Evidence-based Practice : Perspectives of Academic Community Health Nurses and Primary Health Care Nurses

Evidencebased practice (EBP) is an approach that integrates the best current available scientific evidence with the expertise of the health professionals, patient’s preferences and values to make decisions about health condition. EBP provides safe and custom-made care that produces the preferred health outcomes, increases the care satisfaction in care recipients, and reduces the cost of health care. Applying of EBP will facilitate deciding about choosing of the most effective program or intervention, and culturally accepted by a community. EBP as a tool for improving the health care quality will serve the long-term goal of improving the quality of primary care and preventive services. It was very important to explore the views of health care professionals about EBP that concluded their willingness to practice it. While the EBP is a new approach for the Egyptian society, the present study aimed to investigate the perspectives of academic community health nurses and primary health care nurses at local level of Dakahlia governorate. Quasi-interventional study design was used with qualitative data collection approach. The study was based on qualitative investigation of the participants knowledge and views about evidencebased practice, before and after a two days training program that gave an intensive overview about the evidencebased practice. Results of the study showed lack of knowledge among participants about EBP that hindered them to give explicit views before attending the training program. The participants attained knowledge that was sufficient enough to portray their views about EBP after attending the training program. They described EBP to be an objective and practical tool that facilitate decision making in daily practice. They mentioned also that EBP is an approach of life-long learning, but it requires a well-established professional environment. The study concluded that providing essential knowledge about EBP enabled community health nurses to portray perspectives about the values and possibilities of its application. They suggested establishing a partnership system between academic nursing institutions and primary health centers to implement EBP. Based on the illustrated findings the study recommended conducting comprehensive training programs on EBP and to community health nurses, providing raising awareness programs to embed the EBP into the organizational cultures of academic institutions and primary health centers, and carrying out further study on establishing the partnership framework between academic institutions and primary health centers.


INTRODUCTION
Nowadays Evidence-based practice (EBP) have being processed by healthcare professionals at academic and field practice settings in making decisions that Bull High Inst Public Health Vol.40 No. 2 [2010]   fulfill the quality demands of their practice. (1)EBP is as an approach to clinical decision-making that originated in medicine, and has been extended to other health professions.EBP has been defined as "the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care professionals in decisions making.In other words, EBP is a framework for clinical practice that involve the best current available scientific evidence with the expertise of the health professional and the patient's preferences and values to make decisions about health care. (2,3) dence-based nursing (EBN) does not differ too much from EBP, it was defined as "the effort to combine the best scientific evidence from and other research with the special clinical perspective of nurses in performing the full range of patient care activities pertinent to the nursing profession" (4) .
Using of research findings at the setting of care delivery is a core to provide high quality health care services and improve patient outcomes.Health professionals expect to use the research finding of rigorous studies, while the accumulation of research illustrating that some interventions appear to be more effective than others.Therefore, the EBP is a mean for the intended quality care.EBP provides safe and custom-made care that produces the preferred health outcomes and increase the care satisfaction in patients and families, as well as decreasing the cost of health care organizations (5)(6)(7) .
The required skills for EBP in health care is acquiring the evidence, appraising the evidence and applying the evidence, which are encompass the four steps of EBP.These four steps of EBP include formulate an answerable question, track down the best evidence of outcomes available, critically appraise the evidence and apply the evidence (4,8,9) .
In public health, the evidence-based practice was defined as "the process of integrating science-based interventions with community preferences to improve the health of population" (10) .Applying of EBP in community/ public health is very useful to formulate a choice of which program or intervention that would be more effective and culturally accepted by a community. (11)reover, EBP fulfills the demands of community health practice on the issue of updating the knowledge of health care professionals (12) .
EBP improves the process and the effectiveness of care and health outcomes at primary health care services and programs within the scope of community health fields such as (school health units, occupational health settings, chronic illness management, and control of diarrheal and acute respiratory diseases, as well as children's immunization schedules, and screening for antenatal care).The effectiveness of these programs is deadly depends on the competency of health professionals in accessing evidence-based information necessary for decision making (13)(14) .

The Egyptian Ministry of Health and
Population has articulated a long-term goal to improve the quality of primary care and preventive services and the skills of health professionals (13) .This goal could be acquired by integrating the EBP to the other attempts of improving quality of care within a political agenda (15)(16) .
In academic field, academic nurses play three different but interrelated roles that are educators, researchers, and collaborator partners with field practice personnel, which require application of EBP (17) .Therefore, they should be skillful  (18)(19)(20) .Therefore, academics are cues that motivate, educate, and support clinicians in research-based culture, as well as collaborate with them in conducting researches (17) .
Accordingly, nurses need to be well prepared to access the available best evidence to identify, develop, and disseminate the appropriate guideline and/ or other format of evidence application.
The most effective approach to meeting this crucial need is to develop collaborations among nurse researchers, practicing nurses, and the professional organization (21)(22)(23)  throughout the implementation process (24) .

International studies revealed
different nursing views about EBP that concluded their willingness to practice EBP.
Challenges and lacking for EBP skills and facilities were also mentioned (25)

Tool:
Semi-structured interview sheet: Semi structured interview was used to explore the knowledge and perception of participants regarding the application of EBP in community health nursing.

Methods:
I-Preparatory phase: 1-Ethical consideration: The proposal of this study was approved by:

2-Tool development:
After reviewing the literatures of EBP and studies on views of health professionals about EBP, the semiinterview sheet was developed.

Validity of tool:
A jury group of three academic nursing staff members who have experience in qualitative research revised the semistructured interview sheet.
A pilot study conducted on three faculty staff members and two nurses to test the validity of the tools.
Based on the jury group's opinion and the findings of the pilot study, modifications were made.

3-Designing and implementation of the EBP training program:
The training program was consisted of five sessions throughout two days, with total of 11 hours (Table1), different teaching and learning methods were used, which included interactive lecture, small group discussion, self-study, computer hands on practice and role-play.categories and themes (26) .

RESULTS:
The participants of the study consisted of 12 nurses who are working at primary Bull High Inst Public Health Vol.40 No. 2 [2010]   health care units (PN) and 14 academic staff of community health nursing (AN).
The majority of participants' ages ranged from 24 years up to 42 years old (n=17).
Regarding to their gender all of them were females and only one participant was male.
In relation to their qualification, about two thirds (n=16) had a bachelor degree in nursing, five participants had a master degree, three had PhD degree and two are technical nurses.The participants had years of experience that ranged from 2 years up to 19 years and the majority (n=17) had average of 13 experience years.
Only two academic staff members have been attended a session about evidencebased practice (EBP) before.
The results illustrate knowledge and views of participants as the main themes of this study.Quotations illustrating each section are presented with the identifier "AN" if the quote was stated by academic community health nurses and "PN" if the quote was stated by primary health care nurses.

Knowledge of participants about EBP:
The

Steps of evidence-based practice
"There is three steps….determinethe searching questions, searching the internet, and criticize the references" (AN)

Views of participants about EBP:
Due to knowledge insufficiency about EBP in both PN

4-Best method of applying EBP:
Regarding to the application manner of EBP, the majority of participants ("AN" n= 10 and "PN" n=11) found that journal club is the most applicable way that will embed the culture of EBP and keeping individuals' knowledge up to date, "To determine a meeting date to discuss the raised problem during Journal Club" (AN).However, PN added that producing clinical guideline would be a good tool in applying EBP, "Using developed or developing clinical guidelines is a proper way to introduce evidence into practice" (PN).

5-Challenges of applying EBP:
Participants perceived insufficient resources and poor personal interactions to elaborate the application of EBP.Most of them ("AN" n= 9 and "PN" n= 11) indicated that limited financial resources, inadequate electronic infrastructures and absence of experienced personnel among constrains of adopting EBP in primary health care setting, "Limited resources will hinder applying EBP there is not enough budgets and personnel who have experience" (PN).
PN viewed the personal interaction among health care professionals is lacking for cooperation and collaboration, as well as be deficient in teamwork deeds, which is crucial requirements for EBP.About one third of "AN" (n= 4) added that the inadequate statistical skills that they have, and are required for critical appraisal might hinder the application of EBP, "Most of us have poor level in statistical skills…., it is necessary for critical appraisal" (AN).

Box 2: Views of participants about evidence-based practice (EBP)
Perceived values of evidence-based practice Applicable "It is important and needs experiences and extended discussion, but it is applicable" (PN) "It is not time consuming like searching textbooks, or asking a consultant" (AN) Patient participation "Database searching is the most useful in EBP that is considered as an action plan based on patient's values and recent scientific reliable results" (PN) Objective problem solving "It is a realistic method for problem solving" (PN) "EBP will be useful in the daily clinical practice" (PN) "The searching for recent evidence will accumulate experiences that could be applied to solve further problems" (PN) "Seriously I think to use EBP, it increase information and help in problem solving" (AN) Updating nursing interventions

Information technology skills
"EBP needs to be skillful in using computer" (PN)

Statistical skills
"EBP require the health care professionals and academic staff to have a good skills in biostatistics" (AN) Creating environment for evidence-based practice Information technology "Facilities such as computers and internet lines should be provided" (PN)

Personal Interactions
"There is lacking of team work and poor communication" (PN)

Conceptual framework for implementing EBP:
The study participants suggested a conceptual model that would be used for implementing EBP at community health care settings.The model depends on a collaborative and cooperative approach between the academic nursing institution and primary health centers (PHC).

Organizational role:
A-A contract between academic nursing institutions and primary health centers to fulfill the following: • Academic nursing institution to permit PN to use the computer laboratories and to access its web database.Moreover, the present study is in agreement with prior Turkish study, which indicated that nurses perceived EBP to accumulate knowledge and provide standardization in care providing (32) (35)(36) .
Participants of the present study preferred clinical guidelines and journal clubs as methods of disseminating the approved evidence.This is confirmed by other studies, which indicated that journal club is used to introduce new evidence into practice and educate health professionals about evidence.As well as literatures reported that using guidelines improve the effectiveness and efficiency of interventions (37)(38) .
To acquire organizational support for EBP it is important to assess the learning needs of workforce staff and their perceived needs, and abilities (24) .Based computer skills, in addition to insufficient library and internet access (30,(39)(40) , These worksite environmental influences were stated in terms of lacking for tools and resources and absence of mentoring and consultants, other authors mention this views previously (24,(41)(42) .
The  (43)(44) Identification of a well structured framework to guide practice change and adequate mentorship and resources have been recommended by Aitken et al 2011 (45) .It was practical to draw up a conceptual  (46)(47)(48) .

CONCLUSION
The study concluded that providing

Table 1 :
Sessions of evidence-based practice training program Sessions Content The first session Introduction to the concept and skills of evidence-based practice The second session Practical training on "formulating answerable question" The Third session Practical training on "tracking down the evidence" The fourth session A practical training on "critically appraising evidence" Fifth session Applying the evidence III-Data collection: Data collection started one week before conducting the training program to collect the base line knowledge and views of participants about the EBP.The interviews were conducted with each participant for 15-20 minutes to investigate their knowledge and views about the EBP.The brief semi-structured interviews were taperecorded.Immediately at the end of the training program, the post knowledge and views were obtained by conducting another brief taped semi-structured interview with participants.Data analysis: Thematic analysis was used to explore participants' knowledge and views about EBP.The interview transcripts were analyzed to search for common themes, similarities, and/ or variations among students' knowledge and views.Data was coded, identified under categories and subcategories, and organized together under common themes.To boost validity of thematic analysis, three volunteer colleagues reviewed the findings to clarify the analysis in relation to emerging

Box 1 :
In relation to tracking the evidence, before attending the training program, most of "AN" (n= 11) identified the searching engines such as "Google and Yahoo" as evidence resources that they frequently access.No one identified the level of evidence in relation to the type of research design, while just two participants mentioned that the university offers an access to international database.After attending the training program both AN and PN participants acquired basic knowledge about tracking the evidence.One quarter of participants ("AN" n= 6, "PN" n= 2) described the tracking down the best evidence outcomes available in terms of identifying the level of evidence in relation to the different study designs."Systematic review of excremental studies is the least bias"(AN),"Systematic reviews of different study designs are less bias than primary studies" (AN), "Systematic review and guidelines are the most appropriate for actual practice" (PN).They also identified the different sources of evidence: "there are different type website searching engines such as pubmed and Google, EBP resources such as Cochran library"," literatures database such as EBSCO, Ovid and science direct" (AN).Regarding to critical appraisal of the evidence, before attending the training program only two AN mentioned that the tracked evidence should be appraised for its validity.They also pointed out some statistical terms such as confidence interval, odds ratio and relative risk.They mentioned that any articles should include these statistical terms to ensure the validity of the evidence's results.However, after attending the training program, more than two thirds of participants ("AN" n= 11, "PN" n= 7) described the critical appraisal of evidence as step that the obtained research publication to be analyzed for its appropriateness for the existing situations and available resources.Furthermore, other participants ("AN" n= 5, "PN" n= 2) emphasized on the strength of evidence in terms of study design and results validity, "The experimental trials are the strongest type of studies"' (AN), "To appraise an evidence…use a special formats and looks at the aim, research design and results for their strength" (PN) As regards to the application of evidence, journal club and clinical guidelines were mentioned by the majority of participants ("AN" n= 11, "PN" n= 9) as methods of EBP application: "Clinical guidelines, systematic reviews and journal club are methods to illustrate new research findings" (AN), "It will be easier if we used clinical guidelines to illustrate evidence" (PN), "Journal club will be a good chance for discussing new research results: (PN).They mentioned also that needs assessment and administrative support are among the application process of EBP: "To apply EBP, it requires assessing for the facilities of health centers"(PN), "the most common clinical questions should be determined"(PN), "Organizational attitude toward change should be evaluated" (AN).Knowledge of participants about evidence-based practice before and

•
Primary health centers to provide academic nursing institutions with the necessary information for developing research plans and permit conducting research studies at its affiliated health centers B-Primary health centers to provide administration support for adopting EBP, in terms of allocating time for nurses to conduct database searching and attend training program and journal club.Primary health centers to execute efforts for embedding teamwork culture among health care professionals C-Academic nursing institutions to provide academic staff members with continues and comprehensive training on EBP and its supportive courses (statistics and research methodology) Staff role: A-The academic nurses to provide primary care nurses with training programs and consultation in EBP B-The academic nurses to moderate the journal club sessions C-The academic nurses to develop and appraise clinical guidelines in cooperation with PN to provide applicable recommendations for field practice D-Primary health nurses to obtain the necessary information of patients' values and preferences Bull High Inst Public Health Vol.40 No.2 [2010] E-Primary health nurses to implement the approved evidence in caring for patients and consumers F-The academic nurses to conduct research studies according to the actual needs of stockholders (primary health centers and their consumers) Public Health Vol.40 No.2 [2010] coordination with patients.Furthermore, they found that using EBP is a tool of long self-learning that updates nursing competency and interventions.EBP was reported to advance nursing practice either for nurse educators or practitioners, as well as it acquires behavioral change at organizational and individual level. (31) on their experience and self-awareness the participants of the present study determined the hindering factors of EBP that underpinning the worksite environment.Studies allover the world indicated that workload and inadequate time, lack of administrative support are the most frequent barriers of accessing resources for evidence and or conducting meeting to discus about EBP.Other barriers are lacking for research and critique of the obtained articles as well as lacking for framework to implement EBP, which based on the perspectives of the community health-nursing professionals who involved at this study.The designed framework built on a partnership concept between academic nursing institution and primary health centers.This partnership concept mainly depends on the organizational culture that provides administrative support and creating suitable environment for implementing EBP.This in agreement with Bull High Inst Public Health Vol.40 No.2 [2010] several researchers, who have been described infrastructures and models that can sustain EBP.All of these descriptions and models emphasize structuring a proper environment for EBP and integrating efforts of research institutions with clinicians.Some features are underpinning these models that are, creation of expertise leadership, using the "train-of trainer" approach and applying principles of managing change.It was indicated also to involve of endpoint beneficiaries and to evaluate influence of innovated interventions on patients and families essential knowledge about evidencebased practice (EBP) enabled community health nurses to portray their perspectives about the values and possibilities of EBP application.Participants had positive views about the values of EBP as a strengthen approach to the standardization of decision-making.

Best method of applying evidence-based practice
.