- Email: [email protected]
Building evidence-based practice with staff nurses through mentoring
Journal of Neonatal Nursing (2009) 15, 81e87
www.elsevier.com/jneo
Building evidence-based practice with staff nurses through mentoring Kathleen DiGaudio Mariano a,*, Linda M. Caley b, Linda Eschberger c, Ann Woloszyn d, Patricia Volker e, Michael S. Leonard f, Ying Tung g a
D’Youville College, 320 Porter Ave., Buffalo, NY 14201, USA State University of NY at Buffalo, 3211 Main St., Buffalo, NY 14214, USA c Kaleida Health, Women & Children’s Hospital, Nurse Manager NICU, 219 Bryant St., Buffalo, NY 14222, USA d Winnie Palmer Hospital, Women’s & Children Division, Orlando, FL, USA e Kaleida Health, Women & Children’s Hospital, 219 Bryant St., Buffalo, NY 14222, USA f University of Rochester Medical Center, 601 Elmwood Ave., Box 667, Rochester, NY 14642, USA g Kaleida Health, WCHOB Foundation, Office of Health Research, 1260 Delaware Ave Buffalo, NY 14209, USA b
Available online 8 February 2009
KEYWORDS Evidence-based practice; Mentoring; Nursing
Abstract Evidence- based practice (EBP) is an effective way for nurses to improve patient outcomes. Although EBP has gained popularity, barriers to implementation exist. This study explored whether mentoring neonatal intensive care unit (NICU) nurses in EBP would increase their participation in EBP. A sample of 20 nurses were mentored in an EBP project. The EBP Beliefs Scale and EBP Implementation Scale measured scores upon initiation and completion of the project. Statistical analysis showed no significant changes in nurses’ beliefs in EBP or implementation of EBP following mentoring. However, a moderate degree of correlation between changes in beliefs scores and implementation scores was seen with a borderline significance. Age and years of experience did significantly influence changes in EBP beliefs scores. Although the study results did not support that mentoring changed attitudes or utilization of EBP, changes in NICU were implemented as a result of the project activities. ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 716 829 7745; fax: þ1 716 829 8159. E-mail addresses: [email protected] (K. DiGaudio Mariano), [email protected] (L.M. Caley), [email protected] (L. Eschberger), [email protected] (A. Woloszyn), [email protected] (P. Volker), MichaelS_Leonard@URMC. Rochester.edu (M.S. Leonard), [email protected] (Y. Tung). 1355-1841/$ - see front matter ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2009.01.005
82
Introduction Evidence-based practice (EBP) has evolved as a model for delivering the best possible patient care by integrating research, clinical experience, and patient choice. Despite this known fact, clinical practice is often not based on recent research findings. Some barriers to inclusion of research are a lack of time, resources and understanding of the research process (Rutledge and Bookbinder 2002; Hallas and Melnyk, 2003). Pape (2003) describes additional barriers as (1) the shortage of consistent research results, (2) difficulties in applying findings to patient care, and (3) financial and other barriers to providing quality health care. Nurses’ attitudes can also deter use of research in practice decisions (Hicks et al., 1996). Hundley et al. (2000) found nurses with positive attitudes towards research and the nurses who participated in it still did not utilize research in actual clinical practice. These findings are consistent with our experience at a 200 bed pediatric hospital. Melnyk and Fineout-Overholt (2005) propose that an organizational culture change is needed to overcome barriers and facilitate EBP. In our hospital, we implemented organizational changes aimed at changing the culture to be supportive of EBP such as a Nursing Research Council, a web site, and continuing education programs. In spite of the organizational changes, actual inclusion of research in practice did not occur. Therefore, we decided to implement a mentoring program to enhance EBP. Historically, mentoring has been described in academic settings as a means for development of administrative and clinical leadership. Daloz (1999) defines mentors as ‘‘guides’’. Mentors see potential in their mentees helping to define and shape their goals and then provide the support and skills development to achieve the goals (Joel, 1997). In this study, mentoring was examined as a strategy to increase EBP by registered nurses in a clinical setting. Evidence-based practice (EBP) is considered the ‘‘gold standard’’ for patient care because it combines scientific knowledge, clinical expertise and patient choice. Evidence-based practice evolved from evidence-based medicine. Gordon Guyatt, a Canadian, first coined the term ‘‘evidencebased medicine’’ in 1992 (Sackett et al., 2001). Sackett et al. (2001: p. 1) defines evidence-based medicine as ‘‘the integration of best evidence with clinical experience and patient values’’. Evidencebased practice reflects the inclusive nature of health care and is the favored term.
K. DiGaudio Mariano et al. Despite the emphasis on this model, much of nursing practice today is based on the way nurses have historically taken care of patients. Burns and Grove (1999) reported nurses are often unaware or unwilling to read research journals and typically choose to practice the way they have always done things. In our experience at a tertiary care academic pediatric hospital in western New York, a research infrastructure designed to increase nursing research utilization and participation did not change clinical practice. The purpose of this pilot study was to examine the effect of mentoring in EBP on NICU nurses as measured by the EBP Belief and EBP Implementation Scale (Melnyk et al., 2008). The aim was to determine if mentoring could change nursing practice in the study setting by developing a group of nurses with expertise in EBP. By understanding the effect of mentoring on nurses’ participation in EBP, nurses can make an informed choice as to whether to employ mentorship to increase EBP in their clinical settings. This study was designed to answer the following research question: ‘‘Does mentoring nurses in EBP increase their beliefs about and participation in EBP?’’ The hypothesis of this pilot study was that mentorship in EBP increases nurses’ knowledge of the process, promotes positive attitudes towards EBP, and in turn promotes increased utilization of EBP. The two outcome measurements were: (1) increase in EBP beliefs scores and (2) increase in EBP implementation scores.
Theoretical framework The Stetler Model theory integrates EBP with research. Initially developed in 1976 (Stetler and Marram, 1976), it was updated in 1994 (Stetler, 1994), and revised in 2001 to reflect a practitioneroriented approach within the context of EBP (Stetler, 2001). The five phases of the Stetler Model include (1) preparation, (2) validation, (3) comparative evaluation and decision making, (4) translation and application, and (5) evaluation. The Stetler Model of Research Utilization (Stetler, 2001) is the research model that the Nursing Research Council of the hospital system utilizes to guide nursing research in the clinical setting. By following the series of critical-thinking steps in the Stetler Model, potential barriers among the staff nurses can be decreased thereby promoting use of current research findings to change clinical practice in the NICU. In this study, the first four phases of the Stetler Model were utilized. The evaluation phase is being completed informally.
Building evidence-based pratice with staff nurses
Methodology Design This was a descriptive study using a non-experimental pre- and post-test design that measured the effect of mentoring on EBP beliefs and practices. The intervention developed was based on a peer-mentored work group in which the nurse mentors partnered with the staff nurses. In a peermentored model, principles of effective group process are utilized to achieve mutually determined goals Colling et al. (1998). All group members have equal standing and the workload is equally shared. Decision-making is based on consensus. This method of mentoring provided the opportunity to share expertise and collaboratively develop and implement the EBP project in the NICU. Approval to conduct the study was granted by the University of Buffalo Health Sciences Institutional Review Board with exempt status.
Subjects A purposeful convenience sample of 20 NICU nurses who met the eligibility criteria completed the study. Registered nurses who worked in the NICU setting were eligible for this pilot project. The sampling was non-random and participation was voluntary. Data were collected in late 2005 and early 2006. Demographic information was collected pre-intervention describing the nurses’ age, gender, ethnicity, nursing education, nursing experience, and NICU nursing experience. The nurses were all female with 95% Caucasian (n ¼ 19) and 5% African American (n ¼ 1). Thirty percent (n ¼ 6) of the nurses had an Associate’s degree (AAS), 15% (n ¼ 3) had completed diploma programs, 30% (n ¼ 6) had a Bachelor’s degree (BSN), and 25% (n ¼ 5) had a Master’s degree. The mean for years of clinical experience was 18.95 (SD ¼ 8.24; median ¼ 19.50; range 3 e30); the mean for years of practice in an NICU setting was 16.95 (SD ¼ 8.65; median ¼ 18.5; range 3 e30). For the subjects who provided their ages (n ¼ 17), the mean was 42.18 years (SD ¼ 8.37; median ¼ 44; range 26 e58).
Consent Nurses were informed of the purpose and design of the study in a staff meeting. An information sheet was distributed that explained the study and informed the nurses that participation was voluntary. Completion and submission of the questionnaires by the nurses was considered an indication
83 of consent for participation. Therefore, additional written consent was not utilized.
Instruments and analysis In addition to demographic data, two validated survey instruments, the EBP Beliefs Scale and EBP Implementation Scale developed by Melnyk and Fineout-Overholt (2005) were used to measure nurses’ beliefs (attitudes) and their implementation of EBP, respectively. The EBP Beliefs Scale asked the nurses to rate agreement or disagreement with 16 statements about EBP on a five-point Likert scale. The results represent the nurses’ beliefs about the value of EBP. The EBP Implementation Scale provided 18 items for the nurses to rate the frequency with which they performed specific tasks on a scale of zero (not at all) to four (very often). The EBP Implementation Scale measures the degree to which EBP has been achieved. Recent research demonstrated high internal consistency and criterion validity for both instruments (Melnyk et al., 2008). Survey data were analyzed to determine whether mentoring nurses in EBP led to changes in scores for both scales. Data were analyzed with paired t-test and Pearson’s correlation. Regression analysis determined the effect of demographic factors on outcomes. All analyses were done using the Statistical Analysis Software (SAS, version 9.1) for Windows.
Procedure The primary author led the project under the direction of her mentor as a result of their participation in the MaternaleChild Health Leadership Academy sponsored by Sigma Theta Tau. In this study, Melnyk’s PICO process (Melnyk and Fineout-Overholt, 2002) was implemented to guide the evidence-based project (Table 1). Five nurse mentors who agreed to participate in the NICU project attended a presentation on EBP by Dr Bernadette Melnyk. The nurse mentors also attended a MaternaleChild Health Leadership workshop where the plan for the project was developed. The nurse mentors also had support from the medical librarian at the hospital. Communication among the nurse mentors as well as with the participating staff nurses was a priority. Strategies utilized included participation in staff meetings and posting study updates in the NICU on a regular basis. The staff nurses were interested in identifying the best nursing approach to working with families, since they often found discrepancies
84 Table 1
K. DiGaudio Mariano et al. Steps in the PICO process
Step one: problem
Step two: intervention
Step three: comparison
Step four: outcome
Parents’ perception of the severity of their infant’s illness
Potential interventions were identified from the literature. Example: develop a parent ‘‘buddy’’ system for peer support
Interventions were compared; four interventions were chosen to implement in NICU 1. Infant massage 2. Parent orientation video 3. Daily journal for each infant 4. Parent:buddy ‘‘system’’
Outcomes of the project were evaluated. Example: infant journals were implemented
Results Nurses’ beliefs about EBP were measured with the EBP Beliefs Scale, which has a possible score range from 16 to 80. In this study, the mean score was 53.90 (SD ¼ 3.45; median ¼ 54.0; range 47 e61) before mentoring, and 53.82 (SD ¼ 2.47; median ¼ 54.0; range 48 e58) after mentoring (Fig. 1). Nurses’ performance of EBP was measured with the EBP Implementation Scale, which has a possible score range from 0 to 60. As indicated in Fig. 2, the mean score was 12.02 (SD ¼ 10.53; median ¼ 8.86; range 0 e34) before mentoring, and 13.86 (SD ¼ 11.66; median ¼ 9.5; range 1 e 42) after mentoring. Two primary outcome measurements were used to test the hypothesis that mentoring nurses in EBP would increase attitudes and practice of EBP in the NICU: (1) increase in EBP beliefs score and (2) increase in EBP implementation score. A significance level of 0.05 was used for all statistical analyses. The paired t-test results showed no significant increase in either EBP beliefs score (mean ¼ -0.08; SD ¼ 2.89; median ¼ 0; range: 9 to 4; p ¼ 0.90) or EBP implementation score (mean ¼ 1.84; SD ¼ 11.88; median ¼ 3; range 21 to 29; p ¼ 0.50) through mentoring. The Pearson correlation coefficient (r ¼ 0.39; p ¼ 0.092) indicated a moderate degree of correlation between changes in beliefs scores and changes in implementation scores with a trend toward significance. The positive correlation pattern is depicted in the scatter plot in Fig. 3.
Demographic factors under consideration for the regression analysis were age, gender, race, and highest degree in nursing, years of clinical experience and years of NICU experience. Subjects who provided age information (n ¼ 17) were included in this analysis. From the results of regression analysis, none of the above demographic factors showed significant influence on the score increase in EBP implementation. However, age (b1 ¼ 0.28; p ¼ 0.028) and years of experience (b2 ¼ 0.37; p ¼ 0.006) were found to have significant influence on the change in EBP beliefs score. The EBP beliefs regression model predicts that the younger experienced nurse will demonstrate higher change in belief score as indicated in Fig. 4. The equation used for this graph is: score increase (EBP beliefs) ¼ 4.96 0.28 age (years) þ 0.37 clinical experience (years).
Study limitations The results of this study may not reflect the overall beliefs and practices of nurses in the NICU due to the small sample size. This clinical setting is specialized and demands a specific skill set in nurses. The longevity of the nurses in this setting and the average age may reflect a nursing staff that has had
80 70
EBP Beliefs Score
between the parent’s perceptions of their baby’s illness and the infant’s actual health status. Throughout the project, the mentors guided and worked in partnership with the staff nurses. The direction of the project was determined by decision-making by consensus of all participants. The workload was shared and all members had equal standing. The project was completed in 5 months.
60 50
53.9
53.82
Before Mentoring
After Mentoring
40 30 20 10 0
Figure 1 (n ¼ 20).
Statistical summary of EBP beliefs score
Building evidence-based pratice with staff nurses
85
Total number of questions: 15 Survey scale: 0 − 4 Possible range of total scores: 0 − 60
60
N = 20 = -1.84 p = 0.50
in EBP Beliefs
EBP Implementation Total Scores
15 10
Pre
Results and discussion Mentoring provided a positive atmosphere in which the nurse mentors worked closely with staff nurses and provided guidance in the EBP model. Staff nurses were appreciative of the credibility given to their experience and the opportunity to effect changes, and expressed the opinion that it was a worthwhile experience. The inability to demonstrate a significant change in EBP beliefs or implementation scores may be related to the limitation of the small sample size and lack of statistical
40
Score Increase in EBP Implementation
30 20 10 0 -10 -20
0
5
Score Increase in EBP Beliefs (N=20, r=0.39, p=0.092)
Figure 3 Scatter plot with regression line for score increase in EBP beliefs vs. score increase in EBP implementation (n ¼ 20).
s)
60 55 50 45 40 35 30 25
(y r
25
20
e's C
less exposure to EBP. Study findings also may not be generalized to other nursing populations.
-5
-15
Nurs
Post
Figure 2 Statistical summary of EBP implementation score (n ¼ 20).
-30 -10
-10
Ag e
0
-5
15
linica
l Exp
10
's
13.86
12.02
0
erien
5
se
15
Score Increase
30
5
0
ce (y
Nu r
45
rs)
Figure 4 Effects of nurse’s age and clinical experience on score increase in EBP beliefs. On this graph, the darker grey shadow refers to decrease in EBP beliefs score, and the lighter grey shadow refers to increase in EBP beliefs score (n ¼ 17).
power. The results of this study, however, did reveal a positive correlation between EBP beliefs and implementation scores, i.e. a higher amount of EBP beliefs score change is associated with a greater degree of EBP implementation score change. This finding is consistent with recent research demonstrating the increase in EBP strength of beliefs and EBP implementation by Melnyk et al. (2008). Therefore, it is critical to develop strategies to increase nurses’ belief in EBP. In this study, efforts were made to remove known barriers to EBP (Pravikoff et al., 2005; Hutchinson and Johnston, 2006). Nurses were provided with knowledge of literature searches, electronic resources, and analysis of the evidence by the nurse mentors. Efforts were made to provide time to complete the project. Resources were brought to the unit and mentors worked oneon-one with the participants. Further investigation into the barriers needs to be considered prior to initiation of future projects. Perhaps a more formal mentoring program would be beneficial. Because of the small sample size (n ¼ 17) for the regression analysis, the present study model for EBP beliefs score change can only be used as a preliminary one. In order to build a generalized model, a larger randomized sample will be required in future studies to reduce bias and provide more statistical power. Organizational culture has been described as critical for successful implementation of EBP (Stetler, 2003). Although the nurse leaders in the NICU and the administration were supportive of this project, it is possible that the participating nurses did not accurately
86 perceive this support. An analysis of the organizational culture could provide additional data that would identify any organizational barriers that need to be overcome, in order to institute a hospital wide approach to mentoring. Although study results showed mentoring nurses in EBP had a minimal effect on individual scores on EBP beliefs and implementation scales, significant process changes occurred in the NICU that may have been the result of the project. Practice changes based on literature findings and nurses’ clinical experience were proposed that were intended to improve patient outcomes and increase family support. One year after the study completion, positive changes have been integrated into the NICU setting. For example, a bedside journal detailing the infant’s progress has been developed and put into practice. This has improved communication with families and provides data about the infant’s condition. Educational discussions for families are being offered in the evening as an opportunity to meet and learn more about health issues in preterm infants. In the near future, parents of discharged NICU infants will begin rounds to meet parents who currently have hospitalized infants as a means of providing peer support. Although there is no formal evidence that these changes were the result of the EBP project, it is clear the experience opened discussion with the staff nurses and medical staff that supported process changes.
Conclusions and recommendations Although EBP is not new to the nursing profession, much work remains to be done to make it a part of everyday nursing practice. Mentoring is an effective way of teaching nurses ways to change practice by utilizing research. The value of EBP in nursing is improvement of patient outcomes. Implementing EBP requires integration of complex elements beyond convincing staff nurses it is a worthwhile approach. One must also include the organization and the nursing leadership in a consistent long-term approach to effect the needed change. It is also essential that nurses who are knowledgeable in EBP are available and willing to mentor less experienced nurses. In this study, a group of dedicated nurses were interested and willing to participate in this project to seek ways through mentorship to improve relationships with parents in the NICU setting. Although the results are limited, this project led to changes in the NICU and showed nurses that EBP is a useful process. In the future, it would be
K. DiGaudio Mariano et al. important to evaluate the setting and broaden the support for the initiative. Our hope is this small beginning will lead to ongoing mentorship and EBP.
Acknowledgements The authors thank Sigma Theta Tau Gamma Kappa Chapter for financial support. The authors also thank the nurse mentors and the staff nurses who participated in this study; Linda Caley, Michael Leonard, and Patricia Volker, and Linda Eschberger for drafting the article for intellectual content; Ying Tung for her analysis and interpretation of the data; Linda Eschberger and Ann Woloszyn for their assistance in data collection; and Bernadette Melnyk and Beth Griffiths for their review of the manuscript and contributions to concept and design. All authors were involved in the analysis and interpretation of results. Kathleen Mariano led the compilation of this article with supervision from the co-authors.
References Burns, N., Grove, S.K., 1999. Understanding Nursing Research, second ed. W.B. Saunders, Philadelphia, PA. Colling, K., Grabo, T., Rowe, M., Straneva, J., 1998. How to develop and sustain a peer-mentored research work group. Journal of Professional Nursing 14 (5), 298e304. Daloz, L.A., 1999. Mentor. Jossey-Bass, San Francisco, CA. p. 18. Hallas, D., Melnyk, B., 2003. Evidence-based practice: the paradigm shift. Journal of Pediatric Health Care 17 (1), 46e49. Hicks, C., Hennessy, D., Cooper, J., Barwell, F., 1996. Investigating attitudes to research in primary health care teams. Journal of Advanced Nursing 24 (5), 1033e1041. Hundley, V., Milne, J., Leighton-Beck, L., Graham, W., Fitzmaurice, A., 2000. Raising research awareness among midwives and nurses: does it work? Journal of Advanced Nursing 31 (1), 78e88. Hutchinson, A.M., Johnston, L., 2006. Beyond the BARRIERS scale: commonly reported barriers to research use. Journal of Nursing Administration 36 (4), 189e199. Joel, L.A., 1997. Charged to mentor. American Journal of Nursing 97 (2), 7. Melnyk, B.M., Fineout-Overholt, E., 2002. Key steps in implementing evidence-based practice: asking compelling, searchable questions and searching for the best evidence. Pediatric Nursing 22 (3), 262e266. Melnyk, B.M., Fineout-Overholt, E., 2005. Evidence-based Practice in Nursing and Healthcare. Lippincott Williams & Wilkins, Philadelphia, PA. 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 (2), 1e9. Pape, T.M., 2003. Evidence-based nursing practice: to infinity and beyond. Journal of Continuing Education in Nursing 34 (4), 154e161. Pravikoff, D.S., Pierce, S.T., Tanner, A., 2005. Evidencebased practice readiness study supported by academy nursing informatics expert panel. Nursing Outlook 53, 49e50.
Building evidence-based pratice with staff nurses Rutledge, D.N., Bookbinder, M., 2002. Processes and outcomes of evidence-based practice. Seminars in Oncology Nursing 18 (1), 3e10. Sackett, D.L., Strauss, S.E., Richardson, W.S., Rosenberg, W., Haynes, R.B., 2001. Evidence-based Medicine: How to Practice and Teach EBM. Churchill Livingstone, London. Stetler, C.B., Marram, G., 1976. Evaluating research findings for applicability in practice. Nursing Outlook 24, 559e563.
87 Stetler, C., 1994. Refinement of the Stetler/Marram model for application of research findings to practice. Nursing Outlook 42, 15e25. Stetler, C., 2001. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nursing Outlook 49 (6), 272e279. Stetler, C., 2003. Role of the organization in translating research into evidence-based practice. Outcomes Management 7 (3), 97e103.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
Building evidence-based practice with staff nurses through mentoring Kathleen DiGaudio Mariano a,*, Linda M. Caley b, Linda Eschberger c, Ann Woloszyn d, Patricia Volker e, Michael S. Leonard f, Ying Tung g a
D’Youville College, 320 Porter Ave., Buffalo, NY 14201, USA State University of NY at Buffalo, 3211 Main St., Buffalo, NY 14214, USA c Kaleida Health, Women & Children’s Hospital, Nurse Manager NICU, 219 Bryant St., Buffalo, NY 14222, USA d Winnie Palmer Hospital, Women’s & Children Division, Orlando, FL, USA e Kaleida Health, Women & Children’s Hospital, 219 Bryant St., Buffalo, NY 14222, USA f University of Rochester Medical Center, 601 Elmwood Ave., Box 667, Rochester, NY 14642, USA g Kaleida Health, WCHOB Foundation, Office of Health Research, 1260 Delaware Ave Buffalo, NY 14209, USA b
Available online 8 February 2009
KEYWORDS Evidence-based practice; Mentoring; Nursing
Abstract Evidence- based practice (EBP) is an effective way for nurses to improve patient outcomes. Although EBP has gained popularity, barriers to implementation exist. This study explored whether mentoring neonatal intensive care unit (NICU) nurses in EBP would increase their participation in EBP. A sample of 20 nurses were mentored in an EBP project. The EBP Beliefs Scale and EBP Implementation Scale measured scores upon initiation and completion of the project. Statistical analysis showed no significant changes in nurses’ beliefs in EBP or implementation of EBP following mentoring. However, a moderate degree of correlation between changes in beliefs scores and implementation scores was seen with a borderline significance. Age and years of experience did significantly influence changes in EBP beliefs scores. Although the study results did not support that mentoring changed attitudes or utilization of EBP, changes in NICU were implemented as a result of the project activities. ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 716 829 7745; fax: þ1 716 829 8159. E-mail addresses: [email protected] (K. DiGaudio Mariano), [email protected] (L.M. Caley), [email protected] (L. Eschberger), [email protected] (A. Woloszyn), [email protected] (P. Volker), MichaelS_Leonard@URMC. Rochester.edu (M.S. Leonard), [email protected] (Y. Tung). 1355-1841/$ - see front matter ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2009.01.005
82
Introduction Evidence-based practice (EBP) has evolved as a model for delivering the best possible patient care by integrating research, clinical experience, and patient choice. Despite this known fact, clinical practice is often not based on recent research findings. Some barriers to inclusion of research are a lack of time, resources and understanding of the research process (Rutledge and Bookbinder 2002; Hallas and Melnyk, 2003). Pape (2003) describes additional barriers as (1) the shortage of consistent research results, (2) difficulties in applying findings to patient care, and (3) financial and other barriers to providing quality health care. Nurses’ attitudes can also deter use of research in practice decisions (Hicks et al., 1996). Hundley et al. (2000) found nurses with positive attitudes towards research and the nurses who participated in it still did not utilize research in actual clinical practice. These findings are consistent with our experience at a 200 bed pediatric hospital. Melnyk and Fineout-Overholt (2005) propose that an organizational culture change is needed to overcome barriers and facilitate EBP. In our hospital, we implemented organizational changes aimed at changing the culture to be supportive of EBP such as a Nursing Research Council, a web site, and continuing education programs. In spite of the organizational changes, actual inclusion of research in practice did not occur. Therefore, we decided to implement a mentoring program to enhance EBP. Historically, mentoring has been described in academic settings as a means for development of administrative and clinical leadership. Daloz (1999) defines mentors as ‘‘guides’’. Mentors see potential in their mentees helping to define and shape their goals and then provide the support and skills development to achieve the goals (Joel, 1997). In this study, mentoring was examined as a strategy to increase EBP by registered nurses in a clinical setting. Evidence-based practice (EBP) is considered the ‘‘gold standard’’ for patient care because it combines scientific knowledge, clinical expertise and patient choice. Evidence-based practice evolved from evidence-based medicine. Gordon Guyatt, a Canadian, first coined the term ‘‘evidencebased medicine’’ in 1992 (Sackett et al., 2001). Sackett et al. (2001: p. 1) defines evidence-based medicine as ‘‘the integration of best evidence with clinical experience and patient values’’. Evidencebased practice reflects the inclusive nature of health care and is the favored term.
K. DiGaudio Mariano et al. Despite the emphasis on this model, much of nursing practice today is based on the way nurses have historically taken care of patients. Burns and Grove (1999) reported nurses are often unaware or unwilling to read research journals and typically choose to practice the way they have always done things. In our experience at a tertiary care academic pediatric hospital in western New York, a research infrastructure designed to increase nursing research utilization and participation did not change clinical practice. The purpose of this pilot study was to examine the effect of mentoring in EBP on NICU nurses as measured by the EBP Belief and EBP Implementation Scale (Melnyk et al., 2008). The aim was to determine if mentoring could change nursing practice in the study setting by developing a group of nurses with expertise in EBP. By understanding the effect of mentoring on nurses’ participation in EBP, nurses can make an informed choice as to whether to employ mentorship to increase EBP in their clinical settings. This study was designed to answer the following research question: ‘‘Does mentoring nurses in EBP increase their beliefs about and participation in EBP?’’ The hypothesis of this pilot study was that mentorship in EBP increases nurses’ knowledge of the process, promotes positive attitudes towards EBP, and in turn promotes increased utilization of EBP. The two outcome measurements were: (1) increase in EBP beliefs scores and (2) increase in EBP implementation scores.
Theoretical framework The Stetler Model theory integrates EBP with research. Initially developed in 1976 (Stetler and Marram, 1976), it was updated in 1994 (Stetler, 1994), and revised in 2001 to reflect a practitioneroriented approach within the context of EBP (Stetler, 2001). The five phases of the Stetler Model include (1) preparation, (2) validation, (3) comparative evaluation and decision making, (4) translation and application, and (5) evaluation. The Stetler Model of Research Utilization (Stetler, 2001) is the research model that the Nursing Research Council of the hospital system utilizes to guide nursing research in the clinical setting. By following the series of critical-thinking steps in the Stetler Model, potential barriers among the staff nurses can be decreased thereby promoting use of current research findings to change clinical practice in the NICU. In this study, the first four phases of the Stetler Model were utilized. The evaluation phase is being completed informally.
Building evidence-based pratice with staff nurses
Methodology Design This was a descriptive study using a non-experimental pre- and post-test design that measured the effect of mentoring on EBP beliefs and practices. The intervention developed was based on a peer-mentored work group in which the nurse mentors partnered with the staff nurses. In a peermentored model, principles of effective group process are utilized to achieve mutually determined goals Colling et al. (1998). All group members have equal standing and the workload is equally shared. Decision-making is based on consensus. This method of mentoring provided the opportunity to share expertise and collaboratively develop and implement the EBP project in the NICU. Approval to conduct the study was granted by the University of Buffalo Health Sciences Institutional Review Board with exempt status.
Subjects A purposeful convenience sample of 20 NICU nurses who met the eligibility criteria completed the study. Registered nurses who worked in the NICU setting were eligible for this pilot project. The sampling was non-random and participation was voluntary. Data were collected in late 2005 and early 2006. Demographic information was collected pre-intervention describing the nurses’ age, gender, ethnicity, nursing education, nursing experience, and NICU nursing experience. The nurses were all female with 95% Caucasian (n ¼ 19) and 5% African American (n ¼ 1). Thirty percent (n ¼ 6) of the nurses had an Associate’s degree (AAS), 15% (n ¼ 3) had completed diploma programs, 30% (n ¼ 6) had a Bachelor’s degree (BSN), and 25% (n ¼ 5) had a Master’s degree. The mean for years of clinical experience was 18.95 (SD ¼ 8.24; median ¼ 19.50; range 3 e30); the mean for years of practice in an NICU setting was 16.95 (SD ¼ 8.65; median ¼ 18.5; range 3 e30). For the subjects who provided their ages (n ¼ 17), the mean was 42.18 years (SD ¼ 8.37; median ¼ 44; range 26 e58).
Consent Nurses were informed of the purpose and design of the study in a staff meeting. An information sheet was distributed that explained the study and informed the nurses that participation was voluntary. Completion and submission of the questionnaires by the nurses was considered an indication
83 of consent for participation. Therefore, additional written consent was not utilized.
Instruments and analysis In addition to demographic data, two validated survey instruments, the EBP Beliefs Scale and EBP Implementation Scale developed by Melnyk and Fineout-Overholt (2005) were used to measure nurses’ beliefs (attitudes) and their implementation of EBP, respectively. The EBP Beliefs Scale asked the nurses to rate agreement or disagreement with 16 statements about EBP on a five-point Likert scale. The results represent the nurses’ beliefs about the value of EBP. The EBP Implementation Scale provided 18 items for the nurses to rate the frequency with which they performed specific tasks on a scale of zero (not at all) to four (very often). The EBP Implementation Scale measures the degree to which EBP has been achieved. Recent research demonstrated high internal consistency and criterion validity for both instruments (Melnyk et al., 2008). Survey data were analyzed to determine whether mentoring nurses in EBP led to changes in scores for both scales. Data were analyzed with paired t-test and Pearson’s correlation. Regression analysis determined the effect of demographic factors on outcomes. All analyses were done using the Statistical Analysis Software (SAS, version 9.1) for Windows.
Procedure The primary author led the project under the direction of her mentor as a result of their participation in the MaternaleChild Health Leadership Academy sponsored by Sigma Theta Tau. In this study, Melnyk’s PICO process (Melnyk and Fineout-Overholt, 2002) was implemented to guide the evidence-based project (Table 1). Five nurse mentors who agreed to participate in the NICU project attended a presentation on EBP by Dr Bernadette Melnyk. The nurse mentors also attended a MaternaleChild Health Leadership workshop where the plan for the project was developed. The nurse mentors also had support from the medical librarian at the hospital. Communication among the nurse mentors as well as with the participating staff nurses was a priority. Strategies utilized included participation in staff meetings and posting study updates in the NICU on a regular basis. The staff nurses were interested in identifying the best nursing approach to working with families, since they often found discrepancies
84 Table 1
K. DiGaudio Mariano et al. Steps in the PICO process
Step one: problem
Step two: intervention
Step three: comparison
Step four: outcome
Parents’ perception of the severity of their infant’s illness
Potential interventions were identified from the literature. Example: develop a parent ‘‘buddy’’ system for peer support
Interventions were compared; four interventions were chosen to implement in NICU 1. Infant massage 2. Parent orientation video 3. Daily journal for each infant 4. Parent:buddy ‘‘system’’
Outcomes of the project were evaluated. Example: infant journals were implemented
Results Nurses’ beliefs about EBP were measured with the EBP Beliefs Scale, which has a possible score range from 16 to 80. In this study, the mean score was 53.90 (SD ¼ 3.45; median ¼ 54.0; range 47 e61) before mentoring, and 53.82 (SD ¼ 2.47; median ¼ 54.0; range 48 e58) after mentoring (Fig. 1). Nurses’ performance of EBP was measured with the EBP Implementation Scale, which has a possible score range from 0 to 60. As indicated in Fig. 2, the mean score was 12.02 (SD ¼ 10.53; median ¼ 8.86; range 0 e34) before mentoring, and 13.86 (SD ¼ 11.66; median ¼ 9.5; range 1 e 42) after mentoring. Two primary outcome measurements were used to test the hypothesis that mentoring nurses in EBP would increase attitudes and practice of EBP in the NICU: (1) increase in EBP beliefs score and (2) increase in EBP implementation score. A significance level of 0.05 was used for all statistical analyses. The paired t-test results showed no significant increase in either EBP beliefs score (mean ¼ -0.08; SD ¼ 2.89; median ¼ 0; range: 9 to 4; p ¼ 0.90) or EBP implementation score (mean ¼ 1.84; SD ¼ 11.88; median ¼ 3; range 21 to 29; p ¼ 0.50) through mentoring. The Pearson correlation coefficient (r ¼ 0.39; p ¼ 0.092) indicated a moderate degree of correlation between changes in beliefs scores and changes in implementation scores with a trend toward significance. The positive correlation pattern is depicted in the scatter plot in Fig. 3.
Demographic factors under consideration for the regression analysis were age, gender, race, and highest degree in nursing, years of clinical experience and years of NICU experience. Subjects who provided age information (n ¼ 17) were included in this analysis. From the results of regression analysis, none of the above demographic factors showed significant influence on the score increase in EBP implementation. However, age (b1 ¼ 0.28; p ¼ 0.028) and years of experience (b2 ¼ 0.37; p ¼ 0.006) were found to have significant influence on the change in EBP beliefs score. The EBP beliefs regression model predicts that the younger experienced nurse will demonstrate higher change in belief score as indicated in Fig. 4. The equation used for this graph is: score increase (EBP beliefs) ¼ 4.96 0.28 age (years) þ 0.37 clinical experience (years).
Study limitations The results of this study may not reflect the overall beliefs and practices of nurses in the NICU due to the small sample size. This clinical setting is specialized and demands a specific skill set in nurses. The longevity of the nurses in this setting and the average age may reflect a nursing staff that has had
80 70
EBP Beliefs Score
between the parent’s perceptions of their baby’s illness and the infant’s actual health status. Throughout the project, the mentors guided and worked in partnership with the staff nurses. The direction of the project was determined by decision-making by consensus of all participants. The workload was shared and all members had equal standing. The project was completed in 5 months.
60 50
53.9
53.82
Before Mentoring
After Mentoring
40 30 20 10 0
Figure 1 (n ¼ 20).
Statistical summary of EBP beliefs score
Building evidence-based pratice with staff nurses
85
Total number of questions: 15 Survey scale: 0 − 4 Possible range of total scores: 0 − 60
60
N = 20 = -1.84 p = 0.50
in EBP Beliefs
EBP Implementation Total Scores
15 10
Pre
Results and discussion Mentoring provided a positive atmosphere in which the nurse mentors worked closely with staff nurses and provided guidance in the EBP model. Staff nurses were appreciative of the credibility given to their experience and the opportunity to effect changes, and expressed the opinion that it was a worthwhile experience. The inability to demonstrate a significant change in EBP beliefs or implementation scores may be related to the limitation of the small sample size and lack of statistical
40
Score Increase in EBP Implementation
30 20 10 0 -10 -20
0
5
Score Increase in EBP Beliefs (N=20, r=0.39, p=0.092)
Figure 3 Scatter plot with regression line for score increase in EBP beliefs vs. score increase in EBP implementation (n ¼ 20).
s)
60 55 50 45 40 35 30 25
(y r
25
20
e's C
less exposure to EBP. Study findings also may not be generalized to other nursing populations.
-5
-15
Nurs
Post
Figure 2 Statistical summary of EBP implementation score (n ¼ 20).
-30 -10
-10
Ag e
0
-5
15
linica
l Exp
10
's
13.86
12.02
0
erien
5
se
15
Score Increase
30
5
0
ce (y
Nu r
45
rs)
Figure 4 Effects of nurse’s age and clinical experience on score increase in EBP beliefs. On this graph, the darker grey shadow refers to decrease in EBP beliefs score, and the lighter grey shadow refers to increase in EBP beliefs score (n ¼ 17).
power. The results of this study, however, did reveal a positive correlation between EBP beliefs and implementation scores, i.e. a higher amount of EBP beliefs score change is associated with a greater degree of EBP implementation score change. This finding is consistent with recent research demonstrating the increase in EBP strength of beliefs and EBP implementation by Melnyk et al. (2008). Therefore, it is critical to develop strategies to increase nurses’ belief in EBP. In this study, efforts were made to remove known barriers to EBP (Pravikoff et al., 2005; Hutchinson and Johnston, 2006). Nurses were provided with knowledge of literature searches, electronic resources, and analysis of the evidence by the nurse mentors. Efforts were made to provide time to complete the project. Resources were brought to the unit and mentors worked oneon-one with the participants. Further investigation into the barriers needs to be considered prior to initiation of future projects. Perhaps a more formal mentoring program would be beneficial. Because of the small sample size (n ¼ 17) for the regression analysis, the present study model for EBP beliefs score change can only be used as a preliminary one. In order to build a generalized model, a larger randomized sample will be required in future studies to reduce bias and provide more statistical power. Organizational culture has been described as critical for successful implementation of EBP (Stetler, 2003). Although the nurse leaders in the NICU and the administration were supportive of this project, it is possible that the participating nurses did not accurately
86 perceive this support. An analysis of the organizational culture could provide additional data that would identify any organizational barriers that need to be overcome, in order to institute a hospital wide approach to mentoring. Although study results showed mentoring nurses in EBP had a minimal effect on individual scores on EBP beliefs and implementation scales, significant process changes occurred in the NICU that may have been the result of the project. Practice changes based on literature findings and nurses’ clinical experience were proposed that were intended to improve patient outcomes and increase family support. One year after the study completion, positive changes have been integrated into the NICU setting. For example, a bedside journal detailing the infant’s progress has been developed and put into practice. This has improved communication with families and provides data about the infant’s condition. Educational discussions for families are being offered in the evening as an opportunity to meet and learn more about health issues in preterm infants. In the near future, parents of discharged NICU infants will begin rounds to meet parents who currently have hospitalized infants as a means of providing peer support. Although there is no formal evidence that these changes were the result of the EBP project, it is clear the experience opened discussion with the staff nurses and medical staff that supported process changes.
Conclusions and recommendations Although EBP is not new to the nursing profession, much work remains to be done to make it a part of everyday nursing practice. Mentoring is an effective way of teaching nurses ways to change practice by utilizing research. The value of EBP in nursing is improvement of patient outcomes. Implementing EBP requires integration of complex elements beyond convincing staff nurses it is a worthwhile approach. One must also include the organization and the nursing leadership in a consistent long-term approach to effect the needed change. It is also essential that nurses who are knowledgeable in EBP are available and willing to mentor less experienced nurses. In this study, a group of dedicated nurses were interested and willing to participate in this project to seek ways through mentorship to improve relationships with parents in the NICU setting. Although the results are limited, this project led to changes in the NICU and showed nurses that EBP is a useful process. In the future, it would be
K. DiGaudio Mariano et al. important to evaluate the setting and broaden the support for the initiative. Our hope is this small beginning will lead to ongoing mentorship and EBP.
Acknowledgements The authors thank Sigma Theta Tau Gamma Kappa Chapter for financial support. The authors also thank the nurse mentors and the staff nurses who participated in this study; Linda Caley, Michael Leonard, and Patricia Volker, and Linda Eschberger for drafting the article for intellectual content; Ying Tung for her analysis and interpretation of the data; Linda Eschberger and Ann Woloszyn for their assistance in data collection; and Bernadette Melnyk and Beth Griffiths for their review of the manuscript and contributions to concept and design. All authors were involved in the analysis and interpretation of results. Kathleen Mariano led the compilation of this article with supervision from the co-authors.
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