In this study we hypothesized that the EBP activities were associated with characteristics of the individual nurse and the organizational context where the nurse works. The associations between 18 independent variables (five individual and 13 organizational characteristics) and the practice of six distinct EBP activities were examined. One individual factor (EBP capability beliefs) was significantly associated with extensive practice of all EBP activities, and three organizational factors (working in the care of older people, supportive leadership and high collective efficacy) were significantly associated with more extensive practice of three or more of the six EBP activities. These findings support our hypothesis that the six EBP activities are distinct tasks, which require various cognitive skills of the individual and supportive conditions in the organization. In the following we will discuss the implications of these findings for developing strategies for enhancing newly graduated RNs’ practice of EBP.
EBP capability beliefs
EBP capability beliefs association with a higher extent of all EBP activities, is in line with the findings of the systematic review by Godin and colleagues , and shows promise for future intervention studies in nursing education and in clinical practice, as capability beliefs is a modifiable factor . In the field of implementation science there is a call to increase the use of theory in research as a mean to develop interventions for increasing the uptake of evidence into practice . Godin and colleagues  synthesized studies using social cognitive theories to determine factors influencing health professionals’ behavior and behavioral change. The theory of planned behavior  was identified as a useful theory, and capability beliefs (or self-efficacy) was the factor that most often predicted professionals’ behavior. In nursing research, the main focus on individual factors associated with nurses’ practice of EBP and research use (which is a major component of EBP) has been on attitudes towards research and EBP [9, 34]. Some researchers have used cognitive theories in implementation research, especially for exploring the concept of capability beliefs and how it links to EBP among nurses [13, 18, 35]. However, to develop accurate interventions or educational methods to enhance nursing students’ and nurses’ capability beliefs regarding EBP, we believe there is a need for a more complete utilization of the conceptual framework of capability beliefs. Townsend and Scanlan  conducted a concept analysis of self-efficacy related to nursing students in the clinical setting. They identified four defining attributes; namely belief in being capable of performing a task (confidence), ability to carry out the task (capability), ability to be successful in performing the task over time (persistence) and ability to perform in stressful situations (strength). These four attributes and their theoretical base should preferably be considered when planning interventions to enhance EBP capability beliefs among nursing students and nurses. For example, learning interventions should include mastery experiences, role modeling, social persuasion and managing stress in practicing EBP . As capability beliefs is an amendable variable, we suggest that researchers conducting intervention studies using the theory of planned behavior  should evaluate whether changes in EBP capability beliefs will increase, sustain or decrease over a longer time period after the intervention.
Working in the care of older people
Working in the care of older people was the organizational factor most frequently associated with RNs’ practice of EBP activities. In Sweden, the care of older people has been a responsibility of the municipalities for the last 20 years and is today based on a social model of care . The RNs’ work situation in this setting differs compared with RNs in hospitals, particularly with respect to the staff skills mix, e.g. professional groups and education levels . The RNs working in the care of older people are not only accountable for planning the care of the older person, they are also expected to provide leadership for nurse aides and promote quality improvement and EBP . Physicians are not employed by the municipalities but consulted as general practitioners, which puts higher demands on the RNs’ leadership and accountability for the quality of care, including medical care. Thus, the role of RNs in the care of older people requires considerable medical, nursing and pedagogical competence, as well as personal life experience . It is therefore uncommon for RNs to begin their nursing career in the care of older people as the self-governed working conditions are considered to require extensive experience. In our sample, only 12% of the RNs worked in the care of older people, despite many available jobs in this sector and despite the fact that salaries in this sector tend to be higher compared with other areas of healthcare. This might imply that it is predominantly highly committed RNs who begin their career in the care of older people.
Additionally, we believe that some important regulatory, organizational and financial factors may explain the finding that working in the care of older people was associated with more EBP activity. In such care, the care provider (the municipality) is required to have a Chief Nurse who is accountable for patient safety and quality improvement, whereas this is not a requirement in the healthcare provided in hospitals and primary healthcare . In 2005, the Swedish government allocated more than 1 billion SEK (104 million EURO in 2005) to support the municipalities’ work with quality of care and skills development through training for nursing staff, supervisors and leadership . Additional national initiatives have been implemented to support Chief Nurses, managers and staff in the care of older people, e.g. an update of clinical guidelines and the development of indicators for quality improvement [43, 44]. Furthermore, an open access database has been commissioned by the National Board of Health and Welfare – the Elderly Guide – with information on ten quality indicators . Together, all these national initiatives have accentuated the need for – and provided support for – EBP in the care of older people, and in particular the responsibility of RNs in these matters.
Leadership and team capability
Leadership has repeatedly been identified as a factor associated with the uptake of EBP [14, 15]. In our study, supportive leadership was associated with the three EBP activities: Searching other sources, Implementing evidence into practice, and Evaluating practice (Tables 3 and 4). These EBP activities require collaboration in the care team within the organization. The factor Collective efficacy was also associated with these three EBP activities, underscoring the importance of collaborative work. Collective efficacy measured the RNs’ perceptions of their work group’s capability to operate to accomplish good care for patients and a good work climate. It is well known that leadership style might influence a collaborative culture or climate, and establish good conditions for the team . A study of hospital staff nurses revealed that those who perceived their unit-level nurse managers to be strong motivational leaders also reported more structural empowerment in their work environment, and reported more professional practice behaviors (self-efficacy) than nurses who perceived their nurse managers to be weak leaders .The manager has a pivotal role in setting clear and realistic goals for EBP activities . Thus, nurse managers seem to have an important role in creating an organizational culture at all levels within the healthcare system to support nurses’ practice of EBP [13, 14, 49].
As supportive leadership has consistently been identified as a factor associated with nurses’ practice of EBP, one could ask whether or not the newly graduated RNs in this study perceived the nurse manager to be supportive. In fact, only 29% of the newly graduated RNs reported that their nurse manager was supportive (Table 2). With this in mind, two questions could be posed. First, what kind of support do newly graduated RNs need (and expect) from their managers to be able to practice EBP? Second, what capacity and competency does the nurse manager need to be able to support the RNs in practicing EBP? Previous Swedish studies report that nurse managers had positive attitudes to EBP and quality improvement, but few of them were educationally prepared in these areas (i.e., having a Master’s degree) [50, 51]. Many nurse managers were trained in the 1980’s and 1990’s when research methods and nursing science were not as prominent in nursing education as is the case today. Furthermore, RNs educated during this period did not perceive subjects such as research methods, pedagogy, sociology and management as being important . This might explain why supportive leadership was not associated with three of the EBP activities, namely, Formulate questions, Search databases and Compile knowledge, which all require knowledge in research methods. In addition, nurse managers need support and clear goals from their immediate superiors. In the study by Johansson and colleagues , nurse managers who had a superior that stressed the importance of EBP reported a significantly higher number of activities in connection with introducing and discussing research findings with staff members, and also used research findings in quality improvement to a higher extent than nurse managers with less supportive superiors. Thus, it seems crucial to focus on developing nurse managers’ skills and knowledge in EBP, and that their immediate superior in the organization provides support and clear goals for EBP for the nurse managers as well.
We examined the associations between RNs’ practices of six distinct EBP activities with 18 independent variables and found that for the three EBP activities Searching other sources, Implementing evidence and Evaluating practice four to six associated factors were identified, mostly organizational variables. As discussed above these three EBP activities can be considered as collaborative tasks performed in an organizational context, which might explain why several associated organizational factors were identified. The remaining EBP activities Formulating questions, Searching databases and Compiling information can be performed by an individual alone, which might require more of cognitive skills and multiple thinking strategies, e.g., critical thinking, reflection, clinical reasoning and judgment. More research is needed to identify factors associated with these three EBP activities to increase RNs practice of the EBP process. In this study qualitative data was not collected. Future research will benefit by exploring the concept of variables such as role clarity, collective efficacy, leadership, and job demands on RNs’ practice of EBP.
The modified version of the NHS staff survey framework by Michie and West  guided the identification of appropriate organizational variables. Although the focus of the NHS framework is on examining the impact of work contextual factors on patient outcomes, we found the NHS framework helpful for selecting organizational factors from the LANE survey in building a model for the statistical analysis. However, because of NHS framework’s focus on patient outcomes instead of RNs’ practice of EBP, potential organizational variables associated with practicing the distinct EBP activities might not have been identified and included in the regression analyses. A recent published systematic review of measures assessing structural, organizational, provider, patient and innovation factors affecting implementation of health innovation identified 62 different instruments . Frequently assessed organizational factors in the identified instruments not assessed in this present study, were aspects of organizational culture or climate, and organizational readiness for change. These variables should be considered in future studies.
The study has some obvious strengths. It was based on a national sample of RNs with a relatively good response rate, and the sample has been found to be representative of the national population of newly graduated RNs . The instruments have been validated and tested for the target group of respondents. The weakness is that all data were self-reported and that the actual frequencies of EBP activities were not measured. In this study a fairly new scale on EBP capability beliefs was used. This scale was developed by the LANE study team using the framework proposed by Bandura  for measuring an individual’s beliefs regarding capability to perform a certain activity, in this case EBP [18, 19]. As the six items in this new scale are similarly formulated (but with different response formats) to the items measuring the extent of practicing EBP, there is a risk of producing artificial co-variance (common method bias) . However, in the validation study we also identified significant associations between EBP capability beliefs and measures of research use , which vouches for the validity of the scale. The present study contributes with further evidence of the new EBP capability beliefs scale as it generate findings consistent with the validation study but now used with many variables in multivariate models. Although the use of a questionnaire answered by the individual nurse implies that we measure practice of EBP at the individual level – if the nurse in fact is performing the components of EBP – we do not propose that practicing EBP is a purely individual responsibility. Rather, the findings indicate that several organizational prerequisites need to be present if the individual RN should be supported to practice EBP. However, more studies using the new EBP capability beliefs scale are needed to examine the validity of the scale in other health professional groups and in healthcare organizations outside Sweden.