Effect of Educational Program regarding Evidence Based Practice on Beliefs and Implementation among Clinical Instructors.

Introduction

Evidence-based practice (EBP) has become the gold-standard of care in the nursing discipline today. Healthcare and educational institutions need to shift focus on EBP. Subsequently, health professionals are expected to possess the competency in the implementation of EBP to meet the demands of the health care system in this twenty first century. To fulfill this need, numerous academic strategies in the introduction of EBP to undergraduate nursing baccalaureate education have been implemented to prepare future nurses (1).

 Evidence-based practice in healthcare is a decision-making approach for patient care that integrates the best scientific evidence with the clinician's expertise and the patient's preference for care (2).

Nursing faculty's primary goal is to prepare future nurses for clinical practice with competencies to provide safe and quality patient-centered care. Healthcare requires timely information for effective decision-making, and requires the integration of health information-seeking skills throughout nursing education curricula to effectively promote evidence-based practice (3).

Nurse educators or clinical instructors play a key role in creation of opportunities for implementing EBP and in facilitating the implementation process. The question now is how to foster implementation of EBP. The most important factor that is likely to help nurses and nurse educators to adopt EBP is the provision of adequate training in EBP (4).

Nurses need to be competent and confident embracing evidence-based practice as a standard of care, and faculty must seamlessly integrate sufficient skills to navigate electronic databases, comprehend and analyze research, and make decisions based on evidence throughout the various program curricula for nursing practice (5).

Cobus-Kuo and Waller, (2016) concurred with Pierce and reported that the evidence-based practice process requires information literacy skills, which are complex research skills developed over time and with repetitive practice. Nurses need to be knowledgeable and confident in making clinical decisions based on reliable and current evidence, and both competencies should be integrated throughout nursing curricula for students to value and appreciate the importance of evidence-based practice (6)

Significance of the Study

EBP is one of the main professional competencies for health care professionals and a priority for nursing and medical education programs as well. Nursing educators have responsibility to teach the future nurses, and an opportunity to promote positive patient outcomes. Nursing educators are in charge for training the future nurses, so their participation in integrating the EBP into clinical education will improve healthcare outcomes (7) . They must involve themselves in clinical issues and approximate clinical, educational, and research activities through teaching EBP to students and nurses. This requires nursing educators to have sufficient knowledge and skills in EBP before involvement in this sophisticated practice (8).

Despite the significant amount of literature regarding the benefits of EBP and nurse’ positive attitudes toward it, there are many barriers to implementing EBP, and the process of implementing EBP is slow. Lack of time to search for evidence, lack of understanding and interpreting skills for research findings, inadequate access to information technology, limited information technology (IT) skills, lack of autonomy to change practice, and lack of information searching skills are examples of these barriers. Within many healthcare professions such as dentistry, physical therapy, nursing, and medicine, it is estimated that it takes approximately 17 years on average to translate research findings into clinical practice to improve patients’ outcomes (9).

Aim of the study                                                                                                                

The aim of this study was to investigate the effect of educational program regarding evidence based practice on beliefs  and implementation among Clinical instructors

Research Hypothesis

1. Clinical Instructor' beliefs toward EBP will be positive after the educational program than before.
2. 2.       Clinical Instructor' implementation of EBP will be higher after the educational program than before.

Subjects and methods

Research design:

Quasi-experimental design was utilized in this study.

Setting:

Faculty of Nursing at Minia University. The study was conducted at Faculty of nursing, Minia University that was established in (1995) by Presidential Decree number (184) as Higher Institute of Nursing which was affiliated the Faculty of Medicine then issued Presidential Decree number (200) of year(2000) to turn it to a Faculty of Nursing. The study started in the academic year 1997/1998.

Subjects

A convenience sample of all available (78) clinical instructors who were working in a six Departments  in Faculty of Nursing at Minia University at the time of conducting the study and willing to participate in the study was included. Distribution of sample as follows Nursing Administration Department 13, Woman Health and Obstetrics Nursing Department 11, Pediatric Nursing Department 9, Medical- Surgical Nursing Department 26, Community Health Nursing 9 and Psychiatric Health Nursing 10

Tools of data collection:

Two tools were used in this study as follows: -

First Tool: “The Evidence-Based Practice Beliefs (EBPB) Scale” itincludes two parts:

1^st part: - the socio- demographic characteristics of the studied subjects such as (age, gender, Educational qualification , years of experience, Department and marital status).

2^nd part: - The Evidence-Based Practice Beliefs (EBPB) Scale. The scale was developed byMelynk and Fineout-Overholt, (2008) (10).  It consists of 16 item.The EBPB Scale is five point  Likert-type scale designed to measure beliefs about EBP. Responses ranged from 1 = strongly disagree to 5 = strongly agree and included two reverse scored items 11 & 13. The 16 items on the scale were summed with a possible score ranging from 16 to 80. 

Scoring System:

The range of scores for the EBPB is 16 to 80. Interpretation markers are 16, 32, 48, 64 and 80; therefore, scores below a 64 indicate that there is less than agreement with their knowledge of, confidence in and belief in their ability to implement EBP. But when scores were above 48 (neither agree or disagree) (but less than 64) indicate that there is not full commitment at this point to EBP while scores were lower than 48 indicate there is no commitment to EBP. Overall, the closer to 64, the more commitment/belief in EBP. Mean scores > 64 indicate a firm belief in and confidence about implementing EBP.

Second Tool: "The Evidence-Based Practice Implementation (EBPI) Scale ":

The EBPI scale is an 18-items scored on five point Likert  scale based on how many times the participant utilized EBP during the previous 8 weeks. The respondents performed the item in question (1=0 times to 5≤/=8 times).

Scoring System:

The range of scores for EBPI is 18 to 90. To interpret the EBPI scores, a response of 0 -17 indicates that in the past 8 weeks respondents have implemented EBP less than 1 time. An overall mean score of 18 - 35 would indicate respondents have implemented EBP between 1-3 but less than 4 times within the past 8 weeks. A score between 36 – 53 would indicate that respondents have implemented EBP between 4-5 but less than 6 times within the past 8 weeks. A score of 54 – 71 would indicate that respondents had implemented EBP between 6-7 but less than 8 times and a score of 72 would indicate respondents had implemented EBP 8 times or more within the past 8 weeks.

Validity and reliability

The validity were revised and validated by a panel of five experts in Nursing Administration field. The reliability analysis of the study tools was done using alpha coefficient to measure the stability of its internal consistency; it was (0.962)for the Evidence-Based Practice Beliefs (EBPB) Scale, while the test value for the EBP implementation (EBPI) scale was (0.977). Thus indicate High reliability for both tools.

Pilot Study

A pilot study was carried out on 10% of participants (8 clinical instructors) working in the Faculty of Nursing ,Minia University who fulfilled the inclusion criteria to test the feasibility, objectivity, applicability of the study tools, accessibility  of study participants and to estimate the needed time to fill the data collection. Based on the results of the pilot study, no refinement/ modifications were done for data collection instruments; Clinical Instructors who shared in the pilot study were included in the actual study sample.

Procedure

An official permission was obtained from the Dean of Faculty of Nursing, Minia University where the study was carried out. The study was conducted in three phases: Assessment and planning phase, implementation phase, as well as evaluation phase.

A) Assessment and planning phase:

• The purpose of the study was simply explained to the clinical instructors who agree to participate in the study prior to any data collection.
• Individual oral consent was obtained from each participant after explaining the nature and benefits of the study.
• The researcher maintained anonymity and confidentiality of participant.
• Participants were allowed to choose to participate or not in the study, and given the right to withdraw at any time from the study without giving reasons.
• The study tools were filled in and completed by the participants on 3 stages (pre, post & follow up implementation of program).
• Data collection (pretest) was started and completed within 2 months / 2 days per week, starting from May 2018 to June 2018.

B)Implementation phase:

• The program content and its objectives were developed by the researcher in the form of 4 sessions.
• Each session of the educational  program had taken about 2 hours for 2 days per week for each group of clinical instructor to develop their beliefs toward using EBP . These sessions were conducted for each Department.
•  The sessions were conducted in Faculty of Nursing, Minia University.
•  Implementation of educational program lasted over a period of (6) months, starting from September 2018 to February 2019 for all participants under the study.
•  At the beginning of the first session, an orientation of the evidence based practice educational program and its purpose took place. The importance and benefit of the program were explained to all the participants under the study.
• Educational program was divided into four sessions:

ü  Session 1: Introductory session, definition and importance of evidence-based practice.

ü  Session 2:  sources and steps of evidence-based Practice.

ü  Session 3: models ,Barriers and facilitators of evidence-based practice.

ü  Session 4: Giving example about the application of evidence-based practice in nursing and Immediate post-test by using tool I part 2 and tool II .

ü  The booklet was handed for every participant.

C) Evaluation and follow up Phase:

The evaluation phase was done to determine the effect of educational program on clinical instructor' beliefs toward using EBP through filling in the same tools again after implementation of the program. The collection of data was done immediately after the application of the EBP program. Then follow up was done after three months of program implementation by using the same tools.

Ethical considerations       

Official permission to conduct the study was obtained from Faculty Ethical Committee of Research, Dean of the Faculty of Nursing at Minia University. Oral consent was obtained from each clinical instructor after explanation of the nature and purpose of the study. Each clinical instructor was free to either participate or not in this study and had the right to withdraw from the study at any time without any rational; also, clinical instructors were informed that data will not be included in any further researches without another new consent. Confidentiality and anonymity of each subject was assured through coding of all data.

Statistical design

The collected data were tabulated & statistically analyzed using software program and statistical package for social science (IBM SPSS 25.0) to evaluate clinical instructors involved in the study. The statistically analysis included percentage (%), mean, stander deviation (SD). Fisher's exact test used to detect differences between more than two variables and the sample size is small. Quantitative continuous data were compared by using Friedman test in case of comparisons between the mean scores of the three times of studied group. Graphs were done for data visualization using Microsoft Excel. Correlation test and  P - value of ≤ 0.05 indicates a significant result while, P value of > 0.05 indicates a non-significant result.

Results   

Table (1): Percentage distribution of socio-demographic characteristics of clinical instructors in Faculty of Nursing, Minia University  in the study sample (n= 78)

Table (1): reveals that, 50.0% of clinical instructors aged between 29- 34 years with mean aged 30.4 ± 3.9 years, 84.6% of them were females, 74.4% of them married and 69.2% of them had master degree. Regarding years of experience 39.7% of clinical instructors their experience ranged between 1- 5 years and 33.3% of sample was in Medical Surgical department.

Table (2): Relations between clinical instructors' evidence-based practice beliefs in pre, post and follow-up program (n = 78).

SD= Strongly Disagree, D = Disagree, N = Neutral, A= Agree, SA= Strongly Agree

Table (2): Illustrates that, 5.1% of clinical instructors strongly agreed they care delivered was evidence based increased to 53.8% of them post program then to 82.1% of them care delivered was evidence based in the follow-up program, moreover, 39.7% of clinical instructors' strongly agreed evidence-based guidelines can improve their clinical care increased to 62.8% of them post program then to 83.3% of them in follow-up program. Also, 29.5% of clinical instructors strongly agreed with EBP results in the best clinical care for patients increased to 66.7% of them post program then to 98.7% of them in follow-up program

Table (3): Means scores of clinical instructors' evidence-based practice beliefs in pre, post and follow-up program (n = 78).

**= Highly statistical significance difference P- value at .01

Table (3): presents that mean scores of clinical instructors' evidence-based practice beliefs was increased post program than pre-program implementation and follow up session was increased than pre and post program with highly statistically significance differences in all statement.

Table (4): Relations between clinical instructors' evidence-based practice implementation in pre, post and follow-up program (n = 78).

Table (4): shows that, more than half of clinical instructors don't implemented evidence-based practice in their clinical preprogram decreased to minority of them post program then none of them in follow-up the program.

Table (5): The means scores of clinical instructors' evidence-based practice implementation in pre, post and follow-up program (n = 78).

**= Highly statistical significance difference P- value at .01

Table (5): presents that, mean scores of clinical instructors' evidence-based practice implementation was increased post program than pre-program and follow up session was increased than pre and post program with highly statistically significance differences in all statement

Table (6): Relations between clinical instructors' total evidence-based practice beliefs and implementation in pre, post and follow-up program (n = 78).

Table (6): presents that, 15.4% of clinical instructors implement 4-5 times pre-implement EBP program vs 82.1% and 85.9% of them post and follow-up program while 7.7% of them had greater with knowledge confidence in and belief in their ability to implement EBP preprogram vs 92.3% and 100.0% of them post and follow-up program.

Table (7): Relations between clinical instructors' total evidence-based practice beliefs and implementation in pre, post and follow-up program (n = 78).

**= highly statistical significance difference P- value at .01

Table (7): shows that, total mean scores of clinical instructors' evidence-based practice implementation was increased post program than pre-program and follow up session was increased than pre and post program and total mean scores of clinical instructors' evidence-based practice beliefs was increased post program than pre-program and follow up session was increased than pre and post program with highly statistically significance differences which P – value .0001 respectively

Table (8): Correlation matrix between age of clinical instructors, their years of experience, evidence based practice beliefs, and evidence based practice implementation in pre, post and follow-up of program (n = 78)

     **Correlation is significant at the .01 level

Table (8): represents that, there were positive strong  association between age of clinical instructors and their years of experience in pre, post and in follow-up of program  and there was positive fair association between  evidence based practice beliefs of clinical instructors pre the program with evidence based practice implementation which r= .484 and P – value .000