IMPROVING PRACTICE

Factors influencing evidence-based

practice among community nurses
Kate Gerrish, Jo Cooke
Hospital nurses tend to rely
Nurses working in the community may have insufficient time to access, heavily on informal, interactive
interpret and apply research, and, therefore, need information to be sources of evidence (Spenceley et
presented in a format that is easily accessible. As community nurses al, 2008), but little is known about
rise to the challenges outlined in recent health policy, it is increasingly community nurses use of different
important that they maximise their potential to deliver evidence-based sources of evidence. The survey
practice. This article looks at a survey that aimed to identify factors reported in this article seeks to
influencing evidence-based practice among community nurses. The address this gap in knowledge.
findings indicate that in order to make progress it is important to adopt
a multifaceted approach, taking into account the real world in which AIM
nurses currently practice. While it is important to develop nurses skills
in accessing and reviewing research information, constraints on time The aim of this survey was to identify
mean that it will be difficult to achieve a nursing workforce where all factors influencing evidence-based
nurses are active in reviewing research evidence. practice among community nurses.

METHODS
KEYWORDS:
Evidence-based practice Research Practice development A postal survey was sent to
community nurses across six
primary care trusts (PCTs) in South

D
espite the importance of Experience a lack of organisational Yorkshire. The questionnaire was
nursing practice being based support and/or unsupportive a validated instrument (Gerrish et
on robust evidence, nurses colleagues. al, 2007), which sought to identify
encounter considerable challenges to factors influencing the development
achieving evidence-based practice at an Nurses working in the community of evidence-based practice. These
individual and an organisational level may encounter similar problems. factors included:
(Bryar et al, 2003; Gerrish et al, 2008). They can lack the knowledge and Sources of knowledge that
One study examining barriers to using skills to use research findings to nurses use to inform their
research evidence in clinical decision- inform their decision-making, have practice
making (McCaughan et al, 2002) insufficient time to access, interpret Perceived barriers to finding
identified that hospital nurses may: and apply research and, therefore, and reviewing research and
Be willing to use research but lack need research information to be organisational information
the skills to do so presented in a format that is easily Perceived barriers to changing
Encounter problems with accessible with the implications for practice based on best evidence
interpreting research publications, practice made clear (Thompson et al, Perceived factors that facilitate
which are seen to be too complex 2005). Nurses can also find it hard to nurses to provide evidence-
Perceive that research publications use research evidence to influence based practice
lack clinical credibility and fail to changes in primary care (McKenna et Self-assessment of nurses skills
provide sufficient clinical direction al, 2004). in finding, reviewing and using
Prefer to access research-based different sources of evidence.
information through a third party While research findings are an
rather than seek it out important source of evidence, expert The sample included district
for themselves clinical opinion, organisational nurses, community nurses, practice
information and patient preferences nurses, health visitors and school
are additional forms of evidence that nurses. Questionnaires were
Kate Gerrish, Professor of Nursing Research, nurses use in practice (Bucknall and distributed to a random sample from
University of Sheffield/Sheffield Teaching Hospitals
NHS Foundation Trust, School of Nursing and Rycroft-Malone, 2010, Gerrish, 2010). each group in each PCT. Responses
Midwifery; Jo Cooke, Programme Manager Most studies to date have focused were coded for computer analysis
NIHR Collaborations and Leadership in Applied on nurses use of research, however, and statistical testing was performed
Health Research and Care for South Yorkshire
(CLAHRC SY), Sheffield Teaching Hospitals NHS there is a need to understand how using SPSS (Statistical Package for
Foundation Trust nurses use other sources of evidence. the Social Sciences).

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 IMPROVING PRACTICE

and 3) and training and conferences

Table 1: Respondents by nursing group (ranked 4) were also often used.
Nursing group Number of responses % of sample Response rate
District nurses 68 20.2% 47.5 Knowledge gained from
Community nurses 77 22.8% 46.9 colleagues, including senior nurses
(ranked 6), fellow practitioners
Health visitors 72 21.4% 44.7
(ranked 7), and doctors (ranked 9) also
Practice nurses 67 19.9% 37.6 featured prominently. Less frequently
School nurses 53 15.7% 42.0 used sources of knowledge included
Total 337 100% journal articles, textbooks, the internet
and pharmaceutical literature.

Table 2: Sources of knowledge used to inform practice BARRIERS TO REVIEWING

Rank order Source of knowledge Mean score RESEARCH AND INFORMATION
1 Information that I learn about each patient/client as an individual 4.41
This section of the questionnaire asked
2 Information I get from local policy and protocols 4.25 nurses to rate the extent to which 10
3 Information I get from national policy initiatives/guidelines 4.13 items concerned with finding and
4 Information I get from attending in-service training/conferences 4.09 reviewing research and organisational
information were perceived to be
5 My personal experience of caring for patients/clients over time 4.03
barriers to evidence-based practice.
Information senior clinical nurses share, e.g. clinical nurse specialists, Each item was scored on a five-point
6 3.88
nurse practitioners
scale against the statement, ranging
7 Information my fellow practitioners share 3.71 from strongly agree (score 1) to
8 Information I learned in my training 3.53 strongly disagree (score 5). The extent
9 What doctors discuss with me 3.5 to which nurses perceived different
10 Articles published in nursing journals 3.46
items to be a barrier is reflected in the
mean scores. These scores, ordered
11 Information I get from local audit reports 3.38
from the greatest to the least barrier,
New treatments and medications that I learn about when doctors are shown in Table 3.
12 3.27
prescribe them for patients
13 My intuitions about what seems to be right for the patient/client 3.19 The greatest barriers to nurses
14 Information in textbooks 3.13 accessing and reviewing evidence-
15 Articles published in research journals 3.06 based information relate to time and
their skills in judging the quality of
16 Articles published in medical journals 3.04
information. Nurses were generally
17 Information I get from the internet 3.02 more confident about where to
18 Information I get from pharmaceutical or equipment literature 3.01 locate protocols and organisational
19 What has worked for me for years 2.9 information. Research information
Medications and treatments I gain about/from pharmaceutical or
appeared to be more difficult to find.
20 2.61
equipment company representatives
Identifying implications for
21 The ways that I have always done it 2.43
practice was less of a barrier for nurses
22 Information I get from the media (e.g. popular magazines, television) 2.13 in both research and organisational
information. These observations
FINDINGS extent to which they used 22 different highlight the need for strategies
sources of knowledge to inform their that ensure that evidence-based
Of the 766 questionnaires distributed, practice by rating them on a five-point information is readily available to
337 were returned giving an overall scale, ranging from never (score 1) to nurses in a format that is easy to
response rate of 44%. Respondents always (score 5). The frequency with understand and which includes
were evenly distributed across the which nurses used various sources of an indication of the quality of
nursing groups (Table 1). The sample knowledge is reflected in the mean the research.
comprised 331 (98.2%) women (average) scores for each item. These
and 6 (1.8%) men, of which 48.1% scores, ordered from most to least BARRIERS TO CHANGING
(162) worked full time, and 51.6% frequent use, are shown in Table 2. PRACTICE
(175) part time. The average age of
respondents was 44.3 years (range Nurses drew most frequently on Nurses were asked to rate the extent
2366 years). experiential sources of knowledge to which they encountered barriers
gained through interactions with in using evidence to change practice.
SOURCES OF KNOWLEDGE patients (ranked 1 and 5). Workplace Items were scored on a scale of 1
sources of knowledge such as (strongly agree) to 5 (strongly
Nurses were asked to identify the protocols and guidelines (ranked 2 disagree). The mean scores, ordered

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 IMPROVING PRACTICE

Nurses felt most skilled at finding

Table 3: Barriers to finding and reviewing information information from the internet and
Rank order Barrier Mean score the library. The areas where nurses
1 I do not have sufficient time to find research reports 2.49 perceive themselves as less skilled
2 I do not feel confident in judging the quality of research reports 2.96 (novice/complete beginner) related
to finding, reviewing and using
3 Research reports are not easy to find 3.03
research evidence.
4 I find it difficult to understand research reports 3.14

5
I do not have sufficient time to find organisational information (guidelines/
3.20
IMPLICATIONS FOR PRACTICE
protocols, etc)
I find it difficult to identify the implications of research findings for my This study highlights that nurses use a
6 3.37
own practice range of information sources to inform
I find it difficult to identify the implications of organisational information their practice, including patients,
7 3.50 protocols, experience, in-service
for my own practice
8 Organisational information (protocols, guidelines etc) is not easy to find 3.69 training and conferences. Face-to-face
discussions with colleagues were
9 I do not know how to find appropriate research reports 3.72
also a highly used source of
I do not know how to find organisational information (guidelines, knowledge. Nurses used journal
10 4.18
protocols, etc) articles less frequently than other
sources of knowledge.
Table 4: Barriers to changing practice
While barriers to finding and
Rank order Barrier Mean score
reviewing information existed, those
1 There is insufficient time at work to implement changes in practice 3.00 to changing management and practice
2 There are insufficient resources (i.e. equipment) to change practice 3.09 were less evident, with most nurses
3 I lack the authority in the work place to change practice 3.75 feeling that they had the authority and
confidence to instigate such changes.
4 I do not feel confident about beginning to change my practice 3.95
5 The culture of my team is not receptive to changing practice 3.97 The greatest barrier to evidence-
based practice was lack of time.
from the greatest to the least barrier, scale was used to judge the degree Nurses also lacked confidence in
are shown in Table 4. of support ranging from always finding research evidence, reviewing
supportive (score 1) through to it, and judging its quality, with over
The findings highlight how time never supportive (score 5). The mean 40% feeling that they were at the level
is a major constraint in achieving scores, ordered from the greatest to of a complete beginner/novice. High
evidence-based practice. Lack the least lack of support, are shown levels of skills were reported around
of resources is also problematic. in Table 5. These findings indicate that using the internet, even though it was
Barriers to changing practice community nurses generally work in rated low in terms of being a source
were less problematic than those an environment where colleagues, of evidence. These findings indicate
relating to finding and reviewing managers and doctors are supportive that strategies to promote evidence-
information, indicated by the higher of changing practice. based practice should consider the
mean scores (higher score = less of constraints that community nurses
a barrier). USING DIFFERENT SOURCES OF are working under, and ensure that
EVIDENCE TO CHANGE PRACTICE evidence-based information is readily
Transferring these figures to the available and the implications for
percentage of nurses who perceived Nurses were asked to rate how practice made clear.
these items a barrier highlights that experienced they were in finding,
the workforce is quite empowered. reviewing and using different sources Care protocols and guidelines were
Only 5% of the sample agreed that of evidence to change practice using a frequently used by nurses. Therefore,
lack of confidence was a barrier; 8.6% 5-point scale ranging from complete it is important that these are based
agreed that the culture of the team beginner to expert. The percentage on the best available evidence and
was a barrier to changing practice; and of nurses falling into each category is regularly updated, as new evidence
13.2% thought that lack of authority shown in Table 6. becomes available.
was a barrier.
Table 5: Facilitators to changing practice
FACILITATORS TO
CHANGING PRACTICE Rank order Facilitator Mean score
1 Nursing colleagues are supportive of my changing practice 2.23
This section of the questionnaire 2 Nurse managers are supportive of my changing practice 2.41
examined the extent to which nurses
3 Practice managers are supportive of my changing practice 2.67
perceived other staff to be supportive
of changing practice. A 5-point 4 Doctors with whom I work are supportive of my changing practice 2.71

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Table 6: Skills appraisal KEY POINTS

Skill rating Complete Quite skilled Competent/ It is increasingly important that
beginner/novice expert
community nurses can deliver
% % % evidence-based practice.
Using the internet to search for information 25.1 29.6 45.3
A pragmatic approach is needed,
Using the library to locate information 22.6 36.6 40.8 whereby those nurses working
Finding organisational information 22.6 41.4 36 in the community are enabled to
Using organisational information (policies / access research-based guidance.
24.6 41.7 33.7
guidelines, etc) to change practice
Due to the multiple locations of
Reviewing organisational information 27.2 42.5 30.3 community nurses, the internet
Reviewing research evidence 34 35.8 30.2 is a useful source of information.
Using research evidence to change practice 35 35.9 29.1
Finding research evidence 40.7 33.8 25.5 Department of Health/Public Health Nursing
(2013) Care in Local Communities: a new
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