System Factors Influencing the Australian Nurses' Evidence-based Clinical Decision Making: A Systematic Review of Recent Studies

Introduction

The nursing science is growing at an increased pace and the integration of research evidence into care practice becomes a priority in clinical contexts. Evidence-based practice (EBP) is referred to careful and systematic use of best research evidence in the clinical decision-making process (1). The EBP approach integrates three aspects of clinical practice, such as personal knowledge and experiences, available research evidence and values, as well as the preferences of patients in ensuring high quality and safe care (1, 2). However, an 8- to 30-year gap was found in the literature regarding the availability of research and its application into nursing practice (2, 3).

In Australia, nurses have been increasingly cast in the role of active decision makers in clinical practices (4). Nowadays, these nurses consider EBP in their everyday practices and possess a positive attitude towards it because of its efficiency in the promotion of transparency and accountability in the decision-making process (4). While effective decision making is an integral part of their clinical practice, a lack of EBP is involved with a high cost of care provision, degradation of service quality, and lower levels of a harmonious interprofessional working environment (3).

There are several identified factors that hinder the implementation of EBP, including a lack of knowledge and authority to change treatment procedures, not enough time to deal with new ideas, lack of resources, and inadequate support from colleagues and management (5, 6). Although evidence is growing on the identification of these factors, the literature seems to represent a fragmented picture due to inadequate understanding of barriers from the nurses' perspective (6, 7, 8).

Additionally, the clinical tasks and competency standards have been outlined by the Nursing and Midwifery Board of Australia for nurses, which clearly links between research knowledge and its utilization to ensure EBP in the decision-making process (9). The EBP guideline developers agree that guidelines need to be periodically updated due to rapid accumulation of evidence and the upcoming challenges (10, 11). Therefore, this study aimed to review the literature systematically regarding the system factors and their possible impacts on the process of EBP implementation in clinical practices among Australian nurses.

Methods

This literature review was a part of a research project entitled "Adopting evidence-based practice in clinical decision making by nurses", which has been approved by the Social and Behavioral Research Ethics Committee (Project No. 7625). A literature search was conducted across major electronic databases, including MEDLINE, PsycINFO, PubMed, ProQuest, Google Scholar, and CINAHL from January 2018 to March 2018 to identify the research studies on nurses' knowledge and attitudes towards EBP, management, and the implementation of EBP in clinics and hospitals.

A search string was used in the literature with several keywords, such as "evidence based practices or evidence-based practices", "evidence based decisions or evidence-based clinical decisions", "EBP and nursing practices", nursing decision making or nursing clinical practices", "nurses or registered nurses", "clinicians", "nursing AND factors", "challenges", "barriers", "impediments", "logistic supports", "time constraints","understanding AND integrating", "technology skills", "research skills","healthcare providers", "financial problems", "barriers", "challenges", and  "Australia".

A manual search was also undertaken to include the relevant references of the retrieved articles, citations by authors, and important articles. The search string was developed by the first and second authors after consulting with a librarian in the Flinders University. The peer-reviewed research studies published from January 2015 to February 2018 were considered in this study. Furthermore, the studies which included nurses as participants and investigated their perspectives on the implementation of EBP were regarded eligible for the review. Additionally, the intervention studies targeted at the exploration of the factors of EBP implementation were included in this review.

On the other hand, the literature reviews and reports based on the secondary data were excluded from this study. In the same line, the exclusion criteria included studies focusing on the factors of EBP implementation from a non-clinical perspective. It is worth noting that an Australian context and English language were applied in this study. There were 8353 articles identified from the initial electronic and manual search. Out of 8353 citations, 286 articles were considered for the examination of the full texts. In total, 18 articles, including quantitative, qualitative, and mixed-methods ones met all inclusion and exclusion criteria (Figure 1). The systematic literature review guidelines of the Centre for Reviews and Dissemination were employed to assess the quality of each study (12). The quality assessment checklist included items, such as relevant objectives, methodology, and employed methods, the generalizability of findings, and the quality of reporting. Table 1 summarizes data on the authors, years, settings, participants, research methods, and findings on the system factors related to the EBP implementation from each study.

The meta-analysis of the research findings was not appropriate due to the heterogeneity in the selected studies. The extracted data were tabulated according to the research outcomes presented in the selected studies. Multi-layered relationships were found among the factors of EBP implementation, and these factors were grouped into themes and sub-themes using thematic analysis method. This approach thematized the findings into sub-themes and themes, and it was employed to provide a structure to the identified factors of EBP in the data analysis and discussion sections of this review (13).

Figure 1. PRISMA flow diagram in the selection of reference list for literature review

Table 1. Characteristics and Findings obtained from the Review Table of Qualitative Studies Pertaining to the challenges in evidence-based practices of nurses

Results

The selected studies used varying research designs including two randomized control trails; five cross-sectional studies, six descriptive studies; two interpretive approaches; and three constructivist methods. Data collection methods used in the studies were: interviews (2); surveys (13), two studies used a combination of interview and observation; and another study used a combination of focus group and interview. In the selected studies, sample size was ranged from 17 to 484 participants. Three themes emerged from the synthetization of the system factors identified in the literature: individual capacity, interpersonal support and organizational provision (Table 2).

Individual capacity

The first major theme of "individual capacity" represented a situation where the nurses' ability to implement EBP in decision making associated with their clinical knowledge and experience, research skills, time, confidence, and autonomy. According to the results of eight studies, nurses' ability to implement EBP in decision making correlated significantly with clinical education and experience. Duff et al. (2016) revealed a statistically significant association between postgraduate education and

Table 2. System factor categories influencing on nurses’ evidence-based practice

the implementation of EBP (OR 1.69, 95% CI 1.07–2.6, p=0.02) (14). On the other hand, a lack of higher education had a negative impact on nurses' ability to implement EBP in clinical settings (P<0.0001) (15).

In another study, 85% of the participants stated that they required ongoing educational opportunities to implement EBP (16). Moreover, the results obtained from a qualitative study showed that the lack of clinical skills and experience due to limited educational opportunities restricted nurses to implement EBP in their practices (17). As such, the lack of education and clinical experience in combination with little knowledge of the research process were negatively associated with an individual capacity of nurses to implement EBP.

In the same line, eight studies showed a relationship between research skills and the EBP implementation by nurses. Accordingly, due to the lack of research skills, nurses faced challenges regarding the review of the literature, data collection, and understanding the research findings (17).

In a study conducted by Borkowski, McKinstry, and Cotchett (2017), it was found that 40% of the participants had no research skills (18). Furthermore, nearly half of the participant in mixed-methods research confirmed that the research findings were not easily transferrable into practice (19). Consequently, limited knowledge and skills in research which caused by a lack of time resulted in failures to implement EBP in clinical decision making. Lack of time has an influence on nurses' ability to implement EBP in decision making. Competing demands impose pressure on the nurses in the clinical settings, and this hinders their promotion of EBP  (17). In a mixed-methods study, one participant stated, "… in practice there is no time to undertake additional activities and do research" (18). According to the results of the aforementioned study, 69% of the participants agreed that they had no time to conduct research since job duties took the highest priority (18).

There were several identified barriers regarding time management during clinical practices, such as part-time shifts, sense of personal accomplishment, lack of available research reports, and lack of enough time to find research reports, assess the research design, and the quality of outcomes (15, 20). The prioritization of the job duties due to increased workload restricted the nurses to focus on the integration of research evidence into clinical practices. The results obtained from nine studies revealed that nurses' ability to implement EBP in decision making correlated with their confidence and autonomy. The findings of one study indicated positive attitudes of nurses towards the implementation of EBP (mean±SD=4.34±0.536). In this study, the results showed that 59% and 37% of the participants were agreed and strongly agreed, respectively, with this fact that EBP implementation was fundamental to their professional practice (19).

In the same line, confidence was another factor which was beneficial to the participants’ professional development regarding the implementation of EBP in everyday care practice (Mean=4.32, Median=4) (19). However, two studies identified a lack of confidence in EBP implementation among nurses (15, 16). A lack of self-motivation and passion were blamed for making the nurses unsure about their capacity in doing research and implementing EBP (21, 22). In a study,  a question was raised on the authority of nurses to change their practice (Mean±SD=3.04±0.953) (16). One participant stated in a mixed-methods study that: "…in my practical context (i.e., an acute public hospital), a first-year registered nurse would probably not have the opportunity to change practices via guidelines/protocols or to apply evidence to clinical scenario in a formal manner, and s/he would have to consult with senior staff " (23). Lack of authority and confidence makes it difficult for nurses to implement EBP, and this is also associated with their commitment to their job duties and patients.

In summary, lack of knowledge of EBP, confidence, autonomy, and access to ongoing educational opportunities led to the shortage of clinical skills among nurses, which had effects on their EBP implementation. In addition, the lack of research skills was also identified to have negative effects on the implementation of EBP, which might be a result of a lack of higher education. Continuous attempts of nurses to meet the work role demands made it difficult for them to collect data and conduct research, and this has resulted from their lack of confidence in the implementation of EBP and authority to change the practices. This individual capacity was shaped by the interpersonal professional relationships among colleagues in clinical settings. 

Interpersonal support

The second major theme of "interpersonal support" was articulated based on the prevailing professional relationships and support that played a role in restricting nurses to implement EBP. The identified factors associated with interpersonal support included research orientation by the experts and research support within the team. According to the results of several studies, a correlation was observed between the research orientation in the team and the role of EBP coordinator with a lack of EBP implementation among nurses. In a study conducted by Malik, McKenna, and Plummer (2015), one participant stated: "I find the evidence-based practice a new concept to many of my colleagues" (19). The identified factors with the highest scores that had effects on the implementation of EBP at the team level (Median ≥7) were a lack of a team leader to introduce and support research, difficulties in the dissemination of the research outcomes to the colleagues and research forums/seminars, a lack of planning for the implementation of EBP that is guided by evidence, and no collaborative research orientation relating to practice (24).

In addition, a lack of supervision and mentoring was identified regarding the use of computers, literature search, EBP courses, as well as research design and analysis from the EBP coordinator (21). This lack of research orientation caused limited research support from the colleagues which had negative effects on the nurses' ability to implement EBP in clinical decision making. In a study, one participant stated a need for assistance: "…there is a need to have someone to provide the nurses with research articles. It would be really good since we don't have enough time to find and read research articles" (19).

Support from nursing colleagues (Mean=3.59, Median=4.00) and management (Mean=3.53, Median=4.00) in terms of data collection and analysis, as well as a review of the literature,  were found significant in the implementation of EBP (16). Therefore, a lack of collaborative effort and presence of an EBP coordinator in research orientation within the team along with limited support from colleagues and management created difficulty for nurses to implement EBP. The lack of team effort resulted from organizational culture and research support infrastructure in clinical settings. 

Organizational provision

The final theme of "organizational provision" included the research culture and supportive infrastructures in clinics and hospitals, which correlated significantly with the implementation of EBP among nurses. The policies and workplace culture were important to understand the organizational aims and goals. Several studies identified the workplace culture as a key determinant in nurses' ability to implement EBP in clinical decision making. Regarding the organizational research culture,  in a mixed methods study, one participant mentioned that: "…Research is not our core business" (18). The cultural practices in the clinical setting associated with the implementation of EBP included lower levels of credibility of academic projects in practice setting (22, 25), a lack of partnership between academic and practice settings (21, 22), undervaluation of research and EBP implementation (17), a lack of policies for organizational changes (17), and a lack of incentives to develop research skills (25).

However, the cultural change correlated significantly with an increase in the number of staff undertaking training regarding EBP implementation (P=0.008), as well as research design and analysis (P=0.003) (7). Therefore, the organizational culture in the implementation of EBP underwent some changes although there was a lack of identified research infrastructure for the nurses.

The results obtained from 11 studies revealed research infrastructure as one of the factors of the organizational provision in clinical settings. With regard to the support from the organization, one participant in a study stated that: "…I find the organization voices supportive but when it comes to money/resources to implement any changes, the attitude changes" (16). The organizational research infrastructure associated with a lack of access to the Internet, EBP education and training (14), as well as support from experts (18).

Some other factors at the organizational level (Median≤ 4) were the lack of funds and equipment, inadequate administrative support for research activities, and no software to support research activities (24). In addition, a lack of research support was identified as a reason for nurses' inability to implement effective and efficient EBP.

The obtained results suggested several factors at the individual, team, and management levels regarding the implementation of EBP by nurses. It was evident that at the individual level, nurses had a lack of education and clinical experience as well as research skills to implement EBP in clinical decisions making. A lack of time due to work role demands along with the nurses' lack of confidence and autonomy to change their practices were identified as disempowering factors.

At the team level, research orientation in the team by the EBP coordinators and research support from colleagues were identified as facilitating factors regarding the implementation of EBP in clinical decision making. Additionally, at the organizational level, there were two major limiting factors, such as lack of research culture and research support infrastructure, which hindered nurses from adopting EBP. The individual, team, and management factors influenced the nurses' effective participation in clinical decision making.

Discussion

This review contributes to the understanding of the major factors influencing the EBP implementation by nurses within the Australian healthcare system. The factors represented the individual, team, and organizational capacities in the implementation of EBP in clinical practice, which are also reported in the studies published before 2015 (26, 27). The findings of this review study revealed a lack of knowledge about EBP and research skills among the nurses that were significantly associated with their clinical practice. In addition, competing role demands, as well as nurses' lack of confidence and autonomy to change the current practices were reported as important factors.

Regarding the team domain, the facilitating factors to the implementation of EBP were the role of an EBP coordinator in research orientation and support from colleagues. Moreover, the factors in the organizational domain included the culture and research infrastructure in the organization. These cross-sectional factors signify that different policies and strategies are required at each domain to improve EBP capacity and culture among the nurses.

The factors on the individual level were identified as important in all types of quantitative, qualitative, and mixed methods studies. These factors associated with the nurses' knowledge and experience, research skills, time constraint, confidence, and autonomy. Similar to the other studies conducted internationally (26, 28), the results of the present study showed a lack of involvement in research due to insufficient knowledge of EBP implementation as a result of inadequate education and clinical experience.

The research skills of the nurses was another key factor influencing research capacity at the individual level, which included data collection, selecting articles for literature, critical literature review to understand research outcomes, writing for publications, submitting an ethics application, and securing research funding (29). Poor research skills in the clinical setting might result from a lack of research-based education and training (30, 31) since the nurses receive only educations on basic research in undergraduate courses. The nurses' individual capacities to conduct meaningful research are limited, which are also influenced by the time constraint. High expectation from nurses has an influence on their implementation of research practices in the clinical setting; therefore, the work role demands are prioritized by them to meet the job duties. This finding is in line with the results obtained from studies conducted in other developed countries, such as Norway and the USA (32, 33).

This review identified two unique factors, namely working part-time and a sense of accomplishment that hinder the nurses from implementing research-based practices. At the individual level, the most important factor was the lower level of confidence and autonomy in performing research and changing the practices. Several studies showed lower levels of confidence among nurses in conducting research. The nurses believed in this dominating perception that they did not have the ability to conduct research; moreover, they stated that there was no easy method to follow in research procedures (28).

A lack of autonomy in changing the practices in clinical settings led to nurses' inability to implement EBP in clinical decision making. This finding is also consistent with the results obtained from quantitative and qualitative studies (23, 28). The EBP training can lead to a significant and immediate improvement in research knowledge and skills, as well as attitudes, confidence, and behavior (34). These factors can change educational programs with emphasizing on educational strategies. Consequently, changes in educational programs may increase nurses' skills and confidence levels, thereby enabling them to undertake EBP in clinical decision making.

There were two factors influencing the EBP implementation at the team level, namely the role of an EBP coordinator and research support from colleagues. Research orientation by the EBP coordinator was identified as a determinant in the implementation of EBP. This concept encompasses several components, such as attitudes of the EBP coordinator to the needs of nurses, the value of research, involvement in EBP implementation, integration of research findings into clinical practices, and becoming aware of new knowledge and information (35).

Research orientation at team level included sharing of research knowledge and skills, which was inadequate in the clinical practices and had negative effects on the implementation of EBP (36). The other determinant factor was support from colleagues which was associated with the nurses' day to day clinical practices. This factor has been defined by several authors and included components, such as administrative support, time for colleagues, dissemination of information, and access to the library. Accordingly, lack of collaborative efforts at the team level has an impact on the nurses' inability to implement EBP in making decisions (24, 36). This result is in line with the findings obtained from the present review study.

At the organizational level, the culture of the organization and research infrastructure, from a broader perspective, were identified as key factors. The healthcare organization in the present review study had poor research culture in clinical practices. This finding is consistent with the results of other studies (24, 37) in which they showed a lack of partnership between academic and clinical practitioners and less credibility of research projects in the clinical settings. Positive research culture in the organization has been described by Cooke et al. (2006) in terms of organizational policies, valuation of the research activities, and incentives to initiate EBP (36). Such a research-focused culture is considered practical for the adoption of EBP initiatives and behaviors of the nurses employed in any healthcare organization (24, 37). The integration of research culture by the organization to the strategic planning and mission statement may be a key strategy that can foster research culture by signifying that research activities receive high value and become an integral part of the workplace role (38, 39).

The research infrastructure was also identified as an effective factor in EBP implementation. The required research resources and facilities include funds, equipment, the access to computers, the Internet, and software, as well as library resources, such as copies of journals and databases, and workstations for conducting meaningful research and data management (36, 39). Lack of these services in an organization hinders the promotion of EBP in the clinical setting; therefore, it should be ensured that the resources and support are available to assist nurses in performing research.

Overall, the system factors identified at the individual, team, and organizational levels, indicate the challenges in whole-systems approaches. The recognition of the individual capacities in terms of their educational level, clinical expertise, research skills, time, confidence, and autonomy is important since all of these factors have impacts on the nurse's ability to implement EBP which will, in turn, affect the research capacity of the team and organization. The factors at the team level that have a remarkable impact on the performance of nurses' skills and confidence in carrying out clinical research include research orientation and research support from colleagues. In addition, at the organizational level, the most important factors were research culture and infrastructure since they can direct and assist an EBP coordinator, research team, and nurses to implement EBP, thereby ensuring successful clinical decision making.

Although this review paved the way on the factors affecting the EBP implementation in the clinical setting, it suffers from several limitations since it included all quantitative, qualitative, and mixed-method studies in one review, and it was limited to peer-reviewed articles. A review of all types of studies would add value to the growing body of knowledge regarding nurses' EBP implementation in clinical decision making. Excluding book chapters, grey literature, non-English language studies, and country specificity were important decisions in the review because of the practical reasons, such as the complexity of data extraction and analysis as well as focus on topic relevance.

Implications for Practice

This review suggests several system factors the identification of which indicates that healthcare policies and strategies should consider each factor to improve the research capacity of nurses. Nursing educational strategies that contribute to the development of clinical and research skills should be tailored to the nurses' interests and needs to be operative. Teaching EBP at the undergraduate level may have a great impact on nurses since they will be aware of how to become evidence-based practitioners. Another strategy at the team level that can promote research orientation and support is a collaboration between university academics, EBP coordinators and novice nurse researchers within a research team. The involvement of a nurse researcher in the team can provide an opportunity to monitor the activities and prepare performance plans of the nurses. At the organization level, the strategies should include the EBP focus that may increase the confidence and autonomy of nurses in changing their clinical practices.

Acknowledgments

The authors are thankful to the College of Nursing and Health Sciences at the Flinders University of South Australia for funding this project.

Conflicts of Interest

The authors declared no conflicts of interest.