Original Article

A Multisite Health System Survey to Assess

Organizational Context to Support Evidence-­
Based Practice
Joyce Pittman, PhD, ANP-BC, FNP-BC, CWOCN, FAAN ● Andrea Cohee, PhD, RN ●
Susan Storey, PhD, RN, AOCNS ● Julie LaMothe, DNP, RN, CPNP ●
Jason Gilbert, PhD, MBA, RN, NEA-BC ● Giorgos Bakoyannis, PhD ●
Susan Ofner, MS ● Robin Newhouse, PhD, RN, NEA-BC, FAAN

Key words ABSTRACT

evidence-based Background: Implementation and sustainability of a culture of evidence-­based practice (EBP)
practice, require a systematic approach. A baseline assessment of the organizational context can inform
administration/ implementation efforts.
management/ Aims: To examine organizational hospital context and provider characteristics associated with
leadership/ EBP readiness and to describe EBP context across hospitals.
organization, survey,
Methods: A nonexperimental descriptive correlational design was used to conduct a web-­
quantitative, survey
based survey of direct-­care registered nurses (N = 701) and nurse managers (N = 94) across a
methodology/data
large Midwestern multisite healthcare system using the Alberta Context Tool (ACT).
collection,
professional issues/ Results: Many significant relationships existed among nurse characteristics and ACT domains,
professional ethics/ including age (lower age had higher Leadership, Evaluation, and Formal Interactions), educa-
professional tion (graduate education had lower Social Capital than a bachelor’s or associate degree), role
standards (direct-­care nurses had lower Culture than managers and lower Social Capital), and work status
(full-­time employees had lower Evaluation and Social Capital). EBP context across type of hos-
pitals is similar, with marginal differences in Social Capital and Organizational Slack (higher in
critical access hospitals).
Linking Evidence to Action: Assessing organizational context to support EBP is the first step
in developing and enhancing a sustainable culture of inquiry. The ACT has been tested across
countries, settings, and healthcare disciplines to measure perception of readiness of the prac-
tice environment toward EBP. Optimal organizational context is essential to support EBP and
sustain the use of evidence in professional nursing practice. Nursing leaders can use baseline
assessment information to identify strengths and opportunities to enhance EBP implementa-
tion. Enhancing organizational context across nurse characteristics (e.g., age, role, and work
status) to acknowledge nurses’ contributions, balance nurses’ personal and work life, enhance
connectedness, and support work culture is beneficial. Fostering development of Social Capital
in nurses is needed to influence EBP readiness. A systematic and standardized approach to
foster EBP across health systems is key to successful implementation.

BACKGROUND potential strategies to mitigate medical error and improve

Evidence-­ based practice (EBP) is central to the nursing
profession and an essential component of nursing practice
(American Nurses Association, 2015). EBP requires synthe-
sis, evaluation, and application of research to guide clinical
practice decisions and promotes safe, high-­quality patient
care. Medical errors are the third leading cause of death
in the United States following heart disease and cancer,
with preventable deaths reaching an estimated 251,454 per
year (Makary & Daniel, 2016). Others have estimated pre-
ventable deaths being as high as 206,021 annually (Austin
& Derk, 2016). EBP is a central component of the many
quality of care.
High-­reliability organizations are those that consistently
and reliably manage complex and often high-­risk processes
and strive to reduce preventable harm to zero. To be a high-­
reliability organization, a culture of EBP and a spirit of
inquiry are needed (Frankel, Haraden, Federico, & Lenoci-­
Edwards, 2017). High-­reliability organizations establish a
learning healthcare system, which utilizes EBP and research
resulting in new evidence to support high-­quality, safe, and
efficient health care and is used to drive continuous im-
provement (Johnson et al., 2015).

Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280. 271

© 2019 Sigma Theta Tau International
A Multisite Health System Survey
Within a learning healthcare system, nursing leader-
ship’s influence on organizational culture, context, nursing
practice environment, and organizational resources is key
to developing and enhancing a culture of EBP within or-
ganizations. Nursing leaders must consider the value and
challenges of integrating EBP and research to guide quality
improvement and patient care outcomes in order to support
integration of EBP into nursing processes (Johnson et al.,
2015). Implementation and sustainability of a culture of
EBP require a systematic approach, which should begin with
an organizational assessment of readiness for EBP (Melnyk,
2007). This baseline assessment examines the culture, con-
text, environment, strengths, and barriers that influence EBP
within the organization (Melnyk, 2017).
Nursing leadership within a large Midwestern healthcare
system charged their system-­wide research and EBP com-
mittee (research to practice [R2P] committee) with infus-
ing a standard EBP approach across 14 acute care hospitals
and ambulatory settings. A team of nursing leaders from the
healthcare system and university collaborated with the R2P
committee to implement a structured approach consisting
of four phases: A baseline assessment of organizational con-
text standardized EBP training for nurse champions, gen-
eral EBP training for all nurses, and EBP training specific to
nurse managers. In this paper, we describe the results from
the baseline assessment of the organization’s readiness and
context for EBP and research across 14 acute care hospitals.
AIMS
The purpose of this study was to assess organizational
context and capacity for EBP within a large Midwestern
multisite healthcare system. Specific aims were to exam-
ine organizational context and provider characteristics as-
sociated with EBP readiness and to describe EBP resources
across a large Midwestern multisite healthcare system.
METHODS
A nonexperimental descriptive correlational design was
used to conduct a web-­based survey of direct-­care nurses
and nurse managers within a large Midwestern multisite
healthcare system. A convenience sample of registered nurses
(N = 8,003) employed across 14 hospitals were invited to
participate. Prior to the survey, information was commu-
nicated to nurses and nurse managers via an introductory
email, notices in internal web-­based newsletters, and at
hospital-­based committees and councils. The first email of
invitation to participate and all subsequent emails included
the survey link. Email reminders were sent weekly there-
after for 3 weeks for a total of five email communications.
Demographic information was collected about re-
spondents including name of hospital, age range, gender,
years of experience, race, ethnicity, percentage of time
in direct patient care, educational level, type of unit, and
272
employment status. Hospitals were categorized by type
of setting: academic, community, and critical access. For
this study, academic hospitals were defined as those hospi-
tals organizationally or administratively integrated with a
medical school (The Joint Commission, n.d.). Community
hospitals were defined as nonfederal, short-­term general
hospitals (American Hospital Association, 2019). Finally,
critical access hospitals were defined as those hospitals that
furnish 24-­hr emergency services, have no more than 25
inpatient beds, have an average length of stay of 96 hr or
less, and are located more than 35 miles from another hos-
pital (Medical Learning Network, 2017).
The Alberta Context Tool (ACT) was used to measure
nurse perception of readiness of the practice environment
toward EBP (Estabrooks, Squires, Cummings, Birdsell, &
Norton, 2009). The ACT was selected by the R2P committee
as the most appropriate measure of the organizational context
and organizational environment. The ACT has been used in
a variety of countries (e.g., Canada, Sweden, Germany, and
Australia), populations (e.g., nurses, physicians, allied health
professionals, specialists, healthcare aides, and managers), and
settings (e.g., pediatric hospitals, acute care, residential long-­
term care facilities, and community and home care settings),
making it very applicable for use in this large multisite health-
care organization (Eldh, Ehrenberg, Squires, Estabrooks, &
Wallin, 2013; Estabrooks, Squires, Hayduk, Cummings, &
Norton, 2011; Hoben et al., 2014; Squires et al., 2013).
Organizational context is defined as the healthcare en-
vironment or setting where research is implemented and
has been operationalized in the ACT as 8 unique concepts
or domains (Estabrooks et al., 2009). The ACT measures
nurses’ perceptions of Leadership, Culture, Evaluation,
Social Capital, Informal Interactions, Formal Interactions,
Structural and Electronic Resources, and Organizational
Slack. Table 2 includes a description of each domain. The
ACT is a 56-­item survey that takes approximately 15 min to
complete and has demonstrated validity and acceptable re-
liability with a Cronbach alpha of ≥0.70 for all of the 8 con-
cepts, with the exception of a component of Organizational
Slack (Squires et al., 2015).
The ACT domains of Leadership, Culture, Evaluation,
and Social Capital each contain six items; the ACT domain
of Informal Interactions contains 10 items; the ACT do-
main of Formal Interactions contains four items; the ACT
domain of Structural and Electronic Resources contains 11
items; and the Organizational Slack domain is comprised of
three concepts (i.e., staff, space, and time), each containing
two to four items. Scoring for the domains differs accord-
ing to the specific domain. Leadership, Culture, Evaluation,
Social Capital, and Organizational Slack are true scales,
meaning they each contain a cohesive set of items with a
shared concept. The mean of the domain reflects the mean
of the concept. Informal Interactions, Formal Interactions,
and Structural and Electronic Resources are not true scales,
meaning they are a yes or no and reflect a total of the items
Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.
© 2019 Sigma Theta Tau International

in each domain or a list of the resources. The mean reflects
the mean number of resources or interactions in the do-
main (Squires et al., 2014).
REDCap (Research Electronic Data Capture) database
system was used to support the collection and manage-
ment of data for this study. The REDCap software platform
provides a secure, web-­based environment that is flexible
enough to be used for a variety of types of research and
provides an intuitive interface for users to enter data and
have real-­time validation rules (with automated data type
and range checks) at the time of entry.
Ethical Issues and Approval
This study was approved by the Indiana University
Institutional Review Board.
Statistical Analysis
Specific aims were to examine organizational context and
provider characteristics associated with EBP readiness and
describe EBP context across a large Midwestern multisite
healthcare system.
Descriptive statistics were used to summarize the data.
Continuous measures were summarized using mean and
standard deviation, and categorical measures were sum-
marized using frequencies and percentages. Score differ-
ences among hospital types were statistically evaluated
using a rank-­sum test that accounts for the clustering of
the participants within the same facility (Datta & Satten,
2005). The measures that were true scales (Leadership,
Culture, Evaluation, Social Capital, and Organizational
Slack) were modeled simultaneously using multivariate
linear regression. For simplification, the mean of the
three dimensions of Organizational Slack (staff, space,
and time) was used to measure the concept in the mul-
tivariate outcome. Nine explanatory variables were con-
sidered as potential candidate variables: age, gender, race,
education, role, years in the unit, work status, hospital
type, and bed size. Variable selection was based on the
Akaike’s information criterion (AIC), where all models
were fit using all possible combinations of these nine co-
variates (Shao, 1997). This variable approach has been
shown to be consistent, where consistency is defined in
terms of model selection (Shao, 1997). The final model
was selected as the one with the smallest AIC. The mod-
els also included variables that were potentially associ-
ated with the probability of nonresponse, regardless of
their level of statistical significance (e.g., age, education,
participant role and status, gender, race, hospital type,
bed size, and years in unit). By accounting for these vari-
ables, the missing at random assumption due to nonre-
sponse is plausible in our setting (Little & Rubin, 2014),
and therefore, our estimates are expected to be unbiased
even though the response rate was low. To account for
the clustering of the data according to the hospitals, we
used the nonparametric clustered bootstrap approach for
Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.
© 2019 Sigma Theta Tau International
Original Article
standard error estimation (Field & Welsh, 2007). Based
on the estimated variance–covariance matrix of the full
vector of parameters, we constructed a Wald test to eval-
uate the overall effect of each of the covariates on five of
the ACT domains: Leadership, Culture, Evaluation, Social
Capital, and Organizational Slack.
The three domains of mean counts (Informal Interactions,
Formal Interactions, and Structural and Electronic Resources)
were each modeled separately by means of a linear model
with a compound symmetry covariance structure that in-
corporated the correlation of responses by subjects from
the same facility. Standard error estimation was based on a
proper robust sandwich-­type estimator. Estimates were ob-
tained using generalized estimating equation methodology.
Models were fit to all possible combinations of covariates and
the smallest quasi-­likelihood under the independence model
criterion (QIC), which is an estimate of the AIC (Pan, 2001)
statistic that was used to determine the combination that best
fits each outcome. As in the multivariable analysis, we also
included potential confounders but only report estimates for
variables included in the model with the smallest QIC.
RESULTS
Response rate for the survey was 13.4%. Following data re-
view and cleaning, 222 surveys were excluded due to miss-
ing data, resulting in 853 surveys included for analysis.
Of the 14 hospitals, four were academic hospitals, five
were community hospitals, and five were critical access
hospitals. Bed size across hospitals (critical access to aca-
demic) varied, ranging from 15 to 858 beds with a mean
of 407 (SD = 283.1). Over 61% (n = 524) of respondents
worked in an academic hospital, 31% (n = 262) in a com-
munity hospital, and 8% (n = 67) in a critical access hos-
pital. The age groups of those who responded were evenly
distributed: 29% were less than 40 years old (n = 247),
35% were 40–54 years of age (n = 299), and 36% were
55 years old or older (n = 307). Over 82% (n = 701) of the
nurses identified their role as a direct-­care nurse and 11%
(n = 94) as manager. The majority of nurses had a bache-
lor’s degree (n = 570, 67%), whereas 17% (n = 143) had an
associate or other degree, and 16% (n = 140) had a master’s
or doctoral degree. The majority of nurses were Caucasian
(n = 798, 94%), female (n = 792, 93%), and worked full time
(n = 688, 81%). The average length of time on their unit was
7.3 (SD = 8.0) years. Table 1 describes nurse characteristics.
Results aligned with each aim will be further described.
Aim 1: Examine Organizational Context and
Provider Characteristics Associated With
EBP Readiness
Organizational EBP context (ACT)
The aggregate ACT domain mean scores for all hospitals
were as follows: Leadership: 3.9 (SD = 0.9); Culture: 3.9
(SD = 0.6); Evaluation: 3.7 (SD = 0.9); Social Capital: 2.9
273
A Multisite Health System Survey

Table 1.  Respondent Characteristics nurses had a lower perception of Leadership (p = .025)

and Evaluation (p = .001) domains. Nurses with a mas-
n (%) ter’s or PhD degree had lower perceptions of Social Capital
Age
than those with bachelor’s or associate degrees (p = .028).
Moreover, direct-­care nurses had a lower mean perception
<40 years 247 (29.0)
of Culture (p = .012) than managers. Direct-­ care nurses
40–54 years 299 (35.1) also had lower perceptions of Social Capital (p = .034) and
55+ years 307 (36.0) Organizational Slack (p = .004) as compared to “other”
Gender roles but had a higher average perception of Evaluation
(p = .002). In addition, full-­ time employees had lower
Female 792 (92.8)
perceptions of Evaluation (p = .014) and Social Capital
Male 61 (7.2) (p = .017) compared with part-­time (casual) employees.
Race On average, nurses over 40 years old reported fewer
Caucasian 798 (93.6) Formal Interactions (p < .001). Nurses in academic hospi-
Non-­Caucasian 55 (6.4) tals had more Informal Interactions compared with criti-
cal access hospitals (p = .016). Adjusted for hospital type,
Education
nurse respondents perceived the number of Structural and
Certificate/associate/other 143 (16.8) Electronic Resources increased with bed size (approaching
Bachelor’s degree 570 (66.8) significance at p = .073; see Table 3). See Table 4 for a sum-
Master’s/PhD 140 (16.4) mary of EBP nurse readiness by nurse characteristics.
Role
Aim 2: Describe EBP Context Across a Large
Manager 94 (11.0) Midwestern Multisite Healthcare System
RN 701 (82.2) When examining the hospital EBP context, differences
Other 58 (6.8) among hospital types (academic, community, and critical
Status access) for each domain were tested, but significant dif-
ferences were only found in the domains of Social Capital
Full time 688 (80.7)
(p = .039) and Organizational Slack (p = .041). However,
Part time 142 (16.6) these differences were not statistically significant at the .017
Casual 23 (2.7) level after Bonferroni adjustment to account for the three
Years in unit pairwise comparisons between hospital types. Critical ac-
N 853
cess hospitals demonstrated higher means in the domains
of Social Capital and Organizational Slack than academic or
Mean ± SD 7.3 ± 8.0
community hospitals. ACT domain mean scores by hospital
Median (min, max) 5.0 (0.0, 40.8) type are included in Table 3.
Hospital type
Academic 547 (64.1)
DISCUSSION
Community 239 (28.0)
This study examined the context and provider charac-
Critical care 67 (7.9) teristics associated with EBP readiness and described EBP
Bed size context across hospitals using the ACT. Many significant
N 853 individual nurse characteristics were related to ACT do-
Mean ± SD 407.3 ± 283.1
mains including age, education, role, and work status. EBP
context across hospitals was similar, with differences only
Median (min, max) 355.0 (15.0, 858.0)
in the domains of Social Capital and Organizational Slack
(higher in critical access hospitals). Although the ACT was
selected as the measure for this study by the R2P com-
(SD = 1.2); Formal Interactions: 1.9 (SD = 1.0); Informal mittee, it bears mentioning that there are other valid and
Interactions: 5.1 (SD = 1.9); Structural and Electronic reliable tools that could be used to assess organizational
Resources: 4.6 (SD = 2.1); and Organizational Slack: 3.1 context for EBP readiness. One example, utilized in the
(SD = 0.7; see Table 2 for ACT domains by hospital type). Evidence-­Based Advancing Research and Clinical Practice
Through Close Collaboration model, is the Organizational
Nurse characteristics associated with EBP context Culture and Readiness Scale for System-­wide Integration of
Nurse characteristics significantly related to overall ACT Evidence-­Based Practice (OCRSIEP). The OCRSIEP describes
domains were age, education, role, and work status. Older organizational characteristics and identifies strengths and

274 Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.

© 2019 Sigma Theta Tau International
 Original Article
Table 2.  ACT Domains by Hospital Type

Pairwise p values

Academic Academic Community

Critical vs. vs. critical vs. critical
Overall Academic Community access community access access
Leadership
Mean ± SD 3.9 ± 0.9 4.0 ± 0.9 3.8 ± 0.9 4.0 ± 0.7
Median (min, max) 4 (1, 5) 4 (1, 5) 4 (1, 5) 4 (1.7, 5) .060 .347 .451
Culture
Mean ± SD 3.9 ± 0.6 3.9 ± 0.6 3.8 ± 0.7 4.1 ± 0.6
Median (min, max) 4 (1, 5) 4 (1.3, 5) 3.8 (1, 5) 4.2 (2.7, 5) .200 .099 .051
Evaluation
Mean ± SD 3.7 ± 0.9 3.7 ± 0.8 3.5 ± 0.9 3.8 ± 0.7
Median (min, max) 3.8 (1, 5) 4 (1, 5) 3.7 (1, 5) 4 (1.2, 5) .084 .595 .081
Social capital
Mean ± SD 2.9 ± 1.2 2.8 ± 1.2 2.8 ± 1.2 3.6 ± 1.0
Median (min, max) 3 (1, 5) 3 (1, 5) 3 (1, 5) 4 (1, 5) .782 .039 .039
Organizational slack
Mean ± SD 3.1 ± 0.7 3.1 ± 0.7 3.0 ± 0.7 3.6 ± 0.7
Median (min, max) 3.1 (1, 5) 3.1 (1.2, 5) 3 (1, 4.9) 3.7 (1.6, .996 .041 .033
4.8)
Formal interactions
Mean ± SD 1.9 ± 1.0 2.0 ± 1.0 1.8 ± 1.1 2.1 ± 1.0
Median (min, max) 2 (0, 4) 2 (0, 4) 2 (0, 4) 2 (0, 4) .302 .131 .070
Informal interactions
Mean ± SD 5.1 ± 1.9 5.3 ± 1.8 4.9 ± 2.0 4.7 ± 2.1
Median (min, max) 5 (0, 10) 5.5 (0, 10) 5 (0, 10) 4.5 (0, 10) .085 .092 .462
Structural and electronic resources
Mean ± SD 4.6 ± 2.1 4.6 ± 2.1 4.6 ± 2.1 4.6 ± 2.3
Median (min, max) 4.5 (0, 10) 4.5 (0, 10) 4.5 (0, 10) 4.5 (0, 9.5) .726 .446 .347

opportunities for fostering EBP within a healthcare system
(Dang et al., 2015).
Nurse Characteristics Associated with
EBP Readiness
Significant relationships exist among ACT domains (or-
ganizational context) and nurse characteristics includ-
ing age (lower age had higher Leadership, Evaluation,
and Formal Interactions), education (graduate education
had lower Social Capital means than bachelor’s or associ-
ate degrees), role (direct-­care nurses had lower Culture
means than managers and lower Social Capital means than
“other” roles), and work status (full-­time employees had
lower Evaluation and Social Capital means than part-­time
employees). Younger nurses perceived the actions of for-
mal leaders to positively influence change and excellence
in practice, supportive work culture, and participation in
scheduled activities promoting knowledge transfer and
exchange of ideas. These findings are congruent with
a study by Stuenkel, Cohen, and Cuestra (2005) of 272
nurses who found generational differences with younger
nurses reporting greater degree of involvement, supervi-
sor support, autonomy, task orientation, and innovation.
However, in our study, direct-­ care nurses perceived a
less supportive work culture than managers. These find-
ings could raise a concern as they present a difference in
perceptions of the work environment according to the age
and nurses’ role (direct-­care versus managers). The do-
main of Culture encompasses the forces at work providing
the character and feel of the environment. It includes the
prevailing beliefs and values of members of the hospital
setting (Estabrooks et al., 2009). If direct-­care nurses do
not feel supported to undertake professional development
or feel that the organization ineffectively balances best

Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280. 275

© 2019 Sigma Theta Tau International
 A Multisite Health System Survey

practice and productivity, they may perceive there to be a

less supportive work culture.

p value

.3378

.0730
.6015
Structural and electronic resources These findings suggest that nurse characteristics (age,
role, and work status) matter and understanding what is
needed may be different based on these types of demo-
graphic characteristics. These findings also suggest the need

0.001
0.327
0.317
to develop an approach in partnership with staff and to be
95% CI

open for tailoring according to staff characteristics. Nurse

leadership and manager support are important, and an as-

0.000
−0.564
−0.924
sessment to examine the organization’s context can be used
Table 3.  Models for Mean Number of Formal Interactions, Informal Interactions, and Structural and Electronic Resources

to enhance leadership in partnership with nurses; however,

nurse characteristics must be considered. We found that the
difference

type of hospital setting (academic, community, or critical

0.0005
−0.303
Mean

−0.119 access) is not as important as nurse characteristics when

0 examining context domains; individual nurse character-
istics were more highly associated with context domains
than the type of hospital setting. Our findings support the
p value

.1088
.0157

work of Fischer, Horak, and Kelly (2018; N = 1,933), who

explored the role of the nurse (i.e., direct-­care versus man-
ager) and their perception of involvement in decisions that
affect their practice. They found that direct-­care nurses
Informal interactions

0.533
1.061

felt they had lower decision-­ making involvement than

did nurse managers and concluded that awareness of how
95% CI

staff members perceive the culture of the environment is

−0.053
0.111

key to identifying opportunities for improvement (Fischer

et al., 2018). Our study’s findings suggest that nurse char-
acteristics (e.g., age, role, and work status) are associated
with contextual attributes (e.g., culture and nurse manager
difference

support) and should be taken into consideration when en-

Mean

0.586
0.240

abling readiness of the unit for EBP.

0

EBP Context Across Hospitals in a Large System

Aggregate ACT domain scores were similar among hospital
p value

.0004
.0003

settings for each domain. Other studies have found a posi-

tive relationship between most domains and reported re-
–

search utilization (Cummings, Hutchinson, Scott, Norton,

−0.066
Formal interactions

−0.115

& Estabrooks, 2010; Squires et al., 2013). These modifi-

able elements of hospital context (Culture, Leadership,
95% CI

Evaluation, Formal Interactions, Informal Interactions, and

Organizational Slack) positively influence research utiliza-
−0.229
−0.392

tion and adoption of EBP (Cummings et al., 2010; Squires

et al., 2013). Cummings et al. (2010) classified ACT mean
–

scores on Culture, Leadership, and Evaluation as high if

difference

the means were 3.5 or greater (less than 3.5 categorized as

−0.254
Mean

−0.148

low). Similar results were observed in this study, indicating

a high readiness for EBP and research utilization across all
0

14 hospitals.
The opportunity to develop Social Capital in the nursing
workforce emerged as a factor to influence EBP utilization.
Critical access

Overall mean scores for Social Capital indicate that nurses

Community
Hospital type
Academic
Age (years)

have a neutral rather than positive or negative perception

40–54

Bed size

of the social connections in the nursing work environment.

<40

55+

Although there is a paucity of studies that focus on the re-

lationships between Social Capital and research utilization,
other studies have demonstrated positive relationships

276 Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.

© 2019 Sigma Theta Tau International
 Table 4.  Summary Statistics of EBP Readiness Measures by Nurse Characteristics

EBP readiness by nurse characteristics

Structural/
Social Organizational Formal Informal electronic
Leadership Culture Evaluation capital slack interaction interaction resources
Response n M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD M ± SD
Age (years) <40 years 247 4.0 ± 0.8 3.9 ± 0.6 3.8 ± 0.8 2.8 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.3 ± 1.7 4.5 ± 1.9

© 2019 Sigma Theta Tau International

40–54 years 299 3.9 ± 0.9 3.9 ± 0.6 3.6 ± 0.9 2.8 ± 1.2 3.1 ± 0.7 1.9 ± 1.1 5.1 ± 2.0 4.6 ± 2.1
55+ years 307 3.9 ± 0.9 3.9 ± 0.7 3.7 ± 0.9 3.0 ± 1.2 3.2 ± 0.8 1.9 ± 1.0 5.0 ± 2.0 4.7 ± 2.1
Gender Female 792 3.9 ± 0.9 3.9 ± 0.7 3.7 ± 0.9 2.9 ± 1.2 3.1 ± 0.7 1.9 ± 1.0 5.1 ± 1.9 4.6 ± 2.1
Male 61 4.2 ± 0.8 4.0 ± 0.6 3.8 ± 0.8 3.0 ± 1.3 3.2 ± 0.8 2.0 ± 1.0 5.1 ± 2.1 4.8 ± 1.9

Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.

Race Caucasian 798 3.9 ± 0.9 3.9 ± 0.6 3.7 ± 0.9 2.9 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.1 ± 1.9 4.6 ± 2.1
Non-­Caucasian 55 4.1 ± 0.8 3.8 ± 0.7 3.7 ± 0.7 3.0 ± 1.2 3.1 ± 0.8 1.7 ± 1.0 4.7 ± 1.7 4.6 ± 2.1
Education Certificate/associate/other 143 4.0 ± 0.9 4.0 ± 0.6 3.8 ± 0.8 3.0 ± 1.2 3.2 ± 0.8 1.9 ± 1.0 4.8 ± 1.8 4.6 ± 2.1
level
Bachelor’s degree 570 3.9 ± 0.9 3.8 ± 0.7 3.7 ± 0.8 2.9 ± 1.2 3.1 ± 0.7 1.9 ± 1.0 5.0 ± 1.9 4.4 ± 2.0
Master’s/PhD 140 4.0 ± 0.8 4.0 ± 0.6 3.6 ± 1.0 2.8 ± 1.2 3.2 ± 0.7 2.2 ± 1.0 5.8 ± 2.0 5.5 ± 2.0
Role Manager 94 4.1 ± 0.7 4.1 ± 0.5 3.8 ± 0.8 3.1 ± 1.2 3.2 ± 0.7 2.3 ± 0.9 6.2 ± 2.2 5.7 ± 1.9
RN 701 3.9 ± 0.9 3.9 ± 0.7 3.7 ± 0.8 2.8 ± 1.2 3.1 ± 0.7 1.9 ± 1.0 4.9 ± 1.8 4.4 ± 2.0
Other 58 3.9 ± 0.9 4.1 ± 0.7 3.5 ± 1.0 2.9 ± 1.2 3.3 ± 0.7 2.3 ± 1.0 5.7 ± 1.8 5.5 ± 1.9
Status Full-time 688 3.9 ± 0.9 3.9 ± 0.6 3.7 ± 0.8 2.9 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.2 ± 1.9 4.7 ± 2.0
Part-time 142 3.9 ± 0.9 3.8 ± 0.7 3.6 ± 0.9 3.0 ± 1.2 3.1 ± 0.7 1.6 ± 1.1 4.6 ± 1.9 4.1 ± 2.1
Casual 23 4.0 ± 0.9 3.8 ± 0.6 3.9 ± 0.5 3.2 ± 1.1 3.2 ± 0.6 1.2 ± 1.0 4.8 ± 1.7 4.5 ± 2.2
Years in 0–1.5 208 4.0 ± 0.8 4.0 ± 0.6 3.7 ± 0.9 2.9 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.0 ± 1.8 4.8 ± 1.9
unit
1.6–4.9 204 3.9 ± 0.9 3.9 ± 0.6 3.7 ± 0.8 2.8 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.1 ± 1.9 4.6 ± 2.0
5.0–9.7 224 3.9 ± 0.9 3.8 ± 0.7 3.6 ± 0.9 2.8 ± 1.3 3.0 ± 0.8 1.9 ± 1.1 5.1 ± 1.9 4.5 ± 2.2
9.8–40.8 217 3.9 ± 0.9 3.9 ± 0.6 3.8 ± 0.8 3.0 ± 1.1 3.2 ± 0.7 1.9 ± 1.1 5.1 ± 2.0 4.5 ± 2.2
Hospital Academic 524 4.0 ± 0.9 3.9 ± 0.6 3.7 ± 0.8 2.8 ± 1.2 3.1 ± 0.7 2.0 ± 1.0 5.3 ± 1.8 4.6 ± 2.1
type
Community 262 3.8 ± 0.9 3.8 ± 0.7 3.5 ± 0.9 2.8 ± 1.2 3.0 ± 0.7 1.8 ± 1.1 4.9 ± 2.0 4.6 ± 2.1
Critical care 67 4.0 ± 0.7 4.1 ± 0.6 3.8 ± 0.7 3.6 ± 1.0 3.6 ± 0.7 2.1 ± 1.0 4.7 ± 2.1 4.6 ± 2.3
Bed size 15–190 199 3.8 ± 0.8 3.9 ± 0.6 3.5 ± 0.9 3.2 ± 1.1 3.3 ± 0.7 1.8 ± 1.1 4.8 ± 2.1 4.6 ± 2.1
191–364 278 3.9 ± 0.9 3.9 ± 0.7 3.6 ± 0.9 2.9 ± 1.2 3.2 ± 0.7 2.0 ± 1.0 5.1 ± 1.8 4.4 ± 2.1
365–399 64 3.9 ± 1.0 3.9 ± 0.8 3.8 ± 0.8 2.6 ± 1.2 2.9 ± 0.8 2.0 ± 1.1 5.1 ± 2.0 4.7 ± 2.1
400–858 312 4.0 ± 0.9 3.9 ± 0.6 3.8 ± 0.8 2.7 ± 1.2 3.0 ± 0.7 1.9 ± 1.0 5.3 ± 1.9 4.7 ± 2.1

277
Original Article
A Multisite Health System Survey
between Social Capital and turnover intent, nursing unit
effectiveness, and nurse perception of quality of care
(Laschinger, Read, Wilk, & Finegan, 2014; Shin & Lee, 2016).
Nurse leaders influence the creation of Social Capital in the
complex nursing work environment through creating struc-
tures and processes that allow for nurses to access, exchange,
and synthesize information both within and among teams
to improve patient and organizational outcomes (Gilbert,
Von Ah, & Broome, 2017). Intentional creation of social net-
works may increase EBP dissemination and utilization.
It is interesting to note that Social Capital was signifi-
cantly higher in critical access hospitals than in other
settings. This is similar to other studies including urban
and rural hospital settings in which significant differ-
ences in the work environment were observed by unit
size and complexity (Baernholdt & Mark, 2009). This may
be a factor influenced by shared social values in smaller
communities, increased frequency of social interactions,
and increased opportunity to interact with other indi-
viduals and teams in the critical access settings. Nurses
with advanced degrees reported significantly lower lev-
els of Social Capital than those with bachelor’s degrees in
our sample. However, it is important to consider that the
ACT measures Social Capital as a single aggregate score
comprised of a measure of three types of Social Capital:
bonding, bridging, and linking Social Capital (Squires
et al., 2013). As an overall aggregate Social Capital mea-
sure, it does not measure a complete conceptualization
of all domains. It is possible that nurses with advanced
degrees engage in different socially connected groups be-
yond their individual nursing units. Of all the contextual
attributes of organizations, Social Capital emerged as the
most important.
Study Limitations
This study had several limitations including the low re-
sponse rate and use of a cross-­sectional design. First, the
response rate of 13.4% was not optimal in spite of using
the Dillman method to optimize response rate (Dillman,
2007). Potential reasons for the lower response rates in-
clude the population being surveyed, lack of familiarity
with the web, inconsistent reliability of Internet access,
lack of trust in confidentiality of information, and survey
saturation (McPeake, Bateson, & O’Neill, 2014). Second, a
cross-­sectional design using self-­report of data limits valid-
ity of data.
IMPLICATIONS FOR FUTURE RESEARCH
An understanding of the organizational context is needed
to build and sustain EBP. A baseline assessment of the
organizational context provides leaders with information
to develop an approach to enhance EBP. Following this
study, the mean scores for each ACT concept were pro-
vided to nurse leaders at each site. These data provided
278
valuable information about the context currently avail-
able and needed to support system-­w ide EBP and to iden-
tify barriers and opportunities within the organization.
Results from the baseline assessment were used to en-
hance a systematic and standardized approach to increase
EBP across a large multisite healthcare system, including
a system-­w ide EBP training program across the entire
healthcare organization. Future studies would benefit
from using the ACT in the EBP implementation process to
determine how each construct contributes to or detracts
from EBP implementation.
CONCLUSIONS
Within a high-­reliability organization and learning health-
care system, nursing leadership’s influence on organi-
zational culture, context, nursing practice environment,
and organizational resources is key to developing and en-
hancing a culture of EBP. Assessing the context of an or-
ganization to support EBP and research is the first step in
developing and enhancing a sustainable culture of EBP and
research. This study’s findings demonstrate the organiza-
tional context and factors of a large healthcare system and
provide nursing leaders with valuable information to iden-
tify strengths and opportunities to enhance EBP culture and
research implementation. WVN
LINKING EVIDENCE TO ACTION
• Assessing organizational context to support EBP is the
first step in developing and enhancing a sustainable
culture of inquiry.
• The ACT has been tested across countries, settings, and
healthcare disciplines to measure perception of readi-
ness of the practice environment toward EBP.
• Optimal organizational context is essential to support
EBP and sustain the use of evidence in professional
nursing practice. Nursing leaders can use baseline as-
sessment information to identify strengths and oppor-
tunities to enhance EBP implementation.
• Nurse characteristics (age, role, and work status) are
associated with contextual attributes (e.g., culture
and nurse manager support) and should be taken
into consideration when enabling readiness of the
unit for EBP.
• Fostering development of Social Capital in nurses is
needed to influence EBP readiness.
Author information
Joyce Pittman, Coordinator of Wound, Adjunct Assistant
Professor, Ostomy, Continence Program, Indiana
Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.
© 2019 Sigma Theta Tau International

University Health, Indianapolis, IN, USA, and Indiana
University School of Nursing, Indianapolis, IN, USA;
Andrea Cohee, Assistant Professor, Indiana University
School of Nursing, Indianapolis, IN, USA; Susan Storey,
Assistant Professor, Indiana University School of
Nursing, Indianapolis, IN, USA; Julie LaMothe, Lecturer,
Indiana University School of Nursing, Indianapolis,
IN, USA; Jason Gilbert, Chief Nursing Officer, Indiana
University Health Adult Academic Health Center,
Indianapolis, IN, USA; Giorgos Bakoyannis, Assistant
Professor, Fairbanks School of Public Health and School
of Medicine,  Indiana University, Indianapolis, IN, USA;
Susan Ofner, Biostatistician, Indiana University School of
Medicine, Indianapolis, IN, USA; Robin Newhouse, Dean,
Distinguished Professor, Indiana University School of
Nursing, Indianapolis, IN, USA, and Indiana University,
Indianapolis, IN, USA.
Address correspondence to Joyce Pittman, Ostomy,
Continence Program, Indiana University Health, 1701
Senate Blvd., Rm B651, Indianapolis, IN 46202, USA;
jpittma3@iuhealth.org
Accepted 22 February 2019
© 2019 Sigma Theta Tau International
References
American Hospital Association. (2019). Fast facts on U.S. hospitals,
2019. Retrieved from https​://www.aha.org/stati​stics/​fast-
facts-us-hospi​tals
American Nurses Association. (2015). Nursing: Scope and standards
of practice (3rd ed.). Silver Spring, MD: American Nurses
Association.
Austin, M., & Derk, J. (2016). Lives lost, lives saved: A comparative
analysis of avoidable deaths at hospitals graded by the Leapfrog Group.
Retrieved from http://www.hospi​talsa​fetys​core.org/
media/​f ile/Lives​LostL​ivesS​avedW​hiteP​aper.pdf
Baernholdt, M., & Mark, B. A. (2009). The nurse work envi-
ronment, job satisfaction and turnover rates in rural and
urban nursing units. Journal of Nursing Management, 17(8), 994–
1001. https​://doi.org/10.1111/j.1365-2834.2009.01027.x
Cummings, G., Hutchinson, A., Scott, S., Norton, P., &
Estabrooks, C. (2010). The relationship between charac-
teristics of context and research utilization in a pediat-
ric setting. BMC Health Services Research, 10, 168. https​://doi.
org/10.1186/1472-6963-10-168
Dang, D., Melnyk, B. M., Fineout-Overholt, E., Ciliska, D.,
DiCenso, A., Cullen, L., & Stevens, K. R. (2015). Models to
guide implementation and sustainability of evidence-based
practice. In B. M. Melnyk, & E. Fineout-Overholt (Eds.),
Evidence-based practice in nursing and healthcare: A guide to best practice
(3rd ed., pp. 274–315). Philadelphia, PA: Wolters Kluwer
Health.
Datta, S., & Satten, G. A. (2005). Rank-­sum tests for clustered data.
Journal of the American Statistical Association, 100(471), 908–915.
Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.
© 2019 Sigma Theta Tau International
Original Article
Dillman, D. A. (2007). Mail and internet surveys: The tailored design
method (2nd ed.). Hoboken, NJ: John Wiley & Sons.
Eldh, A., Ehrenberg, A., Squires, J., Estabrooks, C. A., &
Wallin, L. (2013). Translating and testing the Alberta
Context Tool for use among nurses in Swedish elder
care. BMC Health Services Research, 13, 68. http://www.
biome​dcent​ral.com/1472-6963/13/68
Estabrooks, C. A., Squires, J., Cummings, G., Birdsell, J., &
Norton, P. (2009). Development and assessment of the
Alberta Context Tool. BMC Health Services Research, 9, 234.
https​://doi.org/10.1186/1472-6963-9-234
Estabrooks, C. A., Squires, J., Hayduk, L., Cummings, G., &
Norton, P. (2011). Advancing the argument for validity of
the Alberta Context Tool with healthcare aides in residen-
tial long-term care. BMC Research Methodology, 11, 107. http://
www.biomedcentral.com/1471-2288/11/107
Field, C. A., & Welsh, A. H. (2007). Bootstrapping clus-
tered data. Journal of the Royal Statistical Society: Series B, 69,
169–390.
Fischer, S., Horak, D., & Kelly, L. (2018). Decisional involve-
ment: Differences related to nurse characteristics, role, and
shared leadership participation. Journal of Nursing Care Quality,
33(4), 354–360.
Frankel, A., Haraden, C., Federico, F., & Lenoci-Edwards, J.
A. (2017). A framework for safe, reliable, and effective care [White
paper]. Retrieved from http://www.ihi.org/resou​
rces/Pages/​I HIWh​itePa​p ers/Frame​work-Safe-Relia​ble-
Effec​tive-Care.aspx
Gilbert, J. H., Von Ah, D., & Broome, M. E. (2017).
Organizational intellectual capital and the role of the
nurse manager: A proposed conceptual model. Nursing
Outlook, 65(6), 697–710. https​ ://doi.org/10.1016/j.
outlo​ok.2017.04.005
Hoben, M., Bar, M., Mahler, C., Berger, S., Squires, J. E.,
Estabrooks, C. A., … Behrens, J. (2014). Linguistic val-
idation of the Alberta Context Tool and two measures
of research use, for German residential long term
care. BMS Research Notes, 7, 67. http://www.bioce​ ntral.
com/1756-0500/7/67
Johnson, K., Grossman, C., Anau, J., Greene, S., Kimbel, K.,
Larson, E., & Newton, K. (2015). Integrating research into
health care systems: Executives’ views [Discussion paper].
National Academy of Sciences. Retrieved from https​://nam.edu/
wp-conte​nt/uploa​ds/2015/06/Integ​ratin​gRese​a rchi​ntoHe​
althc​areSy​stems1.pdf
Laschinger, H., Read, E. A., Wilk, P., & Finegan, J. (2014). The in-
fluence of nursing unit empowerment and social capital on
unit effectiveness and nurse perceptions of patient care qual-
ity. Journal of Nursing Administration, 44(6), 347–352. https​://
doi.org/10.1097/NNA.00000​00000​000080
Little, R., & Rubin, D. (2014). Statistical analysis with missing data.
Hoboken, NJ: John Wiley & Sons.
Makary, M., & Daniel, M. (2016). Medical error: The third
leading cause of death in the US. British Medical Journal, 353,
i2139. https​://doi.org/10.1136/bmj.i2139​
279
A Multisite Health System Survey
McPeake, J., Bateson, M., & O’Neill, A. (2014). Electronic
surveys: How to maximise success. Nurse Researcher, 21(3),
24–26.
Medical Learning Network. (2017). Critical access hospital [Booklet].
Retrieved from https​://www.cms.gov/Outre​ach-and-
E du c a ​t io n /M e d ic ​a r e - L e a r n ​i ng- N e t w o ​rk- M L N/
MLNPr​oduct​s/downl​oads/CritA​ccess​Hospf​ctsht.pdf
Melnyk, B. (2007). The evidence-­based practice mentor: A
promising strategy for implementing and sustaining EBP
in healthcare systems. Worldviews on Evidence-­Based Nursing,
4(3), 123–125.
Melnyk, B. (2017). Models to guide the implementation and
sustainability of evidence-­based practice: A call to action
for further use and research. Worldviews on Evidence-­ Based
Nursing, 14(4), 255–256.
Pan, W. (2001). Akaike’s information criterion in generalized
estimating equations. Biometrics, 57, 120–125.
Shao, J. (1997). An asymptotic theory for linear model selec-
tion. Statistica Sinica, 7, 221–242.
Shin, J. I., & Lee, E. (2016). The effect of social capital on job
satisfaction and quality of care among hospital nurses in
South Korea. Journal of Nursing Management, 24(7), 934–942.
https​://doi.org/10.1111/jonm.12401​
280
Squires, J., Estabrooks, C., Scott, S., Cummings, G., Hayduk,
L., Kang, S., & Stevens, B. (2013). The influence of or-
ganizational context on the use of research by nurses in
Canadian pediatric hospitals. BMC Health Services Research, 13,
351. http://www.biome​dcent​ral.com/1472-6963/13/351
Squires, J. E., Hayduk, L., Hutchinson, A., Mallick, A., Norton,
P., Cummings, G., & Estabrooks, C. (2015). Reliability and
validity of the Alberta Context Tool (ACT) with professional
nurses: Findings from a multi-­study analysis. PLoS One, 10(6),
e0127405. https​://doi.org/10.1371/journ​al.pone.0127405
Squires, J. E., Hutchinson, A. M., Hayduk, L., Cranley, L.,
Cummings, G., Norton, P. G., & Estabrooks, C. A. (2014).
Alberta context tool: User manual. Edmonton, AL: Knowledge
Utilization Studies Program, Faculty of Nursing, University
of Alberta.
Stuenkel, D., Cohen, J., & Cuestra, K. (2005). The multigenera-
tional nursing work force. The Journal of Nursing Administration,
35(6), 283-285.
The Joint Commission. (n.d.). Academic medical center hospitals.
Retrieved from https​://www.joint​commi​ssion​inter​natio​
nal.org/achie​ve/acade​mic-medic​al-center-hospi​tals-1/
10.1111/wvn.12375
WVN 2019;16:271–280
Worldviews on Evidence-Based Nursing, 2019; 16:4, 271–280.
© 2019 Sigma Theta Tau International