Evaluating the effectiveness of educational intervention on evidence based practice knowledge, attitudes and beliefs among vietnamese’ nurses

Evaluating the Effectiveness of Educational Intervention on Evidence-based Practice Knowledge, Attitudes and Beliefs among Vietnamese’ Nurses By Nguyen Van Giang Submitted for the de

Evaluating the Effectiveness of Educational Intervention on

Evidence-based Practice Knowledge, Attitudes and Beliefs among

Vietnamese’ Nurses

By

Nguyen Van Giang

Submitted for the degree of

Evaluating the Effectiveness of Educational Intervention on

Evidence-based Practice Knowledge, Attitudes and Beliefs among

Vietnamese’ Nurses

By

Nguyen Van Giang

Submitted for the degree of

ABSTRACT Background: Evidence-based practice (EBP) has become an important element in delivering

optimal quality of care Barriers to the EBP implementation by nursing professionals include a lack of knowledge, less positive attitude and beliefs on EBP However, few studies have been conducted to evaluate the effectiveness of educational interventions to improve their knowledge, attitudes and beliefs on EBP

Objectives: To evaluate the effectiveness of multiple educational strategies on EBP knowledge, attitude and beliefs among Vietnamese nurses

Methods: This study was an experimental study with an experimental group and a comparison

group using a pretest-posttest design Participants included head nurses, nurses and midwives who were enrolled from August to September 2020 at the national hospital in Vietnam A total of

148 participants (76 in the comparison group and 72 in the experimental group) received four weeks of educational interventions The experimental group received multiple educational

strategies of EBP including face-to-face lectures, mentoring and online learning The comparison group received Incentive spirometry educational intervention on the same date and same period

of intervention The effectiveness of educational interventions was evaluated at pretest and posttest using the Vietnamese version of the EBP Knowledge test, EBP Attitude scale and EBP Beliefs scale The statistical software IBM SPSS 20 was used to analyze the data

Results: A total of 136 participants (66 in the comparison group and 70 in the experimental

group) completed four weeks of educational interventions The attrition rate was 8% The mean age of participants was 36.76 years and more than 77 % of them were females Participants who had never participated in any EBP training course account for 72.2 % There were significant

differences between the experimental group and the comparison group in participants’ EBP

knowledge, attitude and beliefs at posttest Participants’ EBP knowledge, attitudes and beliefs in the experimental group were significantly improved at posttest compared to pretest

Conclusions: Multiple educational strategies of EBP interventions were effectively improved

nurses’ EBP knowledge, attitude and beliefs The findings can be used as an important reference for improving EBP knowledge, attitude and beliefs on nursing students and other healthcare

professionals

KEYWORDS: evidence-based practice, nurses, education, mentoring, knowledge, attitude

ACKNOWLEDGMENTS

I iwould ilike ito iacknowledge iseveral ipeople iwho ihave isupported ime iduring imy

idoctoral ijourney. iFirst, iI iwould ilike ito iexpress imy ispecial ithank ito imy iadvisor iDr. iShu-Yuan

iLin. iI iam igrateful ifor iher iexpertise, iwisdom iand ifriendship iwhich ihave iserved ito ikeep ime

ifocused, igrounded and guided the project from the beginning to the end. iWithout iher isupport

iand iguidance, iI icould inot ihave icompleted ithis idissertation I also would like to thank the other staff and professors at College of Nursing, Kaohsiung Medical University who provided some forms of support

Second, iI iwould ilike ito iextend imy igratitude ito iDr. iStevens ifor iallowing ime ito iuse ithe

iEvidence-based iPractice iKnowledge itest, iDr. iAarons ifor iusing ithe iEvidence-based iPractice

iAttitude iand ito iDr. iBernadette iMelnyk iand iDr. iEllen iFineout-Overholt ifor ipermitting ime ito

iuse ithe iEvidence-based iPractice iBeliefs in this study

Third, iI iwould ilike ito iexpress imy igratitude ito ithe iVice ipresident iof iThai iNguyen

iNational iHospital, iVietnam, iDr. iDuong iHong iThai, iwho isupported iand iapproved imy idata

icollection. iHis iconnections iwith iall iclinical iunits ihelp ime ito iconduct ithe ieducational

interventions iwithout icosting ime itoo imuch. iThat isaved ime ia ilot iof imoney iin icompleting ithis

istudy

Last ibut inot ileast, iI iwould ilike ito ithank iteachers, imentors iand iall iparticipants in this study. iThanks iyou ifor iyour itime iand ihonest iresponses iinvolved iin ithis istudy. i

TABLE OF CONTENTS ABSTRACT II ACKNOWLEDGMENTS III TABLE OF CONTENTS V LIST OF ABBREVIATIONS VIII LIST OF TABLES IX LIST OF FIGURES X LIST OF APPENDICES XI

CHAPTER ONE 1

Introduction 1

Background of the Study 1

Purposes of the Study 4

Research Questions 5

Research Hypotheses 6

Definitions of Variables 7

CHAPTER TWO 9

LITERATURE REVIEW 9

Evidence-based Practice 9

Developing history 9

Definition of evidence-based practice 9

Benefits of evidence-based practice 10

Barriers of evidence-based practice 10

Conceptual models of EBP 11

Nurses’ Knowledge of Evidence-based Practice 13

Nurses’ Attitude toward Evidence-based Practice 14

Nurses’ Beliefs about Evidence-based Practice 16

Reviews the effectiveness of EBP educational intervention 18

Procedures 18

Data extraction and synthesis 19

Main findings 21

Conclusions 22

CHAPTER THREE 23

Methodology 23

Study Design 24

Setting 24

Sampling 24

Cluster randomized design 25

EBP Educational Intervention 25

Incentive Spirometry Educational Intervention 26

Instruments 30

Demographic and work characteristics sheet 30

The V-ACE-ERI knowledge test 30

The V-EBPA 31

The V-EBPB 31

Procedures 32

Data Analysis 35

Ethical Consideration 36

CHAPTER FOUR 37

Results 37

Demographic and Work Characteristics of Participants 37

Comparisons of EBP Knowledge between Two Groups 39

Comparisons of EBP Knowledge within Two Groups 39

Comparisons of the Correct Percentage of Knowledge Items between Pretest and Posttest 40

Comparisons of EBP Attitudes between Two Groups 42

Comparisons of EBP Attitudes within Two Groups 42

Comparisons of the Percent of Positive Attitude Items between Pretest and Posttest 43

Comparisons of EBP Beliefs between Two Groups 45

Comparisons of EBP Beliefs within Two Groups 45

Comparisons of the Percent of Positive Beliefs Items between Pretest and Posttest 46

CHAPTER FIVE 48

Discussion 48

Demographic and Work Characteristic of Participants 48

Comparisons in Changes of EBP Knowledge between Group and Time 49

The Correct Percentage of Knowledge Items between Pretest and Postest 50

Comparisons in Changes of EBP Attitude between Group and Time 51

The Percent of Positive Beliefs Items between Pretest and Posttest 52

Comparisons in Changes of EBP Beliefs between Group and Time 22

The Percent of Positive Beliefs Items between Pretest and Posttest 54

Effectiveness of Educational Intervention in EBP 54

Strengths of the Study 56

Limitations of the Study 57

Implications of the Study 58

CONCLUSION 60

REFERENCES 61

LIST OF ABBREVIATIONS

ACE-ERI Academic Center for Evidence-based Practice Readiness Inventory

EBP-A Evidence-based Practice Attitude

EBP-B Evidence-based Practice Beliefs

EBPQ Evidence-based Practice Questionnaires

PICO Population, Intervention, Comparision and Outcomes

V-ACE-ERI Vietnamese version of the ACE-ERI

V-EBPA Vietnamese version of Evidence-based Practice Attitude

V-EBPB Vietnamese version of Evidence-based Practice Beliefs

LIST OF TABLES

Table 3 Demographic and work characteristics of Participants 38 Table 4 Comparisons of EBP knowledge scores between two groups 39 Table 5 Comparisons of EBP knowledge scores within two groups 39 Table 6 Comparisons of the correct percentage of knowledge items

Table 7 Comparisons of EBP attitude scores between two groups 42 Table 8 Comparisons of EBP attitude scores between two groups 42 Table 9 Comparisons of the percent of positive attitude items between

Table 10 Comparisons of EBP beliefs scores between two groups 45 Table 11 Comparisons of EBP beliefs scores between two groups 45 Table 12 Comparisons of the percent of positive beliefs items between

LIST OF FIGURES

Figure 1 The Stevens Star Model of Knowledge Transformation© 12

LIST OF APPENDICES

Appendix C The Vietnamese evidence-based practice attitude scale 75 Appendix D The Vietnamese evidence-based practice beliefs scale 76

Appendix M Synthesis of the category describing contents, teaching and 98

learning method and outcome of educational intervention

CHAPTER ONE

Introduction

This chapter comprised the background of the study, purposes of the study, research questions, research hypotheses, and definitions of variables

Background of the Study

Globally, evidence-based practice (EBP) has been acknowledged in the nursing profession over the past three decades Evidence-based practice is an approach to narrowing the gap between research and practice (Green, 2014; Worum, Lillekroken, Ahlsen, Roaldsen

& Bergland, 2019), which incorporates the best research evidence with healthcare

professional’s clinical expertise and patient’s preference (Disler, White, Franklin, Armari & Jackson, 2019; Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2014; Straus, Glasziou, Richardson & Haynes, 2018) The Institute of Medicine suggested that 90% of clinical decisions made should base on evidence by 2020 (Institutes of Medicine, 2011)

The evidence-based practice provides nurses a problem-solving approach to assist in developing professional nursing roles, deliver high quality of care, improve patient outcomes and decrease healthcare costs (Khammarnia, Haj, Amani, Rezaeian & Setoodehzadeh, 2015; Melnyk et al., 2014; Stevens, 2013) To date, the progress of implementing EBP in the nursing profession is slow because nurses face numerous barriers (Alatawi et al., 2020; Khammarnia et al., 2015; Malik, McKenna & Plummer, 2016) These barriers include lack of continuous education in academic and practice setting, insufficient EBP knowledge, lack of time, negative attitude toward EBP, negative belief about EBP, lack of searching skills, lack

of mentors’ support, insufficient English proficiency and inadequate databases (Baird & Miller, 2015; Duncombe, 2018; Jun, Kovner & Stimpfel, 2016)

The EBP knowledge, attitude and beliefs among nurses are very important elements

in implementing EBP (AbuRuz, Hayeah, Dweik & Akash, 2017; Jun et al., 2016; Kang &

Yang, 2016) According to Yoo and colleagues (2019), improving the knowledge, attitude and beliefs among nurses is the first step of EBP implementation Nurses’ knowledge,

attitude and skills of EBB allow their abilities to implement EBP (Bianchi et al., 2018;

Khammarnia et al., 2015; Majid et al., 2011) Nurses with positive attitudes and beliefs of EBP would improve their abilities and confidence to implement EBP (Kang & Yang, 2016; Melnyk, Fineout-Overholt, Giggleman & Cruz, 2010)

The EBP educational intervention has been demonstrated to improve nurses’ skills, knowledge of EBP, positive attitudes toward EBP and positive behaviors in implementing EBP (Hassona & Winkelman, 2014; Koota, Kääriäinen & Melender, 2018; Melender, Mattila

& Haggman-Laitila, 2015) The EBP educational intervention plays an important role in assisting nurses to acquire knowledge and skills of EBP (Häggman-Laitila, Mattila, &

Melender, 2016; Keele, 2010) Thus, an effective EBP educational intervention could provide nurses with sufficient knowledge and skills to implement EBP in practice and evaluate the outcomes (Cruz et al., 2016; Verloo, Desmedt & Morin, 2017; Zhou, Hao, Guo & Liu, 2016) Likewise, Wallin and colleagues (2003) indicated nurses who received effective EBP

educational interventions were more likely to implement EBP projects in practice However, effective EBP interventional education has not been identified in the clinical settings (Black, Balneaves, Garossino, Puyat & Qian, 2015; Stokke, Olsen, Espehaug & Nortvedt, 2014)

There is limited study examing the effect of EBP educational intervention on nurses’ knowledge, attitude and beliefs of EBP implementation in developing countries (Saunders & Vehviläinen-Julkunen, 2016) The previous studies reported significant barriers in

implementing EBP in developing countries such as insufficient EBP knowledge, inadequate EBP skills, negative attitude and beliefs of EBP and insufficient administrative supports (Chang, Russell & Jones, 2010; Chen, Shao, Hsiao & Lee, 2013; Wang, Jiang, Wang & Bai, 2013) A study conducted in Taiwan found 25.5 % of nurses had sufficient knowledge and

only 12.3% of them had adequate skills to implement EBP (Weng et al., 2015) A Vietnam study found 60% of healthcare professionals had the basic knowledge of EBP in primary care (Eriksson et al., 2009) Another study conducted in Vietnam showed only 29.5% of

Vietnamese nurses familiar with the EBP terminology and 22.7% of them felt confident about EBP skills Only 57.7% of nurses believed in EBP implementation enhancing the quality of care (Nguyen & Wilson, 2016) A recent Vietnam study found 73.4% of nurses had never received EBP training and 44.4 % of them had never heard about the terminology “EBP” (Giang, Lin & Thai 2020) Therefore, there was an urgent need for implementing EBP

educational intervention to promote nurses’ knowledge, attitude and beliefs of EBP in

Vietnam (Nguyen & Wilson, 2016; Wiechula, Nguyen & Rasmussen, 2014) The purpose of this study was to evaluate the effectiveness of an educational intervention on evidence-based practice knowledge, attitudes and beliefs among Vietnamese nurses

Purposes of the Study

The specific purposes of this study are listed as follows:

1 To evaluate the effectiveness of educational intervention on evidence-based practice knowledge among nurses

2 To evaluate the effectiveness of educational intervention on evidence-based practice attitudes among nurses

3 To evaluate the effectiveness of educational intervention on evidence-based practice beliefs among nurses

Research Questions

Research questions were listed as follows:

Research question 1 What were the differences between the experimental and comparison

groups in nurses’EBP knowledge at the posttest?

Research question 2 What were the changes between pretest and posttest in nurses’EBP

knowledge in the experimental group?

Research question 3 What were the differences between the experimental and comparison

groups in nurses’EBP attitudes at the posttest?

Research question 4 What were the changes between pretest and posttest in nurses’EBP

attitudes in the experimental group?

Research question 5 What were the differences between the experimental and comparison

groups in nurses’EBP beliefs at the posttest?

Research question 6 What were the changes between pretest and posttest in nurses’EBP

beliefs in the experimental group?

Research Hypotheses

Research hypotheses were assumed as follows:

Hypothesis 1 There were significant differences between the experimental and comparison

groups in nurses’EBP knowledge at the posttest

Hypothesis 2 There were significant differences between pretest and posttest in nurses’EBP

knowledge in the experimental group

Hypothesis 3 There were significant differences between the experimental and comparison

groups in nurses’EBP attitudes at the posttest

Hypothesis 4 There were significant differences between pretest and posttest in nurses’EBP

attitudes in the experimental group

Hypothesis 5 There were significant differences between the experimental and comparison

group in nurses’EBP beliefs scores at the posttest

Hypothesis 6 There were significant differences between pretest and posttest in nurses’EBP

beliefs in the experimental group

Definitions of the Variables

Conceptual and operational definitions of the variables were presented as follows:

Knowledge of evidence-based practice

2004) A higher score means more knowledge of EBP

Attitude toward evidence-based practice

Beliefs about evidence-based practice

1 Conceptual definition

It refers to nurses’ perceptions, values, confidence and abilities to implement EBP (Melnyk, Fineout-Overholt & Mays, 2008)

2 Operational definition

It was measured by the Vietnamese version of the evidence-based practice belief scale (Giang et al., 2020) This scale contained 16 items including four dimensions of value beliefs, knowledge beliefs, resource beliefs, and time and difficulty beliefs A higher score means more positive beliefs about EBP implementation

Educational intervention on evidence-based practice

It refers to EBP teaching and learning methods that may be done by a single strategy

or multiple strategies such as face-to-face lectures, workshops, discussion, mentoring,

conferences and online learning sessions (Dawes et al., 2005; Tilson et al., 2011) The EBP curriculum needs to be grounded on the five steps of EBP (Ask, Acquire, Appraise, Apply and Assess) Learning goals should include four components as follows: knowledge/skills, attitude, beliefs and practice (Dawes et al., 2005; Melnyk et al., 2014)

Face-to-face lecture is a teacher-centered method of education where course content and learning material are taught in person to a group of learner This allows learners benefit from a greater level of interaction between learners and an teacher (Davis et al., 2007)

Mentoring is a relationship between a more experienced person, the mentor, and a less experienced person, the mentee or trainee, within which important career skills are

transferred from one to the other (Roe & Whyte-Marshall, 2012)

Online learning is defined as learning that takes place partially or entirely over the Internet (Means et al., 2010)

CHAPTER TWO

Literature Review

This chapter included extensive reviews of evidence-based practice, nurses’

knowledge of EBP, attitude toward EBP, beliefs about EBP and systematic review of EBP educational intervention

Evidence-Based Practice

Developing history

The evidence-based practice was derived from Florence Nightingale in the 1800s to medical physician practice in the 1970s to the nursing profession in the late 1990s It began with an idea of improving patients’ outcomes who experienced unsanitary conditions and develop a foundation for nurses to provide safe care (Mackey & Bassendowski, 2017;

Nightingale, 1992) Although the evidence-based practice term was not mentioned,

Nightingale used evidence through experimental and critical examination to improve the patient’s outcome (Nightingale, 1992) In the 1970s, the term evidence-based medicine was initially mentioned by Dr Cochrane During this time, all of the decision-making regarding patients’ conditions were based on the physician’s assessment and decision (Eddy, 2005) Cochrane stated that randomized control trials provided the best evidence to healthcare decision-making about clinical practice (Aravind & Chung, 2010) In the early 1990s, the term evidence-based medicine was widely used in literature and clearly defined by Sackett (Aravind & Chung, 2010; Beyea & Slattery, 2013) Sackett (1996) recommended that

clinicians should diagnose patients’ conditions based on the best evidence from valid research and integrated with individual patient preference and value (Sackett, Rosenberg, Gray,

Haynes, & Richardson, 1996)

Definitions of evidence-based practice

According to Sacket and colleagues (1996), evidence-based practice is an approach to

Evidence-based nursing has been defined as a problem-solving strategy to translate the theory

to practice that integrates the use of updated evidence, considerations of an individual’s preference and healthcare provider’s expertise (Beyea & Slattery, 2013; Melnyk & Fineout-Overholt, 2011; Stevens, 2013) The International Council of Nurse defined EBP as a

problem-solving approach to clinical decision-making in integrating the best evidence with clinical expertise and patients’ value within the context of caring (International Council of Nurse, 2012)

Benefits of evidence-based practice

Evidence-based practice is a way of healthcare professionals to fix the gap between theory and practice (Hanberg & Brown, 2006; International Council of Nurse, 2012) The translation from research into practice at bedsides may improve the quality of care, patients’ safety, and enhance patients’ outcomes (Curtis, Fry, Shaban & Considine, 2017; Smith & Donze, 2010) Numerous researchers stated that EBP would foster the highest quality of care, improve patients’ outcomes and decrease healthcare costs (Melnyk, Fineout-Overholt,

Gallagher-Ford & Kaplan, 2012; Melnyk et al., 2014) Evidence-based practice also assists healthcare professionals in implementing the best care with proper decision-making and reducing medical errors (Rycroft-Malone & Bucknall, 2011; Stevens, 2013; White, Dudley-

Brown & Terhaar, 2016)

Barriers of evidence-based practice

Healthcare professionals including nurses may face many barriers in translating

evidence to practice (Abrahamson, Fox, & Doebbeling, 2012; Khammarnia et al., 2015; Stavor, Zedreck-Gonzalez, & Hoffmann, 2017; Yoder et al., 2014) These barriers include insufficient knowledge and skills of EBP, negative attitudes and beliefs of the EBP values, time constraints, workload, inexperience in computer and library searching skills, limited understanding of researches and terminologies, lack of confidence in analyzing and

synthesizing literature, insufficient colleagues, mentors and administrators support

(Abrahamson et al., 2012; Khammarnia et al., 2015; Stavor et al., 2017; Yoder et al., 2014)

Conceptual models of evidence-based practice

Many models have been recommended to overcome barriers in implementing EBP and minimize the gap between theory and practice These models include the ACE Star Model of Knowledge Transformation, the Iowa Model, Advancing Research and Clinical through Close Collaboration, the John Hopkins Nursing Evidence-Based Practice, the Promoting Action on Research Implementation, the Roger Diffusion, and the Innovation Model and the Stetler Model (Melnyk, 2017; Schaffer, Sandau, & Diedrick, 2013) Each model had similar core elements: (1) Identifying and asking clinical problems, (2) Searching and critically appraising the best evidence, (3) Recommending for clinical decision making, (4) Applying the

recommendations and (5) Evaluating the outcomes (Melnyk, 2017; Rycroft-Malone &

Bucknall, 2011; Schaffer et al., 2013)

In this study, The ACE Star Model ofKnowledge Transformation (Stevens, 2004) is the most appropriate to be used The ACE Star model is a practical model developed to guide nurses to translate evidence into practice (Stevens, 2004; Stevens, 2012) This model provides

a framework for understanding the cycles, nature, and characteristics ofknowledge used in the EBP process Itexplains how various stages of knowledge transformation reduce the volume ofscientific literature and provide forms of knowledge that can be directly incorporated in

healthcare and the decision-making process (Stevens, 2012)

The ACE Star model is a five-point star (Figure 1), with each point representing a stage

inthe EBP process as follows: (1) Discovery of new knowledge is found through traditional research In this stage,knowledge is generated by research methodologies, (2) Evidence from all research knowledge is synthesized into asingle, integrative review and a meaningful

statement of knowledge, (3) Translation of research evidence is converted to clinical practice

recommendations, (4) Integration is implemented through clinical decision-making that leads

to achange of practice, and (5) Evaluation is done according to patient outcomes, health care provider / patient satisfaction,and efficiency

Figure 1 The Stevens Star Model of Knowledge Transformation© (Stevens, 2012) with five

stars points Reprinted with explicit permission

Nurses’ Knowledge of Evidence-based Practice

Upton, 2006) According to the ACE Star model, nurses’ knowledge is transformed through

various stages such as discovering new knowledge from traditional research, synthesizing all research into meaningful statements, converting the best evidence into recommendations and implementing these recommendations into practice (Stevens et al., 2012; Stevens, 2004)

Measurement of nurses’ knowledge of evidence-based practice

Stevens (2012) developed an Academic Center for Evidence-based Practice Readiness Inventory (ACE-ERI) scale to evaluate nurses’ EBP competence including EBP knowledge and self-efficacy Knowledge of EBP was assessed using the 15-question ACE-ERI knowledge test Nurses were asked to select the best answer for each question The total scores range from 0 to

15 A higher score means more knowledge of EBP The internal consistency reliability of the ACE-ERI scale as indicated by Cronbach's alpha (α) coefficients greater than 0.90 (Stevens, 2012) This scale has been used to assess EBP knowledge of nurses, students and educators in different settings (Orta et al., 2016; Saunders, Vehviläinen-Julkunen & Stevens, 2016; Stevens

et al., 2012)

Upton and Upton (2006) developed the EBP questionnaire (EBPQ) to assess nurses’ knowledge or skills, attitudes, and practice of EBP The knowledge subscale contained 14 items with a 7-point Likert response scale ranging from 1 to 7 The total scores range from 14

to 98 Higher scores indicate more knowledge of EBP The EBPQ has been translated into

many languages, and its psychometric properties were found acceptable (Aburuz et al., 2017; Upton, Upton, & Scurlock‐Evans, 2014)

Empirical studies

In the United States, Orta and colleagues (2016) conducted a quasi-experimental study using the ACE-ERI to measure nurses’ knowledge of EBP The results found no significant improvement in nurses’ knowledge of EBP after receiving EBP educational intervention John (2016) also conducted a quasi-experimental study using the ACE-ERI to assess nurses’ EBP knowledge The findings found significant improvement in nurses’ knowledge of EBP after receiving EBP educational intervention (John, 2016) A Finland study conducted a randomized control trial study using the ACE-ERI knowledge test to measure nurses’ knowledge of EBP The result showed nurses’ EBP knowledge was significantly increased after receiving EBP educational intervention (Saunders et al., 2016)

Nurses’ Attitude toward Evidence-based Practice

Definition

According to Crano and colleagues (2006), attitude reflects individuals’ evaluation to

implement a particular activity Nurses’ attitude toward EBP refers to their intention to adopt new types of therapy, interventions, or treatments in practice (Aarons, 2004)

Measurement of nurses’ attitudes toward evidence-based practice

Aarons (2004) was the first author to develop the EBP attitude scale (EBP-A) to

measure healthcare professionals’ EBP attitudes in mental health settings (Aarons, 2004) The EBP-A scale contained 15 items with requirement (3 items), appeal (4 items), openness (4 items) and divergence (4 items) subscales The scale is rated on a 5-point Likert scale, ranging from 0 (not at all) to 4 (very great extent) The total scores range from 4 to 60

Higher scores mean more positive attitudes toward EBP (Aarons, 2004) Construct validity of the EBP-A scale was evaluated by using exploratory factor analysis (EFA) and confirmatory

factor analysis (CFA) The result of the EFA indicated all items had a factor loading greater than 0.39, with a four-factor structure accounting for 63% of the total variance The result of the CFA confirmed the EFA-based a four-factor structure and the model demonstrated good fit (χ2(84) = 144.92, CFI = 0.93, TLI = 0.92, RMSEA = 0.067, SRMR = 0.077) (Aarons, 2004) The reliability of the original EBP-A scale as indicated by Cronbach's α coefficient was 0.77 (Aarons, 2004) The EBP-A scale has been translated into many languages, and its psychometric properties were found acceptable (Aarons et al., 2010; Santesson, Bäckström, Holmberg, Perrin, & Jarbin, 2020; van Sonsbeek et al., 2015)

Aarons (2012) expanded his EBP-A scale with 15 items and developed a new EBP-A scale renamed as the EBPAS-50 This scale contained 50 items with added more eight

subscales including limitation (7 items), value and needs (7 items), monitoring (4 items), balancing skills (4 items), burden (4 items), job security (3 items), organizational supports ( 3 items) and feedback (3 items) The internal consistency reliabilities of the EBPAS-50 as

indicated by Cronbach's α coefficients ranging from 0.77 to 0.92 (Aarons, Cafri, Lugo, & Sawitzky, 2012)

Upton and Upton (2006) developed EBPQ to assess nurses’ knowledge/skills, attitudes, and practice of EBP The attitude subscale contained four items It was rated on a 7-point Likert scale ranging from 1 to 7 The total scores range from 4 to 28 Higher scores indicate more positive attitudes toward EBP The EBPQ has been translated into many languages with acceptable validity and reliability (Aburuz et al., 2017; Upton et al., 2014)

the EBP-A scale were likely generalizable to various service settings Sonsbeek and

colleagues (2015) evaluated Dutch nurses’ attitudes toward EBP in youth care professionals The results found that the factor structure and internal consistency reliability of the EBP-A scale could generalize to diverse samples of youth care professionals

In the United States, Sciarra (2011) conducted a quasi-experimental study using the EBPQ to assess nurses’ attitudes after receiving EBP educational intervention The result found significant improvement in nurses’ attitude toward EBP after receiving EBP

educational intervention Mollon and colleagues (2012) assessed nurses’ attitudes toward EBP after receiving EBP online learning in a quasi-experimental study The finding found no significant improvement in nurses’ attitudes toward EBP after receiving EBP educational intervention Another study conducted a quasi-experimental study using EBPQ to assess the effectiveness of EBP educational intervention on nurses’ attitudes toward EBP The result found no significant improvement in nurses’ attitudes toward EBP after receiving EBP educational intervention (Ramos-Morcillo, Serafín, Ruzafa-Martínez, & Casado, 2015) The Korean study found a significant improvement in nurses’ attitudes toward EBP after

receiving EBP educational intervention (Sim et al., 2016)

Nurses’ Beliefs about Evidence-based Practice

Definition

Beliefs of nurses to EBP refer to their perceptions, values, confidence andabilities of implementing EBP(Melnyk et al., 2008)

Measurement of nurses’ beliefs of evidence-based practice

Melnyk and colleagues (2008) developed the EBP beliefs scale (EBP-B) to measure beliefs about EBP among nurses from five states in the United States The EBP-B scale was derived from the transtheoretical of change (Melnyk et al., 2008; Prochaska & DiClemente, 2005) The EBP-B scale contained 16 items with four subscales including value beliefs,

knowledge beliefs, resource beliefs, and difficulty beliefs Subjects are asked to rate on a point Likert scale ranging from 1 (disagree strongly) to 5 (agree strongly) Two negative wording items had scored reversely The total scores range from 5 to 80 Higher scores mean more positive beliefs about EBP (Melnyk et al., 2008) Construct validity of the EBP-B scale was evaluated by using principal component analysis (PCA) confirmed all items had a factor loading greater than 0.35, with a four-factor structure accounting for 55% of the total

5-variance.The reliability of the EBP-B scale as indicated by Cronbach's α coefficient was 90 (Estrada, 2009; Melnyk et al., 2008) The EBP-B scale has been tested and used extensively

in Norway, France, Slovak and Czech (Estrada, 2009; Stokke et al., 2014; Verloo et al., 2017; Zeleníková et al., 2016)

Reviews the effectivenss of EBP Educational Intervention

Procedures

The review was implemented based on the Centre for Review and Dissemination (2009) procedure to conduct a systematic review in health care The literature was searched from the following online databases: Embase, Web of Science, Cochrane, PubMed, and CINAHL A search engine such as Google and Google Scholar was used to find the relevant website and scholarly articles The key search terms were modified for each database The keywords included evidence-based practice, nursing, evidence-based practice education, nurse, knowledge, skills, attitude, beliefs, readiness, and competence The search years of each database were limited from January 1st, 1990 to October 31st, 2019 A manual search of the reference was also used

Studies were included in the review with the following inclusion criteria: (1) the participants were nurses or nurses and other healthcare professionals, (2) studied described educational interventions for evidence-based nursing and evaluated its intervention, (3)

studies result comprised of self-report or objective measurement of nurses related outcome in the following at least one of areas: knowledge, attitude, beliefs, skill, self-efficacy,

competence, readiness and implementation related to EBP, (4) studies were experimental

design and quasi-experimental design, and (5) abstract and full text were available for review

Exclusion articles were (1) studies that did not describe educational interventions for EBP, (2) observational studies, correlational studies, cross-sectional studies, mixed-method design and qualitative studies, and (3) The studies that were published as conference

abstracts, conference paper, review and article in press

The PRISMA flow diagram was presented in Figure 2 A total of 10423 articles were identified for screening The titles and abstracts were first screened based on inclusion and exclusion criteria Articles were excluded when (1) studies were not related to EBP

educational intervention, (2) the design was non-experimental, mixed-method and qualitative research, and (3) the studies were published as conference abstracts, conference papers, review, the article in press Then, we included 217 full-text articles to assess for eligibility One hundred seventy-eight articles were excluded after examination of the full text based on reasons of (1) participants were not nurses, (2) studies did not describe the intervention, (3) intervention used were not for evidence-based nursing and (4) outcome evaluations were not measurements of nurses’ EBP knowledge, attitude, beliefs, skill, self-efficacy, competence, readiness and implementation Finally, a total of 30 full- text articles were selected for the final appraisal

Data extraction and synthesis

Data from each study were extracted and placed in the matrix, namely (1) study design and participants, (2) educational intervention and duration, (3) instruments and

outcomes measurement and (4) main results (Appendix L) The information of the matrix was analyzed by narrative synthesis The similarities and differences of contents were reduced with similar information and grouped into categories The process of abstraction continued until categories excluded each other and form mainly categories by combining the same contents and names The process of analysis and synthesis produced four main types: (1) learning content, (2) teaching and learning methods, (3) measurement, and (4) outcome of the intervention The detail was illustrated in Appendix M

Figure 2: The PRISMA diagram

Articles searched through databases: (N = 10421)

- Non-experimental research design, mixed method design and qualitative research (n=2718)

- The studies were published as conference abstract, conference papers, review, article in press (n=247)

Articles assessed for eligibility

N = 217

Full text articles excluded with reasons (n=187) + Participants not nurse or nurses and other healthcare professionals: 93

+ Not describe intervention: 61 + Intervention not for evidence- based nursing: 18

+ Outcome evaluation unclear:

15

Full text articles included in the review

N = 30 (26 articled addressed quasi- experimental design and four articles used randomized control trial design)

Main findings

1 Description of includes studies

The 30 articles included articles in the review were quasi-experimental studies (26 articles) and randomized control trials (4 articles)

2 Learning contents of EBP educational intervention

The category of learning contents could be divided into three categories: the process

of EBP (30 articles), the principle of EBP and research (30 articles), and planning to

implement in practice (11 articles) (Appendix L)

3 Teaching and learning methods

The main category of teaching and learning methods of the educational intervention is divided into five categories including face-to-face lectures (17 articles), online learning (17 articles), small group discussions (15 articles), mentoring (11 articles), and poster

presentations (5 articles) Seventeen studies addressed multiple strategies of EBP educational interventions Thirteen studies used a single strategy of EBP educational intervention

(Appendix M)

4 Measurement of educational intervention

The instruments were used to evaluate the effectiveness of the educational

intervention on nurses could divide into six categories, including attitude toward EBP (13 articles), beliefs about EBP (10 articles), knowledge /skills of EBP (17 articles), self-efficacy

or competence of EBP (9 articles), and practice or implementation of EBP (9 articles)

5 The outcome of the interventions

Outcomes of educational intervention could divide into five categories included positive changes in attitude (8 articles), positive changes in belief (10 articles), improved knowledge/skills of EBP and research (12 articles), improved confidences of EBP (8 articles) and engaged in EBP project (6 articles) (Appendix M)

Conclusions

Most learning contents of EBP intervention included five steps of EBP (Ask, Acquire, Appraise, Apply and Assess) The most common teaching and learning methods were face-to-face lectures, online learning sessions, mentoring and small group discussion The most effective of the EBP educational intervention was multiple strategies This review also found the benefits of EBP educational intervention to improve at least one of the following

indicators: knowledge/skills, attitude, beliefs, confidences and implementation of EBP

The systematic review recommends the need to develop an effective EBP educational intervention to improve nurses’ knowledge, attitude and beliefs on EBP as follows: The goal

of the EBP educational intervention should be as follows: (1) equip nurses with sufficient knowledge to understand EBP concepts and research and have positive attitudes and beliefs about the values of EBP, (2) The curriculum should include a detailed description of learning contents with multiple strategies which should include five steps of EBP, (3)Teachers and mentors who teach and guide EBP education intervention should have knowledge of EBP and adequate critical appraisal skills (4) It is important to use validated instruments that match the aim of the curriculum, the EBP model, contents, and methods of educational

interventions

- Attitude toward EBP

- Beliefs about EBP

Comparison Group

Incentive Spirometry educational intervention

Figure 3 Study Framework

Knowledge of EBP

Attitude toward EBP

Beliefs about EBP

Pretest

Experimental Group

EBP educational intervention

Posttest

4 weeks

4 weeks

Study Design

This study was a quasi-experimental study with an experimental group and a

comparison group using a pre-and-post-test design

invited to this study Inclusion criteria were (1) head nurses, nurses and midwives who

graduated from college degrees and above, and (2) those who gave consent to participate in this study Participants working with non-tenure contracts or employed in the hospital for less than three months were excluded

Sample sizes of this study were calculated using G* Power version 3.1.9 Based on Cohen (1992), a power analysis was computed to determine the expected sample size for the study A sufficient sample size was calculated to detect a mean difference in nurses’

knowledge, attitude and beliefs of EBP between the experimental and comparison groups large enough for a medium-sized effect (0.5) (Julious, 2010; Saunders et al., 2016) Therefore, the estimated sample size with 80% power, an alpha level of 0.05 using a two-sided, independent

sample t-test were set and resulted in 64 participants for each group A total of 148 participants

who met inclusion criteria were recruited in this study Finally, one hundred thirty-six (N=136)

participants completed the study

Cluster Randomized Design

Participants who participated in this study were randomly assigned to either the

experimental or comparison group using the IBM SPSS 20 software The principal researcher made a list of units and inserted the code number The code numbers of units were made and accessed to IBM SPSS 20 software by the principal researcher The code numbers of units were generated as a set of random numbers Then, these random numbers were assigned

randomly to either experimental or comparison groups (1:1 ratio) All participants (N =148) were randomly assigned to the experimental group and the comparison group by units (14 units per group) Seventy-two (n=72) participants were assigned to the experimental group and the comparison group had seventy-six (n=76) participants Unit participants were blinded

as to which group they were assigned They were unaware of the existence of any other group than the one they received

The EBP Educational Intervention

Participants in the experimental group received four weeks of multiple strategies of EBP educational intervention It consisted of a 16-hour face-to-face lecture with mentors, a 5-hour group presentation and supplementary online learning (Table 1)

The contents of the 16-hour lecture were (1) the EBP introduction, (2) Overview of EBP models, (3) Ask the PICO (Population, Intervention, Comparison and Outcome)

questions, (4) Acquire evidence, (5) Appraise evidence, (6) Identify the barriers and facilitators

ofEBP and (7) Assess the outcomes and make changes in practice The administrative hospital approved these materials used in this study Ten mentors who (1) held at least a master’s degree and (2) were experienced in EBP and teaching at Medical University was invited by the principal researcher The principal researcher explained the purpose and process of EBP

educational intervention to them Ten mentors were trained for 3 hours During the training program, the mentors received the whole teaching material of the EBP intervention Mentoring

function in this intervention included strategies to encourage the group members to achieve learning goals, lead the group discussions, prepare presentations that setting in the PowerPoint and participate in evaluations of the group The Vietnamese version of the ACE-ERI

knowledge test (Giang et al.,2020) was used to evaluate the knowledge of EBP among mentors (Appendix B) The mean score of the V-ACE-ERI knowledge test was 14.4 (SD= 52) The results demonstrated ten mentors had competence of EBP knowledge to guide nurses in this EBP educational intervention

The contents of 5-hour group presentations included a clinical PICO question,

searching evidence, appraising evidence and summed up the evidence

Four weeks of supplementary online learning was provided to participants in the

experimental group Each participant was provided a personal account with a password to log into the system at any time during EBP educational intervention The contents of

supplementary online learning included a basic step of EBP (asking PICO questions, searching strategies and critical appraisal), tutorial videos, reference resources and assignments

Incentive Spirometry Educational Intervention

Participants in the experimental group received four weeks of online learning on Incentive spirometry (IS) educational intervention It was activated on the same date and period of intervention as the experimental group Each participant in the comparison group was provided an account with a password to log into the online system at any time during the period of intervention The contents were (1) the introduction and description of the IS device, (2) tutorial videos, (3) reference resources, and (4) the assignments and feedback of the IS course (Table 2)

Table 1 The EBP educational intervention

EBP educational intervention (4 weeks)

Face to face lecture (16 hours)

Week 1

Day 1

5.5

hours

Lesson 3: Ask clinical questions

+ Introduction of PICO format: patient population (P), intervention (I), comparison intervention (C), outcomes (O)

+ Example of PICO, type of PICO + Type of studies

Lesson 4: Acquire evidence

+ Identify the hierarchy of evidence + Introduction of database

+ Search strategies (Choose keywords from PICO, Controlled vocabulary (thesaurus/Mesh), Boolean operators, Limit function

+ Searching databases: Cochrane, PubMed, CINAHL and Google

+ Summary of searching results

+ Lectures + Handouts + Groups discussion with mentors + Groups practice with mentors

+ PICO preparation + Literature search + Groups presentation (formulating PICO question, searching database and presenting searching results)

Week 1

Day 2

6 hours Lesson 5: Appraisal evidence for validity and applicability

+ What is the PICO of the study and is it close enough to the PICO of your clinical question?

+ How well was the study done?

+ What are the results and are they applicable to practice?

+ Critical appraisal checklist

+ Sum up the Evidence (Each group selects one article to appraise: Clinical trial, randomized control trial and a systematic review)

+ Lectures

+ Handouts + Groups discussion with mentors + Groups practice with mentors

+ Clinical trial appraisal + Randomized control trial appraisal

+ Systematic review appraisal + Groups presentation

(Appraisal evidence and Sum up