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

98 JCN 2013, Vol 27, No 4

 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

JCN 2013, Vol 27, No 4 99

 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

100 JCN 2013, Vol 27, No 4


Table 6: Skills appraisal
Skill rating
beginner/novice
Using the internet to search for information
Using the library to locate information
Finding organisational information
Using organisational information (policies /
guidelines, etc) to change practice
Reviewing organisational information
Reviewing research evidence
Using research evidence to change practice
Finding research evidence
Some community nurses are
more skilled than others at finding
and appraising research evidence.
However, there is a need for more
nurses to develop expertise in
appraising evidence and in using
evidence to develop protocols, care
pathways etc, and implementing
change in practice. Nurses in
advanced practice roles, such as
clinical nurse specialists and nurse
consultants, have an important role
to play in promoting evidence-based
practice (Gerrish et al, 2011a,b). It is
important that they have the requisite
knowledge and skills to facilitate
learning among community nurses.
Accessing knowledge using the
internet is becoming increasingly
important. The majority of nurses
felt they were competent at finding
information on the internet, although
this was ranked relatively low as a
source of information for practice.
Community nurses, therefore, need
to be aware of evidence-based
resources such as those supported by
the National Institute for Health and
Clinical Excellence (NICE) and Social
Care Institute for Excellence (SCIE),
in producing quality appraised
research briefings.
CONCLUSION
As community nurses rise to the
challenges outlined in recent health
policy (Department of Health
[DH], 2011; 2013), it is increasingly
important that they maximise their
potential to deliver evidence-based
practice. The findings from this
survey indicate that to make progress
with evidence-based practice, it is
Complete Quite skilled Competent/
expert
% % % evidence-based practice.
25.1 29.6 45.3
22.6 36.6 40.8
22.6 41.4 36
24.6 41.7 33.7
27.2 42.5 30.3
34 35.8 30.2
35 35.9 29.1
40.7 33.8 25.5
important to adopt a multifaceted
approach, considering the real world
in which nurses currently practice.
While it is important to develop
nurses skills in accessing and
reviewing research information,
constraints on time mean that it
will be difficult to achieve a nursing
workforce where all nurses are active
in reviewing research evidence.
A pragmatic approach is needed,
whereby those nurses working in
the community are enabled to access
research-based guidance in the form
of up-to-date protocols and pathways,
through in-service training, and their
interactions with senior clinical nurses.
Due to the multiple locations
of community nurses, the internet
is a useful source of information,
which needs investment in terms of
developing nurses skills in retrieving
online evidence. It is also crucial that
the environment in which nurses work
is receptive to change. JCN
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IMPROVING PRACTICE
KEY POINTS
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