Asian Nursing Research 11 (2017) 253e260

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Asian Nursing Research

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Research Article

Application of a Q Method Study to Understanding Nurses' Perspective

of Adopting Evidence-Based Nursing
Ruo-Nan Jueng, Ph.D., RN, 1 Shu-He Huang, Ph.D., RN, 2 Tsui-Ping Li, MS, RN, 3
Hui-Yu Liang, Ph.D., RN, 1 Chiu-Mieh Huang, Ph.D., RN 4, *, *
1
Department of Nursing, National Yang-Ming University Hospital, Yilan, Taiwan
2
Department of Nursing, School of Nursing, National Yang-Ming University, Taipei, Taiwan
3
Department of Nursing, Mackay Memory Hospital, New Taipei City, Taiwan
4
Institute of Clinical Nursing, School of Nursing, National Yang-Ming University, Taipei, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Purpose: This study applied the Q method to identify and describe the various types of nurse perceptions
Received 5 April 2017 that are crucially associated with their engagement in evidence-based nursing (EBN).
Received in revised form Methods: The study participants were nurses at a medical center and a regional teaching hospital. A
18 September 2017
series of Q sorts was performed by nurses to subjectively rank the Q statements. Q statements were
Accepted 19 September 2017
constructed based on the literature related to EBN adoption by nurses and face-to-face interviews.
Results: A total of 60 participants were invited to rank 44 Q statements related to EBN. Factor analysis
Keywords:
was conducted on the rankings of the Q statements. The following are the five prominent shared per-
clinical competence
evidence-based nursing
spectives: (1) emphasized the obstacles to evidence searching and reading ability; (2) emphasized the
methods organizational promotive strategies; (3) emphasized the available supportive resources; (4) emphasized
nursing care the significance of EBN; and (5) emphasized the evidence-searching ability and external incentives. The
five identified groups of perspectives can enhance hospital administrators to acknowledge the barriers
and incentives associated with EBN practices.
Conclusion: The exploration of clustering nurses' perceptions may facilitate the development of
customized strategies to enable more appropriate training.
© 2017 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The application of evidence-based practices is considered the

Evidence-based nursing (EBN) has become one of the most
effective methods for improving patient outcomes and the quality
of care as well as delivering cost-efficient health care [1,2]. EBN
emphasizes integrating the most valid research evidence with
nursing expertise and findings from research on specific clinical
concerns of nursing care. EBN has been recognized as an excellent
approach for reducing variations and improving the quality of care;
it considers patient preferences, context, health care systems, and
clinician judgment [3]. Despite its many benefits, EBN may not be
the prevailing standard in current health care practices, and its
integration with nursing practice has been challenging.
* Correspondence to: Chiu-Mieh Huang, Ph.D., RN, Institute of Clinical Nursing,
School of Nursing, National Yang-Ming University, 155, Section 2, Li-Nong Street,
Taipei 11221, Taiwan.
E-mail address: cmhuang@ym.edu.tw
*
ORCID: https://orcid.org/0000-0001-9143-9972
optimal method for enhancing nurses' ability to identify and
resolve clinical problems. This implies that nurses have developed
the skills and knowledge to search for, appraise, and use research
evidence for clinical decision-making and to facilitate approaches
to deliver high-quality care [4,5]. Nurses have numerous subjective
perspectives that influence their motivation to promote and
execute EBN. Nurses generally report the following: having limited
time for executing evidence-based practices during scheduled
working hours [6,7], lacking knowledge related to finding and
understanding research reports and data [8,9] and how to change
clinical practices, receiving inadequate support from the organi-
zation in executing evidence-based practices [10,11], and having
limited autonomy in changing their practice and other nurses'
resistance to change [12,13].
Most EBN-related studies have applied Likert-type scale format
questions to measure participants' levels of propensity [8,14e16]. A
limitation of this type of measure is that a midpoint can be an easy

https://doi.org/10.1016/j.anr.2017.09.001
p1976-1317 e2093-7482/© 2017 Korean Society of Nursing Science, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
254 R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260
option when participants are uncertain or do not take time to weigh
the merit of each item [17]. Whether the midpoint is a true neutral
option is questionable. The Q method is a technique to identify
patterns based on opinions rather than to test the proportional
distribution of opinions among participants [18]. The major
objective of this method is to examine individual perceptions of a
designed topic by categorizing participants according to the simi-
larity of their opinions [19]. To avoid the mentioned limitation, the
Q method uses distinguishing statements that are ranked at the
extremes of the composite Q-sort to interpret the characteristics of
the identified patterns. Because of the forced distribution of Q sorts,
the extremes can be interpreted as representing a participant's
opinions with more confidence. Using this procedure, personal
perspectives regarding a specific issue can be systematically eval-
uated [20]. Patterns of shared opinions emerge from Q sorts, and
such analyses may provide novel insights that would otherwise not
have been elicited using conventional Likert scaling techniques.
Successful EBN implementation requires effective teamwork.
Promoting teamwork and cooperation, further EBN studies may not
only identify the barriers and facilitators, but also understand
patterns of shared opinions emerging from nurses' perspectives
toward these factors. Because of the strengths of grouping people
according to their attitude tendency, we adopted the Q method to
investigate nurses' perspectives toward EBN. The aim of this study
was to identify and describe the various types of nurses' percep-
tions that are crucially associated with their engagement in EBN.
Methods
Study design
The Q method was used in this study to investigate the various
common perspectives among nurses.
Setting and sample
We enrolled eligible participants from a medical center and a
regional hospital in Taiwan. Sixty clinical staff members were
recruited from a medical center (n ¼ 30) and regional hospital
(n ¼ 30). The following were the inclusion criteria: nurses who are
currently employed, have at least 1 year of clinical experience, have
general awareness and understanding of the five steps of EBN, and
are willing to participate in the study and provide written informed
consent. The Q method is a type of exploratory factor analysis. To
effectively determine diversity in perspectives, 40 to 60 partici-
pants are required in a group [21]. In this study, 60 nurses partic-
ipated in the Q-sort evaluation of the designed Q statements.
Ethical considerations
The study protocol was approved by the institutional review
boards of the National Yang-Ming University Hospital (NYMUH IRB
No. 2013A016) and MacKay Memorial Hospital (Approval no.
13MMHIS200) before the study commencement. After ethical
approval was obtained for this study, the participants were
informed and invited to voluntarily participate in the study. The Q
sorts were identified by numbers alone; therefore, participant
identity and the collected information were not associated, thereby
ensuring anonymity. All the participants signed informed consent
before participating in the study.
Instruments
This section described the developing process of Q statements.
Initial categories specific to barriers to and facilitators of EBN
adoption by nurses were developed through data extraction from
published nursing research and a review nursing of the literature.
These categories included skills and ability associated with EBN,
attitudes associated with EBN, practicability associated with EBN
practices, and working conditions and supportive resources. Table 1
presents detailed descriptions of each category. Fifteen nurses were
interviewed to obtain their concerns related to EBN, and subse-
quently, a list of sentences under each category was prepared. We
revised these sentences several times until a consensus was
reached. Five experts and scholars with related specialties were
invited to examine the representative Q statements. The content
validity index was used to evaluate the Q statements. Only state-
ments with content validity index values >.80 were retained for
further Q sorting. A modified list of 44 Q statements was obtained
by clarifying the semantics of individual statements and elimi-
nating duplication.
Procedure of data collection
After obtaining their permission to participate, the nurses
performed a series of Q sorts to subjectively rank the Q state-
ments. This technique is a relatively novel approach for identifying
the divergent concerns of nurses regarding barriers to and facili-
tators of EBN adoption. The Q-sorting procedure enables partici-
pants to rank Q statements in a normally distributed 44-cell grid,
according to the extent to which each statement represents their
perspectives. We developed an E-platform for the participants to
perform the Q sorting online. An example of the user interface
was reported in our previous study [22]. The screen was divided
into two panels. The left panel displayed a list of the final Q
statements, and the right panel showed the scoring system in the
form of a Q-sort grid (4 to þ4). The participants were asked to
place the statements most and least crucial to them in the right
(þ4; positively labeled) and left (4; negatively labeled) columns,
respectively. The participants used a mouse to move each state-
ment from the left panel to the Q-sorting grid in the right panel
until all statements were on the grid.
Data analysis
We performed factor analysis on the rankings (Q sorts) of the Q
statements, which were developed according to previous studies.
The PQMethod 2.35 program was used to analyze the Q sorts [23]
(PQMethod 2.35 program was developed by John Atkinson at
Kent State University, Kent, OH, USA in 1992). By-person factor
analysis, rather than traditional item factor analysis, was used to
form participant groups (factors) according to the similarities in
their Q sorts. The prominent shared perspectives, known as factors,
were extracted using principal component analysis with varimax
rotation. Rotation was ensured to maximize similarities within
factors and differences between them. Participants with Q sorts
that were significant for a factor, but not significant for any other
factors were classified into that particular factor. Participants who
significantly loaded on a factor represented similar perspectives of
EBN adoption. An eigenvalue conceptually represented the relative
contribution of the corresponding factor in explaining the total
variance in the data set [17]. A combination of eigenvalues and a
screen plot was used to determine the number of retained factors.
The results and interpretation of each factor are presented ac-
cording to the characterizing and distinguishing statements. The
characterizing statements, ranked at both ends of the composite
sorting of each factor (3, 4, þ3, and þ4), were used to provide an
initial description. The distinguishing statements, statistically sig-
nificant at p < .05, were used to highlight the differences between
the factors examined in this study.
 R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260 255

Table 1 Categories of the Factors Associated with EBN Adoption from Published Literatures.

Categories Skills and ability associated Attitudes associated with EBN Practicability associated with Working conditions and supportive
with EBN EBN practices resources

First author Description

(publication yr)
- Knowledge about
research utilization
- Mentoring
- Learning opportunity
- EBN training
- Skills in retrieving and evalu-
ating research publication
- Skills on managing research-
based evidence
- Meaning
- Beliefs about benefits of EBN
- Nursing confidence
- Nursing responsibility
- Nursing autonomy
- Adequate organizational sup-
port
- Managerial support
- Hospital policy
- Culture adoption
- Supports from colleagues and
other collaborators
- Time constrain
- Heavy workload
- Opportunities for working with a
computer
- Internet use in the workplace
- Availability of professional support
- Availability of library assistance

Gerrish (2004) ✓ ✓ ✓
Melnyk (2004) ✓ ✓
Adib-Hajbaghery (2007) ✓ ✓ ✓
Chau (2008) ✓ ✓ ✓ ✓
Gerrish (2008) ✓
Hart (2008) ✓ ✓
Koehn (2008) ✓ ✓
Brown (2009) ✓ ✓ ✓ ✓
Chien (2010) ✓ ✓
Breimaier (2011) ✓ ✓ ✓
Eizenberg(2011) ✓ ✓ ✓
Majid (2011) ✓ ✓ ✓
Dalheim(2012) ✓ ✓
Grant (2012) ✓ ✓

Note. EBN ¼ evidence-based nursing.

Results Factor 2 emphasized the organizational promotive strategies

The participants were aged 27 to 54 years, with a
mean ± standard deviation of 37.63 ± 6.65 years. The participants
had an average clinical experience of 14.78 ± 7.10 years. Principal
component analysis yielded 18 factors with eigenvalues exceeding
1 (1.00e11.25). After the screen plot analysis, five factors were
retained in the final model. Table 2 shows the corresponding
category, Q statements, and factor arrays of the five factors.
Table 3 presents the distinguishing statements ranked at both
ends of each factor. The following are the five prominent shared
perspectives: (1) Factor 1 emphasized the obstacles to evidence
searching and reading ability; (2) Factor 2 emphasized the orga-
nizational promotive strategies; (3) Factor 3 emphasized the
available supportive resources; (4) Factor 4 emphasized the sig-
nificance of EBN; and (5) Factor 5 emphasized the evidence-
searching ability and external incentives.
Ten participants were significantly loaded on this factor. These
participants favored tangible rewards (leave and allowances) for
EBN practices (þ4) and considered the time spent on EBN practices
as flexible working hours (þ3). This group emphasized attending
EBN training (þ3). The participants were concerned about the lack
of teamwork across disciplines (þ3). By contrast, they were not
highly concerned about obtaining the full text of empirical litera-
ture (3), promoting nursing autonomy by using EBN practices
(3), or their literature appraisal ability (3) (Table 3).
The average age of the participants associated with Factor 2 was
36.20 years, with an average clinical experience of 13.30 years.
Most of the participants were employed at medical centers (90.0%),
60.0% of the participants had an education level equivalent to an
undergraduate degree, and 70.0% had a higher level of nursing
competency (N3 and N4). All the participants attended EBN
training (100.0%) (Table 4).

Factor 1 emphasized the obstacles in evidence searching and
reading ability
Fourteen participants were significantly loaded on this factor.
They strongly emphasized EBN-associated skills and abilities,
particularly the difficulty in evidence searching (þ3) and reading
(þ4), which affected their engagement in EBN. They were not
highly concerned about organizational strategies such as promot-
ing EBN through the publication of the implementation processes
and results (4) or the provision of support and reinforcement (4)
(Table 3).
Among all the participants, those associated with Factor 1 were
relatively young (35.71 years), with an average clinical experience
of 13.07 years. Most of them were employed at a regional hospital
(78.6%), and 92.9% of the participants had an education level
equivalent to an undergraduate degree. Only 35.7% of the partici-
pants had a higher level of nursing competency (N3 and N4). Most
of them attended EBN training (71.4%) (Table 4).
Factor 3 emphasized the available supportive resources
Six participants were significantly loaded on this factor. These
participants emphasized the availability of professional support for
research skills (þ4) and availability of library staff for consultation
(þ4). Compared with the participants in the other groups, these
participants were less concerned about conditional barriers such as
the lack of time at workplaces to search and read research articles
(3) and difficulty in obtaining the full text of empirical literature
(4). They placed less emphasis on the difficulty in searching for
appropriate empirical literature (3) (Table 3).
Among all the participants, those associated with Factor 3 were
relatively old (42.33 years), with an average clinical experience of
20.50 years. These participants were employed at medical centers
(100.0%); 33.3% of the participants had an education level equiva-
lent to an undergraduate degree, and 83.3% had a higher level of
nursing competency (N3 and N4). All the participants attended EBN
training (100.0%) (Table 4).
256 R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260

Table 2 Q Statements and Factor Arrays across the Five Factors.

Categories Factor arrays

F1 F2 F3 F4 F5

Skills and ability associated with EBN

Difficulty in searching for appropriate empirical literature 3 1 3 0 4
Using EBN steps to solve patient problems 1 2 1 0 1
Attending EBN training 1 3 1 4 2
Learning opportunity for new information 2 2 2 2 1
Using competition as a training method of EBN 1 0 2 1 4
Lack of confidence in assessing the quality of empirical literature 1 3 1 4 2
Difficulty in understanding English-language literature 4 2 2 2 2
Lack of professional guidance for EBN 2 1 3 0 3
Requires mentorship of EBN guidance 2 0 0 1 0
Using group discussion as a training method of EBN 1 0 2 4 0
Attitudes associated with EBN
Willingness in adopting EBN 3 1 3 4 2
Appreciating the importance of EBN 1 2 1 2 2
EBN promotes critical thinking 3 1 2 3 3
EBN enhances quality of care 2 0 1 3 1
EBN promotes autonomy in nursing practice 1 3 0 0 0
Offering a scientific explanation for nursing care 1 0 1 1 1
EBN enhances nursing care efficiency 2 1 0 2 0
EBN enhances patient comfort 0 1 0 1 0
Care procedures can be altered according to EBN 2 2 0 0 1
EBN enhances nursing authority 0 1 0 1 0
EBN enhances nursing competence 0 1 0 0 1
EBN demonstrates nursing uniqueness to other professionals 0 1 1 2 1
EBN enhances the respects of colleagues 2 0 0 1 1
Practicability associated with EBN practices
Difficulty in implementing EBN practices that require a doctor's order 0 4 3 1 1
Lack of teamwork cooperation across disciplines 1 3 1 2 3
Applied EBN practices as a mandatory policy 0 2 2 2 4
Require recognition and support from colleagues 0 1 2 0 0
Require support from the hospital management and administrators 1 2 1 1 1
EBN practices against current medical practices 3 2 2 3 3
Require tangible rewards (e.g., leave and allowances) for EBN practices 1 4 2 1 3
Promote EBN practices through publication of implementation process and results 4 0 0 2 1
Regarding the time spending on EBN practices as flexible working hours 2 3 1 2 0
Provision of supports and reinforcement 4 1 2 0 0
Initiating EBN practices on a trial basis for testing feasibility 1 0 1 1 1
Incorporation of EBN knowledge into evaluation for nursing competence advancement 3 4 2 3 2
Working conditions and supportive resources
Lack of time at the workplaces to search and read research articles 4 0 3 2 4
EBN practice increasing in clinical workload 2 2 3 3 2
Time constrains because of too many family responsibilities 3 1 1 3 2
Slow computers and limitations on the number of internet users 0 4 4 1 3
Difficulty in obtaining the full text of empirical literature 1 3 4 1 1
Availability of professional supports for research skills 2 1 4 0 1
Availability of library staff to consult with 0 2 4 2 0
Time constrains because of multiple roles 0 1 0 1 2
Inadequate staffing (large number of patients, heavy workloads) 1 0 1 0 2

Factor 1 emphasized the obstacles to evidence searching and reading ability, Factor 2 emphasized the organizational promotive strategies, Factor 3 emphasized the available
supportive resources, Factor 4 emphasized the significance of EBN, and Factor 5 emphasized the evidence-searching ability and external incentives.
Note. EBN ¼ evidence-based nursing.

Factor 4 emphasized the significance of EBN
Nine participants were significantly loaded on this factor. These
participants supported the value of EBN. They considered that EBN
promotes critical thinking (þ3) and enhances the quality of care
(þ3). This group of participants emphasized attending EBN training
(þ4). By contrast, these participants were not highly concerned
about the ability or training method associated with EBN, such as
the lack of confidence in assessing the quality of empirical literature
(4) or conducting group discussion as a training method of EBN
(4) (Table 3).
The average age of participants associated with Factor 4 was
37.78 years, with an average clinical experience of 13.44 years. All
the participants were employed at a regional hospital (100.0%) and
had an education degree equivalent to an undergraduate degree.
Only 22.2% of the participants had a higher level of nursing com-
petency (N3 and N4). Most of them attended EBN training (77.8%)
(Table 4).
Factor 5 emphasized the evidence-searching ability and external
incentives
Eight participants were significantly loaded on this factor. These
participants were concerned about self-ability and external in-
centives such as the difficulty in searching for appropriate empir-
ical literature (þ4) and provision of tangible rewards (leave and
allowances) for EBN practices (þ3). These participants were not
highly concerned about the practicability of EBN practices, such as
the lack of teamwork across disciplines (3) or application of EBN
as a mandatory policy (4). They did not prefer using competition
as a training method of EBN (4). They were not concerned about
slow computers or a limited number of internet users (3)
(Table 3).
The average age of the participants associated with Factor 5 was
36.50 years, with an average clinical experience of 14.75 years. Half
of the participants were employed at medical centers (50.0%), 75.0%
of the participants had an education degree equivalent to an
Table 3 Distinguishing Statements at Both Extreme Ends across the Five Factors.

Categories Result of Q-sort factor analysis

Emphasized the obstacles to Emphasized the organizational Emphasized the available Emphasized the significance of Emphasized the evidence-
evidence searching and reading promotive strategies supportive resources EBN searching ability and external
ability incentives

Skills and ability Most importance Difficulty in searching for
associated with EBN appropriate empirical literature
(3, 1.25)
Difficulty in understanding
English-language literature (4,
1.86)
Least importance
Attending EBN training (3, 1.43)
Lack of confidence in assessing
the quality of empirical
literature (3, 1.39)
Difficulty in searching for
appropriate empirical literature
(3, 1.36)
Attending EBN training (4, 1.96)
Lack of confidence in assessing
the quality of empirical
literature (4, 1.99)
Using group discussion as a
training method of EBN
(4, 1.66)
Difficulty in searching for
appropriate empirical literature
(4, 2.34)
Using competition as a training
method of EBN
(4, 2.51)

R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260

Attitudes associated Most importance EBN promotes critical thinking
with EBN (3, 1.82)
EBN enhances quality of care (3,
1.57)
Least importance EBN promotes autonomy in
nursing practice (3, 1.33)
Practicability associated Most importance Lack of teamwork cooperation Requires tangible rewards (e.g.,
with EBN practices across disciplines (3, 1.39) leave and allowances) (3, 1.14)
Requires tangible rewards (e.g.,
leave and allowances) for EBN
practices (4, 2.38)
Regarding the time spending on
EBN practices as flexible
working hours (3, 1.53)
Least importance Promote EBN through Lack of teamwork cooperation
publication of implementation across disciplines (3, 1.47)
process and results (4, 1.54) Applied EBN as a mandatory
Provision of supports and policy (4, 1.99)
reinforcement (4, 1.66)
Working conditions Most importance Availability professional
and supportive supports for research skills (4,
resources 1.75)
Availability of library staff to
consult with (4, 1.91)
Least importance Difficulty in obtaining the full Lack of time at the workplaces Slow computers and limitations
text of empirical literature to search and read research on the number of internet users
(3, 1.41) articles (3, 1.27) (3, 1.30)
Difficulty in obtaining the full
text of empirical literature
(4, 2.36)

Both the factors Q-sort value and Z-Score are shown in parentheses. The numbers in the parentheses were identified by Q-sort factor analysis. They represent that the statements were the most/least accurately reflected the
experience of participants who loaded significantly onto the given factor.
Note. EBN ¼ evidence-based nursing.

257
258 R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260

Table 4 Background Information.

Participant background Emphasized the obstacles to Emphasized the Emphasized the Emphasized Emphasized the
evidence searching and organizational promotive available supportive the significance evidence-searching
reading ability strategies resources of EBN ability and external
incentives
(n ¼ 14) (n ¼ 10) (n ¼ 6) (n ¼ 9) (n ¼ 8)

Types of hospital
Medical center 3 9 6 0 4
Regional hospital 11 1 0 9 4
Education level
College/baccalaureate 13 6 2 9 6
Graduate 1 4 4 0 2
Job position
Nurse 10 9 2 6 5
Administer 4 1 4 3 3
Level of nurse career advancement
N1 0 1 1 0 0
N2 9 2 0 7 5
N3 3 6 5 0 3
N4 2 1 0 2 0
Work unit
Emergency and critical care 6 6 1 7 6
Surgical and medical wards 8 4 5 2 2
Attended EBN training
Yes 10 10 6 7 5
No 4 0 0 2 3
Age (yr)
Mean ± SD 35.71 ± 7.41 36.20 ± 5.63 42.33 ± 3.45 37.78 ± 6.30 36.50 ± 7.59
Clinical experience (yr)
Mean ± SD 13.07 ± 7.61 13.30 ± 7.57 20.50 ± 4.46 13.44 ± 5.25 14.75 ± 7.15

Note. EBN ¼ evidence-based nursing; N ¼ level of nursing competency; SD ¼ standard deviation.

undergraduate degree, and 37.5% had a higher level of nursing
competency (N3 and N4). Most of the participants attended EBN
training (62.5%) (Table 4).
Consensus statements
Consensus (a similar magnitude of agreement or disagreement
with the Q statements provided by all participants) was achieved
for only one statement. The study groups ranked the following
statement as relatively neutral: “offer a scientific explanation for
nursing care (1, 0, 1, 1, and 1).”
Discussion
This study identified five shared perspectives regarding the
factors relevant for nurses to adopt EBN. The following are the five
prominent shared perspectives: (1) the obstacles to evidence
searching and reading ability; (2) the organizational promotive
strategies; (3) the available supportive resources; (4) the signifi-
cance of EBN; and (5) the evidence-searching ability and external
incentives. Previous studies have identified factors facilitating and
hindering EBN [24,25] and reported nurses' perceived knowledge,
attitude, and skills regarding EBN [12,16,26]. Our finding contrib-
utes to the literature by revealing different perspectives and a novel
approach to EBN studies. The factors associated with EBN adoption
by nurses in previous studies were organized as a framework to
construct the Q statements in this study. In addition, this study
integrated qualitative interviews into a framework to develop the Q
statements for Q sorting. Using this procedure, a combination of a
literature review and face-to-face interviews, concerns related to
EBN adoption could be adequately addressed and illustrated.
The participants associated with Factor 1 shared an experience
of being discouraged by their evidence searching and reading
abilities. A lack of confidence in retrieving and evaluating nursing
practice evidence was not an unusual barrier to adopting EBN in
noneEnglish-speaking countries [5,27]. Similarly, Dalheim et al [9]
identified a difficulty in understanding English-language publica-
tions. Our finding implied that EBN training alone may not
adequately empower this group of participants because most of
them (more than 70%) attended EBN training. A systematic review
found that lectures/didactic presentations were the most
frequently used training methods [28]. The findings suggested that
not many nurses could perform EBN independently with confi-
dence after receiving lecture-type training [16,28]. It may be more
effective to help and support these nurses by a provision of inter-
active activities, such as small group discussion or establishing a
mentorship model on EBN in clinical practice [14,15,29].
Factor 1 emphasized individual abilities, but participants who
loaded on Factor 2 favored organizational promotive strategies.
They emphasized tangible rewards for their efforts on EBN prac-
tices. Necessary organizational incentives were expected as effec-
tive strategies for the participants who loaded on Factor 2. The
appreciation and reward would promote nurses feeling energized
and a stronger sense of professionalism [15]. If organizations could
provide them external rewards and support, nurses would be able
to engage in EBN and work with satisfaction [4,14,15]. The partici-
pants who loaded on Factor 3 emphasized the availability of sup-
portive resources. They were relatively old (42.33 years), with an
average clinical experience of 20.50 years. All of them attended EBN
training. The findings suggest that EBN training may not satisfy
these experienced nurses. The nurses preferred library assistance
and professional support for research skills while engaging in EBN.
Difficulty navigating online data systems or lacking confidence in
library skills were barriers for nurses [10,25]. A previous study [12]
suggested that provision of guidance by knowledgeable people
(advanced practice nurses and researchers) is effective in over-
coming these barriers.
The participants who loaded on Factor 4 emphasized the value
of EBN. They accredited that EBN is an essential element of nursing
and enhances critical thinking and the quality of care. An
 R.-N. Jueng et al. / Asian Nursing Research 11 (2017) 253e260
integrative review revealed that nurses could not be isolated from
organizational and social factors that affect EBN [25]. However,
these nurses emphasized the value of EBN rather than external
barriers. Positive attitudes associated with EBN enhance nurses'
readiness for engaging in EBN practices [4]. Recognition of nurses
with positive attitudes would be a benefit to construct a supportive
environment for EBN implementation. The participants who loaded
on Factor 5 emphasized both individual ability and external in-
centives. They can be appropriately assisted by integrating indi-
vidual and external strategies. Provisions of training programs and
related tangible rewards were needed to foster EBN implementa-
tion [4,15].
Implication for the nursing practice
Responsive approaches, according to each group, may be
beneficial for attaining more effective collaboration. Educational
training is the most common strategy for motivating nursing staff
to engage in EBN. However, our findings suggest that EBN training
alone may not be sufficient for some nurses. Alternative strategies,
such as providing translation to reduce language barriers to English
literature, are necessary to assist nurses who associate with Factor
1. Our findings highlight the need for strategies to ensure that
evidence-based information is readily available to nurses in a form
that they can easily understand [10].
For some experienced nurses (Factor 3), provision of supportive
resources, such as library assistance and professional support for
research skills, is desired in addition to EBN training. Insufficient
library assistance may hinder nurses from adopting EBN. Promotive
strategies to engage these nurses in EBN should equip them with
sufficient assistance to search and retrieve evidence-based litera-
tures [28,29].
Nurses who associated with Factor 4 appreciated the value of
EBN and could be appropriate advocates of an organizational policy
to implement EBN. Their inclusion as a representative presence on
hospital-wide committees helped to promote EBN practices within
institutions. This can be considered both a strategic and cultural
intervention that enhances nursing authority and autonomy [25].
Finally, for some nurses (Factors 2 and 5), provision of organi-
zational support and rewards or incentives was more effective than
EBN training. Positive reinforcement (exact rewards) of identified
behaviors is perceived as organizational support [11]. Organiza-
tional culture must recognize and reward those who adopt EBN in
nursing practice.
Limitation
The generalizability of results obtained using the Q method is
slightly limited. The study used a purposive sample; therefore,
nonrandom sampling of participants may hinder the generaliz-
ability of the findings. Hence, the findings may not reflect the
perspectives of nurses in other divisions or disciplines. To confirm
the validity of these patterns and perspectives, the replication of
the study is required. However, the Q method is useful for
exploring diverse perspectives rather than potential generalizable
studies.
Conclusion
This study comprehensively presents an understanding of
nurses' perceptions of what they crucially associate with engage-
ment in EBN. Q statements are constructed based on the literature
related to EBN adoption by nurses and face-to-face interviews.
Patterns of shared perspectives emerge from nurses' rankings of
these statements. The five identified groups of perspectives can
259
facilitate the development of customized strategies to meet nurses'
preferences. The exploration of clustering nurses' perceptions may
enable more appropriate training and assistance.
Conflict of interest
The authors declare that they have no conflicts of interest.
Acknowledgments
This work was supported by a grant from the National Yang-
Ming University Hospital Hospital, Yilan, Taiwan (RD2014-026).
The authors would like to express their gratitude to the nursing
staff and the care units that participated in this study.
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