Table of

Contents
Editorial 1

RESEARCH ARTICLES
• Workplace Incivility Among Nurses In A National Tertiary Hospital 3
Paul Froilan U. Garma, MA, RN, RM; Jewell Mari Elaine A. David, RN;
Marivin Joy F. Lim, RN; Maria Clarissa C. Braganza, RN;
Michelle D. Dela Cruz, RN; Steven Paul I. Veloso, RN

• Evidence-based Practice Beliefs and Implementation 11

of Staff Nurses in the Ilocos Region
Bernardo Oliber A. Arde, Jr., PhD, RN

• Childbirth Satisfaction and Maternal Role Confidence of Early Postpartum 21

Mothers from Maternity Units
Artemio M. Gonzales Jr., RN, RM, MPH

• Nurses’ Value Orientation and Intention to Pursue Graduate Education 27

and their Readiness for Evidence-Based Practicea
Paolo T. Lumanlan, PhD, RN

• The Future of Nursing Science: Consilience in Evidence-based Practice 33

Rainier C. Moreno-Lacalle, PhD, RN

• Source And Essence of Gratitude: Re-Examining The Intergenerational 41

Views on Respect for the Older Persons
Laurence L. Garcia, DScN, MN, RN
Letty G. Kuan, EdD, MAN, MSN

FEATURE ARTICLE
• Theory of Commitment and Care 46
Frances Gay L. Pia, RN, MAN, PhD

NURSES’ VOICE FROM THE FIELD

• When Enough is Enough 49
Hazel Vera D. Tan, RN

Guideline for Authors 52

PJN VOL. 88 | NO. 1 Abstracts and articles may may accessed at the following links: http://www.pna-pjn.com
This pubication is not for sale http://www.pna-ph.org/archives/philippine-journal-nursing and http://www.wprim.org

E D I T O R I A L
DEVELOPING NURSING PRACTICE
AND EDUCATION THROUGH
EVIDENCE-BASED PRACTICE
b etter, safer and more meaningful practices and policies
toward nursing practice and education are developed from
evidence-based research. Praxis, theory and practice,
enriches our profession, and with it, the generation and
development of knowledge through research. In the process,
evidences are produced. However, it is not as easy as it seems
to be. Doing research and using EBP are two different things,
but both entail good knowledge on the research process.
Nurses need to be discerning of results so that they can be
implemented in their practice. This expectation of integrating
research-based evidence into the nursing practice has yet to be
fully realized and appreciated. Various factors, including the
nurse and the organization, lends to the research utilization and
uptake into the nursing practice. Some reasons include lack of
time, resources, knowledge and skill, lack of administrative
support, lack of facilities. Thus, it is important to remain
updated of current and emerging research methods, as well as
the various advancements in nursing practice. It is when we
understand the what and the whys of EBP that our work and
relationship with our patients become more meaningful.
In this issue, there are three articles that lend to these claims or
observations. Arde's article, Evidence-based practice beliefs
and implementation of staff nurses in the Ilocos Region
showed that nurses in the Ilocos region are positive about their
knowledge of, confidence in and belief about EBP but are not
fully committal to it, thus implementation of EBP is rare or low. In
Lumanlan's Nurses' value orientation and intention to
pursue graduate education and their readiness for
evidence-based practice, nurses have confidence in
pursuing graduate studies in nursing and intrinsically value
1
graduate education. Nurses have a positive and an above
average attitude toward evidence-based practice. When
nurses intrinsically value evidence-based practice, they
become intensely involved in it and can continue practicing it for
a long time. However, nurses' intention to pursue graduate
education did not significantly predict their readiness for
evidence-based practice. The result is indicative that there is
an inconsistency in translating intention to practice, known as
the “intention-behavior gap”.
On the other hand, Lacalle in his paper, The future of nursing
science: consilience in evidence-based practice, posits
that “nursing science needs to adopt a paradigm that can be
used to apply its knowledge.” He presented the pros and cons
of the two ways to implement nursing science, that is, evidence-
based practice (including translational research and research
utilization) and intuitive nursing. He also differentiated
evidence-based practice (EBP), translational research (TR),
and research utilization (RU). He argued that “EBP as the
paradigm of choice will be the optimal strategy for the future of
nursing science.
With all these limitations, the pressure for evidence-based
practice remains. Nurses are expected to provide quality
patient care based on research and knowledge rather than
“based on traditions, myths, hunches, advices from colleagues,
or outdated textbooks.” Better patient outcomes, contributions
to the science of nursing, keeping practice current and relevant,
and increasing confidence in decision-making (Beyea and
Slatery, 2006 pp.8-9; Melnyk and Fineout-Overholt, 2011 ).
PJN VOL. 88 | NO. 1
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This issue presents other interesting studies. Garma, et al.'s
paper on Workplace incivility among nurses in a national
tertiary hospital explored the situation of incivility being
attributed to “an environment of hostility among healthcare
providers in the workplace, and undermines a culture of
patient safety”. The study revealed that nurse-related
variables have significant impact on incivil interactions in the
hospital setting, which can lead in mitigating its impact on
healthcare delivery and patient outcomes.. Gonzales' study
on Childbirth satisfaction and maternal role confidence
of early postpartum mothers from maternity units, revealed
that the early postpartum mothers in his study were satisfied
with their childbirth experience and confident with their
maternal role, with the childbirth satisfaction being positively
correlated with maternal role confidence. Promoting positive
birth experiences may help create circumstances amenable
to enhancing the quality of obstetric care and improving
outcomes for mothers and infants. The study of Garcia and
Kuan's Source and essence of gratitude: re-examining
the intergenerational views on respect for the older
persons, explored the dynamics and variances of the
manifestation of gratitude towards the older persons utilizing
qualitative survey design. The findings revealed how family,
work and societal changes have contributed to the changes in
the manifestation of gratitude. Gratitude, which is
manifestation of respect, has evolved and is now shown
differently across intergenerational groups and seems to be
experienced similarly across nations.
The feature article of Pia, Theory of Commitment and Care,
asserts that commitment has been associated with quality
nursing care because it contributes to the understanding of
PJN VOL. 88 | NO. 1
finding meaning and value of work. The factors that affect a
person's commitment are job satisfaction, work autonomy,
trainings, working environment conditions, pay and benefits,
investments, retirement plans, obligations, return service.
This commitment propels the nurse to achieve his/her goals
in the nursing process. Tan's voice, When enough is
enough, echoes experiences from the ground that forms
barriers not only to living a satisfying and meaningful
professional and personal life, but to opportunities to fully be a
partner implementing change to best meet the needs of
present and future patients.
Indeed, an empowered profession is one where we have
interest in learning current and emerging research methods.
It is engaging in and pursuing current information and
continue learning research-based developments.
Erlinda Castro-Palaganas, PhD, RN
Editor-in-Chief
......................................
References
Beyea, SV & Slattery, MJ. (2006). Evidence-Based Practice in
Nursing: A Guide to Successful Implementation. HCPro, Inc.,
USA.
Melnyk, BM and Fineout-Overholt, E. (2011). Evidence-Based
Practice in Nursing & Healthcare: A Guide to Best Practice.
Wolter Kluwer/Lippincott Williams & Williams, USA.
 3

RESEARCH ARTICLE

WORKPLACE INCIVILITY AMONG NURSES

IN A NATIONAL TERTIARY HOSPITAL
Paul Froilan U. Garma, MA, RN, RM*1; Jewell Mari Elaine A. David, RN1; Marivin Joy F. Lim, RN1;
Maria Clarissa C. Braganza, RN 1; Michelle D. Dela Cruz, RN 1; Steven Paul I. Veloso, RN 2

Abstract
Incivility creates an environment of hostility among healthcare providers in the workplace, and undermines a culture of patient safety.
Although this phenomenon is pervasive in the profession, nurses tolerate or ignore its occurrence due to inadequate knowledge, fear
and lack of institutional policies. There are no empirical studies in the local context which explore incivility among nurses in the hospital
setting. This study examined the sources and forms of incivility among nurses working in a hospital according to nurse-related
variables. A descriptive, cross-sectional design was utilized. Respondents were asked to answer Nurse's Profile and Nursing Incivility
Scale. A stratified random sampling was used. A sample of 280 nurses from different clinical nursing units in a national tertiary hospital
completed the questionnaire. Incivility outcome was analyzed using One-way Analysis of Variance (ANOVA) according to nurse-
related variables such as nursing designation, practice setting, type of clinical nursing unit and length of hospital work experience. Post-
hoc analysis was performed using Tukey's Honestly Significant Difference. Data were collected from September to October 2017.

Majority of the participants are female (78 %) and single (50 %) with an average age of 36 years old (SD= 9.96, range 21-62). They are
employed in the hospital for an average of 9 years (SD = 8.82). Most of the sample works in general clinical nursing units (68 %) in a
service/ charity setting (57 %). More than half of the respondents are staff nurses (67%) who provide direct care (Nurse I/II) followed by
charge nurses (Nurse III) (19%) and head and chief nurses (IV/VI) (13%). Significant incivil interactions were reported between nurses
and their colleagues at work, physicians and patients and their families according to the nursing designation, practice setting, type of
clinical nursing unit and length of work experience. The moderately incivil interactions were exhibited in the forms of inconsistent
behaviors, hostile climate and displaced frustrations.

Nurse-related variables have significant impact on incivil interactions in the hospital setting. Understanding the sources and forms of
incivility is of paramount importance in mitigating its impact on healthcare delivery and patient outcomes, and developing relevant
policies and interventions that protect the welfare of nursing workforce.

Keywords: nursing incivility, workplace incivility

Introduction

A culture of respect in a workplace free from incivility optimizes

patient health outcomes, and promotes a positive work
environment for nurses (American Nurses Association, 2015).
sarcasm, humiliation, hostile stares, verbal intimidation, gossiping
and abusing other's privileges.

Incivility is a critical issue affecting the welfare of nurses as well as
the quality of care being delivered (Johnson, 2009). Incivility is part
of a complex phenomenon of harmful actions such as bullying and
violence in the workplace. It is a low-intensity, deviant behavior
that demonstrates a lack of regard for other workers that results to
psychological or physiological distress (Hutton & Gates, 2008). It
is characterized by disruptive behaviors such as discourtesy,
Incivility in healthcare settings has potential detrimental effects on
patient safety and the entire organization (Elmblad, Kodjebacheva
& Lebeck, 2014). Its negative impact transcends not only the
victims themselves, but also peers, stakeholders, clients and
organizations. It leads to erosion of professional competence as
well as increased sickness, absenteeism, decreased job
satisfaction, reduced organizational commitment, and employee

1 * Corresponding Author: Division of Nursing Research & Development, University of the Philippines Manila Philippine General Hospital,

Taft Avenue, Manila 1000; pugarma@up.edu.ph; +639279048132.

1 Research Coordinator, Division of Nursing Research & Development, University of the Philippines Manila Philippine General Hospital
2 Nurse IV, Division of Nursing Research & Development, University of the Philippines Manila Philippine General Hospital

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attrition (Chipps&McRury, 2012; Porath& Pearson, 2013). It
harms the victims' self-worth and confidence resulting to stress-
related physical symptoms and psychosocial conditions
(Townsend, 2012). Such circumstances may impair nurse's
clinical judgment to the extent that the performance of duty is
affected. It can lead to dysfunctional patient care, medication and
safety errors and increased direct and indirect healthcare delivery
costs (Holloway &Kusi, 2010).
Strategies to promote a respectful, civil and safe environment is a
must. It is incumbent upon nurse administrators, policy-makers
and front-line nurses to initiate measures that seek to address
workplace incivility. However, nurses tolerate or ignore workplace
incivility due to lack of knowledge and awareness, fear and
inadequate institutional policies and support (Adeniran et al.,
2016). It is important, therefore, to first recognize the existence of
incivil behaviors in the workplace in order to prevent them from
occurring.
Although workplace incivility has been prevalent in nursing, there
is a limited empirical evidence exploring this concept among
hospital nurses in the local setting. To the best of our knowledge,
this is the first study to examine the nature of workplace incivility
among Filipino nurses in the local context. This study aimed to
describe the perceived sources and forms of workplace incivility,
and identify the differences when grouped according to nurse-
related variables. It is hoped that the outcomes of this study shall
inform institutional policies governing work climate to implement
mechanisms that eliminate incivility in its various sources and
forms.
Theoretical Framework
Healthcare environment is more susceptible to incivility due to
stressful conditions, challenging and difficult work situations and
diversity of interactions (Hunt & Marini, 2012). Nurses are
situated in complex environments like hospital setting that have
many stressors such as overwhelming workloads, hierarchal
organizational structures and highly charged emotions due to life
and death decision-making (Croft & Cash, 2012).
Betty Neuman's Systems model (1982) is the theoretical
framework that was used to understand the nature of workplace
incivility. The model posits that human being is unique, a
composite of factors and characteristics, an open system within a
given range of responses to stressors. The client variables are
physiological, psychological, sociocultural, developmental and
spiritual (Fawcett, 2005). Stressors are intra-, inter-, and extra-
personal in nature, and arise from the internal, external, and
created environments. Stressors occur within and outside the
client system boundary, and have an impact to the system. The
goal of the systems model is stability and integrity through
elaborate circles of protection and defenses (Meleis, 2012).
When stressors invade the system, a degree of reaction, entropy
PJN VOL. 88 | NO. 1
and reconstitution occur. Nursing interventions are targeted to
these stressors in varying levels such as primary, secondary and
tertiary modes.
In the study, incivility is conceptualized as a stressor operating
within the workplace of the nurse. It arises during interactions
with hospital personnel, nurse colleagues, direct supervisor,
physicians and patients, families and visitors. Client variables, as
identified in the Neuman's model, are factors that affect
workplace incivility. It should be noted that the occurrence of
incivility happens in a broader context that includes influences
from interpersonal, community, environmental, and policy
sources. Supported by empirical studies, we hypothesized that
certain nurse-related variables will have significant impact on
workplace incivility. These nurse-related factors are nursing
designation, practice setting, clinical nursing unit and length of
hospital work experience.
Methodology
Design and Setting
The study utilized descriptive, cross-sectional design. The study
was conducted in different clinical nursing units in a national
tertiary hospital. These units are further classified according to
the types of patients such as service/ charity, pay and those with
health insurance (i.e., Philhealth). Units which are involved in
training, research and managerial functions are categorized as
administrative units. Data were collected from September to
October 2017.
Sampling
A stratified random sampling technique was used. Inclusion
criteria were (1) registered nurses with a designated plantilla
position assigned in different nursing units; and (2) must have at
least six-month stint in the current area of assignment at the
conduct of the study. Exclusion criteria were those registered
nurses working under a job order item, and those who were
employed not on a staff nurse or nurse managerial position.
Sample size
Sample size requirement was calculated based on estimates of
confidence interval, chance for Type 1 error, population size and
effect size. The online sample size calculator by Raosoft Inc.
(2004) was used to compute for the sample size. To achieve a
confidence level of 95%, error rate set at 5 % in a 1,000 population
size, a minimum sample size of 278 is required. The study had a
sample of 280. Response rate was recorded at 83.83 %.
Research Instruments
The following research instruments were utilized in the study:
1. Nurse's Profile. This tool described the socio-demographic

characteristics of nurses in terms of age, sex, highest
educational attainment, civil status, nursing designation,
practice setting, length of hospital work experience and clinical
nursing unit.
2. Nursing Incivility Scale (NIS). The NIS is a five-point scale, 42-
item tool designed to assess hospital nurses' experiences with
incivility according to specific sources namely hospital
personnel in general, physicians, direct supervisors,
coworkers, patients, families and visitors. The tool is further
divided into eight subscales indicating the forms of incivility
such as hostile climate, inappropriate jokes, inconsiderate
behavior, gossip/rumors, free riding, abusive supervision, lack
of respect, and displaced frustration. The Likert scale ranging
from 1 (strongly disagree) to 5 (strongly agree) measures the
level of agreement on behaviors in different types of
interactions at work. Scores are averaged to compute for
source-level and form-specific incivility. To compute for
subscale scores, individual item scores should be summed
and averaged. Higher score indicates higher degree of
workplace incivility.
The tool was chosen for its ease of use and its ability to provide a
baseline assessment on the sources and forms of workplace
incivility specific in nursing. The survey took approximately 10-15
minutes to complete. The NIS has been utilized in previous
studies conducted in other Asian countries such as Iran, China,
Singapore, Malaysia and Korea. Previous psychometric tests
reported that the NIS has a good internal consistency with a
Cronbach's alpha ranging from 0.88 to 0.94 and excellent
construct and discriminant validity (Guidroz et al., 2010). In the
study, the Cronbach's alpha of the NIS in general was 0.94 with
each subscale ranging from 0.88 to 0.92.
Data Collection Procedures
After the protocol has been approved by the ethics review board,
the researchers coordinated with the head nurse and chief nurse
in each clinical nursing unit about the conduct of study. They were
informed about the purpose and duration of the study and
procedures to be observed during data collection. Likewise, pilot-
testing of research instruments was conducted prior to actual
data collection. Data collectors were given an orientation
regarding the processes involved in the protocol.
Over a month period, respondents were recruited and screened
using the inclusion/exclusion criteria. Announcement regarding
the need for respondents in the study was posted in the bulletin
board in each nursing unit, and disseminated during
endorsements and meetings. The questionnaire was handed to
the respondent in an envelope. All answered questionnaires
were returned to the data collectors sealed in an envelope. Data
obtained from the questionnaire were entered into statistical
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software by the researchers. A statistician assisted the
researchers in data processing, presentation and analysis.
Ethical Considerations
The University of the Philippines Manila Research Ethics Board
provided ethical clearance to conduct the study. Voluntary
participation was emphasized in the recruitment of respondents.
Each respondent received a full disclosure of the study in a cover
letter with corresponding informed consent attached in the
questionnaire. The data collector explained the study purpose,
procedures and rights of the respondents. All respondents signed
a written consent form indicating participation in a study.
Moreover, they were assured that answered questionnaires were
kept privately in a locked cabinet in the researchers' office, and
anonymity was observed. Likewise, permission to use the
research instruments from copyright holders and developers was
sought through electronic mail.
Statistical Considerations
Descriptive statistics was used to present nurse's characteristics.
Normality of data was determined using Shapiro-Wilk test. A one-
way Analysis of Variance (ANOVA) was used to determine
differences between nurse-related variables and sources of
incivility. Post-hoc analysis was performed using Tukey's
Honestly Significant Difference (HSD). The level of significance
was set at 0.05, two-tailed test. Data were analyzed using
Statistical Package for the Social Sciences (SPSS) version 23
software. Data sets were compared for completeness,
inconsistency and accuracy.
Results
Sample Characteristics
Majority of the participants are female (78 %) and single (50 %)
with an average age of 36 years old (SD= 9.96, range 21-62).
They are working in the hospital for an average of 9 years (SD =
8.82). Most of the sample works in general clinical nursing units
(78.20 %) under a service/ charity setting (57 %). More than half
of the respondents (67.50 %) are bedside nurses who private
direct care (Nurse I/II) followed by charge nurses (Nurse III)
(19.30 %) and head and chief nurses (IV/VI) (13.24 %).
Sources of Workplace Incivility
Source of incivility is medium when interacting with hospital
personnel in general and physicians. Low incivility was reported
when dealing with fellow nurses and patient, family and visitors.
Relationship with direct supervisor is the least incivil.
Forms of Workplace Incivility
Inconsistent behaviors, hostile climate and displaced frustration
are the most common forms of incivility reported. Additionally,
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gossip/ rumors, free riding, lack of respect, abusive supervisor Table 2. Mean scores on the sources of workplace incivility.
and inappropriate jokes are also identified as other actions
showing incivility in a lesser extent.

Table 1. Socio-demographic characteristics of sample.

Table 3. Means scores on the forms of workplace incivility.

The nature of incivil interactions when grouped according to

nursing designation did not differ when interacting with hospital
personnel in general and direct supervisor. Significant differences
were observed when dealing with fellow nurses (F (2, 277)= 5.82,
p= 0.003), physician (F (2, 277) = 9.43, p= 0.001), and patients,
families and visitors (F (2, 277)= 6.67, p = 0.001).
Post-hoc Tukey HSD analysis showed that incivil behaviors
among staff nurses were significantly higher when compared
among head/chief nurses when interacting with fellow nurses,
physicians and patients and their loved ones (p= < 0.01). In
addition, incivility scores were significantly higher among staff
nurses when compared among charge nurses in a nurse-
physician interaction (p= < 0.05).

Table 4. Source-specific incivility mean scores according to nursing designation.

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Practice Setting Type of Clinical Nursing Unit

Incivility behaviors between nurses and hospital personnel,
nurse colleagues and direct supervisors did not significantly
differ with regards to practice setting. However, incivil
interactions between nurses and physicians (F (3, 276)
=6.04, p =.001) and patients and loved ones (F (3, 276)
=2.97, p = 0.032) significantly differ according to practices
setting.
Post-hoc analysis revealed that incivil behaviors in dealing
with patients and their loved ones were comparatively
higher among nurses who work in service and pay/
Philhealth settings as compared those who are in
administrative posts (p= < 0.05). Further, nurses assigned in
the pay/Philhealthand general/ mixed type of patients had
significantly higher incivility outcome with physicians when
compared those nurses in the service area (p= < 0.05).
When classified according to the type of clinical nursing unit (i.e., nature
of patient care services being rendered as to general, specialized and
administrative), incivil interactions did not significantly differ except
when dealing with patient, families and visitors (F (2, 277) =5.21, p =
0.006). Post-hoc Tukey HSD analysis indicated that incivil behaviors
were significantly higher among those nurses assigned in non-specialty
areas than those who are in administrative positions (p= < 0.01).
Length of Hospital Work Experience
Significant differences in incivility when interacting with fellow nurses
(F (3, 275) =3.01, p =.031), physician (F (3, 275 =4.01, p =.008) and
patients and loved ones (F (3, 275) =6.12, p = 0.001) were identified
when grouped according to the length of the nurse's hospital work
experience. Incivil behaviors with hospital personnel and direct
supervisors did not significantly vary according to years of service.

Table 5. Source-specific incivility mean scores according to practice setting.

Table 6. Source-specific incivility mean scores according to clinical nursing unit.

Table 7. Source-specific incivility mean scores according to clinical work experience.

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Post-hoc analysis reported that those who has a hospital work
experience of 3-5 years had significantly higher incivil
interactions with physicians, patients and their loved ones and
nurse colleagues than those who have spent at least 11 years and
above of service to the hospital (p= < 0.05).
Discussion
This preliminary study offers evidence on the sources and forms
of workplace incivility among nurses in a national tertiary hospital.
Incivility was analyzed according to nurse-related variables such
as nursing designation, practice setting, type of clinical nursing
unit and length of hospital work experience. These personal and
organizational factors are valuable in understanding and
predicting certain workplace behaviors such as incivility.
It was revealed that nurses encountered moderate incivility when
dealing with hospital personnel in general and physicians. They
reported low incivility when interacting with nurse colleagues at
work and patients and their loved ones assigned under their care.
Relationship with their direct supervisor has been found out to be
least incivil. Empirical studies supported this finding which
showed that incivility was low with supervisors and co-workers in
contrast to anecdotal reports about high levels of co-workers
incivility in healthcare settings (Laschinger, Leieter, Day &Gilind,
2009). The finding is consistent with the prevalence of incivility
among certified registered nurse-anaesthetists which indicated
that the respondents experienced moderately high levels of
incivility from hospital employees in general and physicians,
moderate levels of incivility from nurse colleagues, and low levels
of incivility from supervisors (Elmblad, Kodjebacheva & Lebeck,
2014). However, there are contrasting evidences which reported
that incivility occurs more frequently from superiors, followed by
co-workers and subordinates (Lim & Lee, 2011). Guidroz et al
(2010) who developed the Nursing Incivility Scale identified that
the highest incivility occurs in the general working environment.
The findings supported the tenets of social power theory which
argued that those having more perceived social authority and
resources tend to exert greater coercive and reward power on
those with less resources and authority creating incivility (Lim &
Lee, 2011). The conflicting evidence on the extent of incivility
varies among organizations because each institution has its own
unique culture, values and philosophy.
Inconsistent behaviors and hostile climate are the most common
forms of incivility as perceived by the nurses. Displaced
frustrations, gossips and rumors, free riding and lack of respect
occur in a lesser extent. Abusive supervisor and inappropriate
jokes were identified as the least forms of incivility. Inconsistent
behaviors such displaying offensive body language (i.e, eye
rolling, crossed arms, pinpointing fingers), taking things without
asking and talking too loudly in the workplace permeate incivil
actions. Hostile climate, on the other hand, encompasses a range
PJN VOL. 88 | NO. 1
of adversarial relationship among personnel leading to a working
environment of threat, intimidation and verbal attacks. Budin and
colleagues (2013) concluded that verbal abuse is the most
common form of disruptive behavior experienced by professional
nurses. This includes gossip and rumors from co-workers and
supervisor, lack of respect and inappropriate jokes. Abusive
supervision from physician is a recurring problem of incivility that
leads to intimidation and neglect of duty due to fear of verbal
abuse. Displaced frustration from expectations to services and
facility, on the other hand, may be directed to the nurses in most
cases because they are the ones the patient and visitor interact
with most of the time (Gillian, 2015). It must be noted that although
forms of incivility vary, the cumulative effects derange
collaboration and teamwork in a healthcare team, and negatively
affects patient care outcomes.
Staff nurses exhibited higher incivil interactions with nurse
colleagues, physician and patients and their families than nurse
supervisors due to more frequent interactions, increased patient
workloads, burn-out, physical fatigue and emotional
displacement. This finding is substantiated by prior studies which
reported that younger, front-line nurses with fewer years of
experience are more vulnerable to work-related disruptive
behaviors, aggression and abuse due to their lack of experience
in the work environment (Budin, Brewer, Chao & Kovner, 2013).
The nature of practice setting where a nurse is assigned has
impact on incivility. In this study, practice setting refers to patient
classification according to the mode of payment to hospital
service which includes service/ charity, pay, Philhealth and
general/ mixed. Administrative units are those not directly
involved in patient care, but rather in training, research and
managerial functions. It was noted that nurses in the service and
pay/Philhealth nursing units registered significantly higher
incivility scores with patients and their families because they have
more time of exposure to patients in bedside care in an 8-hour
duty shift. Additionally, nurses in the pay/ Philhealth and areas
with mixed type of patients have higher incivil interactions with
physicians than those in the service areas due to the expectations
and demands of patients and healthcare providers.
Incivil interactions of nurses with patients and their loved ones
differ according to type of clinical nursing unit. The study findings
indicated that nurses in the general clinical nursing units have
significantly higher incivil behaviors than those in administrative
position because they are more exposed to patients being in the
frontline of service. Extant literature supported this finding where it
was ascertained that those assigned in general medical and
surgical wards have higher perceptions of incivil behaviors than
those assigned in specialty areas such as oncology units and
operating room and post-ansethesia care units (Knippschild,
2012). Significantly, nurses in emergency and trauma
departments experienced higher levels of incivility because of
tension from higher health demands for life-threatening

conditions (Ryan &Maguirre, 2006). Similarly, acute care work
settings have higher incidence of disruptive behaviors than those
in outpatient settings (Vessey, Demarco, Gaffney &Budin, 2009).
Kreitzer and colleagues (1997) hypothesized that situational
factors inherent in high stress and high activity areas may
predispose nurses to verbal abuse and disruptive behaviors. The
general clinical nursing units in the study setting have diverse and
complex patient acuity levels because of the influx of patients
being admitted. These high activity areas predispose nurses to
incivil interactions because of overwhelming workloads and care
expectations.
Incivil behaviors when dealing with nurse colleagues, physicians
and patients and loved ones significantly differ according to years
of hospital work experience. In the study, nurses who have spent
at least 3-5 years of hospital work had comparatively higher incivil
interactions than those who have been working for more than a
decade. Length of working experience (5 years), nature of job
(part-time) and age (20-39 years old, above 60 years old) have
been found to be statistically significant predictors of incivility
(Nikstaitis& Coletta Simko, 2014; Knippschild, 2012; Budin,
Brewer, Chao & Kovner, 2013). The finding can be explained by
the work acculturation and adjustment in developing
interpersonal relationship with hospital personnel and patients as
a function of time and maturation.
In summary, this study found out that nurses when grouped
according to designation, practice setting, type of clinical nursing
unit and length of hospital work experience reported significant
incivil interactions with nurse colleagues, physicians and patients
and their families. These incivil acts are usually exhibited as
inconsistent behaviors, hostile climate and displaced frustrations.
Limitations
Study design and data collection procedures are research
imitations. The descriptive design doesn't warrant the
establishment of causal relationships between variables. The
sampling technique limits the generalizability of the findings.
Since data were gathered cross-sectionally, interpretation of
findings should look into the interplay of situational variables and
nature of work climate inherent to each nursing unit.
Conclusion and Recommendation
The study ascertained that nurses have significant incivil
interactions with nurse colleagues, physicians and patients and
families according to their designation, practice setting, type of
clinical nursing unit and length of hospital work experience.
Relationship with direct supervisor has been found out to be least
incivil. The moderately incivil interactions are manifested in
inconsistent behaviors, hostile climate and displaced frustrations.
The preliminary findings provide evidence on the nature of
workplace incivility among nurses in a hospital setting in the local
9
JANUARY-JUNE 2018
context. Understanding the sources and forms of incivility is of
paramount importance in mitigating its impact on healthcare
delivery and patient outcomes, and developing relevant policies
and interventions that protect the welfare of nursing workforce.
Administrators should carefully review existing policies on
promoting safe and healthy working environment for nurses, and
must adopt a zero-tolerance policy for incivility. Nursing policies
should explicitly address measures and processes in dealing with
incivility alongside with bullying and violence in the workplace.
Since nurses usually encounter lateral incivility among colleagues
at work, nurse managers should develop a nurturing leadership
style and creative conflict management skills to address incivil
encounters particularly among the vulnerable ones.
Innovative strategies need to be tailored to promote teamwork in
the inter-professional relationship among nurses and colleagues
in the healthcare team particularly with physicians. There is a
need to further strengthen team cohesiveness development
programs particularly between physicians and nurses. I t h a s
been reported that nurse-patient relationship is oftentimes marred
with incivility. Training and debriefing programs for nurses should
focus on personality development, composure behaviors,
therapeutic communication techniques, enhancing intrapersonal
and interpersonal relationships, conflict management and
handling diverse types of patients.
Lastly, further studies are needed to explore the impact of staff
burn-out, understaffing, patient workload, leadership styles and
organizational climate on workplace incivility using other research
methodology such as qualitative to capture the unique
experiences. Likewise, nurse's interactions with student-nurses,
nurse-trainees, clinical instructors, and other members of
healthcare team need to be investigated.
Conflict of Interest: We declare no conflict of interest.
......................................
References
Adeniran, R., Bolick, B., Cuming, R., Edmonson, C., Khan, B., Lawson,
L., & Wilson, D. (2016). Culture of Civility and Respect: A healthcare
leader's role. Princeton, New Jersey: Robert Johnson Wood
Foundation.
American Nurses Association. (2015). Position Statement: Incivility,
bullying, and workplace violence. Retrieved from
http://www.nursingworld.org/MainMenuCategories/WorkplaceSaf
ety/Healthy-Nurse/bullyingworkplaceviolence/Incivility-Bullying-
and-Workplace-Violence.htm, September 2, 2017.
Budin, W., Brewer, C. Chao, Y., & Kovner, C. (2013). Verbal abuse from
nurse colleagues and work environment of early career registered
nurses. Journal of Nursing Scholarship, 45 (3), 308–316.
Chipps, E. M., &McRury, M. (2012). The development of an educational
intervention to address workplace bullying: A pilot study. Journal for
Nurses in Staff Development, 28 (3), 94-98.
PJN VOL. 88 | NO. 1
10
JANUARY-JUNE 2018
Croft, R.C. & Cash, P.A. (2012). Deconstructing contributing factors to
bullying and lateral violence in nursing using a postcolonial feminist
lens.Contemporary Nurse, 42 (2), 226-242.
Elmblad, R., Kodjebacheva, G., &Lebeck, L. (2014). Workplace Incivility
Affecting CRNAs: A Study of Prevalence, Severity, and
Consequences with Proposed Interventions. AANA Journal, 82 (6),
437-445.
Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis &
Evaluation of Nursing Models and Theories. Second edition.
Philadelphia, PA: F.A. Davis Company.
Guidroz, A. et al. (2010). The Nursing Incivility Scale: Development and
validation of an occupation-specific measure. Journal of Nursing
Measurement, 18 (3), 176-200.
Holloway, E. L. &Kusy, M.E. (2010). Disruptive and toxic behaviors in
healthcare: Zero tolerance, the bottom line and what to do about it.
Med Pract Manage, 25 (6), 335-340. Hunt, C. & Marini, Z. (2012).
Incivility in the practice environment: A perspective from clinical
nursing teachers. Nurse Education in Practice, 1-5.
Hutton S. & Gates, D. (2008). Workplace incivility and productivity loses
among direct care staff. AAOHN Journal, 56 (4), 168-175.
Johnson, S.L. (2009) International perspectives on workplace bullying
among nurses: A review. International Nursing Review, 56, 34-40.
Knippschild, N. (2012). Incivility among nurses: Prevalence and impact.
Unpublished thesis. Gardner-Webb University North Carolina, USA.
Kreitzer, M.J. et al. (2007). Creating a healthy work environment in the
midst of organizational change and transition.Journal of Nursing
Administration, 27 (6), 35-41.
Laschinger, S., Leiter, M., Day, A., Gilin, D. (2009).Workplace
empowerment, incivility, and burnout: impact on staff nurse
recruitment and retention outcomes. Journal of Nursing
Management, 17, 302–311.
Lim, S., & Lee, A. (2011). Work and Nonwork Outcomes of Workplace
Incivility. Journal of Occupational Health Psychology, 95-111.
Meleis, A. (2012). Theoretical Nursing: Development and Progress. Fifth
edition. Philadelphia, PA: Lippincott Williams & Wilkins.
Nikstaitis, T. & Coletta Simko, L. (2014). Incivility among intensive care
nurses: The effects of an educational intervention. Dimensions of
critical care nursing, 33, 293-301.
Porath, C., & Pearson, C. (2013). The price of incivility. Harvard Business
Review, January-February Issue. Retrieved from
https://hbr.org/2013/01/the-price-of-incivility, September 12, 2017.
Ryan, D. & Maguire, J. (2006). Aggression and violence – a problem in
Irish Accident and Emergency departments?Journal of Nursing
Management, 14 (2),106-15.
Townsend, T. (2012). Break the bullying cycle. American Nurse Today,
7(1).
Vessey, J.A., Demarco, R.F., Gaffney, D.A. & Budin, W.C. (2009). Bullying
of staff registered nurses in the workplace: A preliminary study for
developing personal and organizational strategies for the
transformation of hostile to healthy workplace environments.
Journal of Professional Nursing, 25 (5), 299-306.
PJN VOL. 88 | NO. 1
ABOUT THE AUTHORS
Paul Froilan U. Garma earned his BSN,
magna cum laude, in Far Eastern University
Manila, and Master of Arts in Nursing (Adult
Health), dean's lister, in UP Open University. He
is pursuing PhD Nursing in UP Manila. He is a
member of the Sigma Theta Tau International
Honor Society of Nursing (Psi Beta chapter) and
an associate member of the National Research
Council of the Philippines.
Maria Clarissa C. Braganza works as a staff
nurse at the Department of Rehabilitation
Medicine ward of Philippine General Hospital.
She graduated Bachelor of Science in Nursing in
Far Eastern University Manila.
Jewell Mari Ellaine David works as a staff
nurse in the central intensive care unit of
Philippine General Hospital. She graduated
Bachelor of Science in Nursing in Arellano
University. She worked as a faculty of the
International Nursing Program of Arellano
University.
Marivin Joy Lim is a neonatal intensive care
nurse at Philippine General Hospital. She earned
her BSN, cum laude, at St. Paul University
Manila, and is currently completing her thesis
entitled Workplace Organizational
Characteristics and Professional Quality of Life of
Nurses: Basis for a Wellness Program for the
degree of Master of Arts in Nursing at
Pamantasan ng Lungsod ng Maynila.
Michelle dela Cruz is an operating room nurse
in the Philippine General Hospital. She earned
her Master of Arts in Nursing degree in the
Philippine Women's University.
Paul Veloso served in the Department of
Emergency for 20 years, nine years as head
nurse and seven years in the Division of Nursing
Research and Development of Philippine
General Hospital. Trained as an EMT via the
ASEAN/NEDA International Ambulance Services
in 2002, and appointed as TESDA NCII Evaluator
2018
 11

RESEARCH ARTICLE

EVIDENCE-BASED PRACTICE BELIEFS

AND IMPLEMENTATION OF
STAFF NURSES IN THE ILOCOS REGION
Bernardo Oliber A. Arde, Jr., PhD, RN1

Abstract
Purpose of the Study: The study assessed the EBP beliefs and implementation of staff nurses in the Ilocos Region.
Methods: A sample size of 384 nurses was surveyed in this cross-sectional, descriptive-correlational study approved by the Saint
Louis University – Research Ethics Committee. They were selected through simple random sampling in seven (7) different government
and private training hospitals in the Ilocos Region. The EBP Beliefs Scale (EBP-B) and EBP Implementation Scale (EBP-I) were used
to collect the data on the respondents' EBP Beliefs and Implementation respectively. Data collected were analyzed using descriptive
statistics such as frequency, percentage, mean and standard deviation; and inferential statistics such as Spearman rank correlation.
Findings: The mean total score of 58.57 indicated that the respondents have no full commitment or belief to EBP but the possibility
exists. The overall mean rating of 3.63 signified that they “Agree” on the statements in the EBPB scale in general. On the EBP
implementation, a mean summative score of 28.06 specified that the respondents implemented EBP between 1 to 3 times but less than
4 times in the past eight weeks. The overall mean rating was calculated at 1.56 suggestive that EBP is “Rarely implemented”. Moreover,
this study established a weak positive correlation between the respondents' EBP Beliefs and EBP Implementation [rs (384) = 0.252, p <
0.001].
Conclusion: This study has shown that nurses in the Ilocos region are positive about their knowledge of, confidence in and belief about
EBP but are not fully committal to it. However, in spite of having positive EBP belief, their implementation of EBP was rare or low. The
study was able to elicit that EBP implementation is significantly associated by the held beliefs on EBP by the respondents.
Keywords: EBP Beliefs, EBP Implementation, Staff Nurses, Ilocos Region

Introduction

t he Evidence-Based Practice (EBP) approach is consistently

pushed in the development, improvement, and establishment
of professions. Nursing, as a profession, has not been spared
from joining this bandwagon because of the impact of EBP in the
improvement of the quality of care. As it becomes the gold-
standard of nursing care in the 21st century, a growing number of
nurses have become enthusiasts of EBP, and great efforts have
been exerted to implement it. There is a general consensus that
when EBP is used as a framework for practice, patient outcomes
are improved as EBP practitioners are kept up-to-date of ways to
provide effective and efficient care and veer away with the
ritualistic, traditional, and non-systematic clinical experience.
Moreover, many scholars have alluded to EBP as a vital element
to filling the gaps that arise between research, theory and practice
in various work settings (Billings & Kowalski, 2006; Goodfellow,
2004; Mackey & Bassendowski, 2016; McEwen & Wills, 2014;
Upton, 1999).
French (1999) defined EBP as ”the systematic interconnecting of
scientifically generated evidence with the tacit knowledge of the
expert practitioner to achieve a change in particular practice for the
benefit of a well-defined client/patient group.” With the application
of EBP in various health care disciplines, Evidence-Based Nursing
(EBN) has evolved. However, Ingersoll (as cited in Scott &
McSherry, 2009) noted that there are some of nursing scholars
who worry about EBP being applied to nursing. He emphasized
that there are some components essential to nursing care which
are found to be lacking in EBP. These missing components of EBP

1 Correspondence: University of Northern Philippines, Tamag, Vigan City 09175982839; Email address: benardooliberarde@yahoo,com; https://orcid.org/0000-0002-2467-3707

PJN VOL. 88 | NO. 1

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were included in the definition of EBN by Ingersoll (2000) stating
that “evidence-based nursing is the conscientious, explicit and
judicious use of theory-derived, research-based information in
making decisions about care delivery systems and in
consideration of internal and external consumer needs and
preferences.”
Although reasons for introducing EBP together with strategies for
doing so and resource implications have been addressed
(Ciliska, Pinelli, DiCenso & Cullum; Benefield; DiCenso, Prevost,
Benefield, Bingle, Ciliska, Driever, Lock & Titler mentioned in
Adib-Hajbaghery, 2007) in developed and developing countries,
the evidence suggests that a paradigm shift to EBP is happening
very slowly. To explain this scenario, researchers have focused
on individual nurses' knowledge, beliefs and skills in appraising
and using research as the cornerstone of EBP and consequently
have developed models to encourage nurses' use of research in
practice.
Several studies have been conducted in developed countries to
identify the uptake of EBP among nurses and other healthcare
professionals. In 2004, a descriptive study on nurses' knowledge,
beliefs and the extent to which their practice is evidence-based
was conducted by Melnyk, Fineout-Overholt, Fischbeck, Li,
Small, Wilcox, and Kraus in the United States. Results revealed
that even if the beliefs about the benefit of EBP were high,
knowledge of EBP was comparatively low. Significant
relationships were also established between the extent to which
nurses' practice is evidence-based and 1) nurses' knowledge of
EBP, 2) nurses' beliefs about the benefits of EBP, 3) having an
EBP mentor, and 4) using the Cochrane Database of Systematic
Reviews and the National Guideline Clearinghouse (Melnyk et
al., 2004).
In 2009, Waters, Crisp, Rychetnik, and Barratt studied Australian
Nurses experience of nurses' preparedness for evidence-based
practice. The study determined the current knowledge and
attitudes towards EBP among pre- and post-registration nurses in
New South Wales (NSW), Australia. The results of this study
illustrated that with regard to EBP, the issues for nurses in NSW
are similar to those experienced by health professionals
worldwide. NSW nurses responding to the survey had a
welcoming and supportive attitude towards EBP but poor
competence and confidence in many EBP skills.
Similarly, Icelandic nurses' beliefs, skills, and resources
associated with EBP and related factors were explored by
Thorsteinsson in 2012. This descriptive survey determined RNs'
ability to provide care based on evidence by measuring their
beliefs, perception of skills, and access to resources associated
with EBP. Findings showed that respondents had strong beliefs
about the value of EBP for patient care, but showed less
confidence on the knowledge and skills needed for EBP. Peers
were consulted by most (82%) of the respondents (i.e., RNs)
PJN VOL. 88 | NO. 1
when in need of information, rather than peer-reviewed
resources. Only a third of over half of the RNs (54%) who received
instructions in the usage of electronic databases reported
success in using them. They considered “lack of search skills” as
the primary barrier to use of research in practice. Positive EBP
beliefs, familiarity with EBP and other EBP-related activities were
found to be associated with the use of research findings in
practice. A disadvantage on the part of the clinical RNs was found
when it came to accessing of EBP-related resources along with
less frequent participation in EBP-related activities other than
using research in practice.
Heydari, Mazlom, Ranjbar, and Scurlock-Evans (2014)
conducted a study among clinical nurses and midwives in
Mashhad public hospitals in Iran that aimed to determine their
EBP knowledge, attitudes, and practice. This descriptive cross-
sectional study revealed a low knowledge or skills and practice of
EBP, but moderate attitudes toward EBP among most of the
participants. Results further showed that significant differences
exist between the mean scores on knowledge or skills, attitudes,
and practice by field of study. A higher knowledge or skills and
practice of EBP was reported by nurses than midwives (p < .001).
A greater knowledge or skills and practice of EBP, and more
positive attitudes was displayed by nurses and midwives with
master's degrees than nurses with bachelor's degrees (p < .001).
In 2015, Underhill, Roper, Siefert, Boucher, and Berry compared
and described oncology nurse beliefs and perceived
implementation of EBP and explored beliefs and implementation
before and after implementing an institutional EBP initiative.
Results of this descriptive-correlational study revealed that a
history of formal EBP education and nurse role were associated
with higher EBP-B and EBP-I scores (p < .05). Highest level of
education was significantly correlated with both EBP-B (r =.25; p =
.03) and EBP-I (r = .32; p = .01).
Weng, Chen, Kuo, Yang, Lo, Chen, and Chiu (2015) also
surveyed nurses in Taiwan as to the implementation of evidence-
based practice in relation to a clinical nursing ladder system. The
survey showed that advanced nurses were more aware of EBP
than beginning nurses (p<0.001; 91 % vs. 78 %). Additionally,
advanced nurses held more positive beliefs about and attitudes
toward EBP (p < 0.001) and had more sufficient knowledge of and
skills in EBP (p < 0.001). Furthermore, they more often
implemented EBP principles (p < 0.001) and accessed online
evidence-based retrieval databases (p < 0.001). The most
common motivation for using online databases for advanced
nurses was self-learning and for beginning nurses was positional
promotion. Multivariate logistic regression analyses showed
advanced nurses were more aware of EBP, had higher
knowledge and skills of EBP, and more often implemented EBP
than beginning nurses.
While EBP activities have taken place in developed countries
such as Australia, Canada, the UK, and the US, the principle of

incorporating research evidence into practice is still in its infancy
in developing countries (Dizon, Dizon, Regino, & Gabriel, 2014).
The growth of EBP is slow in developing countries like the
Philippines
In the Philippines, the theory-practice gap remains as a key issue
which can be mitigated by the implementation of EBP.
Commission on Higher Education (CHED) Memorandum Order
No. 14, series of 2009 paved the way for the introduction of the
EBP in the nursing curriculum. On Core Competency 5 under
research, it specified that graduates of the BSN Program must be
competent in making use of EBP to enhance nursing practice.
Thus, EBP skills is an expected competency of BSN graduates
who are trained under this curriculum.
Despite EBP skills being expected from BSN graduates, their
commitment to EBP is still sluggish. Issues such as lack of
knowledge regarding EBP principles and lack of skills in applying
and teaching EBP principles, delay the uptake of EBP. In addition
to these, local barriers, tradition, and practices also influence its
uptake (University of South Australia Website [UNISA], 2016).
Like in other parts of the country, the Ilocos Region is no
exemption with regard to the difficulty of diffusing EBP in the
practice setting. With this unique situation in the Ilocos region in
the enculturation of EBP by health care institutions, one might
wonder if the same scenario is experienced by most, if not all
regions of the country.
Figure 1. The ARCC Model
13
JANUARY-JUNE 2018
Although efforts have been made to disseminate the value of EBP
in seminars, conferences and publications, the unavailability of
data on EBP beliefs and implementation among nurses in the
region underscore the need for an investigation. It is within this
context that the need to investigate the belief about and
implementation of EBP among nurses practicing in the Ilocos
region was born.
If Filipino nurses are to be at par with global standards, specific
studies should be conducted on a regional basis to determine the
unique situations of these regions as to their EBP beliefs and
implementation. Assessment of beliefs on and implementation of
EBP among nurses in various regions of the country would fill the
gap on the limited information of EBP utilization of nurses in the
country. Hence, this study attempted to fill in the missing
information of EBP implementation among Filipino nurses,
particularly those who are practicing in Region I.
FRAMEWORK OF THE STUDY
This study was anchored on the Advancing Research and Clinical
practice through Close Collaboration (ARCC) Model (Melnyk &
Fineout-Overholt, 2002; Melnyk, Fineout-Overholt, & Mays,
2008). ARCC is a model for EBP implementation. Valid and
reliable instruments measuring the constructs of the model,
barriers and facilitators to EBP and also the clinicians' beliefs
about and the actual implementation of EBP were developed by
the proponents of the ARCC model.
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JANUARY-JUNE 2018
As this model frames the conduct of this study, this current
investigation is guided by the contention of the ARCC model that
beliefs about the value of EBP and a clinician's ability to
implement it, foster implementation using the EBP paradigm and
subsequently improved outcomes. The model holds that higher
beliefs about EBP are expected to increase EBP implementation
and thereby, improve health outcomes. Moreover, it believes that
EBP implementation will improve healthcare outcomes through
greater participation in evidence-based care. EBP
implementation is expected to be highly associated with higher
nurse satisfaction, which will eventually lead to fewer turnover
rates and healthcare expenditures (Melnyk & Fineout-Overholt,
2010).
Therefore, this study tried to test if there is a positive relationship
between clinicians' belief about EBP and their implementation of
EBP as the model has hypothesized. Congruent with the ARCC
theoretical model, beliefs in EBP were defined as support for the
premise that EBP improves clinical outcomes and confidence in
one's EBP knowledge and skills (Melnyk et al., 2008). Moreover,
implementation of EBP was defined as engaging in relevant
behaviors that included seeking and appraising scientific
evidence, sharing evidence or data with colleagues or patients,
collecting and evaluating outcome data, and using evidence to
change practice (Melnyk et al., 2008). Along with this hypothesis,
the current study was also set to investigate if clinicians who
practice in an organization with stronger EBP cultures, versus
those who practice in organizations with weaker EBP cultures,
will have stronger beliefs and greater implementation of EBP.
METHODS
Research Design. This study used a cross-sectional,
descriptive- correlational design.
Locale of the Study. The study took place in seven different
government and private training hospitals in the Ilocos Region
(Region I), Philippines which serve as base hospitals of various
schools/Higher Education Institutions offering the Nursing
Program. These hospitals were accredited Level III and Level IV
based on the list of Licensed Government and Private Hospitals
of the DOH as of 2011.
Population and Sample. The study involved staff nurses of the
aforementioned hospitals as respondents. They took part in this
study regardless of their area/ward of assignment, years of
service, and status of appointment. From a population of 1,069
staff nurses, the sample size consisting of 384 nurses was
determined using OpenEpi Version 3.01 (2013) website. The
calculated sample size was distributed using the stratified
sampling technique using the geographical locations of these
hospitals as strata. Respondents were selected using the simple
random technique.
PJN VOL. 88 | NO. 1
Of the 384 respondents, mean age was 30.04 (SD = 8.35). Length
of service in years of the respondents has been reported at the
average of 5.54 (SD = 6.37) and have attended an average of
1.84 (SD = 2.97) EBP seminar/training in the last 12 months.
Majority of them are female (63.5%), permanent (54.2%) as to
their status of appointment and are bachelor's (69.3%) degree
holders.
Table 1. Characteristics of Respondents (N=384)
Data Gathering Tool. This study used a three-part questionnaire
to elicit the needed data. It was structured so that demographic
data were solicited first. Demographic data included the
respondent's institution, age, sex, status of appointment, highest
educational attainment, length of service in years, and number of
EBP seminar/training attended for the last 12 months
The EBP Belief (EBP-B) Scale (2003 by Melnyk & Fineout-
Overholt) the second part of the tool, is 16-item scale measuring
nurses' beliefs about and confidence in their ability to implement
EBP. The EPB-B utilizes a 5-point Likert scale and responses
range from 1 (strongly disagree) to 5 (strongly agree) and include
two reverse scored items (items 11 and 13). A summative score
was calculated for this measure and can range from 16 to 80;
higher scores indicate more positive beliefs. For its reliability, the
developers reported a Cronbach's alpha of 0.90 and Spearman-
Brown r reliability coefficient of 0.87 indicating the internal
consistency for the scale was excellent (Melnyk et al., 2008).
The third part is the EBP Implementation (EBP-I) scale (2003 by
Melnyk & Fineout-Overholt), which is an 18-item scale,
measuring the actual implementation of EBP. Responses are
given using a 5-point Likert scale of how often in the previous
eight weeks the respondents performed the item in question (0=0
times to 4= ≥ 8 times). A summative score was calculated and
can range from 0 to 72; higher scores indicate more frequent
implementation. For its reliability, the developers reported a
Cronbach's alpha of 0.96 Spearman-Brown r reliability coefficient
of 0.95 indicating the internal consistency for the scale was
excellent (Melnyk et al., 2008).

Data Gathering Procedure. Before the data collection, the
researcher submitted the study proposal for ethical review by the
Saint Louis University - Research Ethics Committee. The
researcher also obtained permission from the Heads of Hospitals
to conduct the study in their respective institutions through a letter
of request. Possible respondents were determined upon the
recommendation of the respective Chief Nursing Officer of the
institution and were selected through simple random sampling.
Upon identification of possible respondents, the researcher
and/or research assistant explained clearly the objectives of the
study and obtained written consent from the former.
Once consent was granted, the researcher or his research
assistant/s distributed the questionnaire to the respondents
during their duty hours at the institution. Respondents answered
the questionnaire during their break while some brought the
questionnaire home so as not to disrupt their work routine. The
respondents were given one week to accomplish the
questionnaire which was retrieved after that. Data were collected
from March to June 2017. Questionnaire-checklists were
assessed as to the completeness of responses. Those
questionnaires with incomplete responses were discarded.
Responses were tallied and subjected to statistical computation
for analysis and interpretation.
Ethical Considerations. This study was submitted for ethical
review by the SLU Research Ethics Committee. Permission for
the use of the Data Instruments was sought prior to its use. Ethical
considerations in the conduct of this research study are
concerned with obtaining informed consent and maintaining
confidentiality. Hence, an informed consent form containing
pertinent information of the study was formulated, given to and
signed by the respondents to signify their agreement to
participate in the study.
Anonymity of the respondents and confidentiality of the data were
addressed and maintained throughout the duration of the study
and included, but were not limited to the following (a) assigned
number codes for each participant on all research notes and
documents, and (b) survey forms and any other identifying
participant information were kept in a locked file cabinet in the
personal possession of the researcher. The researcher removed
any identifying information after analyzing the data, and all study
results were reported without identifying information so that no
one viewing the results was able to match anyone with the
responses. Soft copy of the data from this study was saved on a
password-protected computer for one year. Only the principal
investigator and study staff had access to this information.
For the principle of justice and fairness, the respondents were
treated fairly regardless of their institution, area/ward of
assignment, years of service, and status of appointment. Each of
them was given equal treatment without judgment or prejudice.
15
JANUARY-JUNE 2018
Data Analysis and Statistical Treatment of Data. Data collected
were analyzed using the Statistical Package for Social Sciences
version 18. Summative scores, mean, standard deviation, and
Spearman's rank Correlation Coefficient were used to summarize
and interpret the findings of this study.
RESULTS
Beliefs of the Staff Nurses towards EBP
Tables 2a and 2b illustrate the EBP beliefs of staff nurses in the
Ilocos region. Specifically, Table 2a shows the summative scores
of the respondents on EBP-B scale while Table 2b depicts the
mean scores and percentage of endorsements of the respondents
on each item of the same scale.
Table 2a. Frequency of Summative Scores
on the Evidence-based Practice Beliefs N=384
Legend 16-31 - No commitment 49-63 - No full commitment
32-47 - Little Commitment 64-80 - Firm Belief
48 - Neutral
The beliefs of staff nurses towards EBP was measured using the
EBP-B scale. The mean total score computed was 58.57
(SD=6.86) with scores ranging from 28 to 76 (with possible scores
16-80) (See Table 2a). This result indicates that the respondents
have no full commitment or belief to EBP at the time of data
collection but the possibility for them to have a firm belief or full
commitment to EBP exists
Meanwhile, the respondents have expressed that they generally
“agree” with the items of the EBP-B scale as evidenced by the
overall mean rating of 3.63 (SD =0.42) across the 16 items of the
scale (See Table 2b). This result implies that the respondents
come to agreement that they have positive belief about EBP
implementation. Specifically, they believe that they have the
adequate knowledge of, confidence in and belief in their ability to
implement EBP.
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Table 2b. Mean Ratings and Percentage of Endorsement on the Table 3a. Frequency of Scores on the Extent
items of Evidence-based Practice Beliefs (N=384) of Evidence-Based Practice Implementation (N=384)

Legend 0-17 implemented EBP less than 1 time

18-35 implemented EBP between 1-3 times but less than 4 times
36-53 implemented EBP between 4-5 times but less than 6 times
54-71 implemented EBP between 6-7 times but less than 8 times
72 implemented EBP between 8 times or more

Table 3b. Mean Ratings of Evidence-based Practice

Implementation (N=384)

* Reversed scored
Legend 16-31 - No commitment 49-63 - No full commitment
32-47 - Little Commitment 64-80 - Firm Belief
48 - Neutral

Implementation of EBP by the Staff Nurses

Tables 3a and 3b indicate the EBP implementation of staff nurses
in the region. Explicitly, Table 3a displays the summative scores of
the respondents on the EBP-I scale whereas Table 3b shows the
mean ratings of each item of the same scale.
The implementation of EBP by the respondents was measured
using the EBP-I scale. A mean summative score of 28.06 (SD =
15.47) was computed based on the raw scores which ranged
from 1 to 70 (possible scores of 0-72) (See Table 3a). Based on
these results of self-report engagement to EBP of the
respondents, it signifies that they are hardly actualizing EBP in
their respective work environment. The computed summative
score indicates that the respondents have implemented EBP
between 1 to 3 times but less than four (4) times in the past eight
(8) weeks. Using this as a reference, actual result of the present
study is indicative of low EBP implementation.
Scrutinizing Table 3b, the overall mean rating was calculated at
1.56 (SD = 0.21). The overall mean rating signifies that the EBP is Norm 3.21 – 4.00 Very frequently implemented (VFI)
2.41 – 3.20 Frequently implemented (FI)
“rarely implemented” by the respondents in their respective work 1.61 – 2.40 Occasionally Implemented (OI)
environment. In other words, the respondents are implementing 0.81 – 1.60 Rarely implemented (RI)
EBP in a low extent. 0.00 – 0.80 Very rarely implemented (VRI)

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Significant Relationship between EBP beliefs and
EBP implementation
Spearman's correlation between EBP beliefs and EBP
implementation of the respondents showed that there is a weak
positive correlation, which was statistically significant [rs (384) =
0.252, p < 0.001] (See Table 4). This result suggests that EBP
beliefs are precursors of EBP implementation where it contends
that as EBP beliefs increase, EBP implementation of the
respondents may also increase.
Table 4. Spearman's Correlation Coefficient of Significant Relationship
Legend: **Correlation is significant at the 0.01 level (2-tailed).
DISCUSSION
The study investigated the EBP beliefs and implementation of
staff nurses in the Ilocos Region. Also, it tested if there is a
positive relationship between clinicians' belief about EBP and
their implementation of EBP as posited by the ARCC model.
The results showed that the respondents are positive yet has no
firm belief on EBP as indicated by their scores in the EBP-B
Scale. The result corroborates the claim that the incorporation of
EBP principles to direct users or implementers in developing
nations, like the Philippines, is slow-moving. As compared to
developed countries, these results are lagging behind. Previous
studies reported in the current investigation laud that nurses
and/or other health care professionals who were investigated
responded and obtained higher scores suggestive of a firmer
belief than the respondents of the present study.
The respondents' positive belief but no full commitment to EBP
implies the need to strengthen the EBP beliefs of the nurses. This
goal can be achieved if hospital administration and nursing staff
are made aware of the current practice guidelines. The
awareness of the need for EBP demands a process/action to
change practice habits, and academician are in the best position
to provide education and increase awareness of point-of-care
clinician. Having the necessary reference materials and facilities,
the academe can develop strategies for teaching experienced
staff about and how to utilize EBP base in their teaching
experience to students. These can be done through formal and
informal communication and conversations. The academe may
opt to spearhead orientation programs, EBP seminars/training. At
the very least, they may decide to become resource speakers or
lecturers in In-service training of hospitals. Topics may include
EBP what it is and what it is not, steps in EBP, skills needed to
implement EBP and how to implement EBP. The educational
17
JANUARY-JUNE 2018
strategy, in turn, transforms the nurses' thinking and eventually
leads to change in practice that is based on evidence. With
education, nurses will find interpretation and implementation of
EBP, reduction of barriers, and the ability to speed up the
translation of research into the use at the bedside as necessary to
provide quality, effective and efficient care to their patients.
Nonetheless, it is interesting to note that the respondents
generally agree with the items of the EBP-B scale. This result can
be attributed to the continual reiteration of EBP and its effects in
seminars, training and even in the professional journal for nurses
– the Philippine Journal of Nursing (PJN). The said journal, as it is
distributed nationwide, might have shaped the views of the
respondents who probably have read the journal. PJN has
consistently echoed the clarion call to shift to EBP from the
traditional way of providing intervention. In its 2009 second issue
“Leading Change Through Evidence-Based Practice in Nursing,”
Palaganas (2009) wrote in her editorial to capitalize on the
enthusiasm for evidence-based practice that is growing in the
nursing community and the need to develop, implement and
evaluate a plan to make it happen. Furthermore, the 2012 first
issue of the same journal “Closing the gap: from Evidence to
Action” further retold the urgent call to constantly strive to use
EBP to nursing services. It was stated in the editorial section that
the evidence-based approach to health care attempts to bridge
the gap between research and nursing practice in various work
settings and that this approach should be seen as a tool to
continually push to more lasting solutions to deeply rooted gaps in
the health care (Palaganas, 2012).
On the other hand, the study results have shown that the
respondents were implementing EBP one (1) to three (3) times in
the last eight (8) weeks. This result is way below the standard of
an EBP clinician. Melnyk and colleagues (2008) argued that EBP
should be implemented by clinicians at a minimum of at least 6-7
times in the last eight (8) weeks. Using this as a reference, actual
result of the present study is indicative of low EBP
implementation. The result of the current study strengthens the
assertion that EBP implementation is slow, particularly in
developing countries.
The findings of this study are similar to those of previous studies
on EBP implementation, therefore, the result is not surprising.
Just like in the case of Stokke and colleagues (2014) where the
results of their study have shown that nurses were practicing EBP
to a small extent. The same finding is also seen by Lynch (2015)
revealing that there was a low use of EBP among nurses.
The low extent of EBP implementation of the present study can be
attributed to several factors both at the individual and
organizational level. This standpoint is further strengthened by
the assumption of the ARCC model that there are barriers (as well
as facilitators of) to EBP implementation for individuals and within
the healthcare systems. The model further reiterated that barriers
to EBP must be removed or mitigated to implement EBP as a
standard of care.
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JANUARY-JUNE 2018
At the individual level, possible reasons for low implementation of
EBP include (a) lack of rigorous educational preparation and
technical skills about EBP, (b) limited or lack of involvement in
research activities of the organization and outside organizations,
and (c) hesitance and decreased intent to spearhead practice
change. In contrast, at the organizational level, potential
explanations could be (a) EBP is not a priority of the organization,
(b) lack of EBP trained staff, (c) staff nurses do not have the
authority and autonomy to change practice, (d) lack of
administrative support, (e) lack of funds to support an EBP
project, (f) lack of logistical support, (g) high workload of nurses,
and (h) a high ratio of patient to one nurse. These factors,
individual or combined, play as major barriers to the acculturation
of EBP in the organization.
Moreover, the absence of a model adopted by health care
institutions is another aspect that perhaps can explain the low
implementation of EBP in their work setting. EBP models have
been developed to help nurses in integrating evidence into their
daily practice. These models assist nurses in directing efforts
derived either from clinical problems or from “good ideas” toward
actual implementation in a specific practice setting. Use of EBP
models leads to systematic approaches to EBP, prevents
incomplete implementation, promotes timely evaluation, and
maximizes use of time and resources (Gawlinski & Rutledge,
2008).
This study also investigated the relationship between EBP beliefs
and EBP Implementation. The finding of the present study seems
to be consistent with the basic hypothesis of the ARCC model that
there is a positive relationship between clinicians' beliefs about
EBP and their implementation of EBP. In the ARCC model, higher
beliefs about EBP are expected to increase EBP implementation.
Similarly, the finding of the current investigation conforms with the
findings of earlier studies in EBP beliefs and implementation that
EBP implementation was explained by EBP beliefs (Estrada,
2009; Kaplan et al., 2014; Kim et al., 2016; Melnyk et al., 2004;
Squires, Estabrooks, Gustavsson, & Wallin, 2011; Wallen et al.,
2010; Weng et al., 2015). When knowledge about EBP is
developed, and conviction is strengthened, the individual will be
motivated to get involved and work in an evidence-based way
(Stokke et al., 2014). The ARCC model shares the same ideas as
it assumes that for clinicians to change their practice to be
evidence-based, cognitive beliefs about the value of EBP and
their confidence in their ability to implement it must be
strengthened. Some studies demonstrate that nurses with
positive EBP beliefs and attitude are more likely to utilize
research and implement EBP (Eizenberg; Koehn & Lehman;
Melnyk et al.; Milner, Estabrooks, & Myrick; Ploeg, Davies,
Edwards, Gifford, & Miller, as cited in Kang & Yang, 2016). EBP
beliefs indicate nurses' cognitive perceptions about the value of
EBP and their ability to implement this in clinical settings.
PJN VOL. 88 | NO. 1
Meanwhile, although the intention to implement EBP is ushered
when EBP beliefs are high, actualizing EBP in the work
environment is more than just believing in its value to produce the
desired outcome or having the confidence to implement it.
Technical preparation and mastery of desired skills are needed
for EBP to materialize in a non-EBP culture. Therefore, contextual
and personal elements are relevant considerations when
implementing EBP. Nero (2016) in his study investigating how
nurses in Region I view the concept of nursing in the Philippines
mentioned that nurses in the region believe that nursing is a
science grounded on theories; and since nursing is a science, it is
considered as evidence-based care. He further noted that today,
Ilocano nurses had adopted the trait of incorporating science into
their practice. However, as they embrace the knowledge
imparted to them by other cultures, Ilocano nurses still preserve
their culture and tradition by continuously practicing and passing
them to the next generation. The hesitance to forego traditional
practices plus the barriers that occur in the organizational context
explains the weak relationship between beliefs on and
implementation of EBP in the Ilocos region.
CONCLUSION
This study has shown that nurses in the Ilocos region, in general,
are positive about their knowledge of, confidence in and belief
about EBP but are non-fully committal to it. Their non-full
committal probably explains why their implementation of EBP
was rare or low. Moreover, the study was able to elicit that EBP
implementation can be affected by EBP beliefs for a positive
correlation exists between EBP beliefs and EBP implementation.
These data could serve as essential bases for developing
strategies that would solidify the nurses' beliefs as well as
improve their actualization of EBP.
RECOMMENDATIONS
Findings of the current study demand for educational
interventions and competence building methods to intensify the
present status of EBP implementation among staff nurses in the
region. Professional organizations and/or higher education
institutions may opt to offer crash courses on EBP. Various
professional nursing organization should establish a unified EBP
training course/program with different levels to address the varied
needs of nurses. First level training courses which highlight the
importance/value, process and competencies needed for EBP
implementation can be attended by point-of-care nurses while
higher level training courses which provide intensive didactics
and practicum can be attended by clinicians who would want
become EBP champions of the organization.
Hospital and Nursing administrators should be committed to
providing necessary resources such as computers and EBP
education to create an environment conducive to EBP. EBP

competencies and initiatives/ projects can also be integrated as
criteria for clinical promotions.
Memorandum of Agreement (MOA) between Higher Education
Institutions (HEIs) offering health-related programs and base
hospitals should include the need for partnership in research
undertaking. Research outputs and the utilization of the findings
of the partnership can become the basis of renewal of
ties/contracts.
It is also recommended that Professional Nursing Organization of
the region should come up with an action plan that outlines
specific strategies and actions to be taken to solidify the beliefs,
knowledge and attitudes and facilitate EBP implementation of
Nurses on EBP.
Since the information at hand provides the unique circumstance
of Region I staff nurses on EBP, it is recommended that similar
studies be conducted in the other regions of the country. This
suggestion is deemed necessary in order to capture the nation-
wide status of EBP in Philippines. Additionally, EBP beliefs and
implementations studies with nurses in the academe as
respondents should also be taken in consideration.
..........................
References
Adib-Hajbaghery, M. (2007). Factors facilitating and inhibiting evidence-
based nursing in Iran. J Adv Nurs Journal of Advanced Nursing,
58(6), 566-575. doi:10.1111/j.1365-2648.2007.04253.x
Billings, D. M. & Kowalski, K. (2006). Bridging the theory-practice gap
with evidencebased practice. The Journal of Continuing Education
in Nursing, 37, 248-249.
Commission on Higher Education. (2009). CMO-No.14-s2009 [PDF].
Commission on Higher Education.
Dizon, J. M., Dizon, R. J., Regino, J., & Gabriel, A. (2014). Evidence-
based practice training for health professionals in the Philippines.
Retrieved April 21, 2016, from http://www.ncbi.nlm.nih.gov/
pmc/articles/PMC3998855/
Estabrooks, C. A., Scott, S., Squires, J. E., Stevens, B., Obrien-Pallas,
L., Watt-Watson, J., . . . Williams, J. (2008). Patterns of research
utilization on patient care units. Implementation Science, 3(1).
doi:10.1186/1748-5908-3-31
Estrada, N. (2009). Exploring Perceptions of a Learning Organization by
RNs and Relationship to EBP Beliefs and Implementation in the
Acute Care Setting. Worldviews on Evidence-Based Nursing, 6(4),
200-209. doi:10.1111/j.1741-6787.2009.00161.x
French, P. (1999). The development of evidence-based nursing. Journal
of Advanced Nursing, 29(1), 72-78.
Gawlinski, A., & Rutledge, D. (2008). Selecting a Model for Evidence-
Based Practice Changes. AACN Advanced Critical Care, 19(3),
291-300. doi:10.1097/01.aacn.0000330380.41766.63
Goodfellow, L. M. (2004). Can a journal club bridge the gap between
research and practice? Nurse- Educator. 29(3): 107-10.
Heydari, A., Mazlom, S. R., Ranjbar, H., & Scurlock-Evans, L. (2014). A
Study of Iranian Nurses' and Midwives' Knowledge, Attitudes, and
19
JANUARY-JUNE 2018
Implementation of Evidence-Based Practice: The Time for Change
Has Arrived. Worldviews on Evidence-Based Nursing, 11(5), 325-
331. doi:10.1111/wvn.12052
Ingersoll, G. L. (2000). Evidence-Based Nursing: What It Is and What It
Isn't. Nursing Outlook, 48(4), 151-152. doi:10.1067/mno.
2000.107690
Kaplan, L., Zeller, E., Damitio, D., Culbert, S., & Bayley, K. (2014).
Improving the Culture of Evidence-Based Practice at a Magnet®
Hospital. Journal for Nurses in Professional Development, 30(6),
274-280. http://dx.doi.org/10.1097/NND.0000000000000089
Kang, Y., & Yang, I. (2016). Evidence-based nursing practice and its
correlates among Korean nurses. Applied Nursing Research, 31,
46-51. doi:10.1016/j.apnr.2015.11.016
Kim, S. C., Stichler, J. F., Ecoff, L., Brown, C. E., Gallo, A., & Davidson, J.
E. (2016). Predictors of Evidence-Based Practice Implementation,
Job Satisfaction, and Group Cohesion Among Regional Fellowship
Program Participants [Abstract]. Worldviews on Evidence-Based
Nursing, 13(5), 340-348. doi:10.1111/wvn.12171
Lynch, S. H. (2015). Nurses' Beliefs About and Use of Evidence-Based
Practice. Retrieved July 4, 2017, from http://web.b.ebscohost.com/
ehost/detail/detail?vid=0&sid=1f2a6d7b-2668-46e7-b624-
aa8b48536ed3%40sessionmgr120&bdata=JnNpdGU9ZWhvc3Qt
bGl2ZQ%3d%3d#AN=109860306&db=c8h
Mackey, A., & Bassendowski, S. (2016). The History of Evidence-Based
Practice in Nursing Education and Practice. Retrieved December
15, 2016, from http://www.professionalnursing.org/article/S8755-
7223(16)30028-X/abstract
McEwen, M. & Wills, E. (2014). Theoretical basis for nursing (4th ed.).
New York: Lippincott, Williams & Wilkins.
Melnyk B. M., & Fineout-Overholt, E. (2010) ARCC (Advancing Research
and Clinical practice through close Collaboration): a model for
system-wide implementation and sustainability of evidence-based
practice. In: RycroftMalone J, Bucknall T, editors. Models and
frameworks for implementing evidence-based practice: linking
evidence to action. Oxford; Ames, IA: Wiley-Blackwell; Sigma Theta
Tau. p. 169-84.
Melnyk, B. M., Fineout-Overholt, E., Fischbeck, N. F., Li, H., Small, L.,
Wilcox, L., & Kraus, R. (2004). Original article: Nurses' perceived
knowledge, beliefs, skills, and needs regarding evidence-based
practice: Implications for accelerating the paradigm shift.
Worldviews on Evidence-Based Nursing, 1(3), 185-193.
Melnyk, B. M., Fineout-Overholt, E., & Mays, M. Z. (2008). The evidence-
based practice beliefs and implementation scales: Psychometric
properties of two new instruments. Worldviews on Evidence-Based
Nursing, 5(4), 208–216
Nero, F.D.L. (2016). The Concept of Nursing in the Philippines from the
Perspective of Nurses in Region I (Unpublished Doctoral
Dissertation).
Palaganas, E. C. (2009). Leading change and Evidence-Based Nursing.
Philippine Journal of Nursing, 79(2), 2009th ser., 1-2.
Palaganas, E. C. (2012). Closing the gap: Moving from Evidence to
Action. Philippine Journal of Nursing, 82(1), 2012th ser., 1-2.
Scott, K., & McSherry, R. (2009). Evidence-based Nursing: Clarifying The
Concepts For Nurses In Practice. Journal of Clinical Nursing, 18(8),
1085-1095.
Squires, J. E., Estabrooks, C. A., Gustavsson, P., & Wallin, L. (2011).
Individual determinants of research utilization by nurses: A
systematic review update. Implementation Science, 6(1).
doi:10.1186/1748-5908-6-1
Stokke, K., Olsen, N. R., Espehaug, B., & Nortvedt, M. W. (2014).
Evidence based practice beliefs and implementation among nurses:
PJN VOL. 88 | NO. 1
20
JANUARY-JUNE 2018

A cross-sectional study. Retrieved June 18, 2017, from

https://www.ncbi.nlm.nih.gov/pubmed/24661602
Thorsteinsson, H. S. (2012). Icelandic Nurses' Beliefs, Skills, and
Resources Associated with Evidence-Based Practice and Related
Factors: A National Survey. Worldviews on Evidence-Based
Nursing, 10(2), 116-126. doi:10.1111/j.1741-6787.2012.00260.x

“
Underhill, M., Roper, K., Siefert, M. L., Boucher, J., & Berry, D. (2015).
Evidence-Based Practice Beliefs and Implementation Before and
After an Initiative to Promote Evidence-Based Nursing in an
Ambulatory Oncology Setting. Worldviews on Evidence-Based
Nursing, 12(2), 70-78. doi:10.1111/wvn.12080
University of South Australia. (n.d.). EBP in the Philippines. Retrieved
June 12, 2016, from http://www.unisa.edu.au/Research/Sansom-
Institute-for-Health-Research/Research/Allied-Health-
Evidence/Quality-Care/EBPPhil/
Upton, D. J. (1999). How can we achieve evidence-based practice if we
have a theory-practice gap in nursing today? Journal of Advanced
Nursing, 29(3), 549-555. doi:10.1046/j.1365-2648.1999.00922.x
Wallen, G.R., Mitchell, S.A., Melnyk, B., Fineout-Overholt, E., Miller-
Davis, C., Yates, J. & Hastings, C. (2010) Implementing evidence-
based practice: effectiveness of a structured multifaceted
mentorship programme. Journal of Advanced Nursing 66(12),
2761–2771
Waters, D., Crisp, J., Rychetnik, L., & Barratt, A. (2009). The Australian
experience of nurses' preparedness for evidence-based practice.
Journal of Nursing Management, 17(4), 510-518.
doi:10.1111/j.1365-2834.2009.00997.x
Weng, Y., Chen, C., Kuo, K. N., Yang, C., Lo, H., Chen, K., & Chiu, Y.
(2015). Implementation of Evidence-Based Practice in Relation to a
Clinical Nursing Ladder System: A National Survey in Taiwan.
Worldviews on Evidence-Based Nursing, 12(1), 22-30.
doi:10.1111/wvn.1207

ABOUT THE AUTHOR

Bernardo Oliber A. Arde, Jr., RN, PhD

received his Bachelor of Science in Nursing and
Master of Arts in Nursing from the University of
Northern Philippines, Vigan City. He obtained
his PhD in Nursing from Saint Louis University.
Currently, he is a faculty and a research
promoter at University of Northern Philippines
with designations as the University’s Coordinator for Health and
Allied Services and the Officer-in-Charge of the Research Unit of
UNP-College of Nursing. His research interest include EBP,
maternal and child nursing, health disparity, HIV/AIDS, and
Nursing pedagogy.
...........
ACKNOWLEDGMENT

The author wishes to thank Dr. Bernadette Melnyk and Dr. Ellen
“
Fineout-Overholt for granting the permission to use the EPB-B and
EBP-I Scales and the ARCC model without charge. As well as to Dr.
Erwin F. Cadorna, Dr. Edelyn A. Cadorna, and Prof. Baby Sophia S.
Alaibilla for their assistance in the statistical computation, Dr.
Annabelle R. Borromeo, Dr. Norenia T. Dao-ayen, Dr. Mary Grace
Lacanaria, and Dr. Erlinda C. Palaganas for their undying support
and guidance to the researcher's endeavours.

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RESEARCH ARTICLE

CHILDBIRTH SATISFACTION AND MATERNAL

ROLE CONFIDENCE OF EARLY POSTPARTUM
MOTHERS FROM MATERNITY UNITS
Artemio M. Gonzales Jr., RN, RM, MPH1

Abstract
Promoting positive birth experiences may help create circumstances amenable to enhancing the quality of obstetric care and
improving outcomes for mothers and infants. This study aims to examine the relationship between childbirth satisfaction and maternal
confidence during early postpartum period in mothers from maternity units of San Jose, Occidental Mindoro. This is a descriptive cross-
sectional study utilizing Women's Views of Birth Labour Satisfaction Questionnaire (WOMBLSQ) and Maternal Confidence
Questionnaire (MCQ). To correlate the level of childbirth satisfaction and maternal role confidence of early postpartum mothers,
Pearson's R correlation was used. A p value of 0.05 was taken for statistical significance. It revealed that the early postpartum mother
respondents in the study were satisfied with their childbirth experience and confident with their maternal role. Moreover, the childbirth
satisfaction was positively correlated with maternal role confidence. It is implicated in the practice of healthcare professionals to
provide better understanding of the factors that influence maternal role within their particular social contexts.

Keywords: Childbirth satisfaction, maternal confidence, early postpartum, WOMBLSQ, MCQ

Introduction

M aternal confidence is a key theme influencing maternal

experience post-parturition, particularly after discharge from
the maternity unit (Murdoch & Franck, 2008). Since infant
regulatory problems had the strongest interaction with maternal
self-confidence, maternal confidence has become an essential
concept in understanding early disturbances in the mother-child
relationship (Matthies et al., 2017). The concept of maternal self-
confidence is understood as a special aspect of self-efficacy.
Maternal self-confidence is defined as a mother's confidence in
her own abilities to successfully raise her child, to be able to
handle aspects of daily parenting, and to correctly interpret her
child's signals (Zahr, 1991). Low maternal self-confidence may
damage the early mother–infant relationship and negatively
influence infant development. Specific interventions should be
implemented within the first few weeks postpartum in order to
prevent developmental disorders, which may result to reduced
feelings of maternal self-efficacy in the context of current and
previous anxiety disorders and depression (Reck, Noe,
Gerstenlauer and Stehle, 2012). The mother's anxiety and mood
were measured in the first days after childbirth and once again at
eight (8) weeks. Infant temperament and the mother's confidence
in caregiving were measured at eight (8) weeks. A mother's
postpartum anxiety following delivery was the best predictor for
most of the variables of infant temperament, including infant
irritability, and other child variables like infant sleep and nursing
difficulty. Contextual-family variables, such as the number of
people at home and whether they were primiparous were the best
predictors for a mother's confidence in caregiving. Support was
found for an early effect of maternal anxiety on infant
temperament (Jover et al., 2014).
Childbirth is one the most important events in a woman's life,
leaving her with profound psychological, physical, and social
effects. Moreover, dissatisfaction with childbirth care can have a
negative impact on a woman's health and well-being, as well as
her relationship with her infant (Mohammad, Alafi, Mohammad,
Gamble & Creedy, 2014). Based on the result of a recent study,
mothers' satisfaction with natural childbirth will be ensured with
the mothers' knowledge of the childbirth process, utilization of
non-medical pain relief techniques, and active involvement and
maintaining control in the process of childbirth. Creating the right,
safe, and quiet ambience is also among the most essential

1 Correspondence: Midwifery Department; College of Arts, Sciences, and Technology; Occidental Mindoro State College; San Jose, Occidental Mindoro; jomergonzalesjr21@gmail.com

PJN VOL. 88 | NO. 1

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requirements to ascertain satisfaction with childbirth (Jafari,
Mohebbi and Mazloomzadeh, 2017). Confidence going into
childbirth was the strongest predictor of confidence during birth.
Promoting positive birth experiences may help create
circumstances amenable to enhancing the quality of obstetric care
and improving outcomes for mothers and infants (Attanasio,
McPherson & Kozhimannil, 2014 ). However, little is known
empirically about the factors affecting maternal role and maternal
confidence relating to birth satisfaction during postpartum period.
Research about enhancing women's confidence for and birth was
limited to qualitative studies. Avery, Saftner, Larson and Weinfurter
(2014) suggest that women desire information during pregnancy
and want to use that information to participate in care decisions in
a relationship with a trusted provider. Further research is needed
to develop interventions to help midwives and physicians enhance
women's confidence in their ability to give birth. Understanding the
determinants of maternal confidence and satisfaction will help
health care providers provide balanced care that meets the needs
of postpartum mothers. This study aims to examine the correlation
between childbirth satisfaction and maternal confidence during
early postpartum period in mothers from maternity units of San
Jose, Occidental Mindoro.
Methodology
Research Design
A descriptive cross-sectional design was used in this study. In this
design, the outcome variable, which is the maternal role
confidence as well as the exposure variables, the childbirth
satisfaction were assessed at a particular point in time. This study
used descriptive correlational to examine the level of childbirth
satisfaction and its influence on maternal role confidence during
early postpartum period. The data were collected one month after
delivery. This study was conducted from November 2017 –
January 2018. In this study, the correlation was built up by the two
known and existing knowledge. Since there are no studies located
in the literature finding the relationship of level of childbirth
satisfaction and maternal role confidence study design facilitated
an early understanding of these relationships in a sample. The
assumption in this study is that the childbirth satisfaction has
influence to maternal role confidence but there was no causal
relationship assumed (childbirth satisfaction do not cause
maternal role attainment).
Setting and Respondents
The study was conducted in selected barangays of San Jose,
Occidental Mindoro that comprised the large populace barangays
and with a high birth rate namely: San Roque, Pag-asa,
Caminawit, and Labangan. The respondents of the study were
175 early postpartum mothers who were systematically chosen
from four purposively selected barangays: San Roque, Pag-asa,
Caminawit and Labangan. For each selected areas, respondents
were chosen using systematic sampling following the inclusion
PJN VOL. 88 | NO. 1
principle: (1) mother who is in early postpartum period (1st week-1st
month postpartum), (2) mother who had normal spontaneous
delivery, and (3) mother who has no known complication/high-risk
condition determined during antenatal visit.
Research Instrument
The research instrument was composed of three parts:
Sociodemographic questionnaire includes questions regarding
age (interval); marital status (nominal); educational attainment
(ordinal); monthly income (interval); number of pregnancies or
gravida (interval); number of deliveries or parity (interval); number
of prenatal visit; place of delivery (nominal); and attendant during
childbirth (nominal). Level of childbirth satisfaction was determined
using the 30-item Women's Views of Birth Labor Satisfaction
Questionnaire (WOMBLSQ), which is a quantitative psychometric
multidimensional maternal-satisfaction questionnaire (Smith,
2001). A five point Likert scale (1=strongly disagree; 2=disagree;
3=neutral; 4=agree; and 5=strongly disagree) was used to rate
satisfaction with various aspects of health care. The satisfaction
variables were grouped into eight categories: professional support
(five items); expectations (four items); holding baby (three items);
support from husband/partner (three items); pain in labor (three
items); pain relief after delivery (three items); environment (three
items); and control (three items). The questionnaire has a high
validity and reliability as it is accounted for the 70.22% of the
variance, and Cronbach'sα of 0.82. Maternal role confidence of
early post-partum mothers was measured using Maternal
Confidence Questionnaire (MCQ), a 14-item questionnaire that
measures maternal confidence in parenting of their infants, and
the ability of mothers to recognize the needs of their infants
adopted from (Parker & Zahr, 1985).The MCQ has demonstrated
internal consistency with a Cronbach's coefficient of 0.95 and the
temporal reliability was also measured and found to have a
moderately high correlation of 0.69. The total mean score alpha
coefficient was 0.89 (Badr, 2005). This was rated using a Likert
scale with five response categories consisting of “Never” (1),
“Seldom” (2), “Sometimes” (3), “Often” (4) and “Always” (5). The
instrument has been divided into the following subscales:
knowledge (6 items), tasks (3 items), and feelings (5 items).
Ethical Considerations
Informed consent was attained from the mothers before the
interview conducted in observance of confidentiality.
Respondent's rights to privacy were practiced as all their
questionnaires and vital information remained confidential.
Principle of truthfulness, confidentiality and equality were applied
and observed during the process. Due acknowledgement was
provided in all written or publication that arose from the study.
Data Collection Procedure
The data collection technique used was survey interview using
questionnaire. Data collection was conducted during scheduled
first postpartum and expanded program for immunization (EPI)

clinic visits in barangay health center. Data were then organized,
and the answers to these questionnaires were filed anonymously.
Data Analysis
Frequency and percentage were computed to describe the
demographic profile such as age; civil status; educational
Table 1. Profile of the respondents (n = 175)
23
JANUARY-JUNE 2018
attainment; monthly income ; gravida; parity; number of prenatal
visit; place of delivery; and attendant during birth. The satisfaction
scores for each item were analyzed using weighted mean and
grouped in either: highly satisfied (4.20-5.00); satisfied (3.40-
4.19); moderately satisfied (2.60-3.39); not satisfied (1.80-2.59);
and highly not satisfied (1.00-1.79). The maternal role confidence
scale were also analyzed using weighted mean and grouped in
either: highly confident (4.20-5.00); confident (3.40-4.19);
moderately confident (2.60-3.39); not confident (1.80-2.59); and
highly not confident (1.00-1.79). To correlate the level of childbirth
satisfaction and maternal role confidence of early postpartum
mothers, Pearson's R correlation was used. A p value of 0.05 was
taken for statistical significance.
Results
Profile of the Respondents
Data presented in Table 1 shows that the mean age of the
respondents (n=175) was 27.3 ± 6.8 years. This suggests that
majority of the respondents were at their adult age. It also reveals
that the respondents were cohabiting (52.6%), reached high
school (50.9%), earning 1,000-5,000 (40.0%), having mostly 2
pregnancies (33.1%) and 2 childbirth (31.5%). In terms of access
in healthcare during pregnancy and delivery, most of the
respondents had prenatal visit of 4 and above (89.7%), gave birth
in a government hospital (40.6%) and handled by a midwife
(54.3%).
Level of Childbirth Satisfaction
Table 2. Level of childbirth satisfaction
Legend: 4.20-5.00 - highly satisfied 1.80-2.59 - not satisfied
3.40-4.19 - satisfied 1.00-1.79 - highly not satisfied
2.60-3.39 -moderately satisfied
Table 2 shows that the early postpartum mothers who responded
in the study was moderately satisfied (mean=3.22) with the overall
childbirth experience. Furthermore, the results also show that the
respondents were satisfied with the professional support
(mean=3.50), expectations (mean=3.75), holding the baby
(mean=3.86), pain after delivery (mean=3.61) and environment
(mean=3.82).
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JANUARY-JUNE 2018
Level of Maternal Role Confidence
Table 3. Maternal role confidence of the respondents
Legend: 4.20-5.00 - highly satisfied 1.80-2.59 - not satisfied
3.40-4.19 - satisfied 1.00-1.79 - highly not satisfied
2.60-3.39 -moderately satisfied
Table 3 reveals that the early postpartum mothers who responded
in the study were confident on their maternal role (mean=3.94).
Moreover it also reveals that the respondents were confident in
the knowledge of care for their baby (mean=3.49), task as a
mother (mean=4.11) and feeling of a mother (mean=4.06).
Correlation between Childbirth Satisfaction and Maternal
Role Confidence
Table 4 shows that the childbirth satisfaction was positively
correlated with maternal role confidence (r=0.301, p >0.01). It
also reveals that the overall childbirth satisfaction was also
positively correlated with knowledge (r=0.440, p >0.01), task
(r=0.263, p >0.01), and feelings (r=0.368, p >0.01) of a mother
with high level of significance.
Discussion
Majority of the respondents were at their early adult age.
According to the Philippine Statistics Authority (2014) fertility
peaks at age 20 – 24 and falls after 25 – 39. The findings on the
current study suggests that majority of them did not pursue the
highest level of formal education. In the study of Oikawa et al.
(2014) it was revealed that educated women are more likely to use
maternal care services than women with no formal education.
Table 4. Correlation between childbirth satisfaction and maternal role confidence
PJN VOL. 88 | NO. 1
Pregnant women who belong to low income family could hardly
afford to subject themselves to take the recommendations required
for health improvement due to economic status (Bircher &
Kuruvillab, 2014). Results of the study show that there is a low
contraceptive prevalence rate in terms of family planning, this was
based on the history of pregnancies and parity revealed by the
respondents. With regards to prenatal check-up during their
pregnancy, the finding was supported by Department of Health
(2012) recommending a minimum of four (4) visits for the whole
course of pregnancy. A pregnant woman has to have at least one
visit for the first and second trimester and two visits for the third
trimester. This was supported by Campbell and Graham (2006),
who stated that quality prenatal care is an important indicator for
maternal and infant health status. If a mother is equipped with
adequate knowledge in prenatal care, she is most likely to comply
with the prenatal check-up and habits to attain maximum health
during pregnancy, childbirth and puerperium. Lastly, Ejigu Tafere,
Afework and Yalew (2018) suggests that provision of quality
antenatal care (ANC) service had a great role in promoting
institutional delivery.
The result of the present study shows that professional support,
expectations, holding the baby, pain after delivery and environment
are the measures of childbirth satisfaction. This was supported by the
current study asserting that interacting with the care providers and
being free from the from the fear of childbirth has overall influence to
the overall satisfaction in childbirth (Jha, Larsson, Christensson and
Skoog Svanberg, 2017). However, the current study do not
corroborate with the findings stating that personal expectations, the
amount of support from caregivers, the quality of the caregiver-
patient relationship, and involvement in decision making appear to be
so important that they outweigh the physical birth environment, pain,
and continuity of care, when women evaluate their childbirth
experiences (Hodnett, 2002). Futhermore, it was revealed that
predictive factors for satisfaction includes warm, non-formal and
supportive approach, sufficient and well-timed provision of
information and explanation, availability of caregivers, and physical
environment. Achieving higher quality of perinatal care in its
psychological dimension would not only raise women's satisfaction
significant at p-value ≥ 0.05

with delivery and hospital care but also make the mothers feel safe
and comfortable during the postpartum period that could positively
influence the early mother-child interaction as well as the start of
breastfeeding (Takács, Seidlerová, Šulová, & Hoskovcová, 2015).
The present study disagrees from that of Goodman, Mackey and
Tavakoli (2004), stating that personal control during childbirth was an
important factor related to the women's satisfaction with the childbirth
experience. Helping women to increase their personal control during
labor and birth may increase the women's childbirth satisfaction.
Moreover, findings of Redshaw and Henderson (2013) convey that
fathers were very positive about their partner's pregnancy; almost all
were present for the whole process. Greater paternal engagement
was positively associated with timing of first contact with health
professionals, having a dating scan, number of antenatal checks,
offer and attendance at antenatal classes, and breastfeeding. This
possibly exists since most of the maternity units do not allow fathers
or partners to enter the delivery room for the reason that it would
cause disruption during the delivery operations.
The present findings would reflect those of previous studies. In this
study it revealed that knowledge, task and feeling is a predictor of
maternal role confidence. The score of comfort subscale was more
than that of knowledge/skill subscale of the parent's sense of
competence scale, which shows that the mothers gave more value
to their role and were comfortable with it rather than being satisfied
with the role (Shrooti, Mangala, Nirmala, Devkumari, & Dharanidhar,
2016). A previous study found that mothers felt unconditional love for
their baby and strong maternal responsibility, while still having
difficulty managing their new life during hospitalization (Sakajo et al.,
2014). As a theoretical basis, a study from Mercer (2004) revealed
that a woman establishes maternal identity as she becomes a
mother through her commitment to and involvement in defining her
new self. Maternal identity continues to evolve as the mother
acquires new skills to regain her confidence in herself as new
challenges arise. The study findings showed that feelings of the
mothers was consistent predictor of perceived maternal role
competence. This corroborates with Ngai, Wai-Chi, and Holroyd
(2007) revealing that mothers who have a high level of self-esteem
are able to deal with their transition to maternal role as a challenge
and perceive themselves competent in their role. Ha and Kim (2013)
stated that self-confidence in the maternal role showed significant
negative correlations with childcare stress. However, a study found
out that mothers who reported lower parenting competence scores
verbalized more problems in the category “feelings about being a
mother” (Copeland and Harbaugh, 2016). Also, another study
revealed that lack of maternal knowledge, experience and skills
reduce self-confidence (Nelson, 2003). It also shows that maternal
confidence has a positive correlation with functional status or tasks
during early postpartum period and increased confidence leads to
improved functional status (Sehati Shafaie, Mirghafourvand and
Bagherinia, 2017).
The findings of the current study supports the previous study,
satisfaction with the birth experience and a longer rooming-in period
were related to greater maternal satisfaction. Lack of prior
experiences with caring for babies and lack of communication with
their partner about parenting role were also associated with lower
confidence and satisfaction. However, same study also contradicts
25
JANUARY-JUNE 2018
about maternal confidence as negatively affected by feeling
overwhelmed by postpartum routines, needing a longer time for
feeding, and a pregnancy with complications (Maehara et al., 2016).
A study disagrees with the findings of this current study, as it found
out that maternal competence significantly reduced during the study,
while perceived social support did not show any significant
reduction. A direct relationship was found between social support
and maternal competent six weeks after childbirth, and also social
support and maternal competence sixteen weeks after childbirth
(Esmaelzadeh Saeieh, Rahimzadeh, Yazdkhasti, & Torkashvand,
2017). Assessment of social support and maternal competence
should start during pregnancy and continue until childbirth. Result of
this study strengthens the role of holistic midwifery in maternal role
competence.
Conclusion and Recommendation
The respondents were in the young adult age, literate, earning
below, having 2 pregnancies and childbirth, having prenatal visit
more than the required, had an institutional birth handled by a
trained professional. The respondents were satisfied with their
childbirth experience and were confident with their maternal role.
Furthermore, childbirth satisfaction is positively correlated with
maternal role confidence. The findings of this study suggest the
health care providers should focus their supportive interventions,
both prenatally and during labor and delivery, on facilitating women's
achievement of meeting expectations. Futhermore, this study
suggests to conduct study on the interventions that focus on
maximizing these psychosocial resources, such as maternal self-
esteem, mother-to-infant attachment, social support and childcare
stress as other measures of maternal role competence. Caregivers
need to fully understand the expectations that patients have in their
care, and provide care that is consistent with those expectations and
refocus on components of maternal role development, including
maternal attachment, identity, and marital intimacy.
..........................
References
Attanasio, L. B., McPherson, M. E., & Kozhimannil, K. B. (2014). Confidence
and positive childbirth experiences in U.S. hospitals: a mixed methods
analysis. Maternal and Child Health Journal, 18(5), 1280–1290.
http://doi.org/10.1007/s10995-013-1363-1
Avery, M.D., Saftner, M.A., Larson, B. & Weinfurter E.V. (2014). A systematic
review of maternal confidence for physiologic birth: characteristics of
prenatal care and confidence measurement. J Midwifery Womens
Health. 59(6), 586-95. doi: 10.1111/jmwh.12269.
Badr, L. (2005). Further psychometric testing and use of the maternal
confidence questionnaire. Issues in Comprehensive Pediatric Nursing,
28, 163-174.
Bircher, J., & Kuruvilla, S. (2014). Defining health by addressing individual,
social, and environmental determinants: new opportunities for health
care and public health. Journal of Public Health policy, 35(3), 363–386.
doi:10.1057/jphp.2014.19
Campbell, O.M. & Graham, W. J. (2006). Strategies for reducing maternal
mortality: getting on with what works. The Lancet. 368, 284-1299.
Copeland, D.B. & Harbaugh, B.L. (2017). Early maternal-efficacy and
competence in first-time, low-income mothers. Comprehensive Child
and Adolescent Nursing. 40:1, 6-28, doi: 10.1080/
24694193.2016.1200695
PJN VOL. 88 | NO. 1
26
JANUARY-JUNE 2018
Department of Health (2012). Field health service information system.
Public Health Surveillance and Infromatics Division. National
Epidemiology Center. Department of Health. Manila, Philippines.
Ejigu Tafere, T., Afework, M.F. &Yalew, A.W. (2018). Antenatal care service
quality increases the odds of utilizing institutional delivery in Bahir Dar
city administration, North Western Ethiopia: A prospective follow up
study. PLOS ONE 13(2): e0192428. https://doi.org/10.1371/
journal.pone.0192428
Esmaelzadeh Saeieh, S., Rahimzadeh, M., Yazdkhasti, M. & Torkashvand,
Sh (2017). Perceived social support and maternal competence in
primipara women during pregnancy and after childbirth. IJCBNM.
2017;5(4):408-416.
Goodman, P., Mackey, M.C. & Tavakoli, A.S. (2004). Factors related to
childbirth satisfaction. Journal of Advanced Nursing, 46: 212-219.
doi:10.1111/j.1365-2648.2003.02981.x
Ha, J.-Y., & Kim, Y.-J. (2013). Factors Influencing Self-confidence in the
Maternal Role among Early Postpartum Mothers. Korean Journal of
Women Health Nursing, 19(1), 48-56. https://doi.org/10.4069/
kjwhn.2013.19.1.48
Hodnett, E.D. (2002). Pain and women's satisfaction with the experience of
childbirth: A systematic review. American Journal of Obstetrics and
Gynecology, 186(5, Supplement), S160–S172.
https://doi.org/https://doi.org/10.1016/S0002-9378(02)70189-0
Jafari, E., Mohebbi, P., & Mazloomzadeh, S. (2017). Factors related to
women's childbirth satisfaction in physiologic and routine childbirth
groups. Iranian Journal of Nursing and Midwifery Research, 22(3),
219–224. http://doi.org/10.4103/1735-9066.208161
Jover, M., Colomer, J., Carot, J., Larsson, C., Bobes, M., Ivorra, J., . . .
Sanjuan, J. (2014). Maternal anxiety following delivery, early infant
temperament and mother´s confidence in caregiving. The Spanish
Journal of Psychology, 17, E95. doi:10.1017/sjp.2014.87
Jha, P., Larsson, M., Christensson, K., & Svanberg. (2017). Satisfaction
with childbirth services provided in public health facilities: results from
a cross- sectional survey among postnatal women in Chhattisgarh,
India, Global Health Action, 10:1, doi: 10.1080/
16549716.2017.1386932
Maehara, K., Mori, E., Tsuchiya, M., Iwata, H., Sakajo, A., & Tamakoshi, K.
(2016) Factors affecting maternal confidence and satisfaction in older
Japanese primiparae during postpartum hospital stay. International
Journal of Nursing Practice, 22: 14–21. doi: 10.1111/ijn.12435.
Matthies, L.M., Wallwiener, S., Müller, M., Doster, A., Plewniok, K., Feller, S.,
… Reck, C. (2017). Maternal self-confidence during the first four
months postpartum and its association with anxiety and early infant
regulatory problems. Infant Behavior and Development, 49, 228–237.
https://doi.org/https://doi.org/10.1016/j.infbeh.2017.09.011
Mercer, R. T. (2004). Becoming a mother versus maternal role attainment.
Journal of Nursing Scholarship, 36(3), 226-232.
Mohammad, K.I., Alafi, K.K., Mohammad, A.I., Gamble, J. & Creedy, D.
(2014). Jordanian women's dissatisfaction with childbirth care. Int
Nurs Rev. 2014;61:278–84.
Murdoch, M.R. & Franck, L.S. (2008). Gaining confidence and perspective:
a phenomenological study of mothers' lived experiences caring for
infants at home after neonatal unit discharge. J Adv Nurs, 68:20.
Nelson, A.M. (2003). Transition to motherhood. J Obstet Gynecol Neonatal
Nurs, 32(4):465-77.
Ngai, F.W., Wai-Chi Chan, S. & Holroyd, E. (2007). Translation and
validation of a chinese version of the parenting sense of competence
scale in chinese mothers. Nursing Research, 56; 348–54.
Oikawa, M., Sonk, A., Faye, E.O., Ndiaye P., Diadhiou, M., Kondo, M.
(2014). Assessment of maternal satisfaction with facility-based
childbirth care in the rural region of Tambacouda, Senegal. African
Journal on Reproductive Health;18 (4):95-104.
Parker, S. & Zahr, L.K. (1985). The maternal confidence questionnaire.
Boston: Boston City Hospital.
PJN VOL. 88 | NO. 1
Philippine Statistics Authority. (2014). Philippine national demographic
health survey 2013. Manila, Philippines.
Reck, C., Noe, D., Gerstenlauer, J. & Stehle, E. (2012). Effects of
postpartum anxiety disorders and depression on maternal self-
confidence. Infant Behavior & Development. 35, 264–272.
Redshaw, M., & Henderson, J. (2013). Fathers' engagement in pregnancy
and childbirth: evidence from a national survey. BMC Pregnancy and
Childbirth, 13, 70. http://doi.org/10.1186/1471-2393-13-70
Sakajo, A. , Mori, E. , Maehara, K. , Maekawa, T. , Ozawa, H. , Morita, A. ,
Aoki, K. and Iwata, H. (2014), Post‐delivery hospital stay experiences.
Int J Nurs Pract, 20: 9-19. doi:10.1111/ijn.12247
Sehati Shafaie, S., Mirghafourvand, M. & Bagherinia M. (2017).
Association between maternal self-confidence and functional status in
primiparouswomen of postpartum period, 2015-2016. International
Journal of Women's Health and Reproduction Sciences, 5(3), 200-204.
Shrooti, S., Mangala, S., Nirmala, P., Devkumari, S., & Dharanidhar, B.
(2016). Perceived maternal role competence among the mothers
attending immunization clinics of Dharan, Nepal. International Journal
of Community Based Nursing and Midwifery, 4(2), 100–106.
Smith, L.F.P. (2001). Development of a multidimensional labour satisfaction
questionnaire: dimensions, validity, and internal reliability. Qual Health
Care;10:17–22.
Takács, L., Seidlerová, J.M., Šulová, L., & Hoskovcová, S.H. (2015). Social
psychological predictors of satisfaction with intrapartum and
postpartum care – what matters to women in Czech maternity
hospitals? Open Medicine, 10(1), 119–127. http://doi.org/10.1515/
med-2015-0022
Zahr, L.K. (1991). The relationship between maternal confidence and
mother-infant behaviors in premature infants. Research in Nursing and
Health, 14 (4), 279-286.
ABOUT THE AUTHOR
Artemio M. Gonzales Jr. works as an
academician at the Occidental Mindoro State
College which he also serves as program and
research coordinator. His professional
experiences include public health and
midwifery practice. He is an active member of
Sigma Theta Tau International Honor Society
of Nursing and Co-Chair for Research Utilization Committee of
MIMAROPA Health Research and Development Consortium
(MHRDC). He finished his Bachelor of Science in Nursing at the
Divine Word College of San Jose. He obtained his Master in
Public Health, cum laude at Saint Louis University. He is currently
obtaining his Master of Arts in Nursing major in Maternal and Child
Health Nursing at University of the Philippines Open University
through UP Presidential Scholarship grant. His research interest
includes community health, maternal and child health and rural
sociology.
...........
ACKNOWLEDGMENT
The author acknowledges all the women who participated in the
study, to the Occidental Mindoro State College – Research
Development and Extension Unit for the financial support. Further;
and to the midwives Rosavelle Hayag, Merlinia Panganiban,
Laurensa Joldanero and Menchie Tayanan for the assistance during
the data collection.
 27

RESEARCH ARTICLE

NURSES' VALUE ORIENTATION AND

INTENTION TO PURSUE GRADUATE EDUCATION
AND THEIR READINESS
FOR EVIDENCE-BASED PRACTICE
Paolo T. Lumanlan, PhD, RN1

Abstract
Purpose: The investigator sought to determine nurses' value orientation and intention to pursue graduate education, as well as their
readiness for evidence-based practice.
Method: A descriptive correlational research design was used. Nurses (n=188) from different government and private healthcare
institutions in Pampanga were purposefully selected to participate in this research undertaking. Three instruments were adopted: the
Valuation of Graduate Studies Questionnaire, the Intention to Pursue Graduate Studies in Nursing Questionnaire, and the Nurses'
Attitudes towards Evidence-Based Practice Scale and Knowledge Scale. Descriptive statistics and regression analysis were used to
analyze the gathered data.
Findings: Based on the results, nurses still have some confidence in pursuing graduate studies in nursing although they intrinsically
value graduate education. Interestingly, nurses have a positive and an above average attitude toward evidence-based practice.
However, results also show that nurses only have average knowledge in evidence-based practice which may be due to limited
opportunities for evidence-based capability-training and insufficient access to technical resources. Regression analysis yielded both
intrinsic value and utility value significantly predicted nurses' attitude toward evidence-based practice; while intrinsic value is also a
significant predictor of nurses' likelihood of pursuing graduate studies.
Conclusions: When nurses intrinsically value evidence-based practice, they become intensely involved in it and can continue
practicing it for a long time. It was found out that nurses' intention to pursue graduate education did not significantly predict their
readiness for evidence-based practice. The result is indicative that there is an inconsistency in translating intention to practice, known
as the “intention-behavior gap”.

Keywords: Value orientation, intention to pursue graduate education, evidence-based practice

Introduction

O ver the recent years, there has been an increasing focus on

quality improvement that involves paradigm shift from the
conventional intuition-based to evidence-based practice (EBP)
(Melnyk & Fineout-Overholt as cited in Eizenberg, 2011). As this
focus intensifies, nurses – as principal care givers – are in a key
position to advance the quality of healthcare (Hughes, 2008)
through the implementation of EBP. However, it has been argued
that EBP is not fully utilized in most practice settings (Institute of
Medicine as cited in Ferguson & Day, 2007), and for nurses,
incorporating research findings into clinical practice has not been
completely integrated as an ordinary practice (Hicks, 1997).
Nurses' application of EBP is compromised by their roles and
personal traits, relationships with stakeholders, organizational
context (Gerrish et al., 2012); as well as anxiety, limited
experiential knowledge, and developing clinical judgment
(Ferguson & Day, 2007).
To address aforementioned problems, White-Williams (2011)
suggests that nurses must develop a culture of EBP and research
to advance the quality of care they provide to their clients. In fact,
the Nursing and Midwifery Council believes that “continuing
professional development (CPD) is essential to enhance nursing
practice and advance nursing as a profession” (as cited in
Watkins, 2011, p. 2006) and one form of CPD is through graduate

1 Correspondence: College of Nursing and Graduate School, Angeles University Foundation, Angeles City, 2009 Philippines; email address: lumanlan.paolo@auf.edu.ph

PJN VOL. 88 | NO. 1

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studies. Nurses are, therefore, highly encouraged to further their
formal education beyond that of the licensure (Altmann, 2012)
since it was found in a study that graduate education influences
professionalization of nursing by increasing nurses' personal
confidence, improving their cognitive functioning, enhancing
their professionalism, and developing in them evidence-based
practices (Watkins, 2011).
Graduate education continues to be an essential element in
nurses' professional growth and development (Chiu, 2006;
Hardcastle, 2008) for it will prepare nurses in acquiring and
utilizing new knowledge in their own respective practices (Levin
et al., 2008). However, some nurses greatly depend on their
subjective experience and other healthcare team members
instead of formal sources of knowledge (Gerrish, Ashworth,
Lacey, & Bailey, 2008). This, then, implies the need for a good
foundation in nursing education to properly apply EBP in the
clinical setting (Gerrish et al., 2008; Waters, Crisp, Rychetnik, &
Barratt, 2009).
There were some published works that tackled different factors
that motivate nurses to pursue graduate studies. In Australia,
Pelletier et al. (1998) found that the most important reasons for
pursuing graduate education are personal or job satisfaction,
increased professional status, and better job opportunities. In
her dissertation, McFadden (2003) explored nurses' decisions
to pursue advanced nursing degrees and found that the desire
for increased autonomy, greater professional recognition and
financial security, supportive work environment, family support,
and the presence of a mentor were the participants' driving
factors to pursue graduate education.
On the one hand, several studies were conducted to determine
nurses' attitude towards EBP. In Denmark, nurses had a positive
attitude towards EBP (Egerod & Hansen, 2005). In Taiwan,
nurses expressed positive attitude toward research and EBP
(Chang, Russell, & Jones, 2010). In Singapore, nurses also
exhibited positive attitude towards EBP (Majid et al., 2011; Yip
Wai, Mordiffi, Shen, Kim, & Majid, 2013). In the United States,
nurses' beliefs about the benefit of EBP were high, however,
knowledge of EBP was relatively low (Melnyk et al., 2004).
White-Williams et al. (2013) believed that continuing education
truly makes a difference in nurses' attitudes, knowledge, and
application of EBP in their practice. Therefore, to expedite the
transfer and adoption of new knowledge into practice, nurses
must pursue a career in continuing professional development
(Gerrish et al., 2008) through graduate education.
However, although nurses showed a positive attitude toward
EBP and are motivated to pursue graduate studies, there is still
a dearth in the literature on nurses' valuation of and intention to
pursue graduate education. According to Wigfield and Eccles
(2000) in their Expectancy-Value Model of Achievement
Motivations, individuals' “expectancies and values are
assumed to directly influence their achievement choices,
performance, effort, and persistence” (p. 69). The choice,
PJN VOL. 88 | NO. 1
perseverance, and how an individual carries out a certain task
may depend on his own beliefs about his performance
expectations and task value (Wigfield, 1994). Eccles et al. (as
cited in Plunkett, Iwasiw, & Kerr, 2010) posited that task value is
a key component of the model and is composed of four aspects:
utility value (usefulness of the task in achieving long-term goals
of an individual), intrinsic value (the pleasure that an individual
gains from doing the task), attainment value (how an individual
perceives the importance of a certain task), and cost (what an
individual must give up to accomplish the task).
Objectives of the Study
After a thorough search in different data bases, the investigator
found a dearth in the literature that dealt with value orientation
and intention to pursue graduate education among nurses in the
clinical setting. Therefore, the investigator sought to determine
nurses' value orientation towards and intention to pursue
graduate education, as well as their readiness for evidence-
based practice. Specifically, the investigator described nurses'
value orientation towards graduate education in nursing, their
intention to pursue graduate education in nursing, and their
readiness for evidence-based practice. More so, the investigator
determined whether nurses' value orientation towards graduate
education in nursing significantly predicts their readiness for
evidence-based practice; whether nurses' intention to pursue
graduate education in nursing significantly predicts their
readiness for evidence-based practice; and whether nurses'
value orientation towards graduate education in nursing
significantly predicts their intention to pursue graduate education
in nursing.
It was hypothesized that nurses' value orientation towards
graduate education in nursing significantly predicts their
readiness for evidence-based practice; nurses' intention to
pursue graduate education in nursing significantly predicts their
readiness for evidence-based practice; and nurses' value
orientation towards graduate education in nursing significantly
predicts their intention to pursue graduate education in nursing.
Methodology
Research Design
The investigator used a correlational design in the conduct of this
study. Nurses' value orientation towards and intention to pursue
graduate studies were treated as predictors of their readiness to
evidence-based practice. More so, the respondents' value
orientation towards graduate education was treated as a
predictor of their intention to pursue graduate studies.
Sample and Setting
A total of 325 survey questionnaires were distributed to three
private medical institutions in Angeles City; however, only 199
were returned. Eleven questionnaires were disregarded due to

severe incompleteness; thus, a total of 188 nurses (response
rate of 57.85%), who are neither graduate-degree holders nor
have taken graduate degree units, were purposively asked to
join in this study. These nurses are working in the different
government and private healthcare institutions in Pampanga.
Nurses' areas of assignment, as well as their length of service,
were not considered during the selection and recruitment
process.
Instruments and Data Collection
Three instruments were adopted (with permission from the
original authors) in this study. First, the Valuation of Graduate
Studies Questionnaire (Battle & Wigfield, 2003), is a 51-item tool
rated using a 5-point Likert scale from 1 (strongly disagree) to 5
(strongly agree). In addition, this tool is composed of 4 subscales
(intrinsic, attainment, utility, and cost) which have Cronbach's
alpha values ranging from 0.82 to 0.93. Second, the Intention to
Pursue Graduate Studies in Nursing Questionnaire (Battle &
Wigfield, 2003) consists of two questions asking the respondents
to rate (using a 10-point Likert scale from 1 [not at all confident] to
10 [complete confidence]) how likely they are to pursue graduate
education in nursing, as well as their two most important reasons
for intending to pursue (or not to pursue) graduate schooling.
Lastly, the Nurses' Attitudes towards Evidence-Based Practice
Scale (NATES) and Knowledge Scale (adopted with permission
from its original author, Dr. Linda Thiel) is a 14-item inventory
answerable by a 5-point Likert scale from 1 (strongly disagree) to
5 (strongly agree) that measures nurses' readiness to evidence-
based practice. Internal reliability test revealed Cronbach's alpha
values of 0.93 for NATES and 0.80 for the Knowledge Scale.
Prior to data collection, the Chief of Nursing Services in each
healthcare institution gave the permission to distribute the survey
forms. Data were collected in all participating institutions where
the respondents were invited to take part in the survey during their
most available time; however, it was stressed that joining the
study was completely voluntary.
After explaining the entire nature of the study, the potential risks
and benefits in joining this study, the respondents' right to
refuse/withdraw at any time of the study and right to privacy, the
investigator has obtained the respondents' voluntary consent.
Lastly, the respondents were given the assurance that the data
will be treated with utmost confidentiality and no identifier for both
respondents and the institutions will be reported in any part of this
study.
Table 2. Percentage distribution of respondents' intention to pursue graduate education in nursing
1 Mean score for the first item is 5.78±2.35.
2 Mean score for the second item is 5.76±2.27.
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JANUARY-JUNE 2018
Data Analysis
Descriptive statistics such as frequency and percentage
distributions, mean, and standard deviation were used to
describe the nurses' value orientation and intention to pursue
graduate education, as well as their readiness for evidence-
based practice. Furthermore, multiple regression analysis was
run using SPSS version 20.0 to examine the relationship and
prediction among nurses' value orientation towards and intention
to pursue graduate education, as well as their readiness for
evidence-based practice.
Results
Table 1 clearly presents the description of the respondents' value
orientation of graduate education based on the four subscales.
The respondents gave the highest score on the intrinsic subscale
(x=3.47±.817), followed by the attainment subscale
(x=3.26±.604), cost subscale (x=3.03±.526), and utility
subscale (x=2.99±.658).
On the other hand, majority of the respondents have some
confidence (17.55%) when asked, “How likely is it that you will
pursue graduate studies in nursing (master's degree or higher)?”
Similarly, most of them also have some confidence (22.34%)
when asked, “How likely is it that you will pursue graduate studies
in nursing eventually?” The mean scores for both questions
(5.78±2.35 and 5.76±2.27 respectively) indicate some
confidence among the respondents in pursuing graduate nursing
education (Table 2).
The two most important reasons for intending to pursue (or not to
pursue) graduate school are seen in Table 3. It can be realized
that more than 40% of the respondents considered money,
status, or career as the most important reasons for intending to
pursue (or not to pursue) further studies in nursing. Professional
goals ranked the second most important reason (29.26%)
among the other choices.
Table 1. Distribution of respondents' value orientation of graduate education
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Table 3. Distribution of respondents' two most important reasons for intending to pursue (or not to pursue) graduate school

Nurses' readiness for evidence-based practice, which is divided

Table 4. Distribution of respondents' readiness for evidence-based practice
into two subscales, is reported in Table 4. It is noteworthy to see
that the respondents have a positive and an above average
attitude toward EBP (x=3.48±.720). However, results yielded that
the respondents have an average knowledge in EBP with a mean
score of 3.29±.885.
with nurses' attitude toward evidence-based practice, while utility
A multiple regression analysis was used to determine if nurses'
value is negatively related with their attitude toward evidence-
value orientation towards graduate education (intrinsic value,
based practice.
attainment value, utility value, and cost) significantly predicted
their readiness for evidence-based practice (attitude and In contrary, it was found out that nurses' intention to pursue
knowledge) (Table 5). The results indicated that the predictor graduate education did not significantly predict their readiness for
variables explain 21.1% of the variance for the dependent evidence-based practice (Table 6).
variable attitude (F(4,183)=12.221, p=.000), and 9.6% for the
dependent variable knowledge (F(4,183)=4.865, p=.001). Also, it On the one hand, value orientation towards graduate education
was found out that both intrinsic value (B=1.934, p=.008) and explained 37.5% of the variance for the dependent variable
utility value (B=-2.894, p=.002) statistically and significantly likelihood of pursuing graduate studies in nursing
predicted nurses' attitude toward evidence-based practice. It is (F(4,164)=24.592, p=.000), and 34.6% for the dependent variable
evident from the results that intrinsic value is positively related knowledge (F(4,165)=21.828, p=.000) (Table 7).
Table 5. Regression coefficients of nurses' value orientation towards graduate studies

Dependent variable: readiness for evidence-based practice

Table 6. Regression coefficients of nurses' intention to pursue graduate studies

Dependent variable: readiness for evidence-based practice

Table 6. Relationship between nurses' value orientation towards graduate education and their intention to pursue graduate studies in nursing

Dependent variable: readiness for evidence-based practice

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More so, it was found out that intrinsic value statistically and
significantly predicted nurses' likelihood of pursuing graduate
studies in nursing (B=1.582, p=.000) and their likelihood of
pursuing graduate studies in nursing eventually (B=1.409,
p=.000). It is evident from the results that intrinsic value is
positively related with nurses' intention to pursue graduate
education.
Discussion
The study involves nurses' value orientation towards graduate
education. Based on the results, nurses value graduate
education primarily because of the enjoyment they get from
performing graduate school activities or the subjective interest
nurses have in graduate schooling. Similarly, Bong (2001) found
out that students who were intrinsically interested in activities
covered in the present course are more enthusiastic to take
similar courses in the future. Also, Wigfield and Cambria (2010)
reported that when students intrinsically value an activity, they
often become deeply engaged in it and can persevere at it for a
period of time. However, mean scores on attainment, cost, and
utility subscales may be indicative, which fell within the unsure
mark, may be indicative of nurses' lack of understanding of the
value of graduate studies. On the one hand, nurses still have
some confidence in pursuing graduate studies in nursing
although they intrinsically value graduate education. Money,
status, or career may affect their confidence in pursuing
graduate education since nurses in the Philippines have very low
remuneration, too much work assignments, and limited career
growth and opportunities.
Evidence-based practice has become increasingly important in
healthcare community (DoH, 2000). In the Philippines, evidence-
based nursing practice has been introduced and was found
effective (Dizon, Dizon, Regino, & Gabriel, 2014). In the current
study, nurses have a positive and an above average attitude
toward EBP. Similarly, nurses in Australia (Waters et al., 2009),
Denmark (Egerod & Hansen, 2005), Queensland (Sherriff,
Wallis, & Chaboyer, 2007), Scotland (O'Donnell, 2003), and
United States (Melnyk et al., 2004; Brown, Wickline, Ecoff, &
Glaser, 2009) have welcoming attitude toward evidence-based
practice. However, results of the current study showed that
nurses only have average knowledge in evidence-based
practice which may be due to limited opportunities for evidence-
based capability-training and insufficient access to technical
resources. Likewise, scholars found that knowledge on
evidence-based practice is relatively low among nurses in
Australia (Waters et al., 2009) and United States (Melnyk et al.,
2004).
Conclusions
Results of the multiple regression analysis showed that both
intrinsic value and utility value statistically and significantly
predicted nurses' attitude toward evidence-based practice; while
31
JANUARY-JUNE 2018
intrinsic value is also a significant predictor of nurses' likelihood
of pursuing graduate studies. This implies that when nurses
intrinsically value evidence-based practice, they become
intensely involved in it and can continue practicing it for a long
time. On the one hand, it was found out that nurses' intention to
pursue graduate education did not significantly predict their
readiness for evidence-based practice. The result is indicative
that there is an inconsistency in translating intention to practice,
known as the “intention-behavior gap”.
Recommendations
Based on the results of the current study, healthcare facilities
may consider institutionalizing various activities which do not
only increase nurses' evidence-based knowledge and skills, but
also brace their views about the importance of evidence-based
care. Nursing service administrators may establish a more
practical approach in training nurses towards evidence-based
practice in the clinical setting. The provision of opportunities for
graduate schooling is thought to be valuable in refining nurses'
attitudes, knowledge, and skills related to evidence-based
practice.
Limitations and Directions for Future Research
One major limitation in this study is sampling. Nurses were
conveniently recruited from different healthcare institutions in
Pampanga. Representativeness may not be accurately
achieved. Therefore, it is recommended that future investigators
may endeavor to involve a large number of nurses in different
provinces in the Philippines. Future investigators may also strive
to explore the unaccounted predictors of nurses' intentions to
pursue graduate education, as well as their readiness for
evidence-based practice.
..........................
References
Altmann, T. K. (2012). Nurses' attitudes towards continuing formal
education: A comparison by level of education and geography.
Nursing Education Perspectives, 33(2), 80-84.
Battle, A., & Wigfield, A. (2003). College women's value orientations
toward family, career, and graduate school. Journal of Vocational
Behavior, 62, 56-75. doi:10.1016/S0001-8791(02)00037-4
Brown, C.E., Wickline, M.A., Ecoff, L., & Glaser, D. (2009). Nursing
practice, knowledge, attitudes and perceived barriers to evidence-
based practice at an academic medical center. Journal of
Advanced Nursing, 65(2), 371-381.
Chang, H. C., Russell, C., & Jones, M. K. (2010). Implementing
evidence-based practice in Taiwanese nursing homes: Attitudes
and perceived barriers and facilitators. Journal of Gerontological
Nursing, 36(1), 41-48. doi:10.3928/00989134-20091204-04
Chiu, L. H. (2006). Malaysian registered nurses' professional learning.
International Journal of Nursing Education Scholarship, 3(1), 1-12.
PJN VOL. 88 | NO. 1
32
JANUARY-JUNE 2018

Dizon, J.M., Dizon, R.J., Regino, J., & Gabriel, A. (2014). Evidence-
based practice training for health professionals in the Philippines.
Advances in Medical Education and Practice, 5, 89-94.
Egerod, I., & Hansen, G. M. (2005). Evidence-based practice among
Danish cardiac nurses: A national survey. Journal of Advanced
Nursing, 51(5), 465-473. doi:10.1111/j.1365-2648.2005.03525.x
Eizenberg, M. M. (2011). Implementation of evidence-based nursing
practice: Nurses' personal and professional factors? Journal of
Advanced Nursing, 67(1), 33-42. doi:10.1111/j.1365-
2648.2010.05488.x
Ferguson, L. M., & Day, R. A. (2007). Challenges for new nurses in
evidence-based practice. Journal of Nursing Management, 15,
107-113. doi:10.1111/j.1365-2934.2006.00638.x
Gerrish, K., Ashworth, P., Lacey, A., & Bailey, J. (2008). Developing
evidence-based practice: Experiences of senior and junior clinical
nurses. Journal of Advanced Nursing, 62(1), 62-73.
doi:10.1111/j.1365-2648.2007.04579.x
Gerrish, K., Nolan, M., McDonnell, A., Tod, A., Kirshbaum, M., &
Guillaume, L. (2012). Factors influencing advanced practice
nurses' ability to promote evidence-based practice among
frontline nurses. Worldviews on Evidence-Based Nursing, 9(1),
30-39. doi:10.1111/j.1741-6787.2011.00230.x
Hardcastle, J. E. (2008). 'Back to the bedside': Graduate level
education in critical care. Nursing Education Practice, 8, 46-53.
doi:10.1016/j.nepr.2007.04.005
Hicks, C. (1997). The dilemma of incorporating research into clinical
practice. British Journal of Nursing, 6(9), 511-515.
Hughes, R. G. (2008). Patient safety and quality: An evidence-based
handbook for nurses. Rockville, MD: Agency for Healthcare
Research and Quality Publication.
McFadden, M. M. (2003). An exploration into nurses' decisions to
pursue advanced nursing degrees. Retrieved from ProQuest
Dissertations and Theses. (250173414)
Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar,
I. A. (2011). Adopting evidence-based practice in clinical decision
making: Nurses' perceptions, knowledge, and barriers. Journal of
the Medical Library Association, 99(3), 229-236.
doi:10.3163/1536-5050.99.3.010
Melnyk, B. M., Fineout-Overholt, E., Feinstein, N. F., Li, H., Small, L.,
Wilcox, L., & Kraus, R. (2004). Nurses' perceived knowledge,
beliefs, skills, and needs regarding evidence-based practice:
Implications for accelerating the paradigm shift. Worldviews on
Evidence-Based Nursing, 1(3), 185-193.
O'Donnell, C.A. (2003). Attitudes and knowledge of primary care
professionals towards evidence-based practice: A postal survey.
Journal of Evaluation in Clinical Practice, 10(2), 197-205.
Plunkett, R. D., Iwasiw, C. L., & Kerr, M. (2010). The intention to pursue
graduate studies in nursing: A look at BScN students' self-efficacy
and value influences. International Journal of Nursing Education
Scholarship, 7(1), 1-13. doi:10.2202/1548-923X.2031
Sherriff, K.L, Wallis, M., & Chaboyer, W. (2007). Nurses' attitudes to
and perceptions of knowledge and skills regarding evidence-
based practice. International Journal of Nursing Practice, 13(6),
363-369.
Waters, D., Crisp, J., Rychetnik, L., & Barratt, A. (2009). The Australian
experience of nurses' preparedness for evidence-based practice.
Journal of Nursing Management, 17, 510-518.
doi:10.1111/j.1365-2834.2009.00997.x
Watkins, D. (2011). The influence of masters education on the
professional lives of British and German nurses and the further
professionalization of nursing. Journal of Advanced Nursing,
67(12), 2605-2614. doi:10.1111/j.1365-2648.2011.05698.x
White-Williams, C. (2011). Evidence-based practice and research: The
challenge for transplant nursing. Progress in Transplantation,
21(4), 299-305.
White-Williams, C., Patrician, P., Fazeli, P., Degges, M. A., Graham, S.
Andison, M., … McCaleb, K. A. (2013). Use, knowledge, and
attitudes toward evidence-based practice among nursing staff.
The Journal of Continuing Education in Nursing, 44(6), 246-254.
doi:10.3928/00220124-20130402-38
Wigfield, A. (1994). Expectancy-value theory of achievement
motivation: A developmental perspective. Educational Psychology
Review, 6(1), 49-78.
Wigfield, A., & Eccles, J. (2000). Expectancy-value theory of
achievement motivation. Contemporary Educational Psychology,
25(1), 68-81. doi:10.1006/ceps.1999.1015
Wigfield, A., & Cambria, J. (2010). Students' achievement values, goal
orientations, and interest: Definitions, development, and relations
to achievement outcomes. Developmental Review, 30, 1-35.
Yip Wai, K., Mordiffi, S., Shen, L., Kim, Z., & Majid, S. (2013). Nurses'
perception towards evidence-based practice: A descriptive study.
Singapore Nursing Journal, 40(1), 34-41.
ABOUT THE AUTHOR
Paolo T. Lumanlan, PhD, RN is a Professor 1
at the College of Nursing and a Graduate
School Professor at the Angeles University
Foundation, Angeles City. He is a registered
nurse and a licensed professional teacher; a
graduate of Master of Arts in Nursing, Master
of Arts in Education, and Doctor of Philosophy in Educational
Management. Currently, he is finishing his Doctor of Philosophy
in Nursing Education program. He has published several articles
in ISI-/Scopus-indexed journals and also served as editorial
board member/peer-reviewer in national and international
journals. His research interests include health education, higher
education studies, instrument development, and spirituality.

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RESEARCH ARTICLE

THE FUTURE OF NURSING SCIENCE:

CONSILIENCE IN EVIDENCE-BASED PRACTICE
Rainier C. Moreno-Lacalle, PhD, RN1

Abstract
Nursing science needs to adopt a paradigm that can be used to apply its knowledge. Notably, how nursing science is applied in nursing
practice or education remains confusing. This article aims to discuss the pros and cons of the two ways to implement nursing science,
that is, evidence-based practice (including translational research and research utilization) and intuitive nursing. Also, I differentiated
evidence-based practice (EBP), translational research (TR), and research utilization (RU). I argued that EBP as the paradigm of
choice will be the optimal strategy for the future of nursing science. Adopting EBP improves patient, organizational, and staffing
outcomes. While basing clinical decisions on intuition alone may imperil patient's safety due to multiple cognitive biases inherent in our
intellectual devices. Combining EBP, TR, RU, and intuitive nursing resulted in a model Consilience in Evidence-based Practice.
Implications of the model for nursing practice, education, and research were also discussed.

Keywords: Evidence-based Practice, Translational Research; Research Utilization, Intuition, Consilience

Introduction

N ursing science is a health science focused on promoting,

restoring, and sustaining health in human beings
(Donaldson, 2003). The definition poses a future of nursing
science that is promising, oblique, and co-dependent with other
professions. These claims are supported by evidence from
scientific articles and books. But, where do we initially ground
these claims? Two opposing articles with an identical title: 'The
idea of nursing science' by Edwards (1999) and Winters and
Ballou (2004) explored the state of nursing science both as
legitimate (promising) and illegitimate (oblique). These articles
are non-sequitur and complementary, therefore not contradictory.
A profession to earn the prestige of science needs to prove itself
in the process (O'Hear, 1990), i.e., evolved based using the
adopted paradigm (Kuhn, 1970). Whether nursing is a science or
not is not the argument I am going to take (much has been written
about that). What I chose to explore is the idea that nursing may
need to substantiate existing paradigm in order to prove itself as a
science and survive, reinvent itself in the realm of scientific
evolution.
Nursing science is metaphorically likened to a sailor experience
of journeying- moved by the wind of change, directed strength
blown to the shrouds, stamina of the hull, the important role of the
boater, and many external factors that may confound the drift of
the seafarer. The unstable, oblique, and opposing melee in this
discussion is marked evidence of the robustness, evolution, and
evinced sailor's excitement to morph nursing science into its
much-deserved pedestal in the realm of professions. A slightly
oblique forestay held by the mast could change the course of
nursing science. That is why the prudent adoption of paradigm is
an important decision contemporary nurse scientists need to
decide and agree. These constructs, I claim, is a burden, a curse,
and responsibility for nurse scholars. Let me tell you why.
In the Philippines and four neighboring countries, Turner (2009)
found out that 93 health workers were apprehensive on evidence-
based practice (EBP). The study findings shows the need to
anchor EBP paradigm from existing way in implementing nursing
science otherwise nurses would resist the approach further.
However, anchoring in existing framework is inadequate. Locsin
and Purnell (2013) argued that professional nursing practice
needs to be grounded in strong nursing science. This does not
stop there; some nursing questions demand answers. Some of
these questions include where we should base nursing
knowledge? What is nursing knowledge in the first place? How do
we develop nursing science? One thing is for sure if we (as nurse
scholars of this generation) tolerate status quo, we are doomed.
That rather than exploring the enigmatic sea, we can be stuck in
one abyssal place. For we determine its trajectory- by what we do
today (Gordon, 2005). We somehow adopt, writes, nor rewrites
what could happen, and how we want the society value what we
do. This is our burden and responsibility. “With power comes

1 Correspondence: Professor Saint Louis University- SON Faculty Room 5th Floor Diego Silang Building Saint Louis University, Baguio City 2600, Philippines; E-mail: moreno@slu.edu.ph

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responsibility,” says a superhero. This responsibility to some
extent is a curse. Because we need to work hard, calling for
healthy and sometimes painful discussions challenging our set of
unchallenged beliefs and ways of doing things to move us
forward.
This article aims to discuss the pros and cons of two ways to
implement nursing science, that is evidence-based practice
(including translational research & research utilization) and
intuitive nursing. Also, I differentiated evidence-based practice,
translational research, and research utilization. I argued that
using evidence-based practice will be of optimal strategy to
advance nursing science.
Evidence-based Practice (EBP), Translational Research
(TR), and Research Utilization (RU)
Let me continue by differentiating the three important paradigms
in implementing nursing science. Evidence-based practice
(EBP) is an approach in informed decision making through the
use of the best evidence considering the individuality of patients
and facilitators (Harvey & Kitson, 2015; Melnyk Fineout-Overholt,
Stillwell, & Williamson, 2010; Sackett, Rosenberg, Gray, Haynes,
& Richardson, 1996). The definition extends to three major
components of EBP: best evidence, patient's values and
preferences, and clinical expertise. In other words, EBP serves
as the bridge to close the gap between the two essential areas
(research and practice) of healthcare industry by considering all
the stakeholders.
The various literature on research uptake led to the development
of tributaries, i.e., translational science, and research utilization.
Table 1 shows that translational research (TR) leans towards
cyclical “bench to bedside approach” (Woolf, 2008 p.211) with
the emphasis in interprofessional collaboration (Woods &
Magyary, 2010). It is believed that using TR would hasten
translation of what is discovered through scientific methods to the
bedside. In general, research uptake could ripple to policy
enhancement such that Pearson, Weeks, and Stern (2011)
emphasized the role of research in shaping health policy.
Moreover, research utilization (RU) commonly used
interchangeably with EBP, is dissimilar (Black, Balneaves,
Garossino, Puyat, & Qian, 2015; Estabrooks, 1999). In RU,
there is a mere translation of research to bedside without
consideration of patient values and preferences and the clinical
expertise of the nurse. While RU often involves just a single
research translation. Which is to say that EBP is an overarching
term subsuming TR and RU. Therefore one knowledge utilization
as the definition of RU and is part of searching the best evidence
(which is the second step of EBP), while interprofessional
collaboration (hallmark in TR) is necessary for considering the
implementability and other contextual facilitating or hindering
factors under the clinical expertise. EBP, TR, and RU may be
different terms, but they are complementary approach as shown
in Table 1.
PJN VOL. 88 | NO. 1
Asking the right (or burning) question is the first step in EBP. The
clinical question will initiate what study to be culled, appraised,
and implemented (Melnyk et al., 2010). After apprasing and
summarizing the selected studies, there is a need to check
patient/ consumer preferences by asking for relevance,
exhaustive presentation of the evidence to the patient, validating
the desire to participate, and ensuring that patient have ample
time to decide (Dearholt & Dang, 2012). This way patient's
participation in the EBP project will be fully optimized. The last
step of EBP is to ensure the clinician experiences jibes with the
EBP intervention. This could be done by checking the attributes of
an expert (e.g., holistic practice knowledge, skilled know-how,
moral agency, and knowledge of the patient) plus enablers (such
as reflexivity, autonomy, authority, good working relationship, and
authentic recognition from others) as Hardy, Tichen, Manley, and
McCormack (2006) proposed.
Dankwa-Mullan et al. (2010) viewed TR as the intersection
among transformational, transdisciplinary, including translational
itself. In transformational research, there is a need to consider the
organizational culture and to identify structure in embedding
research culture in the institution. Part of transformational
research is somehow linked to transdisciplinary research, that is
participatory and team development strategies. These
components constitute a more holistic organizational
involvement. Of which the discovered idea or research is
developed by aligning with the vision and actual scenario in the
institution while encouraging interprofessional to buy the idea. If
they (other team members) saw and developed the willingness as
part of the translational team, then TR is implemented.
In research utilization (RU) there are three major types according
to Estabrooks, Wallin, and Milner(2003): instrumental,
conceptual, and symbolic as shown in Table 1. In instrumental
RU, there is a reified application of the research to tangible clinical
materials like protocols or ward policy. Sometimes this can be in a
more comprehensive form of clinical practice guidelines. A
corollary is the existence of believed research uptake in
someone's head or cognitive faculties but may not necessarily
translate into action called the conceptual RU. There are times
that research is equated to political move influencing policy and
decisions called the symbolic RU. To note, in RU the focus is
clearly in the research. Funk, Tornquist, and Champagne (1989)
presented the three major features of RU: 1. qualities (like
relevance, applicability, availability); 2. communication
characteristics (meaning nontechnical language, strategies in
implementation) and; 3. facilitation of utilization (such as
reinforcement, dialogue, sharing of experience, support). With
this, RU disregards external and internal factors like context,
environment, patients, or the expertise of the nurse. An RU gap
filled by intuition. These may be one of the reasons why nurses in
st
the 21 century still uses instincts or intuition to practice nursing
instead of EBP.
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Table 1. Difference among EBP, TR, and RU

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Evidence-based Practice and Intuitive Nursing
Research use is a complicated endeavor (Poe & White, 2010).
One cannot just focus solely on the research or evidence;
otherwise, the view is narrow. Nurse scientist needs to consider
nursing leadership readiness, organizational infrastructure,
research competencies, the patient's preferences/values, and the
robustness of the evidence (Poe & White, 2010; Gerrish& Clayton,
2004; Kitson, Harvey, &McCormack, 1998). Other contributory
factors such as those mentioned above make research uptake
complicated (Saunders & Vehviläinen-Julkunen, 2016). That
deserves another full paper and is not my focus. What I want to
take as an argument in this section is the word evidence, which is
the same concept that bothered Rycroft-Malone et al. (2004).
Rycroft-Malone et al. (2004) asked what counts as evidence in
evidence-based practice? They explicated that there are two
major approaches to care: external or scientific and internal or
intuitive. Let me walk you through the definition first of what
scientific evidence is. The Popperian view of science demarcates
the scientific and non-scientific works. He posited that if a theory is
so vague, untestable, or unfalsifiable- it is unscientific (Popper,
1999). Therefore theory-informed, logical deductions, and
verifiable constructs which are reachable using the senses are
scientific. Evidence-based practice to a large extent is a science in
action, consistent with the claim that nursing is a practice-based
profession (Dickoff, James, & Weidenbach, 1968). Had I wish that
it is simple as that. But in nursing, even as we claim it as a science,
there are many untestable (or maybe difficult to test) methods that
we use such as intuition. Intuition is the gut feeling (Schmidt &
Brown, 2012) or thinking without awareness (Myers, 2002). The
acceptance of this direct perception brought by informational basis
(Effken, 2007) is deeply embedded in nursing theory. The Stages
of Clinical Competency theory by Benner, Tanner, and Chesla
(2009) regards an expert as possessing a highly developed
intuitive sense. This nursing theory posits that in solving difficult
and complicated clinical problems- an 'expert' acts with agility,
quickly, and fluidly even with the absence of a complete set of
information.
These set of information are the scientific 'evidence.' In
warrantable evidence in nursing science article by Forbes et al.
(1999), it is necessary that to be grounded in strong science, we
must meet three major warrants: (1)methodological soundness,
(2)corroboration and intersubjectivity, and (3) scope of evidence as
can be gleaned in Table 2. These constitute good scientific
scholarship. Methodological soundness conveys precise and strict
adherence to objectivity. In other words, definiteness is good
science. It can be achieved by coherence or systematic approach
in developing evidence-based nursing interventions. If another
nurse scientist replicated a study then intersubjectivity is
warranted. Lastly, the scope may need to be comprehensive. This
is the ability of good evidence to be used for an intended purpose
appropriate for application in a multitude of clinical setting.
Using the above criteria by Forbes et al. (1999), intuition fell short
in the first two warrants. It will have difficulty attaining
PJN VOL. 88 | NO. 1
methodological soundness and is difficult to replicate. Lyneham,
Parkinson, and Denholm (2008) recounted a story during New
Year's Eve in an Emergency Room (ER). Before midnight, a 7-
month-old baby was brought in the ER due to asthma with
respiratory distress, specifying no more complaints. After seeing
the baby, “I felt my stomach turn” says the nurse, requesting the
pediatric resident to move the baby to the resuscitation room. Two
hours later the baby was wheeled to the operating theater for an
undiagnosed ventral septal defect. This is supporting 'evidence' of
the significance of intuition in clinical practice.
Even I cannot avoid using 'hedging' in describing the situation-
'evidence.' The anecdote by Lyneham, Parkinson, and Denholm
(2008) is an example of the deconstructed discourse of EBP (and
science in general) hegemony and its dominance in the healthcare
arena as Holmes, Murrray, Perron, and Rail (2006) argues.
Noteworthy is the Lyneham, Parkinson, and Denholm (2008)
added the three distinct phases of intuition: cognitive (i.e.,
rationalizing ex-post-facto or doing subconsciously), transitional
(meaning physical sensation or other signs felt by the nurse), and
embodied (which is trusting what s/he felt). Also, Green (2012)
added that intuition distinctly starts with the embodying of the
experience. Then the experience may merge with the senses until
it reaches one's conceptual knowledge and understanding. This
will produce an automatic actions which are brought about by
intuition. Holm and Severinsson (2016) summarized the evidence
about the two levels of intuition, namely the conscious thought
processes (sensing, aware, sudden) and the action (as influenced
by external factors). This systematic review implies that intuition
has two phases namely the consistent input to the senses and the
action. These articles support that intuition can be evidential and
consequential hence the promotion of intuition in professional
nursing practice (Payne, 2015).
Contemporary scientific literature seems to negate the acceptance
of intuition in science. Nobel Laureates Daniel Kahneman and
Amos Tversky compiled their lifetime works about intuition in the
book Thinking, fast and slow in 2011. They largely refute intuition
as scientific evidence because it is plagued by biases and
heuristics both conscious and unconscious. One of which is what
Kahneman called availability heuristics, defined as “wish[ing] to
estimate the size of a category or the frequency of an event, but
you report an impression of the ease with which instances come to
mind” (p. 130). Borrowing as an example from Myers (2002 p.
123), “in English words, does k appear more often as the first of
third letter?...words beginning with k come more readily, and so
they assume that k occurs more frequently in first position. Actually,
k appears two to three times more often in the third position.”
Suppose that a Medical ward nurse just read in a local newspaper
that there is a 30% increase of Human Immunodeficiency Virus
(HIV) in their province. Then male patient X was admitted in the
ward with symptoms of a sore throat, muscle pains, rashes, chills,
tiredness and swollen glands. With availability heuristic influence,
the nurse would jump to conclusion that this is an HIV case even
from the very fact that these are nonspecific symptoms. The nurse
need to ask complete information, consider an alternative

hypothesis, and is aware of factors that may have influenced
her/his decision-making. Then availability heuristics will be
overcome. Also, Kahneman (2011 p. 81) discovered confirmation
bias, that is “seek[ing] data that are likely to be compatible with the
belief they currently hold.” Cognitive bias as a way of thinking has
no place in a professional science like nursing that deals with
human life. In intuitive nursing, we could make abrupt decisions,
'because we have seen it in the past,' that can turn out to be
different. Going back to the contrived example of male patient X.
Supposed during the assessment the nurse found additional
symptoms like night sweats, headaches, generally feeling unwell,
and weight loss all other things being equal, this would 'confirm' the
intuition of the nurse. Stigma might ensue, emotions heightened,
resources might be wasted, or inappropriate nursing interventions
might be implemented. For all the heuristics, this could be a plain
influenza case. We change our ideas or belief based on facts not
just because we 'feel' them. Dobelli (2013) called confirmation bias
as the mother of all biases because it influences or distorts how we
make everyday decisions.
The next two paragraphs discusses the disadvantages of using
EBP approach. EBP is not immune to sound criticism. Questions
as to the validity and reliability of research findings have been
raised. Ioannidis (2005) explained that many research is
underpowered and biased. He noted that many published studies
have small effect size calling into question generalizability. Many
research too is susceptible to distorted findings due to publication
bias, measurement errors, and methodologically flawed designs.
True enough, Fanelli (2009) conducted a systematic review and
meta-analysis on fabrication and falsification of research findings.
The results are appalling, 33.7%-72% admitted questionable
research practices with a pooled weighted average 1.97% (N=7,
95%CI: 0.86–4.45). The large distorted studies puzzled me
because we belong in an enterprise committed to finding the truth.
Remember that Forbes et al.(1999) and Popper (1999) proposed
replicability as the mark of good science. Pashler and Harris
(2012) exposed that replicability is excessively inflated. They said
Table 2. Comparison between EBP and Intuitive Nursing
37
JANUARY-JUNE 2018
that 5% as an alpha level is low, resulting in replicability crisis. That
is why Pashler and Harris (2012 p. 531) recommended “systematic
reform in scientific practice.”
Both Thorsteinsson (2013) and Turner (2009) found out that the
major barriers of using EBP are limited access to good evidence
and lack of resources including time, skills, mentors. This means
that from an organizational standpoint, EBP is an investment in
which returns are not seen immediately (Proctor et al., 2015).
Baumann (2010) also added that, despite its advantages, EBP
does not eliminate uncertainty. Recipients of nursing interventions
are unique and have varying degrees of preferences and genetic
predisposition. One intervention that perfectly suits one person
might not be applicable to another person. As the Heisenberg's
uncertainty principle states that what has been accepted as facts
or strong evidence can just be a practical observation (Busch,
Heinonen, & Lahti, 2007). Another argument against EBP was its
obvious bias towards technical nursing actions and not on holistic
approach (Mitchell, 1997). For example, a nurse caring a post-
cardiac surgery might only focus on early ambulation and
medications but not on adequate diet, sunlight, exercise, or good
communication. These other factors are important to patient's
recovery. Both these two arguments against the sole use of EBP
can be summarized in the inability of EBP to capturing the respect
for human dignity and the complexity of patient care (Baumann,
2010).
Reflecting that even EBP is subjected to the type of scrutiny we
impose on intuition. In defense of EBP, the flaw does not emanate
from the scientific method but to the implementers and paradigm
shortcomings. Unlike in intuition that the flaws as Kahneman
(2011) and Myers (2002) infer is deeply rooted in our cognitive
devices. Therefore, apprehension is warranted. Summary of
these arguments can be seen in Table 2.
Despite the cognitive shortcomings of the nurse scientists, the
application of EBP is proven to be beneficial to patients and health
organizations. Recent literature suggests that nurses and
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38
JANUARY-JUNE 2018

organization using EBP approach Figure 1. Consilience in Evidence-Based Practice

can be clinically associated to an
improvement of various patient
outcomes including hospital-
acquired infections, pressure ulcers,
falls, and trauma (Harper et al., 2017;
Stalpers, de Brouwer, Kaljouw, &
Schuurmans, 2015). In the same
way, EBP application can produce
cost-effective, patient-centered,
system-based, and replicable
interventions which might result to
better employee satisfaction and
involvement, scientifically-based
strategies, and clearer guidelines on
health outcome implementation
(Dearholt & Dang, 2012). One
concrete example is the seminal
study on nurse staffing and patient
mortality, readmission, and the failure to rescue by Aiken, Clarke, of Nursing Research. In her guest editorial, she enumerated
Sloane, Sochalski, and Silber (2002) had been influencing staffing four nursing areas of scientific focus: symptom science,
in California and other states in the USA, in Europe (Aiken et al., wellness, self-management, and the science of compassion.
2014), in Australia (Duffield et al., 2011), and in South Korea (Cho, This scientific focus is believed to move nursing science to the
Hwang, & Kim, 2008). This suggests that basing clinical decisions future. If you try to tease these four agenda apart, noticeably is
using EBP tend to be more tractable and produces tangible, the need to focus on an authentic science as mentioned by
measurable outcomes. To achieve the intended outcomes, nurse Forbes et al. (1999). For instance, in symptom science expert
scientists need to generate a holistic, scientific, and uniform nurses can develop and cluster symptoms in support of the
approach. nursing diagnosis. The clustered symptoms can't just be a
textbook example but rather to consider the tested and
The term consilience or the unity of knowledge is borrowed from corroborated experience or instincts of expert nurses over the
the book by the eminent biologist Edward O. Wilson (1998). The years. These commonly unacknowledged factors are
word consilience suggests “interlocking of causal explanation significant to advance nursing science. Following this compass
across discipline” (p.325) implying the need to take combined, means redirecting intuition to the unrequited direction.
applicable idea from different approach, and put them together
until it makes a coherent conjecture. Consilience fits the A word of caution to nurse scientists. Alienating intuitive
framework developed in this paper because it stimulates such an practitioner (whether novice or expert) of their current nursing
appeal of a “prospect of intellectual adventure… the value of practice could create indifference. If such indifference is
understanding the human condition with a higher degree of nurtured, they could detach themselves in doing EBP. This is
certainty” (p. 9). The tripartite interlock of EBP, TR, and RU could the reason why in Figure 1, the arrow is unidirectional. What
create less semantic confusion to nurse scientists venturing into nurse practitioners intuit must be recognized but must not be
nursing science. In the developed model, there are two types of the sole basis of nursing actions. Still, I share this implicit
direction: unidirectional and bidirectional. Unidirectional arrow contention with Grady (2017), that the future of nursing
means that the relationship is one way. For example, intuitive science belongs to EBP, but I do not discount the research by
nursing informs EBP but not the other way around. Bidirectional Lyneham et al. (2008) that intuition can be valid too. This article
arrows mean their relationship is mutual and they inform each can be useful to nurses because it attempts to conceptually
other. As shown in Figure 1, the EBP serves as the core informed close the gap between what is happening and what should be
by RU and TR. The relationship of these three paradigms is happening. In developing countries like the Philippines whose
bidirectional. Intuition and EBP relationship in the model is nursing science is flourishing- context and implementer
unidirectional because of the dearth and conflicting evidence characteristics matters hugely.
supporting intuitive nursing in research uptake.
Implications for Nursing Practice, Education,
The Verdict of the Compass to Follow and Research

“The future of nursing science has never been brighter,” says The consilience EBP model as the future of nursing science
Patricia Grady (2017 p. 247), the Director of the National Institute recognizes the constraints present in nursing practice. That is

PJN VOL. 88 | NO. 1


the acknowledgment of what is being used in the real nursing
setting. Most nurses still use intuition as their guide to delivering
nursing care (Pravikoff, Tanner, & Pierce, 2005). This model can
be a basis to interlock what is happening and what is ideally
expected. I assert that alienating intuitive nurses would create
more gap in EBP rather than furthering the cause of quality
nursing practice. In nursing education, the model could be used
to advance teaching EBP in the beginning and advanced nurse
scientists. The clarity offered by the model advances nursing
education and science in general. Also, the model could
supplement published articles pointed to more research uptake in
the Philippines and worldwide such as Cura (2017).
Summary
In summary, the similarities and differences of evidence-based
practice, translational research, and research utilization were
discussed. I provided arguments of the optimal strategy using
evidence-based practice over intuition. I proposed the model of
the consilience in evidence-based practice. The model interlocks
evidence-based practice, translational research, and research
utilization, with intuitive nursing. Following the compass pointing
through north is the right way to take for nursing science. I argued
that the consilience of EBP is our raison d'être, which can serve
as the cornerstone of our science- the nursing science.
Contemporary nursing science and it's evolution to the future
calls for prudence in selecting paradigm because it may dictate
what we will hand to the future generation. As the former United
Kingdom Prime Minister David Cameron (2016) said as he bows
down in office, “ I am [We are] the future once.”
..........................
References
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H.
(2002). Hospital nurse staffing and patient mortality, nurse burnout,
and job dissatisfaction. JAMA, 288(16), 1987-1993.
Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P.,
Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., &
McHugh, M. D. (2014). Nurse staffing and education and hospital
mortality in nine European countries: a retrospective observational
study. The Lancet, 383(9931), 1824-1830.
Barnsteiner, J. & Prevost, S. (2002) How to implement evidence-based
practice. Some tried and true pointers. Reflections on Nursing
Leadership. 28 (2) 18-21.
Baumann, S. L. (2010). The limitations of evidenced-based practice.
Nursing Science Quarterly, 23(3), 226-230.
Benner, P. E., Tanner, C. A., & Chesla, C. A. (2009). Expertise in nursing
practice: caring, clinical judgment, and ethics. New York: Springer
Publishing Company.
Black, A. T., Balneaves, L. G., Garossino, C., Puyat, J. H., & Qian, H.
(2015). Promoting evidence-based practice through a research
training program for point-of-care clinicians. The Journal of Nursing
Administration, 45(1), 14.
Busch, P., Heinonen, T., & Lahti, P. (2007). Heisenberg's uncertainty
principle. Physics Reports, 452(6) 155-176.
39
JANUARY-JUNE 2018
Cameron, D. (2016, July 13) Cameron's last #PMQs FULL. Retrived from
https://www.youtube.com/watch?v=nFd8mgxAg5U
Cho, S. H., Hwang, J. H., & Kim, J. (2008). Nurse staffing and patient
mortality in intensive care units. Nursing Research, 57(5), 322-330.
Cura, J. (2017) Development of framework for clinical nursing research
fellowship in the Philippines. Philippine Journal of Nursing. 87 (1) 66-
75.
Dankwa-Mullan, I., Rhee, K. B., Stoff, D. M., Pohlhaus, J. R., Sy, F. S.,
Stinson Jr, N., & Ruffin, J. (2010). Moving toward paradigm-shifting
research in health disparities through translational, transformational,
and transdisciplinary approaches. American Journal of Public Health,
100(S1), S19-S24.
Dearholt, S. & Dang, D. (2012) Johns hopkins evidence-based practice:
model and guidelines 2nd edition. Indianapolis: Sigma Theta Tau
International.
Dickoff, J., James, P., &Wiedenbach, E. (1968). Theory in a practice
discipline: part i. Practice oriented theory. Nursing Research. 17 (5)
415-434.
Dobelli, R. (2013). The art of thinking clearly: better thinking, better
decisions. Hachette UK: Harper Paperbacks.
Donaldson, S. K. (2003). Commentary: The Science of Human
Health—Domain Structure and Future Vision. Biological Research
for Nursing, 4(3), 165-169.
Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M.,
& Aisbett, K. (2011). Nursing staffing, nursing workload, the work
environment and patient outcomes. Applied Nursing Research,
24(4), 244-255.
Edwards, S. D. (1999). The idea of nursing science. Journal of Advanced
Nursing, 29(3), 563-569.
Effken, J. A. (2007). The informational basis for nursing intuition:
philosophical underpinnings. Nursing Philosophy, 8(3), 187-200.
Estabrooks, C. A. (1999). The conceptual structure of research utilization.
Research in Nursing & Health, 22(3), 203-216.
Estabrooks, C. A., Wallin, L., & Milner, M. (2003). Measuring knowledge
utilization in health care. International Journal of Policy Evaluation &
Management, 1(1), 3-36.
Fanelli, D. (2009). How many scientists fabricate and falsify research? A
systematic review and meta-analysis of survey data. PLOS ONE,
4(5), 1-11.
Forbes, D. A., King, K. M., Eastlick Kushner, K., Letourneau, N. L., Myrick,
A., &Profetto‐McGrath, J. (1999). Warrantable evidence in nursing
science. Journal of Advanced Nursing, 29(2), 373-379.
Funk, S. G., Tornquist, E. M., & Champagne, M. T. (1989). A model for
improving the dissemination of nursing research. Western Journal of
Nursing Research, 11(3), 361-367.
Gordon, S. (2005) Nursing against odds how health care cost cutting,
media stereotypes, and medical hubris undermine nurses and patient
care. New York: Cornell University Press.
Grady, P. A. (2017). Advancing science, improving lives: NINR's new
strategic plan and the future of sursing science. Journal of Nursing
Scholarship, 49(3), 247-248.
Green, C. (2012). Nursing intuition: a valid form of knowledge. Nursing
Philosophy, 13(2), 98-111.
Hardy, S., Titchen, A., Manley, K., & McCormack, B. (2006). Re-defining
nursing expertise in the United Kingdom. Nursing Science Quarterly,
19(3), 260-264.
Harper, M. G., Gallagher-Ford, L., Warren, J. I., Troseth, M., Sinnott, L. T.,
& Thomas, B. K. (2017). Evidence-based practice and US healthcare
outcomes: findings from a national survey with nursing professional
development practitioners. Journal for Nurses in Professional
Development, 33(4), 170-179.
PJN VOL. 88 | NO. 1
40
JANUARY-JUNE 2018
Harvey, G., & Kitson, A. (2015). Implementing evidence-based practice in
healthcare: a facilitation guide. New York: Routledge.
Holm, A. L., & Severinsson, E. (2016). A systematic review of intuition—a
way of knowing in clinical nursing?. Open Journal of Nursing, 6(05),
412-425.
Holmes, D., Murray, S. J., Perron, A., & Rail, G. (2006). Deconstructing the
evidence‐based discourse in health sciences: truth, power and
fascism. International Journal of Evidence‐Based Healthcare, 4(3),
180-186.
Ioannidis, J. P. (2005). Why most published research findings are false.
PLOS Medicine, 2(8), 1-6.
Kahneman, D. (2011) Thinking, fast and slow. New York: Farrar, Straus and
Giroux.
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the
implementation of evidence based practice: a conceptual framework.
Quality in Health care, 7(3), 149-158.
Kuhn, T. (1970) The structure of scientific revolutions. Chicago, IL: University
of Chicago Press .
Locsin, R. & Purnell, M. (2013) Professional Nursing: scientific practice or
simple care? Philippine Journal of Nursing. 83 (1) 34-36.
Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs‐Gowan, M. J.
(2011). A randomized controlled trial of Child FIRST: A comprehensive
home‐based intervention translating research into early childhood
practice. Child Development, 82(1), 193-208.
Lyneham, J., Parkinson, C., &Denholm, C. (2008). Explicating Benner's
concept of expert practice: intuition in emergency nursing. Journal of
Advanced Nursing, 64(4), 380-387.
Lyneham, J., Parkinson, C., &Denholm, C. (2008). Intuition in emergency
nursing: a phenomenological study. International Journal of Nursing
Practice, 14(2), 101-108.
Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M.
(2010). Evidence-based practice: step by step: the seven steps of
evidence-based practice. AJN The American Journal of Nursing,
110(1), 51-53.
Mitchell, G. J. (1997). Questioning evidence-based practice for nursing.
Nursing Science Quarterly, 10(4), 154-155.
Myers, D. (2002) Intuition its powers and perils. New Haven: Yale University
Press.
Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., &
Schwartz, J. S. (2004). Transitional care of older adults hospitalized
with heart failure: a randomized, controlled trial. Journal of the
American Geriatrics Society, 52(5), 675-684.
O'Hear, A. (1990) An introduction to the philosophy of science. Oxford
University Press: Oxford.
Pashler, H., & Harris, C. R. (2012). Is the replicability crisis overblown? Three
arguments examined. Perspectives on Psychological Science, 7(6),
531-536.
Payne, L. K. (2015). Toward a theory of intuitive decision–making in nursing.
Nursing Science Quarterly, 28(3), 223-228.
Pearson, A., Jordan, Z., & Munn, Z. (2012). Translational science and
evidence-based healthcare: a clarification and reconceptualization of
how knowledge is generated and used in healthcare. Nursing
Research and Practice, 1-6, doi: 10.1155/2012/792519
Pearson, A., Weeks, S., & Stern, C. (2011) Translation science and the JBI
model of evidence-based healthcare. Philadelphia: Lippincott Williams
& Wilkins
Poe, S. & White, K. (2010) Johns hopkins evidence-based practice:
implementation and translation. Indianapolis: Sigma Theta Tau
International
Popper, K. (1999) The logic of scientific discovery. Padstow, Cornwall:
Routledge
Pravikoff, D. S., Tanner, A. B., & Pierce, S. T. (2005). Readiness of US
nurses for evidence-based practice: many don't understand or
value research and have had little or no training to help them find
PJN VOL. 88 | NO. 1
evidence on which to base their practice. AJN The American Journal
of Nursing, 105(9), 40-51.
Proctor, E., Luke, D., Calhoun, A., McMillen, C., Brownson, R., McCrary, S., &
Padek, M. (2015). Sustainability of evidence-based healthcare:
research agenda, methodological advances, and infrastructure
support. Implementation Science, 10(1), 88.
Rycroft‐Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., &
McCormack, B. (2004). What counts as evidence in evidence‐based
practice?. Journal of Advanced Nursing, 47(1), 81-90.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson,
W. S. (1996). Evidence based medicine: what it is and what it isn't. BMJ:
British Medical Journal, 312(7023), 71-72.
Saunders, H., & Vehviläinen-Julkunen, K. (2016). The state of readiness for
evidence-based practice among nurses: An integrative review.
International Journal of Nursing Studies, 56, 128-140.
Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence‐based
practice models for organizational change: overview and practical
applications. Journal of Advanced Nursing, 69(5), 1197-1209.
Schmidt, N. & Brown, J. (2012) Evidence-based practice for nurses appraisal
and application of research. Sudbury: Jones & Bartlett Learning
Stalpers, D., de Brouwer, B. J., Kaljouw, M. J., & Schuurmans, M. J. (2015).
Associations between characteristics of the nurse work environment
and five nurse-sensitive patient outcomes in hospitals: a systematic
review of literature. International Journal of Nursing Studies, 52(4), 817-
835.
Thorsteinsson, H. S. (2013). Icelandic nurses' beliefs, skills, and resources
associated with evidence‐based practice and related factors: a national
survey. Worldviews on Evidence‐Based Nursing, 10(2), 116-126.
Turner, T. J. (2009). Developing evidence-based clinical practice guidelines
in hospitals in Australia, Indonesia, Malaysia, the Philippines and
Thailand: values, requirements and barriers. BMC Health Services
Research, 9(1), 235-241.
Wilson, E. (1998) Consilience the unity of knowledge. New York: Random
House Inc.
Winters, J., &Ballou, K. A. (2004). The idea of nursing science. Journal of
Advanced Nursing, 45(5), 533-535.
Woods, N. F., &Magyary, D. L. (2010). Translational research: why nursing's
interdisciplinary collaboration is essential. Research and Theory for
Nursing Practice, 24(1), 9-24.
Woolf, S. H. (2008). The meaning of translational research and why it
matters. JAMA, 299(2), 211-213.
Zutz, A., Ignaszewski, A., Bates, J., & Lear, S. A. (2007). Utilization of the
internet to deliver cardiac rehabilitation at a distance: a pilot study.
Telemedicine and e-Health, 13(3), 323-330.
ABOUT THE AUTHOR
Rainier C. Moreno-Lacalle, PhD, RN is an
Associate Professor at Saint Louis
University-School of Nursing Baguio City,
Philippines. His primary mission in life is to
help humanity through advancing nursing
science. His current research interests
includes evidence-based practice (EBP), health disparity,
mental health, and statistics. He is a member of Sigma Nursing
Psi Beta chapter. Currently, he leads a community extension
project to promote EBP in one of the local hospitals in Baguio
City.
 41

RESEARCH ARTICLE

SOURCE AND ESSENCE OF GRATITUDE:

RE-EXAMINING THE INTERGENERATIONAL VIEWS
ON RESPECT FOR THE OLDER PERSONS
Laurence L. Garcia, DScN, MN, RN1 and Letty G. Kuan, EdD, MAN, MSN

Abstract
The paper looked into dynamics and variances of the manifestation of gratitude towards the older persons utilizing qualitative survey
design. A total of 300 study participants, which include the young millennials, mid-lifers and older generation groups, were interviewed.
The tool used was a simple interview guide for a freewheeling interview with storytelling style. Three-level classification of qualitative
survey analysis was used. The findings revealed how family, work and societal changes have contributed to the changes in the
manifestation of gratitude. The changes in the social structure and the demand to cope with these changes have caused the gap
between the desire of the older persons to be respected and how the younger generations have shown this to them. Gratitude, which is
manifestation of respect, has evolved and is now shown differently across intergenerational groups and seems to be experienced
similarly across nations. The younger generations have a different view on respect in comparison with the older generations.

Keywords: Gratitude, older persons, culture, intergenerational perspectives, societal changes

Introduction

T he word gratitude is derived from the Latin word gratia, which

means grace, graciousness, or gratefulness (depending on
the context). In some ways gratitude encompasses all of these
meanings. Gratitude is a thankful appreciation for what an
individual receives, whether tangible or intangible. With gratitude,
people acknowledge the goodness in their lives. In the process,
people usually recognize that the source of that goodness lies at
least partially outside themselves. As a result, gratitude also
helps people connect to something larger than themselves as
individuals — whether to other people, nature, or a higher power
(Simon, 2018).
People feel and express gratitude in multiple ways. They can
apply it to the past (retrieving positive memories and being
thankful for elements of childhood or past blessings), the present
(not taking good fortune for granted as it comes), and the future
(maintaining a hopeful and optimistic attitude). Regardless of the
inherent or current level of someone's gratitude, it's a quality that
individuals can successfully cultivate further (Simon, 2018).
Underneath the veneer of change wrought by colonization and
modernization, Filipinos' moral values have remained intact and
continue to influence behavior. Filipinos are more moralistic than
foreigners generally believe. The most powerful moral obligation
in Filipino culture is “utang naloob” or debt of gratitude. It is the
essence of loyalty, commitment, and moral order. Utang naloob is
a form of reciprocity, i.e., a favor must be repaid adequately and
properly to show gratitude. Quantifying the original debt may be
difficult, but repayment is expected to supersede the original or
else acknowledge that payment is partial and needs further
reciprocation.Other moral obligations include dangal (honor),
puri (also honor), pananagutan (responsibility, accountability),
and katapatan (loyalty) (Hays, 2015).
By observation, the young generation and even some of the older
generations do not willfully acknowledge good things done to
them. It is taken for granted that kind deeds are part of life and are
due to everyone. It is likewise observed that it is rarer now to hear
the words “please excuse me” and “I am sorry.” There is more
familiarity in relationships even with older persons. People tend to
neglect that special treatment afforded to older persons and treat
them similarly with people of the same age. Older persons lived
their generation by being acknowledged as “elders” and as such
they expect politeness and respect when dealing with them.
The main objective of this paper is to find dynamics and variances
of the manifestation of gratitude towards the older persons. This
will provide an idea of the problems caused or the level of

1 Correspondence:
Faculty member of the College of Nursing; Director of the Center for Research and Development and the Research Institute for Ageing and Health, Cebu Normal University
Osmeña Boulevard, Cebu City, Philippines 6000; garcial@cnu.edu.ph
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discomfort observed when the older persons do not feel that they
have been paid due respect. It further looked into the effect to the
society when both the young and old are not grateful enough for
the good deeds that they have been provided with. Furthermore,
this will provide an idea on the erosion of the moral culture of
which is a pride of the Philippines. This study also aims to
illuminate how we should interact with older people in the country
so that they feel respected and thus enhanced their level of
wellbeing.
Methodology
This study utilized qualitative survey design. The qualitative type
of survey does not aim at establishing frequencies, means or
other parameters but at finding out the diversity of some topic of
interest within a given population. This type of survey does not
count the number of people with the same characteristic (value of
variable) but it establishes the meaningful variation (relevant
dimensions and values) within that population (Fink, 2003;
Jansen, 2010). In this type of qualitative research, both data
collection and the research question develop in interaction with
data analysis and interpretation.It is only appropriate to study
different population groups when examining the dynamics in
interaction between different age groups in society. For this
particular question, three target groups namely, the seniors, the
adults, and the young persons were included as participants. This
was done purposively to select a diversity sample with the aim to
cover all existing relevant varieties of the phenomenon
(saturation). A total of 300 study participants from different places
across the country were included. A qualitative sample should
represent the diversity of the phenomenon under study within the
target population. This could be achieved by a large random
sample. What saturation is depends on the type and degree of
diversity that is judged relevant. To be sure that all forms of
diversity are covered it would be necessary to include the whole
population in the sample. The data collection method is not limited
by the study design in itself, nor is the type of data to be collected.
This used the familial, freewheeling interview with storytelling
style of what they have observed as behavior of the people of
today. This was done whenever there were important gatherings
and friendly reunions from 2015 to 2017 (Jansen, 2010).The
investigator asked the participants consent to an interview noting
down significant information from their stories. The biases of the
investigators were withheld throughout the interview so as not to
affect the results. In an interview survey with open questions,
each answer is unique. Here also all the members of the
population under study should be included to guarantee full and
detailed coverage (Jansen, 2010).
The main tool used was a very simple interview guide on just two
points: what is the behavior of people in showing gratitude, and
what values are commonly demonstrated by the actions of the
young as well as the older generations towards older people. As
the older study participants were mostly former high school and
college classmates, establishing rapport and getting their
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concerned and cooperative consent went very smoothly. This was
how data gathering was done: During socialization gatherings,
two or three friends would converge in a comfortable place,
usually around a table with snacks, and then in a story telling style,
discussion on how people behave today with a focus on the values
of respect and gratitude went around from one participant to
another. At times, the group that started with to three members
would expand to five and even seven members. It was always a
lively and interesting huddle and causerie of ideas and
observations. Among the younger group, the millennials,
interviews were done after seminar meetings and this took time
because it was more of a one on one manner (Jansen, 2010).
The data gathered from the interviews were noted down by the
main investigator and reviewed for similarities and differences.
The other investigators looked into the summarized data to ensure
there are no biases based on generation the investigators are in.
Both the investigators took part in analyzing the data and referred
to literatures to arrive at a similar understanding. The three-level
classification of qualitative survey analysis was used:
unidimensional description, multidimensional description and
explanation (Jansen, 2010; Corbin and Strauss, 2008;
Sandelowski and Barroso, 2003). Unidimensional description
entails organizing data into objects, dimensions for each object
and categories for each dimension, whereas multidimensional
description synthesizes dimensions and/or categories into more
abstract concepts and/or typologies. Explanation relates
descriptive categories or dimensions to context (social,
biographical, socio-historical, political, etc.) (Corbin and Strauss,
2008). In a qualitative survey, one may analyze relationships
between types (from multidimensional description) and selected
contextual conditions with a conditional matrix, as is sometimes
done in grounded theory studies (Creswell, 1998). Most often,
description and explanation are intertwined in the process of
analysis (Jansen, 2010; Creswell, 1998). The analysis was then
presented to participants from different generations for
verification.
Findings
A total of three hundred study participants comprised the
population, all women. A hundred (100) of them with average age
range of 23-28, the mid-lifers, 100 with average age range of 58-
64 and the senior group 100, with average age range of 78 -84.
One common characteristic is that they were all college degree
holders, and all are professionals. All profess the Roman Catholic
faith. Some of the participants are married, some are widowed,
others remained single and still others are consecrated persons.
Many of the millennials are still single.
With the data analysis approach mentioned above, the following
key concepts/statements describing the dynamics and variances
were found among the seniors and the mid-lifers:
The Fast-paced Life and Self-Centeredness. The two most
prominent concepts coming from the seniors and the mid-lifers are

the fast pace of life in modern societies and the self-centeredness
of people nowadays. They found that there is a decrease of
politeness, as stated:
“There is a decrease of politeness and tact among people,
it seems everything is due them, and when they pass by
senior citizens, few say “excuse me” or say “I am sorry”.”
Another one said:
“Their manners are somehow not so polite anymore
because with the problem of congestion in the traffic, they
have to rush and run around.”
They also expressed that there seemed to be an insistent
need of individuals to do things hastily. An interesting
descriptive phrase used by the participants was “epidemic.”
They used the word to describe how people live their lives in
the fast lane. For senior citizens, this is hurting because the
respect due to elders is no longer there as in the times of old,
as verbalized by one:
“What counts to them is “self”, others are not counted as
important. The focus is more on “self”, and less concern for
others.
The Taking Over by Technology. People have been so hooked
with the ease and comfort afforded by technology. It has taken
away most of the socialization time and has formed part of the
sine-qua-non repertoire of their daily lives. It has made them
always seeking for fast solutions and quick fixes to everything.
This attitude has caused the disregard to the opinions of the old
and of others in solving problems and finds answers through the
use of phones and gadgets.
One participant stated:“Many of the young and even not so young
people are so much in a hurry, they are hooked to modern
gadgets. Cellphones have become an essential part of their daily
life.” This is supported by another statement: “It's so easy for them
to search anything in the internet. They just click their gadgets to
find answers. No need to ask their parents anymore.”
The Breaking of Ties. Families lack close knit ties because
parents are often away from home even if children are still in their
tender young age, in a desire to add earnings to their financial
resources. This is what one participant verbalized:
“Because parents want to earn more income for the
children's future, they leave the children at a very young
age and work overseas. Sometimes both the mother and
father, leave the kids.”
“Some reasons are the personal and family needs that
make them beat the time.”, another one stated.
There is less time spent together as a family even on weekends
because each one is more attuned to personal agenda. Overseas
employment of either father or mother or both have deprived
children of the physical presence and nearness of parents as they
were growing up. Another one verbalized: “There is less time tor
43
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catechesis, less prayer time together and not many are engaged
in evangelizing people especially those in the peripheries. In
addition, “Values are not given importance, many things are done
mechanically without much thought for others.”
In summary, the seniors and the mid-lifers have lost the old way of
showing gratitude. Lack of role models both at home, in
neighborhood and in the community have weakened good
manners and right conduct. Material needs and mundane
aspirations have created selfish satisfaction above the others,
hence there is a sense of being in a hurry to do much volume of
work in so short of time. There is need to earn more. Lack of
community involvement breeds distanced relationships with
neighbors and community members. Many do not know their
neighbors. Both generations ability to show respect has been
eroded by the way they lived their lives.
The following key concepts/statements describing the dynamics
and variances were found among the Millennials:
Born at this Time of Change. In general, the Millennials are not
aware that they lack respect and politeness because this is their
way of life. This generation viewed their behavior as unique and
interesting. They see it as the most fitting for the time they are in.
One said:
“I think they are just used to it. That is how people of their
age behave, without realizing it hurts. They live in a time
where they can justify actions and insist their human rights
when forced to do things they don't like”
However, it has raised doubts among the older generations who
felt disregarded by their belief of their generation's supremacy:
“They act as if we are not anymore part of the world and in this
current time. It's as if this time is only for them.”, as one painfully
mentioned.
Craze Over Tech. Millennials act similarly with older generations
in the way they use technology as part of their daily lives. They
interact more with their gadgets than with parents and other family
members, taking away a big part of socialization, which helps in
forming good attitudes towards others. Parents' opinions are often
disregarded since there is easy access to a wide range of
information online. These were verbalized:
“Parents who work abroad gave them gadgets to
communicate but they got hooked to it. Even when the
parents are around, they spend more time with the gadgets
than with people at home.”
“They easily search for advice on social media than from
their elders”
“It's easier for them to communicate online than face-to-
face. They have global relationships with other countries
because of their internet connections.”
“They are always busy playing with their gadgets than
playing with siblings and cousins. They don't even talk
sometimes despite being seated side-by-side.”
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Oldies as Role Models. The millennials would always use the
justification, “we learned it from them” or “they are doing it, why
can't we?” They do not seem to be wrong because this is what is
being seen today among people, as verbalized:
“They think they are doing right things all the time because
they see this done by other people, especially those in
authority.”
“They would just say they saw it done by others, some saw
it in the internet or on TV, that is why they did it also.”
How gratitude has been eroded in the older generation is
expected to be similarly manifested by the younger ones.
In summary, the line between who influenced who is quite difficult
to distinguish. The millennials are living in a time where
manifesting gratitude has changed. The older generations
seemed to just cope with the recent scenario they are in, instead
of allowing traditional practices to persist. The millennials are just
living the life they thought is appropriate for them. Their perception
of gratitude and respect is based on the way they see and acquire
it from their limited interactions.
Discussion
The degradation of gratitude, which is a form of showing respect,
has been a concern among generations. Researches have been
done which speaks similarly as the findings of this study.
Respect for the elderly is built into the social fabric. The emphasis
on social relationships (Ho, 1982) and their awareness of
hierarchy within these relationships has traditionally resulted in a
special deference paid to the aged (Limanonda, 1995). The value
of filial piety, which is understood as “respect and care for parents
and the aged” has deep roots in culture. This value serves as a
standard by which attitudes and behaviors toward the elderly are
judged (Sung, 1995).
Elder respect has been practiced for generations (Sung & Kim,
2003). The older people were respected and well-regarded. Many
preindustrial societies a social structure where the authority is
assumed by the group's oldest members (Little & McGivern,
2012). In the advent of rapid industrialization, this age-old practice
has become an issue of major concern for policy makers and
gerontologists. Without respect, positive attitudes towards the
older person cannot exist, nor can elders be treated with propriety.
Studies have found that respect was a key factor in determining
an older person's life satisfaction (McCabe, et al, 2010). The
elderly who are respected are likely to increase self-esteem and
involve themselves in a cooperative effort with caregivers to
achieve a desired outcome whereby treatment benefits can be
increased. How the young treat elders is, therefore, important not
only to the elderly but also to caregivers and to society (Sung &
Kim, 2003).
The meaning of respect had changed over time. Respect
connoted obedience in the past, but its meaning had now shifted
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to courtesy and politeness. While this shift in meaning was
generally consistent, it is not possible to generalize this finding
(Mehta, 1997). The traditional view of respect for the elderly is
based on what they have sacrificed for and provided to the
younger generation. This ethic may, however, be changing over
time(Ingersoll-Dayton & Saengtienchai, 1997).
Currently, there are numerous ways in which traditional greetings
and ritualized physical gestures had altered. Younger people
frequently walked by and ignored older people rather than
greeting them with the traditional gesture of hands joined in front of
the head (Ingersoll-Dayton & Saengtienchai, 1997; Sung, 2004).
Others pointed out how few young people bowed in front of elders.
Referring to the younger generation's tendency not to bend low in
the presence of their elders. In the Philippines, older persons
decried the glib way in which younger people now greeted older
people without even kissing their hand. Said one older Filipino
adult, “Nowadays, kids don't know anything about respect. You'll
have to offer your hand for them to kiss. Sometimes, they don't
even want to kiss the older person's hands.” Another Filipino
distinguished greetings between the young and the old in the city
as compared to the country, “In the city, older people are ignored
by the young whereas in the country, young people will at least
greet older people with a few words, such as 'Good morning' or
'Good afternoon.' ” (Ingersoll-Dayton & Saengtienchai, 1997).
Change in respect afforded to older persons exists worldwide
nearly among all age groups including adolescents. Various
studies with explicit reference to youths of various age, sexual
orientation, instructive level, financial foundation, information
about aging and encounters with older people demonstrated that
they had various view of and dispositions toward older people,
however such discoveries are not so much definitive (So & Shek,
2011). Based on the results and other similar studies, these
observations can be alluded to the impact of changes in family
organization and employment. An increased emphasis on the
nuclear family had decreased respect for the elderly. Women's
employment outside of the home had influenced respect for the
elderly. Many associated women's employment with neglect in the
teaching of values. Also, changes in the earning power of young
people made them less reliant on and therefore less respectful
toward their elders (Ingersoll-Dayton & Saengtienchai, 1997).
The educational system can be held responsible for lack of
respect paid to the elderly. The educational system was critiqued
for its lack of emphasis on teaching morals and family values. In
addition, the changes in the broader world, including moving from
an agrarian way of life and adopting Western ways, had negatively
influenced respect for the elderly (Ingersoll-Dayton &
Saengtienchai, 1997). Ageism is now considered to be the most
common form of partiality, and the concern is, its prevalence is not
acknowledged as well as its impact. Most societies are actually
youth-oriented nowadays and don't really respect or care about
older people As the population age rapidly worldwide, it is then
important to rightful to address ageism or disrespect against older
people, such as it being prevalent and/or increasing in prevalence
(University of Alberta, 2019).

Social forces truly play a role in how generations show respect to
older persons. This shapes attitudes about aging, and technology
including social media presents negative depictions of older
adults and the aging process thereby resulting to lack of attention
on this important concern of older persons (Brownell, P, 2010).
Conclusion and Recommendation
The study has pointed out the reasons why values have lessened
its hold among the people today The changes in the social
structure and the demand to cope with these changes have
caused the gap between the desire of the older persons to be
respected and how the younger generations have shown this to
them. It is recommended, based on the findings, to look into
specific ways of showing gratitude through other research
methods. Families should be the focus of health education in
terms of affording respect for the older persons. Considerations in
the perspectives of respect across generations must be included
in the curriculum so as nurses may be sensitive in the provisions of
care.
..........................
References
Brownell, P. (2010). Social issues and social policy response to abuse and
neglect of older adults, Aging, Ageism and Abuse Moving from
Awareness to Action, Chapter 1:1-15.
Corbin, Juliet M. & Strauss, Anselm L. (2008). Basics of qualitative research.
Thousand Oaks, CA: Sage.
Creswell, John W. (1998). Qualitative inquiry and research design: Choosing
among five traditions. Thousand Oaks, CA: Sage.
Fink, Arlene (2003). The survey handbook. Thousand Oaks, CA: Sage.
Hays, J. (2015). Social relations in the philippines: utang na loob, bayanihan
and pakikisama. Retrieved from Facts and Details:
http://factsanddetails.com/southeast-asia/Philippines/ sub5_6c/entry-
3868.html
Ho, D. (1982). Asian concepts in behavioral science. Psychologia, 25(4),
328-235.
Ingersoll-Dayton, B., & Saengtienchai, C. (1997). Respect for the Elderly in
Asia: Stability and Change. University of Michigan, Population Studies
Center. PSC Publications.
Jansen, H. (2010). The Logic of Qualitative Survey Research and its Position
in the Field of Social Research Methods. Forum Qualitative
Sozialforschung / Forum: Qualitative Social Research, 11 (12).
Limanonda, B. (1995). Families in Thailand: Beliefs and realities. Journal of
Comparative Studies, 26(1), 67-82.
Little, W. and McGivern, R. (2010) Introduction to Sociology, 2nd Edition.
O p e n S t a x C o l l e g e . R e t r i e v e d f r o m O p e n Te x t B C :
https://opentextbc.ca/introductiontosociology2ndedition/back-
matter/attributions/
McCabe, M., Mellor, D., McNamara, J., and Hill, B. (2010). Respect in an
Ageing Society. Deakin University Australia. Retrieved from
library.bsl.org: http://library.bsl.org.au/jspui/bitstream/
1/1550/1/Respect%20in%20an%20Ageing%20Society_Benetas201
0.pdf
Mehta, K. (1997). Respect redefined: Focus group insights from Singapore.
International Journal of Aging and Human Development, 44(3), 205-
219.
Sandelowski, Margarete & Barroso, Julie (2003). Classifying the findings in
qualitative studies. Qualitative Health Research, 13, 905-23.
Simon, H. (2018). Giving thanks can make you happier. (Harvard University)
Retrieved from Harvard Men's Health Watch :
45
JANUARY-JUNE 2018
https://www.health.harvard.edu/healthbeat/giving-thanks-can-make-
you-happier
So, K, Shek, D. (2011). Perceptions of older people among Chinese
adolescents: conceptual and methodological issues. International
Journal of Adolescent Medicine and Health 23(2):123-8.
Sung, K., & Kim, H. (2003). Elder respect among young adults: Exploration
of behavioral forms in Korea. Ageing International.
Sung, K. (1995). Measures and dimensions of filial piety in Korea. The
Gerontologist, 35(2), 240-247.
Sung, K. (2004). Elder respect among young adults: A cross-cultural study of
Americans and Koreans. Journal of Aging Studies 18(2):215-230.
https://doi.org/10.1016/j.jaging.2004.01.002
University of Alberta. (2019). Discrimination against older people needs
attention: We still haven't reckoned with how common and harmful age-
related prejudice is in society. ScienceDaily. Retrieved September 17,
2 0 1 9 f r o m w w w . s c i e n c e d a i l y. c o m / r e l e a s e s / 2 0 1 9 /
05/190521124530.htm
ABOUT THE AUTHORS
Laurence L. Garcia, DScN, MN, RN is a
faculty member of the College of Nursing of
Cebu Normal University. He received his
degrees on Bachelor of Science in Nursing,
Master in Nursing major in Mental Health
Psychiatric Nursing and Doctor of Science in
Nursing major in Gerontology Nursing from the same university.
He has served as a research assistant of the college, to being
faculty member and Dean. Currently, he is the Director of the
Center for Research and Development and the Research
Institute for Ageing and Health. His works center on mental
health and care of the older persons. His research interests focus
on this age group and presented research outputs in national and
international conferences and published in local and
international journals. He mentors students who specialize in
Psychiatric Nursing and Gerontology Nursing. He was awarded
the Inaugural Distinguished Educator for Gerontological Nursing
by the National Hartford Center for Gerontological Nursing
Excellence.
Letty G. Kuan, EdD, MAN, MSN is a
consummate educator, nurse, researcher,
nun, counselor, author, mentor and “mother”
to many UPCN alumni and nurses from other
schools and hospitals. Dr. Letty G. Kuan. She
obtained her basic nursing degree from the
Southern Islands Hospital, School of Nursing, and went on to
complete her supplemental baccalaureate nursing degree at St.
Paul College in Manila. She completed her graduate studies at
the University of the Philippines, College of Nursing (UPCN) and
received her Master of Arts in Nursing in 1975, a Master of
Science in Counselor Education in 1979, and Doctor of
Education, Guidance and Counseling in 1985 (both from UP).
She is also a Consecrated Lay Woman, Member of the Notre
Dame de Vie Secular Institute. She is a former member of the
Professional Regulations Commission’s Board of Nursing and
currently a Professor Emerita of the UPCN. She continues to
serve as a Consultant to various schools in the development or
revision of curricula or programs related to Gerontology, Neuro-
Psychology, Counseling, and Bioethics.
PJN VOL. 88 | NO. 1
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FEATURE ARTICLE

THEORY OF COMMITMENT AND CARE

Frances Gay L. Pia, RN, MAN, PhD1

Abstract
Commitment has been associated with quality nursing care because it contributes to the understanding of finding meaning and value of
work. This article describes the Theory on Commitment and Care in Nursing that focus on how the nurses' commitment in an
organization affects the nursing care they are providing to the patients. The factors that affect a person's commitment are job
satisfaction, work autonomy, trainings, working environment conditions, pay and benefits, investments, retirement plans, obligations,
return service. These factors play a vital role in the commitment of nurses and thus, reflect on the delivery of the nursing practice to the
patients. The model shows the framework and the relationship of the internal factors inside the workplace that influence the quality of
patient care. It presents how these internal factors could strengthen or weaken the nurses' commitment to patient care. This
commitment propels the nurse to achieve his/her goals in the nursing process.

Keywords: Theory of commitment and care in nursing, commitment and care in nursing model

The Theory of Commitment and Care in Nursing

Description

T he Theory on Commitment and Care in Nursing is focused on

how the nurses' commitment in an organization affects the
nursing care they are providing to the patients. The factors that
affect a person's commitment are job satisfaction, work
autonomy, trainings, working environment conditions, pay and
benefits, investments, retirement plans, obligations, return
service. These factors play a vital role in the commitment of
nurses and thus, reflect on the delivery of the nursing practice to
the patients.
Classification by Abstraction
The theory of Commitment and Care in Nursing is a middle range
theory that is comprised of relatively concrete concepts that are
operationally defined and relatively concrete propositions that
may be empirically tested (Whall, 2005). In explaining this middle
range theory, Fawcett (2000) said that it may be (1) a description
of a particular phenomenon, (2) an explanation of the relationship
between phenomena, or (3) a prediction of the effects of one
phenomenon or another. Moreover, many investigators favored
working with propositions and theories characterized as middle
range rather than with conceptual frameworks because they
provide the basis for generating testable hypotheses related to
particular nursing phenomena and to particular client populations
(Chinn & Kramer, 2008).
Theoretical Underpinning
The Theory of Commitment and Caring in Nursing is grounded
mainly on Nursing as Caring (Boykin & Schoenhofer, 2001).
Nursing as Caring is anchored on the fundamental assumptions
that (1) to be human is to be caring and (2) the activities of the
discipline and profession of nursing in coming to know persons as
caring and nurturing them as persons living and growing in caring
(Tomey&Allingood, 2006).
Furthermore, nursing as caring gives emphasis on the
fundamental idea that all persons are caring; that to be a human
means to be caring; and that being a person is living in caring.
This means to say that caring is innate to an individual and that a
person lives their lives growing into the capacity of caring. It also
suggests that a person should have an environment that radiates
a sense of nurturing atmosphere, which helps an individual grow
in caring while revealing the richness of nursing (Boykin &
Schoenhofer, 2001).
Philosophical Basis
The theory of commitment and care in nursing is anchored on
historicism's point of view that is derived from collective lived
experiences, interrelatedness, human interpretation, and learned
reality, as opposed to artificially invented reality (Rutty, 1998). It is

1 Correspondence: Capitol University Medical Center at Cagayan de Oro City; Email: fglpla@yahoo.com

PJN VOL. 88 | NO. 1


the pursuit of knowledge and truth that is naturally historical,
contextual, and value-laden. In this theory, actual experiences of
the nurses in giving care to the patients and how their
commitment affects these interventions in the healthcare setting
are considered.
In addition, the theory on commitment and care in nursing views
nursing in a human science perspective (Cody & Mitchell, 2002).
In human science, knowledge takes the form of descriptive
theories regarding the structures, processes, relationship and
tradition that underlie psychological, social and cultural aspects
of reality (Gortner, 1993). This theory gives value to the lived
experiences of the nurses who provide nursing care to the
patients. It also seeks to understand the relationship of the
nursing care given to the patients and the commitment of the
nurses in the healthcare setting.
Assumptions of the Theory
The theory of Commitment and Care in Nursing is grounded in
several key assumptions. These assumptions are:
1. Human beings by nature are caring and nurturing;
2. Persons are caring by virtue of their humanness
(Boykin & Schoenhofer, 2001);
3. Nurses who feel that they are cared for by their
organization provide better care;
4. The humanitarian perspective of a person being
respected and treated fairly reflects on the nursing care;
5. Commitment influences quality nursing care.
Paradigmatic Perspective
To represent a worldview and to provide a frame of reference for
the construct of the nursing theory, the theory of Commitment and
Care in Nursing is clustered within the perspective of interactive-
integrative paradigm that is, humans are viewed as systems with
interrelated dimensions interacting with the environment
(Newman et al., 1991). The interactive-integrative paradigm by
Newman, Sime & Corcoran Perry (1996), includes experiences
and subjective data, multiple interrelationships that are
contextual and reciprocal exists between phenomena. It
considers context and experiences from subjective perspective
as a means of understanding the interrelated nature of the
properties of phenomena.
Increasingly, nurses are practicing in diverse settings and often
develop organized nursing practices through which accessible
healthcare to communities can be provided (Parker & Smith,
2010). Through this, nurses develop a lens which is essential for
a complete picture of the person's health and the goals of caring
and healing (Parker & Smith, 2010). The development of the
theory of Commitment and Care in Nursing will provide this lens
and will guide nursing through its unique contribution to the
interdisciplinary team. In this theory, internal factors in the work
environment such as job satisfaction, training and development,
work autonomy, pay and benefits, investments, obligation and
47
JANUARY-JUNE 2018
return service, influence the level of commitment of the nurse
practitioners in the healthcare setting. These elements contribute
profoundly to the delivery of care to the patients.
Metaparadigm of Nursing
The central concepts of the discipline of nursing are person,
environment, health and nursing. These four concepts of the
metaparadigm of nursing are more specifically “ the person
receiving the nursing”, the environment within which the person
exists, the health-illness continue within which the person falls at
the time of the interaction with the nurse and finally, “nursing
actions themselves” (Fawcett, 1994). The following are the
metaparadigm concepts as defined by the theory of Commitment
and Care in Nursing:
1. Person: The individual needing the nursing care for the
improvement of his/her condition. The person is reliant
and dependent on the individual giving the nursing care.
2. Nursing: A career and a professional discipline. Nursing
focuses on caring for patients in a holistic approach. The
theory also gives importance to caring as the vital part in
the process of giving the care needed by the patient
based on the commitment of the nurse.
3. Health: An overall condition of a person that is
influenced by biological, psychological, sociological and
external stimuli. Health is affected by predisposing and
precipitating factors of a person.
4. Environment: The external factor that greatly affects the
holistic wellbeing of the patient. It is considered as the
physical condition of a place or setting.
The nurse referred to in this theory is someone who is a
professional, licensed individual, who shows, provides and gives
nursing care to the patient depending on their commitment, which
in turn is affected by internal factors, such as pay and benefits,
work autonomy, working conditions, return service, and
obligation. The theory refers to nursing as the care of the
physically, mentally ill, emotionally disturbed and disabled
individuals of all ages in the healthcare realm. The delivery of the
nursing care may vary based on the commitment of the individual
who provides care to the patient as influenced by the internal
factors in the organization.
In this theory, nursing is practiced based on the nursing process
namely assessment, planning, implementation and evaluation.
These processes utilize a systematic, holistic and organized
approach in partnership with the patient and their family. Nursing
occurs when patients are admitted in the healthcare facility.
Nurses provide the complete care for a group of patients
throughout their stay in a hospital unit or department. For the
duration of a patient's episode of care, the primary nurse accepts
responsibility for the nursing process and coordinates all aspects
of the patient's nursing care.
Nursing occurs in the healthcare facility. It is in general, any
location where healthcare is provided including hospitals, publicly
PJN VOL. 88 | NO. 1
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JANUARY-JUNE 2018
or privately owned and operated by the government or
corporations. It could be in the different units of the healthcare
facility namely: Emergency Room, General Wards, Medical-
surgical Ward, Pediatric Ward, Obstetrics and Gynecology ward,
Intensive Care Units, Operating Room, Hemodialysis Unit,
Chemotherapy Unit.
Lastly, it plays a vital role in providing care and addressing the
needs of the patients. Nursing encompasses nursing processes,
which includes: physical assessments, health histories, drug
administrations, wound care, health teachings and education,
coordination of different health teams and being advocates to the
patient. These processes enhance and improve the underlying
condition of the patient and eventually promote healing to the
patient.
Theoretical Model
Below is an illustration of the theoretical model of Commitment
and Care in Nursing. A description of the model and its variables
is given and explained.
Description
The model shows the framework and the relationship of the
internal factors inside the workplace that influence the quality of
patient care. It presents how these internal factors could
strengthen or weaken the nurses' commitment to patient care.
These factors identified in the workplace significantly affect the
commitment of the nurse in his/her job. This commitment propels
the nurse to achieve his/her goals in the nursing process.
The first group of internal factors consist of job satisfaction, work
autonomy, training and development, working environment
condition have significant effects on the nurses' sense of
commitment. Job Satisfaction refers to the extent to which a
person's hopes, desires, and expectations about the employment
he is engaged with are fulfilled. Work Autonomy means the ability
of the nurse to control his/her work situations and to allow a great
PJN VOL. 88 | NO. 1
Commitment and Care
in Nursing Model
Figure 1. Theoretical Model of Commitment
and Care in Nursing.
deal of freedom to make choices in the workplace. Training and
Development refers to the activities that aims at improving the
competency and performance of the nurses in the hospital.
Working Environment Condition describes the surrounding
conditions in which the nurse operates and works. It could be
composed of the physical conditions such as temperature,
equipment, materials and resources.
These factors play a significant role in predicting the patient care
of nurses. An organization with a greater number of satisfied
nurses with adequate freedom and considerable liberty and
choices, adequate training and continuing education has the
tendency to be more effective and efficient in the delivery of
nursing care. Moreover, working environment conditions such as
working area lighting and temperature, availability of resources
needed for patient care is also considered as a vital variable in
establishing nurses' commitment on the workplace.
The second group, pay and benefits and investments are also
integral in shaping commitment to the job. Pay and Benefit refers
to wages, salary, gifts, privileges, perks that the nurse receives in
the healthcare setting. It is believed that providing high pay and
benefits could lead to higher commitment, while investment
refers to the money, time, effort that the nurse established in the
hospital for a certain length or period of time.
For instance, nurses who are compensated well are greatly
encouraged to do more. High pay and good benefits will provide
and help meet the daily needs of the nurses. This is also an
indication of how much the hospital values their nurses. In
addition, if nurses have invested a lot of their effort and time to the
hospital, this will propel nurses to stay longer in the hospital.
The third group contains obligations and return service.
Obligation is described as something that the nurse must do
because of a law, rule or promise that he/she is legally bound to
do; on the other hand, return service is defined as the act of a
nurse to repay or recompense through additional years of service
in the hospital due to the company's investment on the nurse.
(turn to page 50)

NURSES’ VOICE FROM THE FIELD
WHEN ENOUGH IS ENOUGH
Hazel Vera D. Tan, RN1
The Hospital— known to safeguard people's health. Isn't it ironic that the facility obliged
to look after man cannot even take care of its own people?
I t is daunting to see that nursing, a skillful profession, is
perceived being composed of subservient individuals. While
nurses comprise the majority of the healthcare team, they are
voiceless and powerless. A good example of this is how nurses
are used as “cover-ups” and held solely responsible for being
inefficient and negligent whenever errors are committed.
Whereas inaccuracies and errors made by physicians are rarely
pointed out or brought attention to. Nurses are viewed by the
public as merely followers of physicians. Rather than forming
collegial relationships with physicians, nurses are expected to
carry-out and follow orders without question. Nurses are
considered nothing more than a physician's subordinates.
The struggle of changing the image of nurses as submissive
professionals is challenging. Despite nurses asserting their
rights, penetrating and spearheading government sectors, and
creating game-changing policies for nurse's welfare, nurses as a
whole stile remain powerless due to many groups that hinder
their progress.
Adding insult to injury, healthcare institutions, where majority of
nurses are working, are their prime exploiters. Nurses are taken
advantage of, abused, shamed, and slaved. They are confronted
with various unjust labor practices that are not addressed by
most institutions. They have to go on forced overtime or unpaid
overtime. While the law states that employees have to render 40-
48 hours a week, nurses go beyond 60 hours work time. Their
lives do not end inside the four walls of their workplace. How
much time do they still have to do things outside of their work? In
some institutions, nurses have to pay first their training before
they can be hired. However, paying and undergoing the said
training doesn't give assurance that they will be employed. There
are those who are on contractualization status or job orders, and
thus, cannot enjoy the non-monetary benefits they should be
enjoying when they are tied up with the institution. Nurse bullying
and shaming are ubiquitous. They are shamed incessantly by the
managers, supervisors, doctors, and the administrators
themselves. The administrators, who receive the grievances of
nurses, sugar-coats their indirect sanctions to “erring” nurses by
1 Correspondence: Staff Nurse, University of Santo Tomas Hospital, España, Manila; hvdtan18@gmail.com
49
either transferring them to different areas or bully them verbally at
workplace. What's worse than all these? The unjustifiable nurse-
patient ratio that is based on quantity of patients rather than on
nursing workload. There are instances where 1 nurse have to
cater to 1 whole unit with a bed capacity of 20 to 30 to 50. Even
more devastating, nurses are sorely underpaid (below minimum
wage salary). There are nurses who receive a salary amounting
to 250-550php per day. There are also those who receive their
salaries after a month or so.
Nurses are being treated like mere laborers… robots…
dispensable employees. Their work-life balance? Non-
existence. Their compensation? Insultingly low. But still, they are
given no other option but to chew on these yolks in the hopes that
they will one day reach greener pastures. Sadly enough, the
greener pastures they aspire are the opportunities offered
abroad. To blame them for leaving their country for such hopes
would be unfair to them. In other countries, nurses are better
compensated and treated justly despite working with the same
rigors they endure here. What the employers are taking for
granted of— overworking, underpaying, and un-appreciating
nurses impact the quality of healthcare services they provide.
Nurse's work performances can be affected if they are not resting
well enough, are not included in decision making, feel like they
are not part of the company, unempowered, and treated as
dispensable laborers. Increasing the workloads of nurses result
in increased anxiety and stress levels, leading to burnout. A
burnout nurse with plenty of patients to take care of will result in
failure to rescue them on time and increase sentinel events.
If their mission, as an institution, is to serve people by giving the
best quality of health care, aren't nurses people as well? Before
they can give their best service to the patients, they have to take
care of their own employees— their nurses and other healthcare
practitioners. Thus, institutions not only violate the dignity of
nurses, but also their mission to serve patients with utmost care.
This modern-slavery has to end! Enough of tolerating all these
insults to the profession. Nurses are great in numbers. Unitedly,
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JANUARY-JUNE 2018
smaller voices become bigger voices that can change and rattle
the people in power. Just as Martin Luther King, Jr. said “Our lives
begin to end the day we become silent about things that matter.”
With this, nurses should start breaking their silence, and let their
voices be heard. It's about time that nurses become actively
involved in speaking up for their profession. Small solutions if
clustered together become more effective solutions. Nurses can
start airing their angst through the Philippine Nurses Association,
the organization tasked to help protect their welfare. Enough of
just rants… Be part of the solution… Be actively involved on the
matters that will improve the profession… Be the change!
ABOUT THE AUTHOR
Ms. Hazel Vera D. Tan RN, a nurse by
profession and a writer by vocation, obtained
her baccalaureate degree in Nursing at the
University of Santo Tomas (UST) College of
Nursing in 2014. She is taking up her master's
degree in nursing at the same university where
she graduated. Currently, she works as a staff nurse. And in her
free time, she participates in various advocacy campaigns and
volunteer works, and manages to watch Netflix series.
- Donna Wilk Cardillo
PJN VOL. 88 | NO. 1
Theory of Commitment and Care...(from page 48)
These two factors significantly affect the nurses'
commitment because of the investment that the hospital
spent for them. This will create a feeling of the need to stay
and reciprocate because of the privileges the hospital has
given to the nurse. If the nurses' needs are met through the
fulfilment of these factors, then the nurses will surely have
greater commitment to the job, better work performance
and enhanced motivation. However, failure to meet these
needs by the institution they are working for would
dishearten nurses and lead to less commitment and low
work performance in delivering patient care.
..........................
References
Boykin, A., & Schoenhofer, S. (2001). Nursing as caring: A model
for transforming practice. Sudbury, England, MA: Jones &
Bartlett.
Chinn, P. L., & Kramer, M. K. (2008). Theory and nursing:
Integrated knowledge development. St. Louis, Toronto,
London: C.V. Mosby.
Parker, M. & Smith, M. (2010). Nursing theories and nursing
practice. Philidelphia, PA: F.A. Davis Company.
Tomey, A.,M., & Alligood, M.,R., (2006). Nursing theorists and
their work. 7th ed. Missouri, MO: Mosby Elsevier
Publication.
Whall, A., & Hicks, F. (2002). The unrecognized paradigm shift in
nursing: Implications, problems and possibilities.
Philidelphia, PA: F.A. Davis Company.
ABOUT THE AUTHOR
Dr. Frances Gay Pia is an Assistant
Nursing Director of Capitol University
Medical Center at Cagayan de Oro
City. She received her BSN at Capitol
University, her Masters of Arts in
Nursing at Xavier University (Ateneo
de Cagayan) then eventually achieved her PhD in
Nursing at Silliman University. She worked as an ICU
Nurse for five years in CUMC then pursued a career as an
Infection Control Practitioner in Prince Sultan Military
Medical City, Kingdom of Saudi Arabia for 2 years. She is
a member of the Sigma Theta Tau Psi Beta Chapter an
international honor society in nursing. Her dissertation
focused on the lived experience of violence among
migrant Filipino nurses in the workplace.
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