Nurses’ Perception of Evidence-Based Practice at
the National University Hospital of Singapore
Schubert Foo, PhD, FBCS, FIMechE, Shaheen Majid, PhD, Intan Azura Mokhtar, PhD,
Xue Zhang, MSc, Brendan Luyt, PhD, Yun-Ke Chang, PhD, and Yin-Leng Theng, PhD
abstract
Background: A study was conducted at Singapore’s
National University Hospital to elicit registered nurses’
attitudes, knowledge, barriers, facilitating factors, edu-
cation, and training regarding evidence-based practice.
Methods: A 13-question survey that was adminis-
tered to all registered nurses yielded 1,114 (75.4%) us-
able returns for analysis.
Results: Findings showed that Singapore nurses had a
positive and supportive attitude toward evidence-based
practice but lacked the competence and knowledge to
conduct it. Time constraints were identified as the main
barrier to implementing evidence-based practice. There
is a need for proper training, mentoring by senior nurses,
and adequate time for evidence-based practice. Nurses
with a higher level of nursing education who indicated
the greatest perceived barriers tended to have less dif-
ficulty applying evidence-based practice but identified a
need for more training in information skills.
Conclusion: Evidence-based practice is still in its in-
fancy in Singapore compared with hospitals in other de-
veloped countries.
J Contin Educ Nurs 2011;42(11):522-528.
E vidence-based practice is defined as the integration
of best research evidence with clinical expertise and
patient values and the conscientious, explicit, and judi-
cious use of such evidence in making decisions about the
care of individual patients (Sackett, Straus, Richardson,
Rosenberg, & Haynes, 2000). It is expected that best
evidence-based clinical practice will be promoted and
adopted for health care (Miller, Jones, Graves, & Sievert,
2010).
522
Since the 1990s, several evidence-based practice-
related survey questionnaires and studies have been
conducted worldwide in a range of health care profes-
sions (e.g., Ahmad et al., 2009; Brown, Wicklines, Ecoff,
& Glaser, 2009; Gerrish, Ashworth, Lacey, & Bailey,
2008; Jette et al., 2003; Koehn & Lehman, 2008; Mc-
Coll, Smith, White, & Field, 1998; Pravikoff, Tanner, &
Pierce, 2005; Waters, Crisp, Rychetnik, & Barratt, 2009).
Broadly, these and other studies collectively covered the
following: (1) beliefs, attitudes toward, and knowledge
of evidence-based practice; (2) skills and competencies
involved in evidence-based practice; (3) barriers to pro-
moting and implementing evidence-based practice; and
(4) educational and training needs for evidence-based
practice. The questionnaires used were almost all self-
reporting and used a combination of a 5-, 7-, or 11-point
Likert scale; “yes,” “no,” and “do not know” state-
ments; and free text input to elicit responses. Content
validation was generally established by nursing experts,
Dr. Foo is Professor and Associate Dean, College of Humanities,
Arts and Social Sciences, Dr. Majid is Associate Professor, Ms. Zhang is
PhD candidate, Dr. Luyt is Associate Professor, Dr. Chang is Assistant
Professor, and Dr. Theng is Associate Professor, Division of Informa-
tion Studies, Wee Kim Wee School of Communication and Information,
Nanyang Technological University, Singapore. Dr. Mokhtar is Assistant
Professor, Department of Policy and Leadership Studies, National Insti-
tute of Education, Nanyang Technological University, Singapore.
The authors disclose that they have no significant financial interests
in any product or class of products discussed directly or indirectly in this
activity, including research support.
Address correspondence to Schubert Foo, PhD, FBCS, FIMechE,
Professor and Associate Dean, College of Humanities, Arts and Social
Sciences, Nanyang Technological University, HSS-06-16D, 14 Nan-
yang Drive, Singapore 637332. E-mail: sfoo@pmail.ntu.edu.sg.
Received: February 9, 2011; Accepted: April 18, 2011; Posted: May
23, 2011.
doi:10.3928/00220124-20110516-04
Copyright © SLACK Incorporated
the use of psychometric methods, and pilot studies to
ensure validity and reliability. Collectively, these stud-
ies covered findings from the United States, Canada, the
United Kingdom, Sweden, Denmark, Finland, Saudi
Arabia, Bahrain, Iran, Kuwait, Zimbabwe, Hong Kong,
and Australia.
Although there would be obvious contradictions in
the specific findings of these various studies, there are
also clear common observations that are shown in the
literature. Almost all studies reported positive attitudes
toward evidence-based practice among both practitio-
ners and managers, mainly as a result of the potential
ability of evidence-based practice to provide consistently
high-quality health care to patients. Most studies agreed
that evidence-based practice is necessary, that litera-
ture is useful to improve practice, that evidence aids in
decision-making, and that evidence-based practice helps
to improve patient care (Jette et al., 2003; McColl et al.,
1998). The adoption and use of evidence-based practice
varies among work settings and countries. This could
be a result of the differing state of health care in various
countries, the presence and strength of the barriers to
evidence-based practice, and the education and pre-
paredness of professionals in evidence-based practice.
In cases where evidence-based practice is not pervasive,
there is a general recognition of the need to increase the
use of evidence in daily practice (McColl et al., 1998).
In terms of nurses’ skills and competencies in
evidence-based practice, most health care professionals
reported general awareness but limited use of key data-
bases and sources (Rolfe, Segrott, & Jordan, 2008). Re-
ported competency in the ability to search for and find
relevant and useful information was mixed across stud-
ies, with health care professionals in developed countries
having an advantage because of their better information
technology infrastructure and greater access to the In-
ternet. In contrast to using literature for evidence-based
practice, consulting peers and colleagues seems to be a
common and ongoing practice (Gerrish et al., 2008; Mc-
Coll et al., 1998). The use of “intuition” and “reflection
of life experience” are other cited sources of evidence
employed in practice (Rolfe et al., 2008).
Seniority and experience in terms of age, years since
licensure and professional entry, advanced academic
degrees, and accumulated training was associated with
greater reported confidence in the knowledge and use of
evidence-based practice (Gerrish et al., 2008; Jette et al.,
2003). In contrast, searching skills and familiarity with
the online environment seemed to favor the younger
generation of health care professionals, who are better
equipped in their educational preparation for this phase
of evidence-based practice (Jette et al., 2003).
The Journal of Continuing Education in Nursing · Vol 42, No 11, 2011
Lack of time was the most frequently cited barrier to
evidence-based practice in almost all studies. This has
been attributed typically to heavy workloads and other
personal commitments. Organizational barriers included
the presence of other goals with a higher priority, diffi-
culty in recruiting and retaining staff, lack of autonomy,
and budgetary constraints (Brown et al., 2009; Pravikoff
et al., 2005). Personal barriers included lack of perceived
value of research in practice, lack of skills and compe-
tencies to carry out different stages of evidence-based
practice effectively (Pravikoff, Tanner, & Pierce, 2005;
Penz & Bassendowski, 2006), and problems associat-
ed with individual learning styles (Reavy & Tavernier,
2008). Challenges remain in finding and understanding
research reports that are prone to methodological in-
adequacies and conflicting findings (Koehn & Lehman,
2008; O’Conner & Pettigrew, 2009).
Health care professionals generally seek education and
training because they view it as part of a lifelong learning
journey to provide evidence-based practice (Jette et al.,
2003). Needs in terms of knowledge of sources, search-
ing skills, and critical appraisal of the literature have been
cited in different studies. Being able to critically appraise
evidence from different sources and select and apply
the most appropriate evidence in practice appears to be
the most challenging aspect of evidence-based practice
(Waters et al., 2009). Miller et al. (2010) pointed out that
front-line nurses usually did not have the ability to find
relevant information, evaluate its credibility, and apply
it to practice. A more realistic suggested approach is to
develop the skills to appraise information, such as clini-
cal protocols, in the context of the local setting in which
it is to be applied (Gerrish et al., 2008).
This was the first study on this topic conducted in
Singapore, and the goal was to contribute to the growing
literature on evidence-based practice from the perspec-
tive of nurses to examine whether the findings are similar
to those of other studies. The study was conducted at the
National University Hospital, a 935-bed acute care spe-
cialty hospital that provides advanced medical care and
services and serves as a major referral center that handles
a wide range of medical and dental specialties.
METHODS
The survey instrument consisted of six demographic
and seven evidence-based practice-related questions ex-
tracted and adopted from existing survey questionnaires.
A consistent five-point scale, ranging from 1 to 5 points
to indicate “strongly disagree” to “strongly agree,” “least
important” to “most important,” and “poor” to “excel-
lent,” was used to elicit nurses’ responses. Approval for
the study was obtained from the domain specific review
523
 TABLE 1
RESPONSE OF NURSES TO STATEMENTS ABOUT EVIDENCE-BASED PRACTICE
My workload is too great to keep up-to-date with all of the new evidence.
I believe that evidence-based practice has limited utility.
Most research articles are not relevant to my daily practice.
I dislike people questioning my clinical practice, which is based on established methods.
I prefer using more traditional methods instead of changing to new approaches.
Note. Mean is arranged in descending order. Cronbach’s alpha = 0.681 for all five items.
board. Content validity was established by experts, in-
cluding information studies lecturers, nursing managers,
nurse researchers, and registered nurses. Internal con-
sistency reliability was evaluated with Cronbach’s al-
pha coefficient, which yielded a range of values between
0.691 and 0.954. The questionnaire was pilot tested on 20
nurses, refined, and distributed to all 1,518 part-time and
full-time registered nurses at the National University
Hospital. A total of 1,144 usable returns, representing
a 75.4% return rate, were used for analysis, which was
conducted with SPSS software, version 14.
RESULTS
The demographic profile of nurses showed that the
respondents included 1,054 (92.2%) registered nurses, 39
(3.4%) nurse managers or senior nurse managers, and 47
(4.1%) nurse clinicians, nurse educators, or senior nurse
clinicians or nurse educators. Of the respondents, 505
(44.1%) had a bachelor’s or master’s degree in nursing,
whereas 158 (13.9%) had a post basic or advanced di-
ploma in nursing and 468 (40.9%) had a certificate or
diploma in nursing. A total of 553 (48.3%) of the nurses
had less than 5 years of nursing experience, 234 (20.5%)
had 6 to 10 years, and 307 (26.8%) had more than 10
years. A large majority (922; 83%) of the nurses indi-
cated that they had not attended any training courses on
evidence-based practice.
Nurses were asked what evidence-based practice
meant to them and how they understood and adopted
evidence-based practice in providing nursing care and
making clinical decisions based on a different set of
choices. Forty-nine (4.3%) of the nurses believed that
they were practicing and adopting evidence-based prac-
tice as long as they made clinical decisions based on a pa-
tient’s subjective and objective data; 108 (9.4%) perceived
evidence-based practice to be using information obtained
from textbooks; and 121 (10.6%) perceived evidence-
based practice to be using a combination of previous ex-
periences and research findings. Nonetheless, a majority
524
n M SD
1,127 3.2138 0.9654
1,115 2.7731 0.8093
1,120 2.5527 0.8213
1,119 2.5496 0.7828
1,118 2.3175 0.7403
(412; 36.8%) of the nurses indicated that evidence-based
practice includes all of the above, whereas 417 (36.5%)
indicated that evidence-based practice includes all of
the above except using information obtained from text-
books, but recognized the importance of considering the
patient’s values and preferences as part of the process of
adopting evidence-based practice. The responses indi-
cated that most nurses were not fully aware of what evi-
dence-based practice means, and this could be explained
by the finding that most of the respondents (922; 83%)
lacked formal training in evidence-based practice.
Nurses stated their opinions and beliefs using a scale
ranging from 1 (strongly disagree) to 5 (strongly agree)
to respond to a series of statements about evidence-based
practice, as shown in Table 1. The table shows the total
number of responses and the mean and standard devia-
tion.
Nurses generally expressed very positive opinions of
evidence-based practice despite their somewhat shallow
knowledge and understanding of it. Most reported that
their workload was too great for them to keep up to date
with all new evidence (M = 3.2138, SD = 0.9654). None-
theless, they disagreed with most of the other statements,
thereby showing a positive opinion of evidence-based
practice. They disagreed with the statement that they did
not like people questioning their clinical practice that was
based on established methods (M = 2.5496, SD = 0.7828).
They disagreed that evidence-based practice has limited
utility (M = 2.7731, SD = 0.8093), and that they preferred
using more traditional methods instead of changing to
new approaches (M = 2.3175, SD = 0.7403). Further, they
disagreed that most research articles were not relevant to
their daily practice (M = 2.5527, SD = 0.8213).
Table 2 shows the nurses’ responses to nine state-
ments about their self-efficacy in performing activities
related to evidence-based practice. Most results hover
around the midpoint score of 3, implying that the nurses
rated themselves as average on various evidence-based
practice activities. The overall mean for all nine state-
Copyright © SLACK Incorporated
 TABLE 2
SELF-EFFICACY OF NURSES IN PERFORMING EVIDENCE-BASED PRACTICE ACTIVITIES
n M SD
Identify clinical issues and problems. 1,127 3.2547 0.6107
Translate a clinical issue or problem into a well-formulated clinical question. 1,126 3.0142 0.6238
Distinguish among different types of questions. 1,126 3.1865 0.6386
Conduct online searches. 1,121 3.0946 0.7962
Relate research findings to clinical practice and point out similarities and differences. 1,127 3.1624 0.6605
Use a checklist to assess research articles. 1,128 2.9654 0.7343
Read a research report and have a general idea about its strengths and weaknesses. 1,127 3.0150 0.7057
Apply an intervention based on the most applicable evidence. 1,128 3.0869 0.6343
Evaluate the application of interventions and identify areas for improvement. 1,127 3.0985 0.6611
Note. Cronbach’s alpha = 0.897 for all nine items.

TABLE 3
BARRIERS TO EVIDENCE-BASED PRACTICE
n M SD
Difficulty finding time at work to search for and read research articles and reports. 1,133 3.5172 0.8700
Insufficient time at work to implement changes in current practice. 1,132 3.3975 0.8138
Difficulty judging the quality of research papers and reports. 1,133 3.3928 0.7876
Inability to understand statistical terms used in research articles. 1,136 3.3917 0.7548
Inadequate understanding of terms used in research articles. 1,136 3.3627 0.7489
Insufficient resources. 1,120 3.3107 0.8175
Inability to properly interpret the results of research studies. 1,132 3.2597 0.7853
Difficulty determining the applicability of research findings. 1,133 3.2418 0.7506
Inability to implement the recommendations of research studies in clinical practice. 1,132 3.2031 0.7941
Note. Mean arranged in descending order. Cronbach’s alpha = 0.873 for all nine items.

ments was 3.0996 (SD = 0.5000). The ability to identify
clinical issues and problems yielded the highest score
(M = 3.2547, SD = 0.6107), with 61.85% of nurses rat-
ing themselves as average and 31.5% rating themselves
as above average to excellent. In contrast, nurses rated
themselves as least adequate in the area of using check-
lists to assess research articles. This response yielded the
lowest score (M = 2.9654, SD = 0.7343), with 55.59% of
nurses rating themselves as average and 23.22% rating
themselves as below average to poor. This may point to
a lack of competency in research (information evalua-
tion) skills, a lack of or limited actual practice in using
research articles, or both.
Table 3 shows the nurses’ ratings of the perceived bar-
riers sorted in descending order. No single barrier was
rated by a mean value below the midpoint, which sug-
gests that the nurses perceived barriers that prevented
them from adopting evidence-based practice at work.
The overall mean for all nine barriers was 3.3473 (SD =
0.5555). The top barrier identified was time. The highest
scored barrier was the difficulty in finding time at work
to search for and read articles and reports (M = 3.5172,
SD = 0.8700), with more than half of respondents, or a
total of 610 nurses (53.84%), agreeing or strongly agree-
ing that this is most challenging. The second highest
scored barrier was insufficient time at work to imple-
ment changes to current practice (M = 3.3975, SD =
0.8138), with 529 nurses (46.73%) agreeing or strongly
agreeing. This was followed by difficulty judging the
quality of research papers and reports (M = 3.3928,
SD = 0.7876) and inability to understand statistical terms
used in research articles (M = 3.3917, SD = 0.7548). The
lowest scored perceived barrier was inability to imple-
ment the recommendations of research studies in clinical

The Journal of Continuing Education in Nursing · Vol 42, No 11, 2011 525
 TABLE 4
FACTORS DEEMED IMPORTANT BY NURSES FOR ADOPTING EVIDENCE-BASED PRACTICE
n M SD
Adequate training in evidence-based practice. 1,138 3.9165 0.7986
Protected time to conduct evidence-based practice. 1,135 3.8881 0.8006
Mentoring by nurses who have adequate experience in evidence-based practice. 1,134 3.8765 0.7909
Nurse managers who embrace evidence-based practice. 1,134 3.8130 0.7851
Access to a system for comprehensive literature searching. 1,133 3.8049 0.7795
Nursing colleagues who embrace evidence-based practice. 1,134 3.6552 0.7906
Note. Mean arranged in descending order. Cronbach’s alpha = 0.919 for all six items.

TABLE 5
PERCEIVED IMPORTANCE OF RECEIVING TRAINING IN SPECIFIC AREAS OF EVIDENCE-BASED PRACTICE
n M SD
Identifying clinical issues for implementing evidence-based practice. 1,138 3.9200 0.7698
Understanding what constitutes evidence-based practice. 1,140 3.9158 0.8328
Implementing recommendations in practice. 1,137 3.8733 0.7528
Understanding research and statistical terms and methods. 1,137 3.8514 0.7736
Synthesizing evidence. 1,137 3.7704 0.7845
Conducting literature searches. 1,135 3.7471 0.7849
Conducting critical appraisal of articles. 1,135 3.7445 0.7990
Note. Mean arranged in descending order. Cronbach’s alpha = 0.954 for all seven items.

practice, a factor that may be a direct consequence of the
time constraint associated with adopting evidence-based
practice that was cited previously.
Table 4 shows the ratings of the six factors that are
considered important for adopting evidence-based prac-
tice in the workplace. Most of the nurses stated that
proper and adequate training (M = 3.9165, SD = 0.7986),
protected time to conduct evidence-based practice (M =
3.8881, SD = 0.8006), and mentoring by nurses with ad-
equate evidence-based practice experience (M = 3.8765,
SD = 0.7909) were the three most important factors to be
considered for the adoption of evidence-based practice.
More than two thirds of respondents (798; 70.12%) con-
sidered the top factor, the need for adequate training in
evidence-based practice, very important (45.52%) or ex-
tremely important (24.60%) to promote the adoption of
evidence-based practice in the hospital. In view of this,
the next set of findings on training needs is particularly
appropriate and relevant.
Table 5 shows the ratings of the seven areas of train-
ing. The findings showed that the top three training
needs are as follows: (1) identifying clinical issues for
implementing evidence-based practice (M = 3.9200,
SD = 0.7698); (2) understanding what constitutes evi-
dence-based practice (M = 3.9158, SD = 0.8328); and (3)
implementing recommendations in practice (M = 3.8733,
SD = 0.7528).
Additional statistical tests that were performed on the
demographic variables against the evidence-based prac-
tice variables showed that senior highly qualified nurses
with training in evidence-based practice are most confi-
dent and knowledgeable in their ability to perform evi-
dence-based practice activities. Nurses with higher levels
of nursing education tend to have better reported infor-
mation-related skills (e.g., sourcing, searching, evaluat-
ing, and using evidence-based practice information) and
less difficulty in applying evidence-based practice, but
at the same time, these nurses reported the highest per-
ceived barriers and indicated the greatest need for train-
ing in evidence-based practice.
DISCUSSION
The findings showed that the majority of nurses sur-
veyed did not have any formal training or courses in
evidence-based practice. This finding is somewhat sur-
prising because 44.1% of these nurses had a degree or

526 Copyright © SLACK Incorporated

postgraduate degree that normally has a component of
formal training in evidence-based practice. It may be the
case that these respondents did not receive training in
evidence-based practice as part of their nursing educa-
tion curriculum because this material was not routinely
covered at that time. These nurses had a mean of approx-
imately 8 years of nursing experience. Nurses who had
diplomas (55% of those surveyed) did not seem to have
any evidence-based practice courses in their curriculum,
which may further explain the lack of formal training in
this area.
The issues and perceptions reported by nurses in
Singapore are similar to those of their counterparts
worldwide. The respondents were open to evidence-
based practice but felt that they lacked competence and
knowledge in conducting evidence-based practice activi-
ties. These findings mirror those of studies conducted
in nurses in New South Wales, Australia (Waters et al.,
2009); primary care physicians in Kuwait (Ahmad et al.,
2009); and nurses at a large Midwestern urban medical
center in the United States (Koehn & Lehman, 2008). In
Singapore, the lack of competence and knowledge can be
attributed to the lack of formal training and coursework
in evidence-based practice for most nurses.
The main barriers to adopting evidence-based prac-
tice are related to time: the need to find time at work to
search for and read articles and reports and insufficient
time at work to implement changes to current practice.
The respondents also reported inability to judge the
quality of research papers and reports, understand the
contents, and interpret the results to apply to practice.
These trends were widely reported in other studies
(Brown et al., 2009; Jette et al., 2003; Koehn & Lehman,
2008; O’Conner & Pettigrew, 2009).
The respondents suggested that adequate training,
the availability of protected time to conduct evidence-
based practice, and mentoring by nurses with experience
in evidence-based practice were the most important fac-
tors to enable better and more widespread adoption of
evidence-based practice. This finding is logical and aligns
with respondents’ perceived inadequacy and competence
in knowledge and skills related to evidence-based prac-
tice as well as the time barriers that nurses currently face.
Almost all areas of training listed in the questionnaire
were deemed important by the nurses because most of
them have yet to receive formal training in evidence-
based practice. The findings also concur with other stud-
ies indicating that nurses’ qualifications and experiences
are directly related to their attitudes, skills, competen-
cies, confidence, and training regarding evidence-based
practice (Gerrish et al., 2008; Jette et al., 2003; Johansson,
Fogelberg-Dahm, & Wadensten, 2010).
The Journal of Continuing Education in Nursing · Vol 42, No 11, 2011
key points
Evidence-Based Practice
Foo, S., Majid, S., Mokhtar, I. A., Zhang, X., Luyt, B., Chang, Y.-
K., Theng, Y.-L. (2011). Nurses’ Perception of Evidence-Based
Practice at the National University Hospital of Singapore. The
Journal of Continuing Education in Nursing, 42(11), 522-528.
1 Registered nurses in Singapore, like most of their counterparts
around the world, reported a positive and supportive attitude
toward evidence-based practice but lacked the competence and
knowledge to conduct evidence-based practice.
2 To enable evidence-based practice to succeed, there is a need for
proper education and training, mentoring by senior nurses, and
adequate time to conduct proper evidence-based practice.
3
Nurses with a higher level of nursing education indicated the
highest perceived barriers, had less difficulty applying evidence-
based practice, and described the need for more training in
information skills.
4 Evidence-based practice is still in its infancy in Singapore, with
a long way to go to reach the level of maturity that has been
attained by some hospitals in other developed countries.
CONCLUSION
Because of its high participation rate, this study yield-
ed a set of reliable data on the current state of evidence-
based practice in one of the largest hospitals in Singa-
pore. The findings suggest that evidence-based practice
is in its infancy in Singapore, with a long way to go to
reach the level of maturity attained by some hospitals in
other developed countries. There remains much to learn
and emulate. Against this scenario, nurses’ perceptions
of the entire evidence-based practice process is an im-
portant factor if evidence-based practice is deemed an
area of concern and development in the future.
Existing evidence-based practice questionnaires
help to identify previous conditions that affect nurses’
decision to adopt evidence-based practice and aid hos-
pitals and decision makers to identify areas for further
review and assessment. This study showed that even
at a medically advanced hospital in Singapore, nurses
face similar and challenging evidence-based practice
scenarios. The study results can be used as a basis for
further investigation and to develop training and in-
tervention programs to better prepare nurses to imple-
ment evidence-based practice in the hospital to offer
even better patient care.
527
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