CSN Expectation On Nurses To Stay Current Regarding Evidence Based Practice Discussion

Answer questions based on the article attached below:

Do you think it is reasonable to expect nurses to stay current regarding new research/Evidence-Based Practice findings in their area of practice? Or is this an agency/organization responsibility?

RESEARCH ARTICLE
Clinical nurses’ beliefs, knowledge,
organizational readiness and level of
implementation of evidence-based practice:
The first step to creating an evidence-based
practice culture
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Jae Yong Yoo ID1☯, Jin Hee Kim ID1☯*, Jin Sun Kim ID1☯, Hyun Lye Kim1☯, Jung Suk Ki2
1 Department of Nursing, College of Medicine, Chosun University, Gwangju, South Korea, 2 Department of
Nursing, Chosun University Hospital, Gwangju, South Korea
☯ These authors contributed equally to this work.
* jinheeara@chosun.ac.kr
Abstract
OPEN ACCESS
Citation: Yoo JY, Kim JH, Kim JS, Kim HL, Ki JS
(2019) Clinical nurses’ beliefs, knowledge,
organizational readiness and level of
implementation of evidence-based practice: The
first step to creating an evidence-based practice
culture. PLoS ONE 14(12): e0226742. https://doi.
org/10.1371/journal.pone.0226742
Editor: Tim Schultz, University of Adelaide,
AUSTRALIA
Background
This study aimed to identify clinical nurses’ evidence-based practice (EBP) knowledge,
beliefs, organizational readiness, and EBP implementation levels, and to determine the factors that affect EBP implementation in order to successfully establish EBP. This study was
conducted at a university-affiliated tertiary hospital located in a provincial area in Korea. The
research design was based on Melnyk and Fineout-Overholt’s Advancing Research & Clinical Practice through Close Collaboration model as the first step.
Received: October 23, 2018
Accepted: December 3, 2019
Methods
Published: December 26, 2019
Copyright: © 2019 Yoo et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: This study was supported by research
fund from Chosun University (2016, PI: Jaeyong
Yoo). The funders had no role in study design, data
collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
A descriptive and cross-sectional design was conducted and a convenience sample of 521
full-time registered nurses from an 849-bed tertiary hospital were included. Structured questionnaires were used to assess EBP knowledge, EBP beliefs, organizational culture & readiness and EBP implementation. Data were analyzed using SPSS V 25.0 by using descriptive
and inferential statistics and hierarchical multiple regression was performed to determine
the factors affecting the implementation of EBP.
Results
Our findings showed that the clinical nurses had a positive level of EBP beliefs, but the level
of EBP knowledge, organizational readiness and EBP implementation were insufficient.
EBP knowledge, beliefs, and organizational readiness were significantly positively correlated with EBP implementation. In the final model, EBP knowledge and organizational readiness were significant predictors of EBP implementation; the model predicted 22.2% of the
variance in implementation.
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Analyzing EBP among clinical nurses in Korea
Conclusions
Based on these results, the main focus of the study was the importance of individual nurses’
efforts in carrying out EBP, but above all efforts to create an organizational culture to prepare and support EBP at the nursing organization level. In the initial process of introducing
and establishing EBP, nurse administrators will need to minimize expected barriers,
enhance facilitators, and strive to build an infrastructure based on vision, policy-making,
budgeting, excellent personnel and facilities within the organization.
Introduction
Evidence-based practice (EBP) is a problem-solving approach to clinical care that incorporates
the conscious use of the best available scientific evidence, clinicians’ expertise, and patients’
values [1]. This leads to safe patient care and positive patient outcomes, reduces nursing time
and medical costs through standardization of nursing practice [2–5]. It also improves professional autonomy and job satisfaction for clinical nurses, ultimately bringing potential benefits
to patients, nurses and the health care system [6–8]. For this reason, EBP has emerged as a central concept in the planning and implementation of healthcare systems worldwide. As EBP
rapidly replaces the traditional paradigm of authority in healthcare decision-making, health
professionals have an obligation to access knowledge, apply it in practice, and lead others to
use it appropriately [8–10].
Western countries, such as the United States (US), United Kingdom (UK), and Australia,
have emphasized nursing through EBP since the 1990s, and there are active movements such
as developing evidence-based guidelines providing various resources related to EBP from
organizations specialized in EBP (Cochrane, Joanna Briggs Institute, etc.) [11, 12]. In addition,
the Institute of Medicine presented EBP competency as one of the five core competencies of
healthcare professionals [13], and the American Association of Colleges of Nursing also presented EBP as one of the nine essential elements of professional nursing practice [14]. Over the
past 30 years, there has been marked theoretical and practical growth associated with EBP,
including education and training for EBP in nursing practice, and research conducted including various facilitation strategies [9, 15].
In Korea, however, EBP in nursing was first introduced in the early 2000s [16]. Awareness
on the importance of EBP has spread around major large tertiary hospitals in Seoul, but the
actual performance of EBP has been reported to be poor outside of the metropolitan area [17–
19]. A study involving 437 nurses at tertiary hospitals conducted in 2004, which was the very
first time the concept of EBP was introduced in Korea, found that 58% of nurses did not perform nursing practice according to the latest guidelines [20]. Korean nurses were reported to
be underperforming EBP until recently [19]. In 2013, only 12 of the 30 tertiary hospitals surveyed (40.0%) were organized by EBP committees and were conducting EBP-related clinical
nursing studies [18]. Although various efforts have been made to promote EBP in Korea in
recent years, it is apparent that institutional support for EBP is not systematic and insufficient
throughout the country.
Barriers to conducting EBP for Korean nurses include: the lack of knowledge and skills,
lack of belief and capacity, lack of database access and utilization, and insufficient critical
thinking and motivation [20–22]. The barriers to conducting EBP in Korea at the organizational level are organizational culture, insufficient education programs, lack of well-trained
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Analyzing EBP among clinical nurses in Korea
EBP experts, lack of time, and inadequate communication [20, 21, 23]. While EBP is a valuable
concept, it is difficult for a nurse to implement it first before a nursing organization embraces
this new concept [24]. Therefore, for a successful implementation of EBP, the readiness of an
individual nurse and organization must be assessed.
First, EBP implementation is influenced by the knowledge, skills, and beliefs of the individual nurse on EBP [22, 25, 26]. At the organizational level, it is necessary to create an organizational culture that strengthens and supports the nurse’s values and beliefs on EBP, and to share
the common beliefs or values of its members to achieve the common goal of successful implementation of EBP [12, 27]. It is also important to provide training programs for nurses to
strengthen their EBP capabilities and to foster leaders who can effectively lead EBP implementation [7, 28, 29]. There are various strategic models for successful EBP implementation [15].
The Advancing Research and Clinical Practice through Close Collaboration (ARCC©) model
proposed by Melnyk and Fineout-Overholt [24] is a representative strategic model that
emphasizes personal and organizational elements. The ARCC©, a strategic model developed
by the EBP center of the University of Arizona in the US, proposes the use of methodological
strategies to promote the implementation of EBP based on the close cooperation between clinical nurses and researchers [24]. The first step in the ARCC© model is to assess the organizational culture and readiness of the medical institution to successfully establish EBP. This will
help identify the strengths and barriers of the organization and improve the nurses’ knowledge
on, belief regarding, and capacity to adopt and implement EBP through education and training, environmental improvement, and organizational support while focusing on mentors who
act as facilitators in the performance of EBP [24, 30]. Successful implementation of EBP can
increase the job satisfaction of professional nurses and ultimately improve nursing-sensitive
outcomes [6, 7, 31, 32]. The conceptual framework in this study was constructed based on the
ARCC© model.
To date, only a few studies have evaluated the level of preparation, correlation, and influencing factors of EBP implementation among individual nurses and organizations in Korea.
This study was conducted at a university-affiliated tertiary hospital located in a provincial area
in Korea, as the first step in implementing EBP in accordance with the ARCC© model. This
study aimed to identify the clinical nurses’ EBP knowledge, beliefs, organizational readiness,
and EBP implementation levels, and to determine the factors that affect EBP implementation
in order to successfully establish EBP. The specific objectives of this study were as follows:
1. To identify the clinical nurses’ EBP knowledge, beliefs, organizational readiness, and EBP
implementation levels
2. To examine the differences in clinical nurses’ EBP knowledge, beliefs, organizational readiness, and EBP implementation levels based on the general and research-related characteristics of participants and explore the relationships among these variables
3. To identify the factors that affect EBP implementation
Methods
Study design and participants
This was a cross-sectional, descriptive study. The participants were recruited from an 849-bed
acute care tertiary hospital in South Korea. Convenience sampling was used to select full-time
registered nurses employed at this hospital. The sample size required for the multiple regression analysis was calculated using G-Power 3.1 [33], with an effect size of 0.02, significance
level of 0.05, and test power of 0.80 with 14 predictors. It was determined that at least 485
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Analyzing EBP among clinical nurses in Korea
participants were required for analysis. However, this study was the first step involved in the
ARCC© model, and all nurses were surveyed to identify the current state of nurses belonging
to the abovementioned hospital. Among the 632 registered nurses, 82 of the following nurses
were excluded from the survey: 1) part-time nurses, 2) nurses participating in training for new
nurses without full-time assignments in the hospital, and 3) laboratory and research nurses
not involved with direct patient care. A total of 550 questionnaires were distributed; 521 were
returned (94.7% response rate). Finally, 521 who fully understood the purpose of this study
and voluntarily consented to participate were included. Participants included clinical nurses
working in the wards and special units, clinical nurse specialists, nurse managers, and nurse
administrators.
Measurements
This study used structured questionnaires, consisting of the following items: general and
research-related characteristics (13), EBP knowledge (14), EBP beliefs (16), organizational
readiness for EBP (25), and EBP implementation (18). The measurements used in this study
were approved by the original authors and translated versions into Korean have already been
used in the previous studies [19, 22, 34]. However, researchers have modified and supplemented some of the items with words or expressions that are commonly used by nurses in this
hospital where the study was conducted. Prior to the survey, a pilot test of five clinical nurses
identified and revised problematic questionnaire items. The details of the measurements for
each variable are as follows.
EBP knowledge. Participants’ knowledge in implementing EBP was measured using
knowledge-related questions from the Evidence-based Practice Questionnaire, developed by
Upton & Upton [35]. This tool consists of 14 items, including “converting your information
needs into a research question” and “ability to analyze critically, evidence against set standards.” Response scores on the scale range from 1 (very lacking) to 7 (excellent). Possible total
scores range from 14 to 98 points, with higher scores indicating higher levels of knowledge
regarding EBP. At the time of its development, the Cronbach’s alpha of the tool was 0.91 [35]
and 0.93 for Korean nurses [19]. In this study, the Cronbach’s alpha was found to be 0.83.
EBP beliefs. Participants’ beliefs in valuing EBP were measured using the Evidence-based
Practice Beliefs (EBPB) tool, developed by Melnyk and colleagues [36]. This tool consists of 16
questions. Examples of the items in the EBPB include “I am sure that I can implement EBP in
a time efficient way” and “I am sure about how to measure the outcomes of clinical care.” Each
question is rated on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree), but
scoring for items 11 and 13 was reversed. Possible total scores range from 16 to 80 points, with
higher scores indicating positive EBP beliefs. At the time of its development, the Cronbach’s
alpha of the tool was 0.90 [36] and 0.88 for Korean nurses [34]. In this study, the Cronbach’s
alpha was found to be 0.81.
Organizational readiness for EBP. The organization’s culture and its readiness for system-wide EBP implementation were measured using the Organizational Culture and Readiness Scale for System-Wide Integration of Evidence-Based Practice (OCRSIEP) [27]. The
OCRSIEP scale was developed to measure the levels of readiness in performing EBP, at the
organizational level, and consists of 25 questions that offer insights into the strengths of and
opportunities related to fostering EBP. Possible total scores range from 25 to 125 points, indicating that the higher the score, the better the organizational readiness and cultural cultivation
for implementing EBP. The following questions are asked: “To what extent is EBP clearly
described as central to the mission and philosophy of your institution?” and “To what extent is
the nursing staff with whom you work committed to EBP?” At the time of its development, the
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Analyzing EBP among clinical nurses in Korea
Cronbach’s alpha of the tool was 0.94 [27] and 0.95 for Korean nurses [22]. In this study, the
Cronbach’s alpha was found to be 0.87.
EBP implementation. The frequency of performing EBP-related activities was measured
using the Evidence-Based Practice Implementation tool, developed by Melnyk and colleagues
[36]. This tool consists of 18 questions pertaining to how often, in the last 8 weeks, participants
performed certain EBP activities, such as “Generated a PICOT (P = patient, I = intervention,
C = comparison, O = outcome, T = time) question about my clinical practice,” “Accessed the
National Guidelines Clearinghouse,” and “Evaluated a care initiative by collecting patient outcome data.” Responses on the scale range from 0 (0 times) to 4 (over 8 times). The possible
total scores range from 0 to 72 points, with higher scores indicating higher levels of commitment to implementing EBP-related activities. At the time of its development, the Cronbach’s
alpha of the tool was 0.96 [36] and 0.95 for Korean nurses [22]. In this study, the Cronbach’s
alpha was found to be 0.81.
Data collection and ethical considerations
The Institutional Review Board (IRB) approval was obtained prior to data collection from the
authors’ institution (no. 2-1041055-AB-N-01-2018-10, Chosun University Institutional Review
Board). Data were collected from December 2017 to January 2018. For data collection, we contacted a nurse administrator at Chosun University Hospital and explained the purpose of this
study. Chosun University Hospital is a private university-affiliated, tertiary care hospital
located in Gwangju city, South Korea. It is located in Gwangju Metropolitan City in the southern district of Korea and is in charge of medical services in Jeolla province. The hospital consists of 849 beds, with 25 medical departments in operation, including 15 general wards, 4
intensive care units, regional emergency medical center, operating rooms, outpatient departments, and laboratories. A researcher visited the hospital to explain the purpose of this study
as well as the inclusion criteria to the nurse unit managers, during a supervisor meeting. The
questionnaires were enclosed in different envelopes for each ward and distributed by the staff
and assistants of the nursing education team who did not participate in this survey. The collection boxes were made and distributed to each ward, and nurses were allowed to submit questionnaires voluntarily at any time. To ensure anonymity of the participants, the consent form
was given in writing with a mark or numbers that could only be known to themselves. Therefore, all nurses, whose questionnaires were collected, were considered to have participated in
this study of their own will.
Statistical analysis
Data analysis was performed using SPSS V 25.0. Descriptive statistics, including the means,
standard deviations, frequencies, and percentages, were used to describe the participants’ general and research-related characteristics, and EBP-related variables. Differences between major
variables, by participants’ characteristics, were analyzed through independent t-tests, analysis
of variance, and Scheffe test. The relationships between major variables were analyzed using
Pearson’s correlation coefficient. Hierarchical multiple regression was performed to determine
the factors affecting the implementation of EBP.
Results
General and research-related characteristics of the participants
Table 1 presents the participants’ characteristics. The mean age of all participants was 31.9±9.2
years, with 58.9% aged 21 to 30. Their overall clinical experience was 9.0+4.2 years, with 80.1%
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Analyzing EBP among clinical nurses in Korea
Table 1. General and research-related characteristics of the participants.
Variables
Gender
Women
Men
n (%)
Variables
n (%)
Working unit
486(93.3) General ward
308(59.1)
35(6.7) Intensive care unit
80(15.4)
(31.9, 9.2) Emergency room
40(7.7)
�25
158(30.3) Operation room/recovery room
43(8.2)
26–30
149(28.6) Outpatient
48(9.2)
31–35
79(15.2) Nursing administration
2(0.4)
36–40
36(6.9) Completed nursing research course
Age (Years; Mean, SD)
�41
Clinical experience (Mean, SD)
99(19.0) Yes
383(73.5)
(9.03, 4.2) No
138(26.5)
�12 months
96(18.4) Completed statistics course
13-36months
105(20.3) Yes
311(59.7)
37-60months
40(7.7) No
210(40.3)
61-120months
117(22.5) Attendance of EBP lecture
121-240months
74(14.2) Yes
243(46.6)
�241months
88(16.9) No
278(53.4)
Educational level
Research conducting/participated
Diploma/associates
77(14.8) Yes
147(28.2)
Bachelors
343(65.7) No
374(71.8)
Masters or ongoing
93(17.9) Membership of academic society
Doctors or ongoing
Position
Staff nurse
8(1.6) Yes
41(7.9)
No
480(92.1)
418(80.1) Attendance of academic conference
Charge nurse
42(8.1) Yes
72(13.8)
Advanced nurse practitioner
28(5.4) No
449(86.2)
Head nurse
29(5.6) Familiar to EBP terminology
Team manager/administrator
4(0.8) Yes
134(25.7)
No
387(74.3)
Abbreviations: EBP = evidence-based practice
https://doi.org/10.1371/journal.pone.0226742.t001
working as staff nurse. Approximately 80.5% of the participants had an associate or bachelor’s
degree in nursing, 80.1% worked as staff nurses, and 59.1% worked in a general ward. Approximately 73.5% and 59.7% of nurses completed nursing research and statistics classes, respectively,
but most of them answered that they only completed their undergraduate courses. While 46.6% of
nurses had experience taking EBP classes, only 25.7% were familiar with EBP-related terms.
Level of EBP knowledge, beliefs, organizational readiness, and EBP
implementation
The level of EBP knowledge was 52.5 ± 11.1 points out of 98. Participants were highly knowledgeable on the use of information technology to search for and use data (4.3 ± 0.9) and shared
these ideas and information with colleagues (4.3 ± 1.0). However, they have less knowledge on
how to convert these data into research problems (3.8 ± 1.0) and critically analyze existing evidence (3.8 ± 0.9).
The level of EBP beliefs, among the participants, was relatively positive, with a total score of
51.7 ± 5.9 points out of 80. The items with the highest score were “I am sure that evidencebased guidelines can improve clinical care” (3.8 ± 0.6) and “I am sure that implementing EBP will
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Analyzing EBP among clinical nurses in Korea
improve the care that I deliver to my patients” (3.7 ± 0.6). The items with the lowest scores were “I
believe EBP is difficult” (2.5 ± 0.6) and “I believe that EBP takes too much time” (2.7 ± 0.6).
The level of the organizational readiness to perform EBP perceived by nurses was
76.4 ± 13.0 points out of 125. The participants demonstrated lowest level of readiness on the
following aspects: “To what extent are decisions generated from direct care providers”
(2.7 ± 0.8) and “To what extent are librarians used to search for evidence” (2.7 ± 0.7). The participants demonstrated high levels of readiness on the following aspect: “To what extent are
decisions generated from upper administration” (3.7 ± 0.8) and “To what extent are there EBP
champions in the environment among administrators” (3.3 ± 0.7).
The level of EBP implementation was 15.0 ± 3.2 points out of 72. The items with the lowest
scores were “accessed the National Guideline Clearinghouse” (0.4 ± 0.2) and “accessed the
Cochrane database of systematic reviews” (0.4 ± 0.2). Participants had low levels of engagement in the following activities: “used an EBP guideline or systematic review to change clinical
practice where I work” (0.6 ± 0.2) and “shared evidence from studies to over 2 colleagues”
(0.7 ± 0.2). Items were listed in order, and details are given in Table 2 and S1 Appendix.
Differences in the levels of EBP knowledge, beliefs, organizational
readiness, and EBP implementation according to participant
characteristics
Table 3 presents the differences in EBP variables according to the participants’ characteristics.
The level of EBP knowledge significantly differed by age (F = 5.542), clinical experience
(F = 4.545), position (F = 9.292), educational level (F = 5.084), and research-related activities.
The level of EBP beliefs significantly differed by age (F = 5.370), clinical experience (F = 2.653),
position (F = 9.142), educational level (F = 4.585), and research-related activities. Organizational readiness significantly differed by age (F = 13.149), clinical experience (F = 12.814), educational level (F = 5.132), attendance to EBP lectures (t = 2.191), research conducted or
research participation (t = 4.033), and familiarity to EBP terminologies (t = 4.062). In terms of
characteristics by units, nursing administrators with decision-making authority recognized
that the organization’s readiness (F = 3.626) was relatively low compared with that of staff
nurses. The level of EBP implementation was mainly related to the experience of statistics
courses (t = 2.004), attendance to EBP lectures (t = 2.069), research conducted or research
participation (t = 2.953), and familiarity to EBP terminologies (t = 2.508). In terms of characteristics by units, nursing administrators recognized that the level of EBP implementation
(F = 2.385) were relatively low compared to staff nurses.
Relationship among EBP knowledge, beliefs, organizational readiness, and
EBP implementation
Bivariate Pearson’s correlation analysis showed that EBP implementation had a significantly
positive correlation with EBP knowledge (r = .304, p < .001), beliefs (r = .272, p < .001), and Table 2. Level of EBP knowledge, beliefs, organizational readiness and EBP implementation. Items Mean, SD EBP knowledge 52.5, 11.1 EBP beliefs 51.7, 5.9 Organizational readiness for EBP 76.4, 13.0 EBP implementation 15.0, 3.2 Abbreviations: EBP = evidence-based practice https://doi.org/10.1371/journal.pone.0226742.t002 PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 7 / 15 Analyzing EBP among clinical nurses in Korea Table 3. Differences in the levels of EBP beliefs, knowledge, organizational readiness, and EBP implementation according to the participants characteristics. Variables Age (years) Category Working unit t / F (p) EBP Implementation M, SD 55.1, 9.8 57.4, 10.1 (< .001) 31–35 c 56.5, 11.1 d 60.4, 13.6 52.6, 6.1 74.1, 13.0 14.1, 10.3 �41 e 61.2, 12.3 53.8, 5.9 72.8, 13.5 14.1, 10.2 a 53.8, 10.1 �12 5.524 e>a
51.7, 5.3
t/F
(p)
5.370
82.2, 11.5
13.149
15.3, 11.1
.365
50.4, 5.8 (< .001) 75.4, 12.1 (< .001) 15.1, 10.2 (.834) e>b
72.1, 13.4
a>b,c,d,e
51.1, 6.6
16.0, 11.4
4.545
51.2, 5.3
2.653
82.6, 11.4
12.814
14.5, 11.7
.984
13–36 b
57.1, 9.7 (< .001) 51.9, 5.8 (.022) 80.7, 11.6 (< .001) 15.4, 12.0 (.427) 37–60 c 56.1, 9.1 f>a
50.4, 6.5
76.8, 11.9
a,b >d,e,f
13.1, 10.2
60–120 d
57.9, 10.8
50.9, 5.7
72.6, 12.9
16.9, 13.2
121–240 e
58.3, 12.3
51.9, 7.1
71.6, 12.2
14.7, 11.6
f
61.1, 12.4
Staff nurse a
56.3, 10.4
Charge nurse b
61.1, 13.0 (< .001) Nurse practitioner c 65.2, 10.7 Head nurse/Team leader d 61.3, 12.2 General ward a 57.2, 10.5 .993 51.9, 6.1 1.442 77.3, 13.1 3.626 14.2, 12.0 2.385 Intensive care unit b 57.5, 11.5 (.421) 50.7, 6.2 (.208) 76.4, 12.6 (.003) 18.2, 11.2 (.037) Emergency room c 55.8, 12.9 50.9, 5.8 75.2, 12.0 a >f
57.7,11.1
53.1, 5.0
76.6, 13.3
12.6, 10.8
Operating/Recovery
room e
60.3, 12.0
51.0, 5.6
71.8, 12.3
17.0, 12.3
Nursing
administration f
65.5, 10.6
55.5, 7.7
46.0, 9.8
5.5, 3.5
Diploma/associate a
57.6, 10.5
5.084
51.5, 5.9
4.585
76.7, 12.6
5.123
17.1, 11.6
1.065
Bachelors b
56.5, 10.7
(.002)
51.2, 5.8 (< .001) 77.6, 12.8 (.002) 14.9, 12.4 (.363) Masters or ongoing 60.0, 12.0 d> b
c>b
72.7, 12.9
c>b
13.8,11.5
Outpatient
Education
Organizational
Readiness M, SD
26–30 b
�241
Position
t / F (p) EBP Beliefs t / F (p)
M, SD
�25 a
36–40
Clinical experience
(months)
EBP�
Knowledge M,
SD
d
53.5, 5.5
9.292
c>a
51.1, 5.7
73.3, 13.6
13.9, 12.4
9.142
77.0, 12.7
2.123
15.0, 11.8
.432
53.0, 6.6 (< .001) 73.7, 13.8 (.096) 14.3, 12.3 (.730) 55.0, 7.4 c,d>a
55.2, 4.4
53.3, 6.3
77.0, 15.1
17.5, 16.2
72.0, 13.5
14.8, 11.8
16.7, 14.5
c
Doctors or ongoing
68.1, 9.9
56.3, 3.9
66.3, 17.9
14.2, 11.3
d
Completed nursing
research course
Yes
57.5, 11.0
.484
51.7, 5.9
.549
Completed statistics
course
76.8, 12.8
1.476
No
57.0, 10.8
Yes
58.7, 11.0
No
Attendance of EBP
lecture
Yes
Conducting research
or
Research
participation
Membership of
academic
15.3, 12.2
1.159
(.643)
51.4, 6.0
2.994
52.1, 5.9
(.583)
74.9, 13.4
1.744
76.6, 12.6
(.141)
13.9, 11.8
(.247)
.536
15.9, 12.2
2.004
55.7, 11.0
(.003)
51.1, 6.0
(.082)
76.0, 13.7
(.529)
13.7, 11.9
(.046)
58.1, 11.9
1.271
52.4, 6.1
2.528
77.7, 13.2
2.191
16.2, 12.8
2.069
No
56.9, 10.3
Yes
59.6, 11.4
(.204)
51.1, 5.8
2.824
52.6, 5.8
(.012)
75.1, 12.7
(.029)
14.0, 11.4
(.039)
2.276
80.0, 12.6
4.033
17.5, 13.2
2.953
No
56.6, 10.8
(.005)
51.3, 6.0
(.023)
74.9, 12.9
(< .001) 14.0, 11.5 (.003) Yes 63.2, 12.1 3.485 54.7, 5.5 3.403 76.4, 12.0 .021 15.3, 12.9 .123 society No 57.0, 10.8 (.001) 51.4, 5.9 (.001) 76.4, 13.1 (.983) 15.0, 12.1 (.902) Attendance of academic Yes 62.5, 13.4 3.497 53.8, 6.5 3.179 76.1, 12.3 .228 15.8, 13.7 .567 (Continued ) PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 8 / 15 Analyzing EBP among clinical nurses in Korea Table 3. (Continued) Variables Category EBP� Knowledge M, SD t / F (p) EBP Beliefs t / F (p) M, SD Organizational Readiness M, SD t / F (p) EBP Implementation M, SD t/F (p) conference regularly No 56.7, 10.4 (.001) 51.4, 5.8 (.002) 76.4, 13.0 (.820) 14.9, 11.9 (.571) Familiar to EBP terminology Yes 61.0, 11.6 4.299 54.7, 5.4 7.127 80.3, 13.1 4.062 17.3, 13.2 2.508 No 56.3, 10.6 (< .001) 50.6, 5.0 (< .001) 75.0, 12.8 (< .001) 14.3, 11.6 (.012) https://doi.org/10.1371/journal.pone.0226742.t003 organizational readiness (r = .430, p < .001). In addition, EBP knowledge were statistically positively correlated with EBP beliefs (r = .555, p < .001) and organizational readiness (r = .314, p < .001). EBP beliefs and organizational readiness were statistically positively correlated (r = .406, p < .001) (Table 4). Factors affecting EBP implementation In the final model, EBP knowledge (β = .15) and organizational readiness (β = .36) were significant predictors of EBP implementation; the model predicted 22.2% of the variance in EBP implementation (F = 10.098, p < .001) (Table 5). Age was highly correlated with clinical experience and was excluded from independent variables. Prior to the regression analysis, the data were checked for multicollinearity using tolerance (0.366–0.911) and the variance inflation factor (1.183–2.733). Variance inflation factor values greater than 10 and tolerance-values smaller than 0.10 may indicate multicollinearity. The Durbin-Watson value was 1.905, and each model demonstrated good statistical values. Discussion EBP knowledge, beliefs, and organizational readiness were significantly correlated with EBP implementation and hierarchical regression presented them as major predictors. Model 1 of regression shows that completing a postgraduate or higher curricula and conducting or participating in research had a significant impact on the level of EBP implementation. In Models 2 and 3 of EBP knowledge, beliefs, and organizational readiness, each variable had a significant effect. In Model 4, EBP knowledge and organizational readiness were the main influencing factors on EBP implementation. Based on these findings, the successful implementation of EBP should prioritize efforts to establish an education strategy to improve EBP knowledge and to create an organizational culture for preparing and supporting EBP at the nursing organization level. Table 4. Correlation between EBP knowledge, beliefs, organizational readiness and EBP implementation. Pearson’s correlation coefficients, r� Variables EBP knowledge EBP beliefs Organizational readiness EBP knowledge 1.000 - - EBP beliefs .555 1.000 - Organizational readiness .314 .406 1.000 EBP implementation .304 .272 .430 Abbreviations: EBP = evidence-based practice. p < .001 for all the Pearson’s correlation coefficients in the table. � https://doi.org/10.1371/journal.pone.0226742.t004 PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 9 / 15 Analyzing EBP among clinical nurses in Korea Table 5. Factors affecting EBP implementation. Model 1� Variables Model 2� Model 3� Model 4� b β p b β p b β p β p VIF Clinical experience -.01 -.06 .342 -0.1 -.07 .246 -.00 -.06 .322 .00 .03 .558 2.733 Educational level -2.35 -.21 .028 -2.16 -.11 .036 -2.26 -.11 .027 -1.76 -.09 .069 1.576 Position 1.38 .09 .132 .94 .06 .285 .68 .04 .442 .49 .03 .558 2.231 Working unit .36 .04 .402 .34 .03 .400 .42 .04 .303 .65 .07 .097 1.195 Completed nursing research course Completed statistics course b .69 .02 .671 .01 .00 .994 -.07 -.00 .961 .60 .02 .684 1.838 -2.30 -.09 .113 -1.37 -.05 .329 -1.37 -.05 .325 -1.96 -.08 .138 1.826 1.446 Attendance EBP lecture -.02 -.00 .982 -.25 -.01 .835 -.20 -.00 .870 .55 -.02 .630 Conducting research -3.09 1.11 .018 -2.39 -.08 .059 -2.39 -.08 .057 -1.09 -.04 .364 1.273 Membership of academic society 1.11 .02 .635 1.76 .03 .46 2.04 .04 .363 2.21 .04 .298 1.385 Attendance of academic conference regularly .12 .00 .946 .68 .01 .701 .59 .01 .740 .68 .01 .686 1.445 -2.16 -.07 .109 -1.18 -.04 .358 -.46 -.01 .723 .28 .01 .819 1.272 .31 .28 .000 .23 .21 .000 .16 .15 .002 1.526 .29 .14 .006 .05 .02 .597 1.707 .33 .36 .000 1.430 Familiar to EBP terminology EBP knowledge EBP belief Organizational readiness R2 (⊿R2) .045 .118 (.073) .131 (.013) .222 (.091) F (p) 2.111 (.018) 5.521 (< .001) 5.738 (< .001) 10.098 (< .001) Abbreviations: EBP = evidence-based practice Model 1: General, research-related Characteristics, Model 2: General, research-related Characteristics, EBP knowledge, Model 3: General, research-related � Characteristics, EBP knowledge, EBP beliefs, Model 4: General, research-related Characteristics, EBP knowledge, EBP beliefs, Organizational readiness. https://doi.org/10.1371/journal.pone.0226742.t005 In this study, the EBP implementation level was 15.0 out of 72 points. Melnyk et al.’s study [37] reported an implementation level of 18.9 points, while that in Korea study [26] was 33.0 points, which were relatively higher than that reported in this study. A previous study of 410 nurses working at 10 tertiary hospitals in Korea also showed an average implementation level of 0.95 points [22]. Considering that the EBP implementing scores in this study ranged from zero (when there has been no EBP-related activity over the past 8 weeks) to 1 point (when EBP-related activities were performed one or three times) [36], suggests that EBP implementation has not been activated at the actual clinical setting. This shows that in South Korea, EBP are only implemented around major large-scale tertiary hospitals located in the Seoul metropolitan area, and the spread and implementation of EBP to a wide range of areas and smaller hospitals, including provincial cities, is insufficient [17–19, 22]. Previous studies in South Korea also pointed out the spread of EBP concentrated only in Seoul and its surrounding metropolitan areas and stressed the need for efforts to overcome these limitations [17,18]. In recent studies [18, 22, 23], the lack of knowledge among nurses regarding research and statistical methods, education, and lack of experience in research and statistics are reported as important predictors of a nurse’s poor performance of EBP. These studies also point out the overall lack of clinical inquiry creation, accessing and searching for evidence, and critical appraisal and practical application by nurses. EBP experts emphasize that nurses should be sensitive to the continuously generated scientific knowledge and have sufficient knowledge to make critical judgments about such research in order to perform EBP [12, 15, 24, 25]. However, EBP knowledge is difficult to improve by nurses’ personal efforts alone, so organizational support is needed [34]. Several previous studies suggest the necessity of learning atmospheres and facilities for successful EBP establishment in nursing organizations [12, 21, 38, 39]. Beyond acquiring knowledge at the individual level, in order to efficiently acquire the knowledge necessary for decision making at the clinical setting, organizations need a system of PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 10 / 15 Analyzing EBP among clinical nurses in Korea knowledge management, information systems and databases related to nursing. Encouraging organizational team learning and continuing learning opportunities to improve nurses’ EBP knowledge can be used as an educational strategy. Cho et al. [38] emphasized using a learning organization as an alternative rather than traditional lecturing methods as a way of delivering knowledge. To do this, it is necessary to operate a ward-level education program in the form of workshops, which includes discussions and brainstorming sessions, rather than a lecture-style education. It is also necessary to establish customized education strategies, such as the operation of journal clubs in wards considering clinical topics specified by each ward. A learning organization that includes an EBP preceptor or EBP mentoring program may also be considered. Introducing and providing the EBP concept in the preceptor training program at the organizational level, helps to have knowledge and positive beliefs about EBP. In addition, it will be necessary to motivate nurses to participate in the conference and to provide incentives for them to present at the conference. Human resources such as EBP mentors will need to be trained so that they can serve as EBP facilitators and EBP champions in wards. In addition, when developing EBP education programs, a hands-on education must be developed and implemented in collaboration with librarians so that practical performance can now be carried out beyond the EBP concept or its importance should be emphasized. Nam et al. [39] reported that EBP education programs, which include intensive training such as a four-hour workshop per day, computer-based training consisting of a total of three modules that take 15–20 minutes per module, and team-based training programs of 2–3 hours per week, were effective in improving EBP knowledge. One option would be to develop EBP-related cases for each clinical scenario, and to operate a simulation-based EBP training program. Along with educational strategies for improving EBP knowledge, the establishment of organizational cultural development and support strategies should be considered [10, 24]. Organizational readiness for EBP in this study (76.4 points out of 125) was relatively low compared to a recent large online survey conducted in the US (80.2 points) [37]. In Korea, direct comparisons are limited due to the use of different tools. In the study of Cho et al. [17], the level of organization support was 3.7 points out of a 5-point scale and 3.3 points as reported by Kim et al. [40]. In particular, the items with the lowest level of organizational readiness in this study reported lack of the decision-making authority of clinical nurses who perform direct care, lack of support personnel such as librarians, and lack of budget support of nursing organizations to perform EBP. These results suggest that it is urgent to create a nursing organizational culture that facilitates access and utilization of EBP within clinical settings, and prepare all clinical nurses for the successful implementation of the EBP [8, 41]. The ARCC© model emphasizes that in order to establish the concept of EBP in organizational culture, the contents of EBP must be clearly stated in the organization’s mission and vision, and consensus on common values. It also emphasizes the need for human resources such as EBP mentors to facilitate EBP, along with improvements in the physical environment [24]. In this study, there is a shortage of human resources, such as nursing researchers with doctoral degrees or higher, or educators with expertise in EBP, and nurses providing direct care have limited participation and authority in the decision-making in the organization, which requires active intervention and support at the organization level. It is necessary to form an independent EBP committee within the nursing organization for the facilitation of EBP and to establish and implement policies for the creation of EBP culture by leading this committee. To create such an organizational culture, it is necessary to understand the characteristics of Korean nursing organizations. In general, south Korea has a higher nurse-to-patient ratio, a relatively high working time for nurses in three shifts, and a high workload compared with other countries such as the US, UK and Canada [42, 43]. Additionally, South Korea’s nursing organizational culture has a tendency to be mainly hierarchical compared with other Western PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 11 / 15 Analyzing EBP among clinical nurses in Korea countries, and this vertical structure has been shown to reduce nurses’ work performance, professional autonomy, job satisfaction, and willingness to serve compared with other organizational cultures [16, 22, 42–44]. The ARCC© model emphasizes the creation of an EBP culture that facilitates clinical inquiry as part of the EBP facilitation strategy [24]. This culture emphasizes the flexibility of the nursing organization to respond to the rapidly changing environment and supports nurses questioning existing nursing practices with professional autonomy [7, 24]. In this culture, nurses can perform a series of EBP steps to create various clinical questions, search for evidence, and critically evaluate and apply to practice [45]. Therefore, the willingness and leadership of nursing administrators with decision-making authority to facilitate EBP implementation are very important. After analyzing the differences in major variables according to the characteristics of the nurses, higher educational status and experiences of conducting or participating in research had a significant impact on EBP implementation. The more research-related activities, the higher the level of EBP knowledge, beliefs, and organizational readiness, and the higher the level of EBP implementation [17, 22, 26, 34, 46]. It is necessary to provide both nursing managers and staff nurses with the opportunity to participate directly in the process of planning and carrying out EBP-related research projects at actual clinical settings [21]. Through this, it is necessary to reduce the unfamiliarity with EBP and to support frequent positive experiences through direct activities. The results of this study will contribute to establishing systematic education/training programs and provide the basis for fostering EBP cultures for the successful implementation of the EBP, but there are some limitations. The level of EBP implementation can be affected by various factors, including the type of organizational culture, the characteristics of each hospital organization, regional characteristics, the type of leadership by units, and the composition of nursing staff. Therefore, in future studies, it is expected that the variance of the regression model will be improved by considering these variables. Moreover, as this survey was conducted at one particular hospital located in Korea, the results of this study cannot be generalized. Despite these limitations, we expect that active implementation of these strategies will contribute to providing a stepping stone for the next phase of EBP. Conclusions The results of this study suggest that the level of organizational readiness is the greatest factor in EBP implementation. Based on these results, the main focus of the study was the importance of individual nurses’ efforts in carrying out EBP, but above all efforts to create an organizational culture to prepare and support EBP at the nursing organization level. While the performance of EBP positively improves nursing-sensitive outcomes, the process of establishing such EBP also creates a work and psychological burden for clinical nurses and can also lead to resistance from unfamiliar concepts [10]. The hospital where this study was conducted has not yet activated EBP, but there has been a high demand for nursing managers and nurses to accept the new concept of EBP. In the initial process of introducing and establishing EBP, nursing organizations will need to minimize expected barriers, enhance facilitators, and strive to build an infrastructure that includes vision, policy-making, budgeting, excellent personnel and facilities within the organization. In addition, it is necessary to participate in ongoing education training, as the improvement of individual EBP knowledge among nurses can enhance positive beliefs and values regarding EBP and actual performance. To this end, of course, the nursing administration will need to develop a curriculum that will foster and evaluate the EBP knowledge of each nurse. PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 12 / 15 Analyzing EBP among clinical nurses in Korea Supporting information S1 Appendix. Table 2. Level of EBP knowledge, beliefs, organizational readiness and EBP implementation. (DOCX) S2 Appendix. The original questionnaire (Korean version). (PDF) S1 Dataset. Data of questionnaire. (XLSX) Acknowledgments The contributions of all participants in this study are greatly appreciated. We would like to thank Editage (www.editage.co.kr) for English language editing. Author Contributions Conceptualization: Jae Yong Yoo, Jin Hee Kim, Jin Sun Kim, Hyun Lye Kim. Data curation: Jae Yong Yoo, Jin Hee Kim, Jung Suk Ki. Formal analysis: Jae Yong Yoo, Jin Hee Kim. Funding acquisition: Jae Yong Yoo. Investigation: Jae Yong Yoo, Jin Hee Kim, Jin Sun Kim, Hyun Lye Kim, Jung Suk Ki. Methodology: Jae Yong Yoo, Jin Hee Kim, Jin Sun Kim, Hyun Lye Kim. Project administration: Jae Yong Yoo. Resources: Jae Yong Yoo, Jin Hee Kim, Jung Suk Ki. Software: Jae Yong Yoo. Supervision: Jae Yong Yoo, Jung Suk Ki. Validation: Jae Yong Yoo, Jin Hee Kim, Jin Sun Kim, Hyun Lye Kim. 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Level of beliefs, knowledge and performance for evidence-based practice among nurses experienced in preceptor role. J Korean Acad Nurs Adm. 2012; 18(2):202–12. PLOS ONE | https://doi.org/10.1371/journal.pone.0226742 December 26, 2019 15 / 15 Copyright of PLoS ONE is the property of Public Library of Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

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