshrined in the quality improvement framework developed by [71]. They are the strategic, cultural, structural and technical factors.

Strategic factors
Strategic dimension of the organisation relates to, for example, the vision, mission and priorities. This involves actions and processes that are very crucial to the organisation, and can provide greatest chances for quality improvement within the healthcare setting [71]. Barriers to knowledge utilisation can result when intervention or innovations are not aligned with goals and priorities of the organisation. Barriers to knowledge utilisation in nursing practice include lack of resources, heavy workload, time constraints, lack of prioritisation of EBP initiatives by the management. Lack of autonomy and administrative support for changing practice are barriers to EBP implementation in nursing practice [22,27,29,31,49,58]. Key facilitating conditions captured in the strategic dimension as reported in four of the studies are inclusion of nurses in organisational governance as well as hospital-wide committees [29,53]. Fink et al.,'s [44] preimplementation and post-implementation intervention found that implementation can be promoted by incorporating EBP into the vision, philosophy, skills and nurses' job description, and included as a mandatory requirement for promotion in clinical ladders. Providing nurses opportunities to train and develop practice change activities aimed at facilitating EBP implementation [29,53]. Kueny et al., [53] described nursing units where nurse managers are committed to EBP, provided support and opportunities for communicating EBP activities. These nurse Managers provided opportunities for nurses to drive change in practice within their various units, and made available adequate resources, leadership and mentorship to facilitate EBP implementation [53]. Therefore, administrative support and commitment allows nurses some degree of authority and autonomy to initiate and implement EBP initiatives [22,29,53].

Cultural factors
Evidence-based practice may be embedded in health care organisations that do not value or reward behaviours that promote quality improvement within the setting. As seen in table 1, numerous studies report findings on impact of organisational cultural factors on EBP. The most cited cultural barrier is lack of nursing autonomy and authority to change practice due to resistance from physicians and top management. Hannes et al., [48] and Heydari and Zeydi [49] described a medically dominated culture and lack of physicians' cooperation as barriers to implementation of EBP in nursing practice. They found that lack of physicians' cooperation was a barrier to evidence implementation by nurses. A unique barrier, hierarchy and power were reported by Cheng et al., [31]. Cheng et al., [31] found that administrative power and hierarchical clinical system that is top down drive can constitute barriers to EBP implementation in a healthcare setting. Compliance with administrative rules in a non-democratic practice setting prevented nurses from implementing EBP as they imbibed the culture of seeking harmony with the authority [31]. Gerrish et al., [46] described a culture that devalues nursing and does not provide managerial support for EBP as disempowering as nurses are unable to develop autonomy in implementing EBP. Adoption of EBP is impeded within a culture that does not pay adequate attention to quality improvement [46].
Interventions targeted at addressing cultural barriers to EBP implementation are reported in four studies [29,44,53]. Implementation of EBP is facilitated in workplace cultures that clearly communicates EBP goals between top management and nurse managers [53]. Within a nursing unit that performed well in EBP, there were structures such as nursing-specific committees that allowed nurses to drive change in practice and articulate internal resources such as quality-monitoring committees which are critical to EBP implementation [53]. Funk et al., [44] described an organisational cultural intervention in which EBP champions were appointed to drive initiatives and organise research activities as well as symposium on regular basis. A culture where nurses are supported, encouraged, rewarded for developing EBP initiatives and engaging in critical thinking was reported in Brown et al., [44]. Gifford et al., [73] described a culture where nurse leaders adopted role modelling and mentoring in promoting of EBP. While Fink et al., [44] reported measurable strategies and their outcomes, the rest of other studies [29,53,73] focusing on how to address cultural barriers only reported strategies but not outcomes.

Technical factors
Technical factor relates to skills required for implementing EBP. Inaccessibility of EB information due to lack of relevant skills required to retrieve or search for resources, example, research article, inability to appraise research constitute barriers to knowledge use in nursing practice. They added that lack of appropriate mechanisms for communicating EBP information, lack of ICT facilities within the practice and inability to retrieve research reports from appropriate databases such as MEDLINE, CINAHL, PsychINFO rather than Google or yahoo were reported as barriers.
Inability to seek research evidence due to lack of skills to critically appraise or critique relevant research reports are known factors leading to nurses relying heavily on their personal experiences rather than formal sources of knowledge [73]. Facilitators of EBP implementation were workshop training programme on how to conduct literature search and provision of enabling environment for research activities [29,44]. Sherriff et al., [60] organised an eight-hour workshop for nurses focusing on the principles of EBP and systematic reviewing. They provided nurses with workbooks that supplied them with relevant information prior to the workshop. In the end, nurses managed to develop search strategies utilising the PICO, thereby improving nurses' literature searching skills which in turn facilitated research utilisation [60].

Structural factors
This relates to structures available for EBP within the health care setting, for example, research or EBP committees can influence implementation process. Structural barriers of EBP implementation are non-availability of well-equipped library and lack of clarity in the presentation of evidence (e.g. clinical practice guidelines). Intervention known to resolve structural barriers to utilisation of knowledge in nursing practice are availability of quality-monitoring department, nursing-specific committees and change champions. Availability of Nursing Research Committee provided experienced nurse researchers who acted as champions and authority in leading change implementation [53]. Nursing Journal Club [44], and formatting of clinical practice guidelines to enable clarity, facilitated the diffusion of practice change activities [29].

Contextual factors
Contextual influences seem to overlap with some of the findings already reported in organisational determinant above. However, several studies that specifically examine context factors categorise contextual influences into two broad dimensions: the social dynamic and structural context factors [23,27]. Social dynamic context factors include leadership, culture, communication, commitment whereas structural context factors include, for example, hierarchy and power [73]. Several studies reported that contextual factors influence user's ability to make EB decisions and conclude that identifying or addressing contextual factors increases the likelihood of achieving successful knowledge implementation (23,27,29]. While these studies identify influence of context on knowledge implementation, they did not state how they might be managed. However, Rycroft-Malone et al., [85] recommends that use of existing structures within settings, aligning with organisational initiatives and those with pivotal roles can potentially promote successful implementation. They emphasise that implementation contexts, inter-professional functioning and organisational processes were challenging to utilisation of knowledge in practice. They recommend further attention to implementation context as its impact on EBP remains largely unclear.

Strategies for facilitating implementation of interventions
Findings focusing on strategies used in promoting implementation of intervention in different aspects of nursing practice were retrieved and reported in this subtheme. Eight studies reports use of educational materials as facilitating strategy for implementation of EB interventions. The commonly reported factor being targeted messaging, for example, email, posters, and newsletters which were used in disseminating EB information as a reminder to clinicians. Use of point of care reminders and decision aids, for example, charting tools, as well as point of care reference guide were found as promoter of EB intervention in nursing practice.
Additionally, use of change champions or opinion leaders yielded progress in the implementation of EB interventions in nursing and healthcare practice [5,52,53,63,66,67,68]. These studies report that identifying specific individuals or group to undertake the role of leading change promotes implementation of EB interventions. Involving nurse leaders and managerial was another way of promoting knowledge implementation in nursing practice [5,8,53,66,67].
Organisational policies with added auditing mechanisms can drive implementation processes if stakeholders are committed in practice [5,63,67,68].

Discussion
Findings showed that circumstances influencing implementation of EBP in nursing practice relate mainly to the organisations, but also the individual practitioners. The individual nurses as well as healthcare organisations may be interested in implementing initiatives that can enhance quality patient care delivery. However, obstacles may arise when the organisation or individual clinicians do not have relevant knowledge of, or value for the innovation to be implemented. Therefore, successful implementation of EBP in nursing will depend on strategies applied in driving implementation agenda.
This review provides insight into different methodological approaches that have commonly been used in investigating barriers and facilitators of EBP, and a possible direction for future research. Much of the studies utilised self-reported questionnaires which were developed and subsequently utilised in investigating perceived barriers to EBP and research utilization in nursing practice, as opposed to qualitative methods that could provide in-depth exploration of how implementation efforts are shaped by the wider organisational contextual processes. The suitability of investigating nurses' attitudes to, and belief about EBP using the self-reported methods appeared to be problematic from the perspective of several authors [54,56,73], as nurses are likely to state what they perceive as the correct answers rather than the actual situation.
However, a few studies utilised theories and theoretical frameworks [22,29,44,54]. Meijers et al., [54] examined relationships between contextual factors and research utilisation and mapped the contextual factors on the Promoting Action for Research Implementation and Healthcare Services (PARIHS) framework. The use of PARIHS framework was useful in revealing contextual factors which included context, culture, and leadership, but the study has failed to provide further explanation on how these factors shaped knowledge implementation. As reported in Cheng et al., [31], there is an indication that power and hierarchy has an impact on the delivery of change in practice. However, as Cheng et al., [31] has failed to explore the nature of this impact, this study will pay attention to the influence of power and hierarchy on EBP implementation which was also implicated in [13].
Some studies utilised experimental design focusing on implementation of complex health intervention, for example, prevention of infections, prevention of falls and other clinical adverse effects. Although experimental research can provide casual evidence, it can be biased by the creation of manufactured situation and researcher's inability to control variables [78]. Five implementation models or frameworks were utilised and reported in six studies and they include PARIHS framework [52], Ottawa Model of Research Use [5], Plan-Do-Study-Act framework [63], Knowledge-To-Action framework [40], and Translation Research Model [66,67]. Findings indicated that much of the studies utilised a multifaceted implementation approaches or strategies. It is difficult to accrue evidence for effectiveness of these strategies or identify similarities and differences between them as result of lack of common taxonomy [79]. Stevens et al., [63] identified different strategies for testing improvements in implementation process and outcome. Biai et al., [26] tested the effect of financial incentive as a strategy on outcome of implementation of clinical practice guidelines for malaria treatment while some studies did not report effectiveness of implementation strategies on the outcome, thereby making it impossible to determine most effective interventions in the various practice settings that they studied.
These studies largely focused on the adoption and implementation of a specific intervention without investigating the impact of settings in which they were implemented, thereby limiting understanding of what strategies work for whom and in what circumstances. While findings included data describing context factors, that is information related to the settings in which implementation occurred, it has failed to explore the unique impact of context factors to provide insights into the outcomes of implementation. The impact of social dynamic (e.g. nurse manager and leadership behaviours, workplace climate) and structural (e.g. staffing) context factors were not clearly examined. The significance of adopting implementation strategies that can also address factors within the organisational and unit contexts has been highlighted. The dynamic as well as complex nature of implementation context demands that multifaceted implementation strategies be adopted in facilitating adoption and implementation of EBP [65,80,81]. Context has been recognised as an essential mediator of change in different domains; diffusion of innovation [82], organisational change [83], EBP [84,85], quality improvement [86,87].

Conclusion
Findings of this review depict several implications for research and practice. Majority of these studies utilised quantitative methodologies to determine variables affecting knowledge use while those utilising qualitative approaches have merely examined nurses' perceptions. These studies are limited in value due to lack of transferability because of variations in healthcare systems, culture and socio-political context. There is an abundance of research investigating barriers to knowledge use relating to organisation with no clarity on how and why it is so. Findings reveal the impact of power and influence on evidence implementation in nursing practice but failed to state how it happens. Therefore, further inquiry into practice context impact on knowledge implementation is required. Additionally, there is need to examine influence of power dynamics on knowledge implementation in nursing practice. Overall, influences on EBP in nursing practice largely exist in four main levels: professional or individuals, organisation; context; and nature of evidence or intervention. Adverse effects may result from non-delivery of EBP in nursing practice, resulting poor clinical outcomes.