FACTORS INFLUENCING IMPLEMENTATION OF EVIDENCE BASED PRACTICE AMONG NURSES IN SELECTED TERTIARY HOSPITALS IN ENUGU URBAN

CHAPTER ONE
INTRODUCTION
Background to the Study
The increased emphasis internationally on clinical and cost effectiveness in health policy has highlighted the need for quality health services to be built upon the use of best evidence (McKenna, Ashton & Keeney, 2010). Various governments have introduced initiatives to support the development of evidence-based healthcare systems in which decisions made by healthcare practitioners, managers, policy makers and patients are based on high quality evidence. Activity has focused on developing evidence-based guidelines for clinical interventions. For example, in the USA, the Agency for Healthcare Research and Quality leads national efforts in the use of evidence to guide healthcare decisions.
Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that started in medicine as evidence based medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library, information science and other fields. (Titler, Cullen & Ardery, 2013). Polit and Beck (2011) define EBP as requiring the use of the best available research evidence and practical experience to make clinical decisions. EBP leads to cost-efficient, quality patient care and improved patient outcomes (Burns & Grove, 2010). Policy, political and professional imperatives have made EBP a clinical prerequisite for daily practice. Over the years since its formal introduction in 1992, EBP has emerged as a major policy theme in Western healthcare systems, especially, the United States of America (USA), Australia and the United Kingdom (Rycroft-Malone, 2011).
EBP is not only applying research-based evidence to assist in making decision about the healthcare of patients but rather extends to identify the knowledge gaps and finding systematically appraising and condensing the evidence to assist clinical expertise, rather than replacing it (Elshaug, 2010). In accordance with most health-related professions, there has been a growing focus on quality improvement including moving from a traditional intuition-based paradigm to evidence-based nursing practice (EBNP) (Melnyk & Fineout-Overholt, 2011).
The EBNP process consists of five stages: (1) formulating a question that will yield the most suitable answer; (2) gathering the most relevant information by systematic search of the literature or clinical guidelines; (3) performing critical evaluation of the evidence and its validity, relevance and feasibility; (4) integrating research evidence with clinical experience, patients’ values and preferences and (5) assessing treatment outcomes (Melnyk & Fineout-Overholt, 2010). Implementing EBNP is potentially beneficial for patients and healthcare systems in general, and for nurses in particular. It enhances patients’ access to information about effective treatment (Melnyk & Fineout-Overholt, 2012). EBNP can also improve the healthcare system by facilitating consistent decision making and advancing cost-effectiveness. Furthermore, EBNP can help nurses by facilitating informed and evidence-based clinical decision-making, support them to bewell informed with technologies and enable greater efficiency (Melnyk & Fineout-Overholt, 2011).
EBP in nursing has been strongly presented in the agendas of many professional organisations as an undergraduate requirement in countries, like the USA, Canada and Jordan (Baumbusch, 2010). Among the many professional organisations is the Jordanian Nursing Council (JNC), which emphasizes the implementation of EBP as one fundamental component of nursing practice and education (Jordanian Nursing Council, 2010).It is believed that the evidence-based practice in nursing education should commence in the undergraduate preparation, which provide the skills required to find, analyze and, later, synthesize best evidence for practice (Balakas & Sparks, 2010). Therefore, assessing factors influencing the implementation of EBP in nursing programs, withfuture graduate nurses, is crucial to prepare nursing graduates to adopt and implement these principles in their work.
Despite the plethora of literature on what evidence-based nursing is and is not, EBP in nursing education is still struggling and has not been addressed adequately. Many researchers identified that some problems that inhibit the implementation of EBP in nursing practice (Brown, 2009; Thompson, 2010), include insufficient educators’ skills and time to find research studies, inadequate knowledge on how to evaluate research findings, and lack of organisational support, lack of adequate understanding of technologies associated with the teaching strategies promoting EBP such as the use of human simulation in the nursing laboratories and lack of consensus on the best strategies, material, time and level of students to engage in EBP (Stichler, 2013). Other  related problem to  teaching process, especially in undergraduate education, focuses mainly on the process of deducting evidence from research rather than conducting research (Ciliska, 2010) abandoning an essential component of EBP.
By and large, the predicament of EBP is enormous. Thus, in Nigeria, EBP is still far from its realizations and under studied. It is in line with the above that the researcher seeks to find out factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals in Enugu urban.
Statement of the Problem
Research has shown that evidence-based practice (EBP) leads to higher quality care, improved patient outcomes, reduced costs and greater nurse satisfaction than traditional approaches to care (Melnyk & Fineout-Overholt, 2011). Despite these favorable findings, many nurses remain inconsistent in their implementation of EBP (Stevens, 2011). According to Egerod and Hansen, (2012) nurses prefer to be informed by colleagues, rather than using the internet or nursing databases and most nurses rely only on what they learned during their nursing education and from experience. Even nurses with substantial knowledge about evaluating research evidence find themselves powerless and with limited authority to introduce changes in their workplaces (Banning, 2012).
In Nigeria, Ojong, Ukaegbu and Ebong ( 2012) observed that the implementation of EBP which is the bedrock of higher quality care and best patient outcomes has beenneglected and abandoned in many if not all Nigerian hospitals. In National Orthopaedic Hospital,Enugu (NOHE) and Enugu State University Teaching Hospital (ESUTH) which are the areas of study,the researcher has observed that nurses do not utilize current nursing approaches to EBP and nursing process in care of patients despite numerous workshops that have been organised in these areas.
These have raised some basic questions in the researcher’s mind thus- Are there personal/individual and organisational/institutional factors influencing the implementation of EBP? Are there potential interventions that will motivate nurses to implement EBP? This study is an attempt to answer the above questions.
Purpose of the Study
The purpose of this study is to investigate the factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals in Enugu urban.
 
 
 
Objectives of the Study
The specific objectives are to:

• Determine personal motivating factors contributing to implementation of evidence based practice among nurses.
• Determine organisational motivating factors contributing to implementation of evidence based practice among nurses.
• Determine the perceived differences in personal factors contributing to evidence based practice among nurses in the selected hospitals.
• Determine the perceived differences in organisational factors contributing to evidence based practice to evidence based practice among nurses in the selected hospitals.

Research Questions

• What are the personal motivating factors that will influence the implementation of evidence based practice among nurses?
• What are the organisational motivating factors that will influence the implementation of evidenced based practice among nurses?
• What are the perceived differences in personal factors contributing to evidence based practice among nurses in the selected hospitals?
• What are the perceived differences in organisational factors contributing to evidence based practice to evidence based practice among nurses in the selected hospitals?

Hypothesis

• There is no significant relationship between the age of the respondents and perceived factors to implementation of EBP.
• There is no significant relationship between the educational level of the respondents and perceived factors to implementation of EBP.
• There is no significant relationship between the years of experience of the respondents and perceived factors to implementation of EBP.

Significance of the study
This study will help to stimulate discussions and research on the importance of the concept of evidence-based practice in nursingwhile the result from this study will highlight areas that may require adequate attention.The findings will provide nurses with information that will enhance the delivery of the highest quality healthcare to patients as well as ensure best patient outcome.
The results from this study will equally assist the nurses and improve their knowledge on how to operate computer, time management to improve the implementation of EBP. It will also assist the organisation and hospital management on its health policy, especially, as regards the formulation of a comprehensive evidence-based nursing practice guideline.
Scope of the study
The study is delimited to nurses in the selected tertiary hospitals in Enugu urban (National Orthopaedic Hospital, Enugu and Enugu State University Teaching Hospital, ESUTH).It is also confined to variables such as personal, organisational, perceived differences in personal and organisational factors that influence the implementation of evidence-based practice among nurses in selected tertiary hospitals.
 
 
 
Operational definition of terms
Factors influencing implementation of evidence-based practice among nurses; refer to respondents’ views, opinions on factors like personal, organisational that will positively influence nurses in implementation of evidence-based practice.
Personal/individual factors refer to certain individual constraints that influence the implementation of evidence-based practice. This may include limited knowledge, lack of interest, lack of time, lack of skills, level of education, inability to access the internet, .
Organisational/Institutional factors refer to provision/availability of internets, hospital policy, ward routine, supportive leadership, access to resources, and shortage of staff.
Evidence-Based Practice refers to application of researches that has been carried out on how to give highest quality of care that will lead to best patient outcomes.
Motivational factors refer to resources available to encourage the nurses to implement EBP like satisfactory incentives/allowances, availability of resources, and access to internet search.