Journal of Nursing Management, 2015, 23, 651–660

Relationships between evidence-based practice, quality

improvement and clinical error experience of nurses in Korean
hospitals
1 2
JEE-IN HWANG RN, PhD and HYEOUN-AE PARK RN, PhD, FAAN

1
Associate Professor, Department of Nursing, College of Nursing Science, Kyung Hee University and 2Professor,
College of Nursing and Systems Biomedical Informatics Research Center, Seoul National University, Korea

Correspondence (2015) Journal of Nursing Management 23, 651–660.

HWANG J.-I. & PARK H.-A.
Hyeoun-Ae Park Relationships between evidence-based practice, quality improvement and
College of Nursing clinical error experience of nurses in Korean hospitals
Seoul National University
28 Yongon-dong Chongno-gu Aim This study investigated individual and work-related factors associated with
Seoul 110-799 nurses’ perceptions of evidence-based practice (EBP) and quality improvement
Korea (QI), and the relationships between evidence-based practice, quality improvement
E-mail: hapark@snu.ac.kr and clinical errors.
Background Understanding the factors affecting evidence-based practice and
quality improvement activities and their relationships with clinical errors is
important for designing strategies to promote evidence-based practice, quality
improvement and patient safety.
Method A cross-sectional survey was conducted with 594 nurses in two Korean
teaching hospitals using the evidence-based practice Questionnaire and quality
improvement scale developed in this study.
Result Four hundred and forty-three nurses (74.6%) returned the completed
survey. Nurses’ ages and educational levels were significantly associated with
evidence-based practice scores whereas age and job position were associated with
quality improvement scores. There were positive, moderate correlations between
evidence-based practice and quality improvement scores. Nurses who had not
made any clinical errors during the past 12 months had significantly higher
quality improvement skills scores than those who had.
Conclusion The findings indicated the necessity of educational support regarding
evidence-based practice and quality improvement for younger staff nurses who have
no master degrees. Enhancing quality improvement skills may reduce clinical errors.
Implications for nursing management Nurse managers should consider the
characteristics of their staff when implementing educational and clinical strategies
for evidence-based practice and quality improvement.
Keywords: evidence-based practice, medical errors, nursing, quality improvement

Accepted for publication: 24 September 2013

by integrating research evidence, clinical expertise, and

Introduction
There is increasing interest in promoting evidence-
based practice (EBP) and quality improvement (QI) in
clinical practice in order to provide high-quality care
and better patient outcomes. EBP is a problem-solving
approach in which the best available evidence is used
patient values and preferences in order to improve
health outcomes (Melnyk & Fineout-Overholt 2011).
QI is defined as systematic, data-guided activities
designed to improve health care delivery (Lynn et al.
2007, Shirey et al. 2011). QI has focused on making
changes to the health care system that will lead to better

DOI: 10.1111/jonm.12193
ª 2013 John Wiley & Sons Ltd 651
J.-I. Hwang and H.-A. Park
outcomes (Batalden & Davidoff 2007). Implementing
EBP and QI has been recognised as core competencies
that all health care professionals should possess (Insti-
tute of Medicine 2003). To encourage EBP and QI
activities in nursing practice, the assessment of the
knowledge, skills and attitudes regarding EBP and QI
in the current workforce provides a starting point.
Previous research regarding EBP in nursing has
shown that although nurses have a positive attitude
towards EBP, their knowledge and skills of EBP were
only slightly low to moderate (Melnyk et al. 2004,
Koehn & Lehman 2008, Thiel & Ghosh 2008, Brown
et al. 2009, Waters et al. 2009, Johansson et al. 2010,
Foo et al. 2011, Majid et al. 2011, Linton & Prasun
2013). A lack of knowledge and skills regarding EBP
has been recognised as a major barrier to EBP, along
with practice characteristics such as time constraint
and paucity of resources (Brown et al. 2009, Asadoo-
rian et al. 2010, Majid et al. 2011, Melnyk et al.
2012). In addition, studies have found that individual
and work-related characteristics such as age, educa-
tional level, years of nursing experience, job position
and workplace were associated with knowledge, skills
and attitudes regarding EBP (Gerrish et al. 2008,
Koehn & Lehman 2008, Filippini et al. 2011, Gonz
alez-
Torrente et al. 2012, Melnyk et al. 2012, Linton &
Prasun 2013). As such, nurses with a higher education
had a higher level of knowledge and attitudes regard-
ing EBP (Koehn & Lehman 2008, Linton & Prasun
2013), and they were more confident in implementing
EBP (Melnyk et al. 2012). Nurse managers had more
positive attitudes towards EBP than staff nurses did
(Gonz
alez-Torrente et al. 2012). However, these stud-
ies covered findings from several countries such as
Australia, Canada, Italy, Singapore, Spain, Sweden,
the United Kingdom and the United States. The adop-
tion and use of EBP and its associated factors can vary
in different work settings and countries.
Nurses, who are the frontline of health care, have
played an important role in QI activities. Along with
increased needs in practice, QI competency has been
emphasised in nursing education (Cronenwett et al.
2007, 2009). However, nursing curricula seldom
include QI content (Smith et al. 2007, Sullivan et al.
2009). Assessment of the current levels of knowledge,
skills and attitudes regarding QI of the nursing work-
force and exploration of factors associated with QI
levels are necessary to develop strategies to enhance the
QI competency of nurses in practice. To the best of our
knowledge, there is a paucity of literature in this area.
Researchers have pointed out that EBP and QI are
distinct but overlapped in part (Newhouse 2007, Shirey
652
et al. 2011). Solomons and Spross (2011) suggested that
QI provides a specific context for EBP. Shuval et al.
(2010) found that the EBP knowledge of physicians was
positively associated with quality of patient care. In
addition, EBP and QI activities can prevent and reduce
incorrect/unnecessary acts and errors of omission by
employing best evidences and improving the process of
health care (Batalden & Davidoff 2007, Rosenthal 2007,
Melnyk & Fineout-Overholt 2011). Reducing clinical
errors is critical and necessary for ensuring patient
safety. However, few empirical studies have explored the
relationships among EBP, QI and clinical errors.
Therefore, this study aimed to describe the levels of
EBP and QI perceived by nurses in terms of knowledge,
skills and attitude, and to identify the factors associated
with EBP and QI levels. Furthermore, the relationships
of EBP and QI levels with nurses’ experience of clinical
errors were explored. The results will help design inter-
ventions to enhance EBP and QI activities and improve
patient safety. Specific research questions include (1)
what are the levels of EBP and QI perceived by nurses
in terms of knowledge, skills and attitude, (2) what are
the individual and work-related characteristics associ-
ated with levels of EBP and QI, (3) what is the relation-
ship between EBP and QI, and (4) are there any
differences in the levels of EBP and QI between nurses
with and without clinical error experience?
Methods
Study design
A cross-sectional survey design was employed. This study
is part of a larger research project on evidence-based
knowledge translation among hospital nurses. A related
article has been published elsewhere (Hwang, 2013).
Setting and samples
This study was conducted at two teaching hospitals
(designated A and B) in Seoul, Korea. The study hospi-
tals had electronic medical records systems. The nurses
work 8-hour shifts. The target population for this study
was nurses in adult inpatient departments. At the time
of this study, the number of nurses in the study hospitals
was 990 (578 nurses in Hospital A and 412 nurses in
Hospital B). We included nurses working at general
medical and surgical care units, intensive care units,
operating rooms and oriental medicine units; these
departments were considered as major workplaces of
nurses. Nurses in departments such as paediatrics and
psychiatrics were excluded. Thus, the study sample
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2015, 23, 651–660

comprised 594 nurses: 394 nurses in Hospital A and 200
nurses in Hospital B. To evaluate the appropriateness of
this sample size, we considered the following three rec-
ommendations: (1) at least 10 cases per item for factor
analyses, (2) a ratio of 40 cases per predictor in stepwise
multiple regression analyses, and (3) an ability to obtain
a power of 0.80 with a medium effect size (Cohen’s
d = 0.50) and a significance criterion of 0.05 in t-tests
(Polit 2010, Tabachnick & Fidell 2013). The sample size
met these criteria. The post-hoc power with the final
sample size was calculated as 0.527 in t-tests, and 0.992
and 0.999 each in the two multiple regression models.
Ethical considerations
The protocol of the overall study was approved by the
University Institutional Review Board (IRB no. 2009-
003). Participation was on a voluntary basis, and the
anonymity of the participants was ensured. The confi-
dentiality of responses was also guaranteed.
Measurements
Evidence-Based Practice Questionnaire (EBPQ)
The Evidence-Based Practice Questionnaire (EBPQ)
was employed to measure nurses’ perceptions of EBP.
The EBPQ was developed by Upton and Upton (2006).
This scale has been used and validated in previous stud-
ies (Koehn & Lehman 2008, Brown et al. 2009,
Gonz
alez-Torrente et al. 2012, Linton & Prasun
2013). It consists of three subscales: knowledge of EBP
(14 items), EBP use (six items) and attitudes towards
EBP (four items). Each item is rated on a 7-point Likert
scale, with a higher score indicating a higher level of
knowledge of EBP or EBP use, or a more positive atti-
tude towards EBP. The present authors obtained per-
mission to use this questionnaire from the developers.
The first author translated the EBPQ into Korean
for use in this study. The translated version was vali-
dated by a professional English editor and bilingual
professor. In this study, the overall Cronbach’s alpha
coefficient was 0.94 (0.92, 0.94 and 0.68 for the
knowledge, use and attitudes subscales, respectively).
A principal components factor analysis extracted three
factors reflecting the dimensions of knowledge, use
and attitudes towards EBP (Upton & Upton 2006).
Quality improvement (QI) scale
We developed a questionnaire to measure nurses’ lev-
els of QI in terms of knowledge, skills and attitudes.
The draft questionnaire items were derived from the
lists on knowledge, skills and attitudes regarding QI
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Journal of Nursing Management, 2015, 23, 651–660
Relationships between EBP, QI and error experience
competency developed by the faculty of Quality and
Safety Education for Nurses (Cronenwett et al. 2007).
As this questionnaire has distinct, clearly defined sets
of QI knowledge, skills and attitudes in addition to
including characteristics of QI suggested by other pre-
vious studies (Lynn et al. 2007, Newhouse 2007), we
adopted it for the purpose of this study.
For this study, the content validity of the draft items
was examined using a 4-point Likert scale (where
1 = not relevant and 4 = highly relevant) by an expert
panel consisting of three nursing professors and eight
members of the board of directors of the Korean Qual-
ity Improvement Nurses Society. Three of the 21 draft
items that had a content validity index (CVI) of <0.70
were removed (Yamada et al. 2010). Each item was
rated on a 5-point Likert scale (where 1 = minimal or
strongly disagree and 5 = excellent or strongly agree),
with a higher score indicating a higher level of knowl-
edge or skills, or a more positive attitude regarding QI.
The items were then pretested for clarity and compre-
hensibility by two head nurses and two registered
nurses. Minor modifications were made to the wording
according to the feedback received. One item was also
removed because it was more relevant to QI specialists
than staff nurses. Thus, the final version of the scale
consisted of 17 items. Cronbach’s alpha coefficients
were 0.93 for the entire scale, and 0.67, 0.90 and 0.71
for the knowledge (three items), skills (nine items), and
attitude (five items) subscales, respectively (Table 1).
Clinical error experience
A clinical error was defined as a preventable adverse
event or near miss, including medication errors, health-
care-related infection and patient falls (World Health
Organization 2009). We asked nurses to indicate
whether they had made an error within the previous
12 months using one question with a simple ‘yes/no’
response. To improve their responses, we provided a
brief definition and clinical examples. The nurses were
then requested to indicate the frequency.
Other study variables
We collected data on participants’ general characteris-
tics, including individual and work-related variables
such as their age, gender, marital status, educational
level, years of nursing experience, job position and the
department where they worked.
Data collection procedure
The questionnaire was distributed to each nurse along
with a return envelope. A cover letter explained the
653
J.-I. Hwang and H.-A. Park
Table 1
Quality improvement (QI) scale
Item*
QI knowledge
Recognising nursing and other health professions as
parts of care systems
Recognising the importance of measurement in
quality assessment
Explaining learning strategies about the outcomes of
care in practice
QI skills
Seeking information about patient outcomes
Identifying differences between current practice and
best practice
Seeking information about QI projects
Implementing changes and measures for care
improvement
Using QI tools for process (e.g. flow charts, cause-
effect diagrams)
Using quality indicators regarding performance
Measuring the effect of changes
Using QI tools to identify variation (e.g. control
charts, run charts)
Designing small projects for changes using Plan-Do-
Study-Act cycle
Attitudes towards QI
Valuing staff’s contributions to outcomes of care
Appreciating that quality improvement is an essential
part of the daily work
Appreciating the values of what staff do for care
improvement
Valuing measurement for better care
Appreciating how unwanted variation affects care
*Excerpted and reprinted from Cronenwett et al. (2007) with permission
from Elsevier.
†
Five-point Likert scale.
purpose of the study, the voluntary nature of partici-
pation and data confidentiality. To increase the
response rate, we provided a gift (US$ 5) to participat-
ing nurses as a token of appreciation for their partici-
pation. Return of the completed questionnaire was
taken as consent to participate in the study.
Data analysis
Data were analysed using the SAS statistical software
package version 9.2 (SAS Institute, Cary, NC, USA).
The internal consistencies of the EBPQ and QI scales
were determined with Cronbach’s alpha coefficients.
A principal components factor analysis using the vari-
max rotation method was performed to test the valid-
ity of the EBPQ. The Kaiser–Meyer–Olkin measures
of sampling adequacy was 0.941, indicating that the
data were amenable to factor analysis. Content valid-
ity of the QI scale was examined by computing the
CVI. The overall and subscale scores for the two
scales were calculated by averaging the scores of
related items.
654
Data on nurses’ general characteristics, the levels of
EBP and QI, and the occurrence of clinical errors are
Mean† SD summarised using descriptive statistics such as means,
standard deviations (SDs), frequencies and percentages.
3.49 0.67 Independent two-sample t-tests or analyses of variance
(ANOVAs) were used to examine differences in EBPQ and
3.29 0.75
QI scores according to the individual and work-related
3.28 0.63 characteristics of participants. Based on the univariate
analysis, stepwise multiple regression analyses were per-
3.35 0.67 formed to determine factors associated with EBP and
3.28 0.73 QI levels, respectively. In multiple regression models,
years of nursing experience was converted into categori-
3.15 0.72
3.12 0.83 cal variables because of a high correlation between
nurses’ age and years of nursing experience (r = 0.95).
3.12 0.79
As the overall scores were strongly correlated with the
3.11 0.81 subscale scores for both EBPQ and QI scales, we
2.98 0.85 utilised the overall scale scores in the analysis. The vari-
2.86 0.83
ance of inflation factors (VIFs) was calculated to exam-
2.83 0.91 ine multicollinearity among independent variables. The
calculated VIFs ranged from 1.34 to 1.59 for the EBPQ
3.64 0.70 scores and from 1.03 to 1.67 for the QI scores.
3.51 0.68 Pearson’s correlation coefficients were calculated to
examine the relationship between EBP and QI. In
3.42 0.79
addition, t-tests were employed to determine differences
3.37 0.76 in the scores on the EBP and QI between nurses who
3.19 0.75
had made at least one clinical error during the last
year and those who had not. The level of statistical
significance was set at P < 0.05.
Results
Of the 594 nurses who received the questionnaire,
591 returned them. Of these, 148 questionnaires were
excluded because they were incomplete. Question-
naires with missing responses for any of the items
were considered incomplete. The final sample was
therefore 443 (307 from Hospital A and 136 from
Hospital B), giving a response rate of 74.6%.
General characteristics of participants
The general characteristics of participants are given in
Table 2. Of the 443 participants, 437 were women
(98.7%). The mean age of the participants was
32.6 years (SD = 7.2). Two hundred and ninety-three
(66.1%) were unmarried and 262 had a baccalaureate
degree (50.6%). Participants had an average of
8.3 years (SD = 7.2) of nursing experience, and 396
were staff nurses (89.4%). They were distributed
across surgical care units (33.4%, n = 148), medical
care units (26.0%, n = 115), intensive care units
(18.3%, n = 81), Oriental medicine units (11.7%,
ª 2013 John Wiley & Sons Ltd
Journal of Nursing Management, 2015, 23, 651–660
 Relationships between EBP, QI and error experience

Table 2
General characteristics of participants and evidence-based practice (EBP) and quality improvement (QI) scores

EBPQ* QI score†

Variables n % Mean SD t/F P Mean SD t/F P

Gender
Male 6 1.4 3.8 0.9 -0.88 0.379 3.3 0.4 0.18 0.856
Female 437 98.7 4.1 0.8 3.2 0.5
Age (years)
20–30 182 41.1 4.0 0.7 7.92 <0.001 3.1 0.5 14.36 <0.001
31–40 191 43.1 4.2 0.8 3.3 0.5
41–60 70 15.8 4.4 0.9 3.5 0.6
Marital status
Not married 293 66.1 4.1 0.7 -1.35 0.180 3.2 0.5 -3.81 <0.001
Married 150 33.9 4.2 0.9 3.4 0.5
Education
3-year diploma 127 28.7 3.9 0.7 13.84 <0.001 3.2 0.5 6.08 0.003
4-year baccalaureate 224 50.6 4.1 0.7 3.2 0.5
Master or higher 92 20.8 4.5 0.9 3.4 0.6
Years in nursing
<3 129 29.1 3.9 0.7 4.84 0.003 3.1 0.5 8.4 <0.001
3–<5 73 16.5 4.0 0.7 3.1 0.5
5–<10 122 27.5 4.1 0.7 3.3 0.5
10 or more 119 26.9 4.3 0.9 3.4 0.6
Job position
Manager 47 10.6 4.5 0.9 4.16 <0.001 3.6 0.5 5.06 <0.001
Staff 396 89.4 4.1 0.7 3.2 0.5
Department
Medical care unit 115 26.0 4.1 0.8 1.43 0.225 3.2 0.5 0.72 0.579
Surgical care unit 148 33.4 4.1 0.8 3.2 0.5
Intensive care unit 81 18.3 4.3 0.7 3.3 0.5
Operating room 47 10.6 4.1 0.7 3.2 0.5
Oriental medicine unit 52 11.7 4.0 0.8 3.2 0.6

*Seven-point Likert scale, †Five-point Likert scale.

n = 52) and operating rooms (10.6%, n = 47). Of the
participants, 198 (44.7%) responded that they had
made clinical errors during the previous 12 months.
Among them, only 182 nurses reported the frequency
of making clinical errors. The mean number of errors
made was 4.1 (95% confidence interval = 0.0–8.1).
EBPQ and QI scale scores
The mean overall EBPQ score was 4.1 (SD = 0.8) on
a 7-point Likert scale. The mean scores for the EBP
knowledge, use and attitude subscales were 4.1
(SD = 0.8), 3.9 (SD = 1.1) and 4.5 (SD = 0.9), respec-
tively. The mean score for the overall QI scale was
3.2 (SD = 0.5) on a 5-point Likert scale. With regard
to QI knowledge, skills and attitude subscales, the
mean scores were 3.4 (SD = 0.5), 3.1 (SD = 0.6) and
3.4 (SD = 0.5), respectively.
Factors associated with nurses’ perceptions of
EBP and QI
Regarding EBP, univariate analyses showed signifi-
cant differences in EBPQ scores according to nurses’
age, educational level, years in nursing and job
position (Table 2). A stepwise multiple regression
analysis revealed that nurses’ age and educa-
tional level were significantly associated with EBPQ
scores (F = 10.98, P < 0.001). Specifically, older
nurses (b = 0.01) and nurses with a master degree
or higher (b = 0.43) had higher EBPQ scores
(Table 3).
As for QI, univariate analyses revealed significant
differences in QI scores according to nurses’ age, mar-
ital status, educational level, years in nursing and job
position (Table 2). A stepwise multiple regression
analysis showed that statistically significant factors
associated with QI scores were age and job position
(F = 14.85, P < 0.001). Specifically, older nurses
(b = 0.02) and nurse managers (b = 0.20) had higher
QI scores (Table 3).
Relationship between EBP, QI and clinical error
experience
We examined the relationship between EBP and QI
using Pearson’d correlation coefficients. Table 4 shows
a positive, moderate correlation between EBPQ and

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J.-I. Hwang and H.-A. Park

Table 3 Korean hospitals. Understanding the factors associated

Stepwise multiple regression results for evidence-based practice
with EBP and QI levels has great implications in
(EBP) and quality improvement (QI) scores
designing nurse education and supporting programmes
Parameter Variance to promote EBP and QI in nursing practice. The find-
Variable estimate SE t P inflation
ings also indicated the importance of enhancing QI
Dependent variable: EBPQ skills as a strategy to reduce clinical errors made by
Intercept 3.53 0.20 17.82 <0.001 0.00
Age 0.01 0.01 2.19 0.029 1.34
nurses.
Baccalaureate 0.14 0.09 1.59 0.112 1.41 In this study, nurses perceived their EBP knowledge
degree and use levels as moderate, and had a positive attitude
Master degree 0.43 0.11 3.90 <0.001 1.59
or higher towards EBP. These findings are similar to those of
Dependent variable: QI previous studies (Koehn & Lehman 2008, Thiel &
Intercept 2.68 0.13 20.00 <0.001 0.00 Ghosh 2008, Brown et al. 2009, Waters et al. 2009,
Age 0.02 0.00 3.69 <0.001 1.63
Years of nursing 0.10 0.05 1.91 0.057 1.03 Foo et al. 2011, Majid et al. 2011, Linton & Prasun
(5–<10) 2013). Overall, the scores for EBPQ were somewhat
Manager 0.20 0.10 1.99 0.047 1.67
low compared with the findings of other previous
position
studies (Koehn & Lehman 2008, Brown et al. 2009).
SE, standard error. Specifically, items measuring knowledge and skills
regarding research methods and critical appraisal of
QI scores at both the entire scale and subscale levels the literature had the lowest score. This might relate
(Pearson’s r = 0.29–0.59). to the fact that nursing research was not a mandatory
To determine the relationship of EBP and QI levels course requirement in all undergraduate programmes
with clinical error experience, we performed t-tests. in Korea (Lee et al. 2011). Although information
The t-tests revealed that the knowledge, use and about clinical questions is available along with
attitude scores on the EBP did not differ significantly advanced information and communication technolo-
between nurses who had made clinical errors during gies, a lack of knowledge and skills in conducting
the previous 12 months and those who had not. The research and critically appraising research findings is a
knowledge and attitude scores for QI also did not major obstacle to practising EBP. The finding that
differ significantly between the two nurse groups. younger nurses had lower EBPQ scores is consistent
However, a significant difference in QI skills scores with a previous finding of a positive correlation
between the two nurse groups was found. Specifically, between EBP knowledge and attitudes and age (Linton
nurses who had made no errors during the previous & Prasun 2013). Nurses with diplomas and baccalau-
12 months had higher QI skills scores (Table 5). reate degrees had lower EBPQ scores compared with
those with master degrees or higher. This is also con-
sistent with previous findings (Melnyk et al. 2012,
Discussion Linton & Prasun 2013). This might be because of a
Evidence-based practice and QI activities are recogni- lack of formal training and education regarding EBP
sed as core components of high-quality care and in undergraduate nursing curricular (Lee et al. 2011).
patient safety. To the best of our knowledge, this is Therefore, nurse executives and managers need to not
the first study to investigate the relationships among only introduce in-service or continuing education
EBP, QI and the clinical error experience of nurses in programmes on EBP to nurses, who are relatively

Table 4
Pearson’s correlation coefficients between evidence-based practice (EBP) and quality improvement (QI) scores

Variables EBPQ EBPQ knowledge EBPQ use EBPQ attitude QI QI knowledge QI skills

Overall score for EBPQ 1

EBP knowledge 0.93 1
EBP use 0.81 0.59 1
EBP attitude 0.60 0.42 0.38 1
Overall score for QI 0.59 0.57 0.45 0.34 1
QI Knowledge 0.54 0.51 0.42 0.34 0.85 1
QI Skills 0.57 0.56 0.42 0.29 0.95 0.72 1
QI attitude 0.49 0.45 0.37 0.33 0.86 0.72 0.69

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656 Journal of Nursing Management, 2015, 23, 651–660
 Relationships between EBP, QI and error experience

Table 5
Evidence-based practice (EBP) and quality improvement (QI) scores by clinical error experience

Clinical error experience

Total (n = 443) Yes (n = 198) No (n = 245)

EBPQ and QI scores Mean SD Mean SD Mean SD t P

Overall score for EBPQ* 4.1 0.8 4.1 0.8 4.1 0.8 1.10 0.271
EBP knowledge 4.1 0.8 4.1 0.8 4.2 0.9 1.18 0.241
EBP use 3.9 1.1 3.8 1.1 3.9 1.1 0.86 0.391
EBP attitude 4.5 0.9 4.4 0.9 4.5 0.9 0.24 0.811
Overall score for QI† 3.2 0.5 3.2 0.5 3.3 0.5 1.40 0.163
QI knowledge 3.4 0.5 3.4 0.6 3.4 0.5 0.18 0.856
QI skills 3.1 0.6 3.0 0.6 3.1 0.6 2.03 0.043
QI attitude 3.4 0.5 3.4 0.5 3.4 0.5 0.65 0.517

*Seven-point Likert scale.

†
Five-point Likert scale.

young and who hold diploma and baccalaureate
degrees, but also encourage them to participate in
such programmes in order to build their workforce
competency.
Nurses perceived their QI knowledge and skills level
as above average and had positive attitudes towards QI.
The implementation of QI programmes is required for
hospital accreditation (Ministry of Health & Welfare
& Korean Institute for Healthcare Accreditation 2011),
which has prompted efforts to improve nurses’ compe-
tency for QI through in-service education programmes.
However, there was a perceived lack of skills regarding
the use of QI methods. Specifically, these items included
‘design small projects for changes using the Plan-
Do-Study-Act cycle’, ‘utilizing QI tools to identify
variations’ and ‘measuring the effect of change’. In a
study involving graduating nursing students, the skill of
evaluating the effect of changes using QI methods and
measures was rated as the lowest among the skills for
quality and safety competencies (Sullivan et al. 2009).
In particular, younger staff nurses had significantly
lower QI scores compared with nurse managers.
Therefore, education regarding QI methods for these
nurses needs to be further emphasised in in-service QI
programmes. Practical training using various examples
in nursing practice will be useful.
This study finding showed a positive, moderate cor-
relation between EBP and QI. This supported the
argument that EBP and QI are distinct but related
(Newhouse 2007, Shirey et al. 2011). This finding
indicates that integrated, collaborative approaches
rather than separate programmes regarding EBP and
QI are suggested.
We considered it surprising that a substantial pro-
portion of nurses had made at least one error during
the previous 12 months. This is a higher proportion
than other self-reported error rates (12–20%) (O’Ha-
gan et al. 2009, Hwang & Hwang 2011). This differ-
ence might be partly attributable to the fact that we
sampled only nurses in inpatient care departments
who have more opportunities to make clinical errors
than nurses in outpatient departments. Interestingly,
nurses who responded that they had made no clinical
errors had higher scores on the QI skills subscale. This
indicates that the measurement of quality indicators
and monitoring of variations in patient outcomes are
useful for identifying hazards and risks in care and for
preventing and reducing nursing errors. Therefore,
hospital executives and nurse managers need to pro-
mote the use of QI tools and methods as a strategy
for reducing clinical errors.
This study had several limitations that should be
noted when interpreting the findings. First, although
the study sample had a gender distribution similar to
the actively working nurse population in Korea (Korean
Nurses Association & Korean Research Institute
for Nursing Policy 2007), there was a significant dif-
ference in the age distribution. Thus, the generalisabil-
ity of our findings is limited by the study being
conducted with only nurses working in inpatient care
departments in two university hospitals. Second, the
study measured retrospective clinical error rates
through a self-reported questionnaire because we had
difficulty obtaining objective data owing to concerns
related to lawsuits in the Korean hospital context.
Thus, recall bias is possible, and some nurses may not
even be aware of their near misses or errors. Third,
this study had a cross-sectional design, so we cannot
determine causal relationships; a longitudinal study is
required to examine such relationships. Fourth, the
present study used validated questionnaire tools to
measure perceived EBP and QI, but different methods

ª 2013 John Wiley & Sons Ltd

Journal of Nursing Management, 2015, 23, 651–660 657
J.-I. Hwang and H.-A. Park
can be considered. Therefore, we suggest that future
studies investigate the relationships between EBP, QI
and clinical errors using different methodologies such
as knowledge assessment tests and observation-based
performance testing, while including more nurses in
more varied health care settings. In addition, we
focused on individual characteristics associated with
the levels of EBP and QI and did not include organisa-
tional factors such as nursing leadership and organisa-
tional culture (Johansson et al. 2010, Sandstr€
om et al.
2011). We therefore recommend that future studies
include these variables.
Implications for nursing management
The findings of this study have practical implications
for hospital policy makers and nurse managers in
enhancing nurses’ EBP and QI activities, and improv-
ing patient safety. Overall, the nurses exhibited mod-
erate levels of both EBP and QI. However, they
perceived themselves to lack skills in conducting
research and critically appraising research findings.
Nurses reported a lack of knowledge and skills in
applying specific QI methods. These findings indicate
priority areas that should be stressed to improve
nurses’ competencies regarding EBP and QI. Nurse
managers should support nurses in enhancing their
competencies for EBP and QI by developing education
and training programmes or providing opportunities
to participate in existing programmes. In designing
and implementing such education programmes, indi-
vidual characteristics of nurses such as age, educa-
tional level and job position should be considered. At
the national or international levels, development and
dissemination of practical guidance for effective nurse
education and training on EBP and QI could provide
an important reference point for facilitating EBP and
QI in nursing practice.
In addition, reducing clinical errors, with increased
emphasis on patient safety, continues to be a major
challenge in health care worldwide (Research Priority
Setting Working Group of the WHO World Alliance
for Patient Safety 2008, Brady et al. 2009). A substan-
tial proportion of nurses responded that they had
made clinical errors during the previous 12 months.
Although we could not measure each proportion of
near misses and events resulting in patient harm, this
finding indicates an urgent need to reduce errors. The
results of this study suggest that enhancing nurses’ QI
skills could prevent errors and bolster patient safety.
Thus, nurse education programmes focusing on the
improvement of QI skills should be emphasised. Nurse
658
managers should encourage and support their nurses’
active use of QI methods in order to identify and
resolve issues that impact the delivery and organisa-
tion of quality care. The development and dissemina-
tion of the best QI practices that result in error
reduction can facilitate nurses’ application of QI
methods.
Conclusion
The nurses perceived their EBP knowledge and use
levels as moderate, and had positive attitudes towards
EBP. In addition, nurses perceived their QI knowledge
and skill levels as above average, with positive atti-
tudes towards QI. Significant factors associated with
EBP were nurses’ age and educational level, and those
associated with QI levels were age and job position.
Younger nurses showed lower levels of perceived EBP
and QI. Nurses with diplomas or baccalaureate
degrees had lower EBPQ scores than those with mas-
ter degrees or higher, and staff nurses had lower QI
scores than nurse mangers did. Therefore, nurse man-
agers should consider nurses’ characteristics in design-
ing and implementing strategies to promote EBP and
QI activities. In addition, positive, moderate correla-
tions between EBP and QI were found. The prevalence
of clinical errors was low among nurses with high QI
skills scores. In order to promote nurses’ EBP and QI
activities, integrated approaches that link each other
rather than separate programmes will be more effi-
cient. Furthermore, enhancing nurses’ skills in using
QI methods are promising strategies to prevent and
reduce clinical errors in practice, thereby improving
patient safety.
Source of funding
This research was supported by National Research
Foundation of Korea – Grant funded by the Korean
Government (NRF-2009-327-H00039).
Ethical approval
Ethical approval was provided by the Kyung Hee Uni-
versity Institutional Review Board (no. 2009-003).
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