Evidence-based Nursing Practice and Its correlates among Korean Nurses

Younhee Kang RN, MSN-ANP, PhD, In-Suk Yang RN, MSN, PhD

PII: S0897-1897(15)00233-5
DOI: doi: 10.1016/j.apnr.2015.11.016
Reference: YAPNR 50757

To appear in: Applied Nursing Research

Received date: 19 May 2014

Revised date: 23 November 2015
Accepted date: 24 November 2015

Please cite this article as: Kang, Y. & Yang, I.-S., Evidence-based Nursing Prac-
tice and Its correlates among Korean Nurses, Applied Nursing Research (2015), doi:
10.1016/j.apnr.2015.11.016

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 ACCEPTED MANUSCRIPT
[텍스트 입력][텍스트 입력] Evidence-Based Practice

Evidence-based Nursing Practice and Its correlates among Korean Nurses

Younhee Kang1*, RN, MSN-ANP, PhD. In-Suk Yang2, RN, MSN, PhD.

T
1
Professor,

P
Division of Nursing Science, College of Health Sciences,

RI
EwhaWomans University, Seoul, Korea.

SC
2
Assistant professor,

Department of Nursing, Kyungil University, Daegu, Korea

Ewha Womans University

NU
MA
Corresponding Author:

Younhee Kang, RN, MSN-ANP, PhD.

ED

Division of Nursing Science, College of Health Sciences, EwhaWomans University, 11-1

Daehyun-dong, Seodaemun-gu, Seoul, 120-750, Korea

PT

Email: yxk12@ewha.ac.kr

Phone: 82-10-8541-1600
CE

Fax: 82-2-3277-2850
AC

** Running Head: Evidence-Based Practice

** There are no conflicts of interest in relation to this manuscript.

Author contributions:

YK:study conception/design;critical revisions for important intellectual content; supervision;

statistical expertise; administrative/technical/material support

IY:data collection/analysis; drafting of manuscript

 ACCEPTED MANUSCRIPT
[텍스트 입력][텍스트 입력] Evidence-Based Practice

Abstract

Aim. To explore evidence-based nursing practice (EBNP) in Korean and identify factors influencing

its implementation.

P T
Background. EBNP is relatively new in Korea, and there is a lack of consistency about the factors

RI
that affect EBNP implementation.

Methods. A descriptive correlational and cross-sectional design was employed and a convenience

SC
sample of 392 nurses were recruited from two general hospitals. Data were analyzed by using

NU
descriptive and inferential statistics.

Results. The overall model significantly explained 17.1% of variance in EBNP implementation.
MA
Among the predictors of EBNP implementation, regularly reading research articles, level of searching

skills for literature, degree of understanding EBNP, professional autonomy, and EBNP beliefs had
ED

statistically significant influences on EBNP implementation.

Conclusion. Findings suggest the necessity for Korean nurses to regularly read research articles,
PT

develop greater skills in developing searching research documents, gain clearer understanding of

EBNP, EBNP beliefs, and particularly, high level of professional autonomy.

CE

Key words: Evidence-Based Practice, Research Implementation, Research in Practice

AC
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 1

INTRODUCTION

Evidence-based nursing practice (EBNP) is the practical application of the best available clinical

T
evidence which is derived from systemic and scientific research findings, regarding the health or

P
nursing problems of the patient, their preferences and values (Ingersoll, 2000).Today the nursing

RI
paradigm is shifting from traditional intuition, clinical experience, and pathophysiological rationale to

SC
EBNP, which integrates clinical expertise into current best evidence for the patient and clinical

circumstances (Salmond, 2007).

NU
EBNP implementation follows a process of formulating questions to search research evidence,

obtaining appropriate evidence using various information sources, critically appraising and comparing
MA
research evidence, applying research evidence into nursing practice, and evaluating nursing practice

based on research evidence (Boström et al., 2009). Implementing EBNP is considered best practice in
ED

health care service and results in improving patients’ benefits and outcomes, such as, time interval in

initiation of antibiotic therapy for adult patients with febrile neutropenia, and prevention and
PT

treatment among patients with pressure ulcers (Best et al., 2011; Clarke et al., 2005). Nurses as

health professionals have an accountability to integrate research evidence into nursing practice in
CE

order to implement EBNP (Hart et al., 2008).

However, studies have shown that most nurses use their own knowledge, their colleagues'
AC

knowledge, knowledge acquired during nursing education, nursing literature, and guidance from

expert personnel, but seldom research evidence (Berland et al., 2012; Dalheim et al., 2012). Moreover,

barriers, such as a lack of time and skills to find, review, and use research evidence, have been found

to hinder implementation of EBNP (Dalheim et al., 2012). Research findings also indicate that beliefs

about the knowledge and value of EBNP, confidence in implementing this into practice,

organizational culture, group cohesion, leader support, and job satisfaction have been associated with

its implementation (Aarons et al., 2015; Melnyk et al., 2010; Kjersti et al., 2014).

Professional autonomy refers to a discretionary decision-making based on nursing evidence with

an emphasis on the patient. Nurses who have higher professional autonomy are obligated to take make
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 2

decisions in an authorized way in their nursing practice, and this is an influencing factor on

professionalism (Wade, 1999). Professional autonomy allows that nurses to understand patient-

centered circumstantial problems; provide improved diagnostic and technical skills; and apply

T
comprehensive and holistic care, all of which can facilitate EBNP implementation, and produce

P
positive patient outcomes (Abad-Corpa et al., 2013; Carryer et al., 2007). Some researchers are

RI
concerned that following standardized guidelines such as EBP (Evidence-Based Practice) could be

SC
hinder professional autonomy (Magill, 2006). Recently, the issue of professional autonomy has being

controversial in health care system. Crosby (2013) has emphasized that professional autonomy is an

NU
integral element in EBP. Moreover, it offers clearer clear professional identity and authority

supporting clinical nursing practice (Carryer et al., 2007). Nevertheless, there is minimal research
MA
that has attempted to identify various influencing factors, including professional autonomy, on EBNP

implementation, hence this study.

ED
PT

BACKGROUND
CE

The Ottawa Model of Research Use (OMRU) (Logan and Graham, 1998) was developed to

stimulate research utilization. The OMRU comprises six elements: the practice environment, potential
AC

adopters of evidence, evidence-based innovation, research transfer strategies, evidence adoption, and

outcomes. These elements interact with each other through outcomes. Structural and social practice

environments, adopters’ attitudes and current practice, and adopters’ perception of the attributes of

innovation process or the innovation itself might encourage or discourage research utilization (Logan

and Graham (1998). Implementing strategies that might overcome potential barriers to research

utilization could integrate research evidence into clinical nursing practice, and thus ultimately

improve patient health-related outcomes. Based on the OMRU, the above authors hypothesized that

environmental elements disturbing research utilization and research activity, clinical nurses’ attitudes
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 3

toward EBNP, clinical practice using autonomic decision-making, and their perception of EBNP itself,

would be associated with its implementation.

Previous studies report that barriers to research utilization such as lack of time, restricted

T
knowledge understanding statistical analyses, and inadequate organizational support hinder EBNP

P
implementation (Glacken et al., 2004; Koehn and Lehman, 2008; Solomons and Spross, 2011). It is

RI
important to understand barriers to research utilization in clinical settings so that successful

SC
implementation of EBNP can be achieved (Pallen and Timmins, 2002). Despite the frequent citing of

barriers to the use of research in clinical practice (Shifaza et al., 2014) these have not yet been

NU
investigated in Korea, the site of this study.

Some studies demonstrate that nurses with positive EBNP beliefs and attitude are more likely to
MA
utilize research and implement EBNP (Eizenberg, 2011; Koehn and Lehman, 2008; Melnyk et al.,

2004; Melnyk et al., 2010; Milner et al., 2006; Ploeg et al., 2007). EBNP beliefs signify nurses’
ED

cognitive perceptions about the value of EBNP and their ability to implement this in clinical settings.

The Transtheoretical Model (Prochaska and Valicer, 1997) was applied to the field of organizational
PT

change, which included recognizing significance of change, in the belief that change can succeed, and

have an immediate and vital influence on working conditions (Melnyk et al., 2004; Melnyk et al.,
CE

2008). Using this theory, a relationship was found between EBNP beliefs and EBNP implementation.

In many previous studies, EBNP implementation has been affected by various individual factors
AC

such as nurses’ education; research activity; skills in finding, understanding and applying various

research sources; attitudes towards research; regular reading of research articles; knowledge based on

literature; collaboration with colleagues; and technological deficiencies (Clarke et al., 2005;

Eizenberg, 2011; Milner et al., 2006; van Achterberg et al., 2008).

As EBNP is a relatively new concept in Korea. Our experience has been there is the lack of

consistency in influencing factors of EBNP implementation, and mutual recognition has not been

universally applied to clinical nurses. To identify the factors promoting EBNP implementation can

help health care providers, nurse leaders and educators to develop practical strategies for clinical
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 4

practice. This study aimed to identify influencing factors of EBNP implementation among Korean

nurses. Specific objectives were to:

1. Examine differences in EBNP implementation by demographic characteristics, research activity,

T
and EBNP characteristics;

P
2. Explore relationships among professional autonomy, barriers to research utilization, EBNP beliefs,

RI
and EBNP implementation; and

SC
3. Identify factors influencing EBNP implementation.

NU
MA METHOD

Study design

A descriptive correlational and cross-sectional design was used

ED

Setting and Sample

PT

Convenience sampling was recruit clinical nurses at two general metropolitan hospitals in Korea.

Inclusion criteria were registered nurses who were: (a) staff or head nurses with clinical experience
CE

>13 months (b) providing direct nursing care in general wards, intensive care units, emergency room,

operative and recovery rooms, or a maternal and child center. Exclusion criteria were working in
AC

outpatient department, central supply room, and a quality improvement center.

Ethical considerations

Approval was obtained from the human research ethics committees of both the two general

hospitals and the affiliated university before commencing data collection. All subjects were given

written information about the study and informed of their rights: voluntary participation, guarantee of

anonymity, and ability to withdraw from the study at any time without penalty. Upon written consents

from the subjects, data were collected.

 ACCEPTED MANUSCRIPT
Evidence-Based Practice 5

Measurements

T
The structured questionnaire was organized with items asking the demographic characteristics,

P
research activity, understanding EBNP, professional autonomy, barrier to research utilization, EBNP

RI
beliefs, and EBNP implementation. Demographic characteristics included gender, age, education,

SC
hospital scale and overall clinical experience. The questionnaire asking on research activity was

composed of 5 items: (1) Do you have experience of research participation as a researcher? (2) Do

NU
you have a positive intention about future research participation? (3) Do you regularly read research

articles? (4) Do you belong to a nursing academy? and (5) What do you think about the level of
MA
searching skill related to research documents?
ED

Professional autonomy

The Schutzenhofer Professional Autonomy Scale (SPAS) assesses how likely nurses would be to
PT

carry out nursing practice through autonomic decision making (Schutzenhofer, 1987), and consists of

30 items rated on a 4-point Likert scale (ranging from 1 = very unlikely to 4 = very likely). Each item
CE

is assigned to a weight from 1- 3. A weight of 1 (10 items), a weight of 2 (10 items), and a weight of

3 (10 items) indicates a low, moderate, and high level of autonomy, respectively. The total score is
AC

achieved by summing the weights for all items, with a possible range of 60-240. Scores of 60-120,

121-180, and 181-240 indicate a low, moderate, and high level of professional autonomy, respectively.

In a previous study, the Cronbach’s alpha for professional autonomy was .92 (Schutzenhofer, 1987).

In this study, Cronbach’s alpha was .89.

Barrier to research utilization

The BARRIERS scale assesses health care professionals’ perceptions of barriers to the utilization

of research findings in clinical practice (Funk et al., 1991). The scale consists of 29 items and

comprises 4 domains: 1) nurse - 8 items indicating nurse’s research values, skills, and awareness, 2)
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 6

setting - 8 items indicating organizational barriers and limitations, 3) research - 6 items indicating

quality of research, and 4) research communication - 6 items indicating presentation and accessibility

of research. One item was not scored since it did not load on any of the four factors. Respondents rate

T
items on a 5-point Likert scale, regarding the extent to which they believe each item is a barrier to

P
their use of research in practice ranging from 1 = to no extent to 4 = large extent; and 5 = no opinion.

RI
The final score is the mean score of all items. A higher mean score indicates a greater level of barriers

SC
to research utilization. The BARRIERS scale has been tested and found to have a high face and

content validity, with Cronbach’s alpha of .65 ~ .80 for the four factors and item-total correlations

NU
from .32 ~ .65 (Funk et al., 1991). In this study, Cronbach’s alpha for barriers to research utilization

was .72 ~ .84.

MA

Evidence-based practice beliefs

ED

The Evidence-based Practice Beliefs Scale (EBPBS) was developed to investigate the level of

value of EBNP and nurses’ confidence in EBNP implementation (Melnyk et al., 2008). The scale
PT

comprises 16 items. Each item is scored on a 5-point Likert scale ranging from 1 = strongly disagree

to 5 = strongly agree. After calculating reversed scores for 2 negatively phrased items, the total score
CE

is obtained by summing the scores of all items with a possible range of 16-80. A higher score

indicates a greater level of EBNP beliefs. In a previous study, Cronbach’s alpha for EBNP beliefs
AC

was .90. Adequate construct and criterion validity of the EBP beliefs has been demonstrated (Melnyk

et al., 2008). In this study, Cronbach’s alpha of EBNP beliefs was .84.

Evidence-based practice implementation

The EBP Implementation Scale (EBPIS) was developed to investigate the level of EBP

implementation, including relevant behaviors of seeking and appraising research evidence, sharing

research evidence with colleagues or patients, incorporating research evidence into practice, and

evaluating outcomes (Melnyk et al., 2008). The EBPIS comprises 18 items, scored on a 5-point Likert

scale ranging from 0-4 (0 - 0 time; 1 – 1~3 times; 2 – 4~5 times; 3 – 6~7 times; 4 – over 8 times),
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 7

depending on the number of times that the behaviors were practiced over the previous 8 weeks. The

total score is obtained by summing the scores of all items, with a possible range of 0-72. A higher

score indicates greater EBNP implementation. In a previous study, the Cronbach’s alpha of EBP

T
implementation was .96. Adequate construct and criterion validity was also reported (Melnyk et al.,

P
2008). In this study, Cronbach’s alpha of EBNP implementation was .95.

RI
SC
Data collection procedure

Data were collected with the assistance of a designated nurse from each ward who took

NU
responsibility for distribution and collection. A total of 491 subjects were invited to participate and

484 finally agreed (98.6% response rate). We ended up excluding 92 subjects who did not completely
MA
answer the questionnaire or did not satisfy inclusion criteria, thus data from 392 subjects were

included for further analyses.

ED

Data analysis
PT

Data were analyzed by using SPSS 18.0 program (SPSS Inc., Chicago, IL, USA). Descriptive

statistics including frequency, percentage, mean and standard deviation were used to describe subject
CE

demographic characteristics, research activity, and understanding EBNP. Association of EBNP

implementation with demography, research activity, and understanding EBNP were tested using the t-
AC

test, ANOVA, Scheffe test, and Pearson's correlations coefficient. Relationships among professional

autonomy, barriers to research utilization, EBNP beliefs and EBNP implementation were tested using

the Kruskal-Wallis test, Bonferroni test, and Pearson's correlations coefficient. And hierarchical

multiple regression was used to determine influencing factors of EBNP implementation after

controlling for demographic characteristics, research activity, and understanding EBNP.

 ACCEPTED MANUSCRIPT
Evidence-Based Practice 8

RESULTS

Differences in EBNP Implementation by Demographic Characteristics

P T
Table 1 shows the demographic characteristics of the 392 subjects (Kang and Yang, 2015). The

RI
mean age of all subjects was 29.74 ± 5.81 years (Kang and Yang, 2015), ranging from 22 to 54 years.

SC
The majority (97.4%) were female; about 84.7% had an associate or bachelor degree in nursing;

80.6% had worked at tertiary hospitals; and their overall clinical experience was 84.44 ± 62.28

NU
months (Kang and Yang, 2015). There was no statistically significant difference in EBNP

implementation by gender, age, education, hospital scale, and overall clinical experience.
MA

Differences in EBNP Implementation by Research Activity and Understanding EBNP

ED

Table 2 shows the research activity and understanding EBNP of subjects: 41.6% had experienced
PT

research participation but only 27.3% had a positive intention about future research participation

(Kang and Yang, 2015). A minority (6.1%) read research articles regularly, and 22.2% had joined a
CE

nursing academy (Kang and Yang, 2015). Only 19.6% of subjects had a higher level of skills

searching research documents, while 37.8% reported clearly understanding EBNP (Kang and Yang,
AC

2015).

Subjects who had experienced research participation (t = 2.409, p = .016), had a positive intention

about future research participation (t = 2.568, p = .011), regularly read research articles (t = 4.611, p

< .001), and joined a nursing academy (t = 2.139, p = .033) showed significantly higher EBNP

implementation than others. There was statistically significant difference in EBNP implementation

among the group by level of searching skill related to research documents (F = 7.299, p < .001), and

those with higher searching skill level tended to implement EBNP. Subjects who clearly understand

EBNP presented statistically significant difference in EBNP implementation than those who did not.

(F = 7.736, p =.001).
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 9

Relationships among Professional Autonomy, Barriers to Research Utilization, EBNP Beliefs

and EBNP Implementation

P T
In this study, the levels of professional autonomy were high (9.9%), moderate (87.8%), and low

RI
(2.3%). Barriers to research utilization scored 2.67 ± 0.48 with a range from 1.21 - 4, and subscale

SC
scores for communication, nurse, setting, and research were 2.73 ± 0.54, 2.58 ± 0.57, 2.77 ± 0.54, and

2.59 ± 0.54, respectively months (Kang and Yang, 2015). EBNP beliefs scored 51.55 ± 6.05 with

NU
ranging from 22 to 71, and EBNP implementation scores were 33.07 ± 12.43 with a range from 18 to

72. These results are reported in Table 3.

MA
Group who had high professional autonomy showed a statistically significant difference in EBNP

implementation than other groups (χ2 = 16.607, p <.001). There was a statistically significant negative
ED

correlation between barrier to research utilization – communication and EBNP implementation (r = -

.100, p = .049). EBNP beliefs and EBNP implementation were statistically positively correlated (r
PT

= .287, p < .001).

CE

Effects of Research Activity, Understanding EBNP, Professional Autonomy, Barriers to

Research Utilization, EBNP Beliefs on EBNP Implementation

AC

The overall model significantly explained 17.1% of variance in EBNP implementation (F = 5.560,

p < .001). Among all predictors, regularly read research articles, level of searching skill of research

documents, degree of understanding of EBNP, professional autonomy, and EBNP beliefs had

statistically significant influences on EBNP implementation. The high level of professional autonomy

had the greatest influence on EBNP implementation (β = .213). However, barrier to research

utilization had no statistical association with EBNP implementation (Table 4).

DISCUSSION
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 10

Our findings demonstrate that the Korean nurses’ in this study had low levels of EBNP

implementation. This does not coincide with a previous study reporting a moderate level for EBNP

T
implementation in a western country, US (Koehn and Lehman, 2008). This finding might be

P
explained in that two-thirds of respondents did not clearly understand EBNP and most did not

RI
regularly read research articles. This is based on the collective experiences of the authors that the low

SC
level of EBNP implementation in these two hospitals has several plausible explanations related to

specific clinical nursing situations generally in Korea, including the high workload for nurses, a high

NU
ratio of patients to one nurse; and hospital organizational cultures not allowing nurses to search or

read research articles during work-hours. This in important in view of the fact that organizational
MA
support for reading and searching nursing and medical journals is associated with EBNP

implementation (Eizenberg, 2011). Therefore, organizational support should be provided for clinical
ED

nurses to implement EBNP, including support for academic conference participation allowing nurses

to have an understanding of EBNP, as well as opportunities and resources for easily assessing
PT

professional articles and data bases at work.

We found that differences in EBNP implementation related to nurses’ research participation,

CE

positive intention about future research participation, regular reading of the research articles,

membership of nursing academy, higher level skill levels in searching research documents, and
AC

clearer understanding of EBNP. This finding is congruent with Milner et al. (2006) who found that

nurses who had a more positive attitude towards research and more frequently read research articles,

had better EBNP implementation. This is consistent with our finding that 93.9% of respondents who

did not regularly read research articles showed poor EBNP implementation. This could be explained

by the fact that research articles are far away from the clinical settings where nurses work and so they

may have to work extra hours in order to search relevant research evidence (Glacken and Chaney,

2004). It is necessary for health care managers and administrators to arrange the latest articles in order

to obtain systematic and scientific evidence without difficulty and to offer educational programs to

improve searching skills related to research evidence using the Internet. In addition, the health care
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 11

managers and administrators should encourage nurses to join a nursing academy. Thus, our finding

suggests the need for EBNP education for those nurses who did not clearly understand EBNP.

Unlike previous studies (Eizenberg, 2011; Gerrish et al., 2011; Koehn and Lehman, 2008; Milner

T
et al., 2006), there was no difference in EBNP implementation according to education levels in this

P
study. This indicates that low levels of EBNP implementation occurred in our Korean nurses

RI
regardless of education.

SC
Many previous studies have found that individual and organizational barriers to research

utilization such as lack of time, lack of authority to change practice, poor access to resources, and

NU
inadequate knowledge can undermine EBNP implementation (Koehn and Lehman., 2008; Solomons

and Spross, 2011). However, in our study, a negative correlation was found between communication
MA
barriers to research utilization and EBNP implementation. This finding points to lower the barrier to

presentation and accessibility of the research results in better EBNP implementation. There is a need
ED

for educational programs to include research terminology, statistical methods, and interpretation of

results. Also, educational programs appraising research evidence and integrating research evidence
PT

into clinical practice are recommended to improve EBNP implementation.

The significant predictors of EBNP implementation in our study were regular reading of
CE

research articles, very high levels skills to search research documents, clear understanding of EBNP, a

high level of professional autonomy, and a belief in EBNP. In a number of previous studies, results
AC

showed that were facilitators for EBNP implementation occurred in those nurses with positive

attitudes and beliefs regarding EBNP – they could appropriately search for research findings,

critically appraise research findings, use research findings into nursing practice, and evaluate nursing

practice based on research findings (Eizenberg, 2011; Koehn and Lehman, 2008; Melnyk et al., 2004;

Milner et al., 2006; Ploeg et al. 2007). Another study showed that nurses who received well-structured

research education reported improvements in their critical appraisal, searching skill, using research

findings into practice, and positive attitudes related to research (Veeramah, 2004). Improvements in

nurses’ perception of knowledge, attitude, and skill levels related to EBNP can also occur through a

computer-based educational intervention (Hart et al., 2008). Therefore, both health care educators and
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 12

managers have made an endeavor to try to decrease the distinction between research and practice

through various educational programs in order to deal with problems in knowledge, attitudes, and

skills to improve EBNP beliefs and implement EBNP (Hart et al., 2008). In our opinion this is also

T
needed in Korea, where more energy needs to be expended in developing national and local evidence-

P
based clinical guidelines, which are an important means of EBNP implementation.

RI
This research provides a meaningful contribution to understanding the relationship between

SC
professional autonomy and EBNP implementation. Professional autonomy involves nurses who assess

patients’ needs, develop and implement individualized nursing care, and evaluate patients’ outcomes

NU
based on research evidence, all of which facilitate EBNP implementation (Bonell, 1999). Specific

activities such as regular cycles of nursing mortality and morbidity conferences, a journal club, and
MA
interdisciplinary educational sessions could help to provide for better patient safety, improve

professional autonomy, and implement EBNP (Staveski et al., 2012). Participatory conferences,
ED

journal clubs using an interdisciplinary approach, and organizational support could also enhance

professional autonomy. This study’s findings indicate that Korean health care managers and
PT

administrators should establish organizational and educational strategies which might enable for

clinical nurses to regularly read research articles, improve level of searching skill, clearly understand
CE

EBNP, and have professional autonomy and positive beliefs towards EPNP to enhance EBP

implementation.
AC

CONCLUSION AND LIMITATIONS

The findings from this study suggest the necessity of nurses regular reading of the research articles,

higher level of searching skill on research documents, clear understanding of EBNP, EBNP beliefs

and, particularly, high level of professional autonomy. These findings highlight the importance of

educational preparation and provide fundamental information to health care managers and

administrators in developing actual educational programs for nurses working at clinical settings.

However more studies about this are needed across the country, in both regional and urban settings.
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 13

There were a few limitations. First, the findings of this study were limited in terms of generalizing

beyond the sample due to our use of non-probability sampling. Second, we were not fully considerate

of organizational characteristics as function and structure, which are actually different in various

T
countries and cultures. Actually, Korea’s corporate culture is somewhat bureaucratic, and hinders

P
professional autonomy and EBNP implementation. Further research is needed to identify the influence

RI
of organizational factors on EBNP implementation after considering organizational characteristics.

SC
Future cross-country comparisons might be useful because Asian nations might have different

processing rate of diffusion of innovation than do western countries, have different nursing cultures,

NU
or might not have been previously exposed to EBP as much as western nurses.
MA
ED
PT
CE
AC
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 14

REFERENCES

Aarons GA, Ehrhart MG, Farahnak LR, Hurlburt MS. Leadership and organizational change for

T
implementation (LOCI): A randomized mixed method pilot study of a leadership and

P
organization development intervention for evidence-based practice implementation.

RI
Implement Sci. 2015;10:11. doi:10.1186/s13012-014-0192-y.

SC
Abad-Corpa E, Delgado-Hito P, Cabrero-García J, Meseguer-Liza C, Zárate-Riscal CL, Carrillo-

Alcaraz A, et al. Implementing evidence in an onco-haematology nursing unit: A process

NU
of change using participatory action research. Int J Evid Based Healthc. 2013;11:46-55.

doi: 10.1111/1744-1609.12006.
MA
Berland A, Gundersen D, Bentsen SB. Evidence-based practice in primary care: An explorative study

of nurse practitioners in Norway. Nurse Educ Pract. 2012;12:361-365. doi:

ED

10.1016/j.nepr.2012.05.002.

Best JT, Frith K, Anderson F, Rapp CG, Rioux L, Ciccarello C. Implementation of an evidence-based
PT

order set to impact initial antibiotic time intervals in adult febrile neutropenia. Oncol
CE

Nurs Forum. 2011;38:661-668. doi: 10.1188/11.ONF.661-668.

Bonell C. Evidence-based nursing: A stereotyped view of quantitative and experimental research

AC

could work against professional autonomy and authority. J Adv Nurs. 1999;30:18-23.

doi: 10.1046/j.1365-2648.1999.01044.x.

Boström AM, Ehrenberg A, Gustavsson JP, Wallin L. Registered nurses’ application of evidence-

based practice: A national survey. J Eval Clin Pract. 2009;15:1159-1163. doi:

10.1111/j.1365-2753.2009.01316.x.

Carryer J, Gardner G, Dunn S, Gardner A. The core role of the nurse practitioner: Practice,

professionalism and clinical leadership. J Clin Nurs. 2007;16:1818-1825. doi:

10.1111/j.1365-2702.2007.01823.x.
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 15

Clarke HF, Bradley C, Whytock S, Handfield S, van der Wal R, Gundry S. Pressure ulcers:

Implementation of evidence-based nursing practice. J Adv Nurs. 2005;49:578-590. doi:

10.1111/j.1365-2648.2004.03333.x.

T
Crosby E. Review article: The role of practice guidelines and evidence-based medicine in

P
perioperative patient safety. Can J Anaesth. 2013;60:143-151. doi: 10.1007/s12630-012-

RI
9855-9.

SC
Dalheim A, Harthug S, Nilsen RM, Nortvedt MW. Factors influencing the development of evidence-

based practice among nurses: a self-report survey. BMC Health Serv Res. 2012;12:367.

NU
doi: 10.1186/1472-6963-12-367.

Eizenberg MM. Implementation of evidence-based nursing practice: Nurses’ personal and

MA
professional factors? J Adv Nurs. 2011;67:33-42. doi: 10.1111/j.1365-2648.2010.05488.x.

Funk SG, Champagne MT, Wiese RA, Tornquist EM. BARRIERS: The barriers to research
ED

utilization scale. Appl Nurs Res. 1991;4:39-45. doi: 10.1016/S0897-1897(05)80052-7.

Gerrish K, Guillaume L, Kirshbaum M, McDonnell A, Tod A, Nolan M. Factors influencing the

PT

contribution of advanced practice nurses to promoting evidence-based practice among

front-line nurses: Finding from a cross-sectional survey. J Adv Nurs. 2011;67:1079-1090.

CE

doi: 10.1111/j.1365-2648.2010.05560.x.

Glacken M, Chaney D. Perceived barriers and facilitators to implementing research findings in the
AC

Irish practice setting. J Clin Nurs. 2004;13:731-740. doi: 10.1111/j.1365-

2702.2004.00941.x.

Hart P, Eaton L, Buckner M, Morrow BN, Barrett DT, Fraser DD, et al. Effectiveness of a computer-

based educational program on nurses’ knowledge, attitude, and skill level related to

evidence-based practice. Worldviews Evid Based Nurs. 2008;5:75-84. doi:

10.1111/j.1741-6787.2008.00123.x.

Ingersoll GL. Evidence-based nursing: What it is and what it isn’t. Nurs Outlook. 2000;48: 151-152.

doi. 10.1067/mno.2000.107690.
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 16

Kang Y, Yang IS. Clinical nurses’ perception on the barriers to research utilization. J Korean Acad

Fundam Nurs. 2015;22:198-206. doi: 10.7739/jkafn.2015.22.2.198.

Koehn ML, Lehman K. Nurses’ perceptions of evidence-based nursing practice. J Adv Nurs.

T
2008;62:209-215. doi: 10.1111/j.1365-2648.2007.04589.x.

P
Logan J, Graham ID. Toward a comprehensive interdisciplinary model of health care research use. Sci

RI
Com. 1998;20:227-246. doi: 10.1177/1075547098020002004.

SC
Magill M. The future of evidence in evidence-based practice: Who will answer the call for clinical

relevance? J Soc Work. 2006;6:101–115. doi: 10.1177/1468017306066737.

NU
Melnyk BM, Fineout-Overholt E, Feinstein NF, Li H, Small L, Wilcox L, et al. Nurses’ perceived

knowledge, beliefs, skills, and needs regarding evidence-based practice: Implications for
MA
accelerating the paradigm shift. Worldviews Evid Based Nurs. 2004;1:185-193. doi:

10.1111/j.1524-475X.2004.04024.x.
ED

Melnyk BM, Fineout-Overholt E, Giggleman M, Cruz R. Correlates among cognitive beliefs, EBP

implementation, organizational culture, cohesion and job satisfaction in evidence-based

PT

practice mentors from a community hospital system. Nurs Outlook. 2010;58:301–308. doi:

10.1016/j.outlook.2010.06.002
CE

Melnyk BM, Fineout-Overholt E, Mays MZ. The evidence-based practice beliefs and implementation

scales: Psychometric properties of two new instruments. Worldviews Evid Based Nurs.
AC

2008;5:208-216. doi: 10.1111/j.1741-6787.2008.00126.x.

Milner M, Estabrooks CA, Myrick F. Research utilization and clinical nurse educators: A systematic

review. J Eval Clin Pract. 2006;12:639-655. doi: 10.1111/j.1365-2753.2006.00632.x.

Pallen N, Timmins F. Research-based practice: Myth or reality? A review of the barriers affecting

research utilization in practice. Nurse Educ Pract. 2002;2:99-108. doi:

10.1054/nepr.2002.0058.

Ploeg J, Davies B, Edwards N, Gifford W, Miller PE. Factors influencing best-practice guideline

implementation: Lessons learned from administrators, nursing staff, and project leaders.

Worldviews Evid Based Nurs. 2007;4:210-219. doi: 10.1111/j.1741-6787.2007.00106.x.

 ACCEPTED MANUSCRIPT
Evidence-Based Practice 17

Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot.

1997;12:38-48. doi: 10.4278/0890-1171-12.1.38.

Salmond SW. Advancing evidence-based practice: A primer. Orthop Nurs. 2007;26:114-123. doi:

T
10.1097/01.NOR.0000265869.72265.0a.

P
Schutzenhofer KK. The measurement of professional Autonomy. J Prof Nurs. 1987;3:278-283. doi:

RI
10.1016/S8755-7223(87)80039-X.

SC
Shifaza F, Evans D, Bradley, H. Nurses’ perceptions of barriers and facilitators to implement EBP in

the Maldives. Advances in Nurs. 2014, ID 698604, doi:10.1155/2014/698604

NU
Solomons NM, Spross JA. Evidence-based practice barriers and facilitators from a continuous quality

improvement perspective: an integrative review. J Nurs Manag. 2011;19:109-120. doi:

MA
10.1111/j.1365-2834.2010.01144.x.

Staveski S, Leong K, Graham K, Pu L, Roth S. Nursing mortality and morbidity and journal club
ED

cycles: Paving the way for nursing autonomy, patient safety, and evidence-based practice.

AACN Adv Crit Care. 2012;23:133-141. doi: 10.1097/NCI.0b013e3182424ce7.

PT

Stokke K, Olsen NR, Espehaug B, Nortvedt MW. Evidence based practice beliefs and implementation

among nurses: A cross-sectional study. BMC Nurs. 2014;13:8. doi: 10.1186/1472-6955-

CE

13-8.

van Achterberg T, Schoonhoven L, Grol R. Nursing implementation science: How evidence-based

AC

nursing requires evidence-based implementation. J Nurs Scholarsh. 2008;40:302-310.

doi: 10.1111/j.1547-5069.2008.00243.x.

Veeramah V. Utilization of research findings by graduate nurses and midwives. J Adv Nurs.

2004;47:183-191. doi: 10.1111/j.1365-2648.2004.03077.x.

Wade GH. Professional nurse autonomy: Concept analysis and application to nursing education. J

Adv Nurs. 1999;30:310-318. doi: 10.1046/j.1365-2648.1999.01083.x.

 ACCEPTED MANUSCRIPT
Evidence-Based Practice 18

Table 1. Demographic Characteristics and Differences in EBNP Implementation by Demographic

T
Characteristics (N=392)

P
n (%)/ EBNP implementation

RI
Items Categories
M ± SD M ± SD t/ r (p)

SC
Age (years) 29.74 ± 5.81 .035 (.487)

NU
Gender Male 10 (2.6) 40.00 ± 12.13 1.791 (.074)

Female 382 (97.4) 32.89 ± 12.40

MA
Education
Below bachelor degree 332 (84.7) 32.87 ± 12.51 -0.760 (.447)

Pursuing the advanced degree 60 (15.3) 34.19 ± 12.04

ED

Hospital scale Secondary hospitals 76 (19.4) 30.67 ± 10.71 -1.878 (.061)

PT

316 (80.6)
Tertiary hospitals 33.65 ± 12.76

Overall clinical 84.44 ± 62.28 .003 (.953)

CE

experience
AC

(months)
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 19

Table 2. Research Activity, Understanding EBNP and Differences in EBNP Implementation by

Research Activity and Understanding EBNP (N=392)

T
EBNP implementation
Items Categories n (%)

P
M ± SD t/ F (p) Scheffe

RI
Experience of research Yes 163 (41.6) 34.85 ± 13.67 2.409 (.016*)

SC
participation No 229 (58.4) 31.80 ± 11.33

Positive intention Yes 107 (27.3) 35.68 ± 13.32 2.568 (.011*)

about future research

participation
No
NU
285 (72.7) 32.09 ± 11.96
MA
Regularly read Yes 24 (6.1) 44.13 ± 15.11 4.611 (.000***)

research articles No 368 (93.9) 32.35 ± 11.91

ED

Membership of Yes 87 (22.2) 35.57 ± 12.67 2.139 (.033*)

PT

nursing academy No 305 (77.8) 32.36 ± 12.29

Level of searching Vary lowa 6 (1.5) 23.17 ± 5.85 7.299 (.000***) a<e
CE

skill related to Lowb 71 (18.1) 29.00 ± 10.68 b<e

research documents Moderatec 238 (60.7) 33.50 ± 12.50 e<e

AC

Highd 71 (18.1) 34.92 ± 11.93 d<e

Very highe 6 (1.5) 52.17 ± 14.50

Degree of Knowna 148 (37.8) 36.00 ± 13.01 7.736 (.001**) a>c

understanding EBNP† Unknownb 80 (20.4) 32.80 ± 12.53

Not sure 164 (41.8) 30.56 ± 11.31

about EBNPc

*<.05, ** < .01, *** < .001

†
EBNP : Evidence-based Nursing Practice
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 20

Table 3. Relationships among Professional Autonomy, Barriers to Research Utilization, EBNP Beliefs

and EBNP Implementation (N=392)

T
EBNP implementation
Possible

P
Items n (%) Bonferro

RI
range M ± SD χ2/r (p)
ni

SC
Professional autonomy§ Higha 181 - 240 39 (9.9) 42.21 ± 16.75 16.607 a>b

Moderateb 121 - 180 344 (87.8) 32.20 ± 11.51 (.000***) a>c

NU
Lowc 60 - 120 9 (2.3) 26.78 ± 7.50

Barrier to research
MA
1-4 2.67 ± 0.48 -.038 (.459)
utilization

Communication 1–4 2.73 ± 0.54 -.100 (.049*)

ED

Nurse 1–4 2.58 ± 0.57 .009 (.863)

Setting 1–4 2.77 ± 0.54 -.051 (.311)

PT

Research 1-4 2.59 ± 0.54 .001 (.992)

CE

.287
EBNP† Beliefs 16 - 80 51.55 ± 6.05
(.000***)
AC

EBNP† Implementation 0 - 72 33.07 ± 12.43

*<.05, ** < .01, *** < .001

†
EBNP : Evidence-based Nursing Practice
§
Kruskal-Wallis test
 ACCEPTED MANUSCRIPT
Evidence-Based Practice 21

Table 4. Effects of Research Activity, Understanding EBNP, Professional Autonomy, Barriers to

Research Utilization, EBNP Beliefs on EBNP Implementation (N=392)

T
Predictors β t p β t P

P
Constant 4.589 .000*** 0.438 .662

RI
Experience of research participation (ref‡: no) .049 0.945 .345 .030 0.589 .557
Positive intention about future research .016 0.303 .762 -.013 -0.257 .798

SC
‡
participation (ref : no)
Regularly read research articles (ref‡: no) .153 2.962 .003** .110 2.145 .033*

NU
Membership of nursing academy (ref‡: no) -.006 -0.117 .907 -.006 -0.114 .909
Level of searching skill related to research .145 0.924 .356 .191 1.240 .216
MA
‡
documents – low (ref : very low)
Level of searching skill related to research .337 1.742 .082 .346 1.823 .069
documents – moderate (ref‡: very low)
ED

Level of searching skill related to research .276 1.742 .082 .255 1.644 .101
documents – high (ref‡: very low)
PT

Level of searching skill related to research .217 3.115 .002** .184 2.668 .008**
documents – very high (ref‡: very low)
CE

Degree of understanding EBNP† - unknown .070 1.324 .186 .097 1.848 .065
‡
(ref : not sure)
Degree of understanding EBNP† - known
AC

.137 2.453 .015* .113 2.040 .042*

(ref‡: not sure)
Professional autonomy – moderate (ref‡: low) .066 0.620 .536
Professional autonomy – high (ref‡: low) .213 1.989 .048*
Barrier to research utilization - communication -.017 -0.344 .731
EBNP† beliefs .159 2.863 .004**
R2 .120 .171
F 5.190 .000*** 5.560 .000***
*
p <. 05, **p <. 01, ***p <. 001
†
EBNP : Evidence-based Nursing Practice
‡
Ref : Reference group