-choose a health care organization (your choice)-a specific HCO

-review attached articles

-describe the healthcare organization website you reviewed. 

-Describe where, if at all, EBP appears (e.g., the mission, vision, philosophy, and/or goals of the healthcare organization, or in other locations on the website). 

-explain whether this healthcare organization’s work is grounded in EBP and why or why not. 

-explain whether the information you discovered on the healthcare organization’s website has changed your perception of the healthcare organization. 

-Be specific and provide examples

-350 words

-3 reference

-use references from articles attached

-APA

evidence based practice

R
esearch studies show that
evidence-based practice
(EBP) leads to higher qual-

ity care, improved patient out-
comes, reduced costs, and greater
nurse satisfaction than traditional
approaches to care.1-5 Despite
these favorable findings, many
nurses remain inconsistent in their
implementation of evidence-based
care. Moreover, some nurses,
whose education predates the in-
clusion of EBP in the nursing cur-
riculum, still lack the computer
and Internet search skills neces-
sary to implement these practices.
As a result, misconceptions about
EBP—that it’s too difficult or too
time-consuming—continue to
flourish.

In the first article in this series
(“Igniting a Spirit of Inquiry: An
Essential Foundation for Evidence-
Based Practice,” November 2009),
we described EBP as a problem-
solving approach to the delivery
of health care that integrates the
best evidence from well-designed
studies and patient care data,
and combines it with patient

preferences and values and nurse
expertise. We also addressed the
contribution of EBP to improved
care and patient outcomes, de-
scribed barriers to EBP as well as
factors facilitating its implementa-
tion, and discussed strategies for
igniting a spirit of inquiry in clin-
ical practice, which is the founda-
tion of EBP, referred to as Step
Zero. (Editor’s note: although
EBP has seven steps, they are
numbered zero to six.) In this
article, we offer a brief overview
of the multistep EBP process.
Future articles will elaborate on
each of the EBP steps, using
the context provided by the

Case Scenario for EBP: Rapid
Response Teams.

Step Zero: Cultivate a spirit of
inquiry. If you’ve been following
this series, you may have already
started asking the kinds of ques-
tions that lay the groundwork
for EBP, for example: in patients
with head injuries, how does
supine positioning compared
with elevating the head of the
bed 30 degrees affect intracranial
pressure? Or, in patients with
supraventricular tachycardia,
how does administering the
β-blocker metoprolol (Lopressor,
Toprol-XL) compared with ad-
ministering no medicine affect

By Bernadette Mazurek Melnyk, PhD,
RN, CPNP/PMHNP, FNAP, FAAN,
Ellen Fineout-Overholt, PhD, RN,

FNAP, FAAN, Susan B. Stillwell, DNP,
RN, CNE, and Kathleen M.

Williamson, PhD, RN

The Seven Steps of Evidence-Based Practice
Following this progressive, sequential approach will lead
to improved health care and patient outcomes.

This is the second article in a new series from the Arizona State University College of Nursing and Health Innova-
tion’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving
approach to the delivery of health care that integrates the best evidence from studies and patient care data with clini-
cian expertise and patient preferences and values. When delivered in a context of caring and in a supportive organi-
zational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one
step at a time. Articles will appear every two months to allow you time to incorporate information as you work
toward implementing EBP at your institution. Also, we’ve scheduled “Ask the Authors” calls every few months to pro-
vide a direct line to the experts to help you resolve questions. See details below.

ajn@wolterskluwer.com AJN � January 2010 � Vol. 110, No. 1 51

Ask the Authors on January 22!

On January 22 at 3:30 PM EST, join the “Ask the Authors”call. It’s your chance to get personal consultation from the
experts! And it’s limited to the first 50 callers, so dial-in early!
U.S. and Canada, dial 1-800-947-5134 (International, dial
001-574-941-6964). When prompted, enter code 121028#.

Go to www.ajnonline.com and click on “Podcasts” and then
on “Conversations” to listen to our interview with the authors.

www.ajnonline.com

the frequency of tachycardic
episodes? Without this spirit of
inquiry, the next steps in the EBP
process are not likely to happen.

Step 1: Ask clinical questions
in PICOT format. Inquiries in this
format take into account patient
population of interest (P), inter-
vention or area of interest (I),
comparison intervention or group
(C), outcome (O), and time (T).

The PICOT format provides an
efficient framework for searching
electronic databases, one designed
to retrieve only those articles rel-
evant to the clinical question.
Using the case scenario on rapid
response teams as an example,
the way to frame a question about
whether use of such teams would
result in positive outcomes would
be: “In acute care hospitals
(patient population), how does
having a rapid response team
(intervention) compared with not
having a response team (compar-
ison) affect the number of car-
diac arrests (outcome) during a
three-month period (time)?”

Step 2: Search for the best
evidence. The search for evidence
to inform clinical practice is tre-
mendously streamlined when
questions are asked in PICOT
format. If the nurse in the rapid
response scenario had simply
typed “What is the impact of
having a rapid response team?”
into the search field of the data-
base, the result would have been
hundreds of abstracts, most of
them irrelevant. Using the PICOT
format helps to identify key words
or phrases that, when entered
successively and then combined,

validity centers on whether the
research methods are rigorous
enough to render findings as
close to the truth as possible.
For example, did the re-
searchers randomly assign
subjects to treatment or con-
trol groups and ensure that
they shared key characteristics
prior to treatment? Were valid
and reliable instruments used
to measure key outcomes?

• What are the results and are
they important? For interven-
tion studies, this question of
study reliability addresses
whether the intervention
worked, its impact on out-
comes, and the likelihood of
obtaining similar results in the
clinicians’ own practice set-
tings. For qualitative studies,
this includes assessing whether
the research approach fits the
purpose of the study, along
with evaluating other aspects
of the research such as wheth-
er the results can be confirmed.

• Will the results help me care
for my patients? This question
of study applicability covers
clinical considerations such as
whether subjects in the study
are similar to one’s own pa-
tients, whether benefits out-
weigh risks, feasibility and
cost-effectiveness, and patient
values and preferences.
After appraising each study, the

next step is to synthesize the stud-
ies to determine if they come to
similar conclusions, thus support-
ing an EBP decision or change.

Step 4: Integrate the evidence
with clinical expertise and pa-
tient preferences and values.
Research evidence alone is not
sufficient to justify a change in
practice. Clinical expertise, based
on patient assessments, laborato-
ry data, and data from outcomes
management programs, as well
as patients’ preferences and val-
ues are important components of

expedite the location of rele-
vant articles in massive research
databases such as MEDLINE or
CINAHL. For the PICOT ques-
tion on rapid response teams,
the first key phrase to be entered
into the database would be acute
care hospitals, a common subject
that will most likely result in thou-
sands of citations and abstracts.
The second term to be searched

would be rapid response team,
followed by cardiac arrests and
the remaining terms in the
PICOT question. The last step of
the search is to combine the
results of the searches for each
of the terms. This method nar-
rows the results to articles perti-
nent to the clinical question, often
resulting in fewer than 20. It also
helps to set limits on the final
search, such as “human subjects”
or “English,” to eliminate animal
studies or articles in foreign lan-
guages.

Step 3: Critically appraise
the evidence. Once articles are
selected for review, they must be
rapidly appraised to determine
which are most relevant, valid,
reliable, and applicable to the clin-
ical question. These studies are the
“keeper studies.” One reason cli-
nicians worry that they don’t have
time to implement EBP is that
many have been taught a labori-
ous critiquing process, including
the use of numerous questions de-
signed to reveal every element of
a study. Rapid critical appraisal
uses three important questions to
evaluate a study’s worth.6-8

• Are the results of the study
valid? This question of study

Research evidence alone is not sufficient to

justify a change in practice.

52 AJN � January 2010 � Vol. 110, No. 1 ajnonline.com

which patients are most likely to
benefit. When results differ from
those reported in the research
literature, monitoring can help
determine why.

Step 6: Disseminate EBP re-
sults. Clinicians can achieve won-
derful outcomes for their patients
through EBP, but they often fail
to share their experiences with
colleagues and their own or other
health care organizations. This
leads to needless duplication of
effort, and perpetuates clinical
approaches that are not evidence
based. Among ways to dissemi-
nate successful initiatives are EBP
rounds in your institution, pres-
entations at local, regional, and
national conferences, and reports
in peer-reviewed journals, profes-
sional newsletters, and publica-
tions for general audiences.

When health care organiza-
tions adopt EBP as the standard
for clinical decision making, the
steps outlined in this article nat-
urally fall into place. The next
article in our series will feature a
staff nurse on a medical–surgical
unit who approached her hospi-
tal’s EBP mentor to learn how
to formulate a clinical question
about rapid response teams in
PICOT format. �

Bernadette Mazurek Melnyk is dean and
distinguished foundation professor of
nursing at Arizona State University in
Phoenix, where Ellen Fineout-Overholt
is clinical professor and director of the
Center for the Advancement of Evidence-
Based Practice, Susan B. Stillwell is clinical
associate professor and program coordi-
nator of the Nurse Educator Evidence-
Based Practice Mentorship Program, and
Kathleen M. Williamson is associate direc-
tor of the Center for the Advancement
of Evidence-Based Practice. Contact
author: Bernadette Mazurek Melnyk,
bernadette.melnyk@asu.edu.

REFERENCES
1.Grimshaw J, et al. Toward evidence-
based quality improvement. Evidence
(and its limitations) of the effective-
ness of guideline dissemination and
implementation strategies 1966-1998.
J Gen Intern Med 2006;21 Suppl
2:S14-S20.

2.McGinty J, Anderson G. Predictors of
physician compliance with American
Heart Association guidelines for acute
myocardial infarction. Crit Care Nurs
Q 2008;31(2):161-72.

3.Shortell SM, et al. Improving patient
care by linking evidence-based medi-
cine and evidence-based management.
JAMA 2007;298(6):673-6.

4.Strout TD. Curiosity and reflective
thinking: renewal of the spirit. Indi-
anapolis, IN: Sigma Theta Tau Inter-
national; 2005.

5.Williams DO. Treatment delayed is
treatment denied. Circulation 2004;
109(15):1806-8.

6.Giacomini MK, Cook DJ. Users’
guides to the medical literature: XXIII.
Qualitative research in health care A.
Are the results of the study valid?
Evidence-Based Medicine Working
Group. JAMA 2000;284(3):357-62.

7.Giacomini MK, Cook DJ. Users’
guides to the medical literature: XXIII.
Qualitative research in health care B.
What are the results and how do they
help me care for my patients? Evidence-
Based Medicine Working Group.
JAMA 2000;284(4):478-82.

8.Stevens KR. Critically appraising
quantitative evidence. In: Melnyk BM,
Fineout-Overholt E, editors. Evidence-
based practice in nursing and health-
care: a guide to best practice.
Philadelphia: Lippincott Williams and
Wilkins; 2005.

9.Dacey MJ, et al. The effect of a rapid
response team on major clinical out-
come measures in a community hos-
pital. Crit Care Med 2007;35(9):
2076-82.

EBP. There is no magic formula
for how to weigh each of these
elements; implementation of EBP
is highly influenced by institution-
al and clinical variables. For ex-
ample, say there’s a strong body
of evidence showing reduced in-
cidence of depression in burn pa-
tients if they receive eight sessions
of cognitive-behavioral therapy
prior to hospital discharge. You
want your patients to have this
therapy and so do they. But budg-
et constraints at your hospital
prevent hiring a therapist to
offer the treatment. This resource
deficit hinders implementation
of EBP.

Step 5: Evaluate the out-
comes of the practice decisions
or changes based on evidence.
After implementing EBP, it’s im-
portant to monitor and evaluate
any changes in outcomes so that
positive effects can be supported
and negative ones remedied. Just
because an intervention was ef-
fective in a rigorously controlled
trial doesn’t mean it will work
exactly the same way in the clin-
ical setting. Monitoring the effect
of an EBP change on health care
quality and outcomes can help
clinicians spot flaws in implemen-
tation and identify more precisely

Case Scenario for EBP: Rapid Response Teams

You’re a staff nurse on a busy medical–surgical unit. Over the pastthree months, you’ve noticed that the patients on your unit seem to
have a higher acuity level than usual, with at least three cardiac arrests
per month, and of those patients who arrested, four died. Today, you
saw a report about a recently published study in Critical Care Medi-
cine on the use of rapid response teams to decrease rates of in-hospital
cardiac arrests and unplanned ICU admissions. The study found a sig-
nificant decrease in both outcomes after implementation of a rapid re-
sponse team led by physician assistants with specialized skills.9 You’re
so impressed with these findings that you bring the report to your nurse
manager, believing that a rapid response team would be a great idea
for your hospital. The nurse manager is excited that you have come to
her with these findings and encourages you to search for more evidence
to support this practice and for research on whether rapid response
teams are valid and reliable.

ajn@wolterskluwer.com AJN � January 2010 � Vol. 110, No. 1 53

Implementing EBP Column

Improving Patient Care Through Nursing
Engagement in Evidence-Based Practice
Elizabeth Crabtree, MPH • Emily Brennan, MLIS • Amanda Davis, MPH, RD •
Andrea Coyle, MSN, MHA, RN, CMSRN

This column shares the best evidence-based strategies and innovative ideas on how
to facilitate the learning of EBP principles and processes by clinicians as well as
nursing and interprofessional students. Guidelines for submission are available at
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787

INTRODUCTION AND BACKGROUND
The Medical University of South Carolina (MUSC) is a large
academic health science center, with a 700-bed medical cen-
ter (MUSC Health), and six colleges that train approximately
2,600 healthcare professionals annually. The MUSC Center
for Evidence-Based Practice (EBP), housed jointly in the Li-
brary and the Quality Management department of the MUSC
Hospital, aims to promote scientific inquiry, EBP, and quality
outcomes at MUSC. Through education, the development of
evidence-based clinical decision support tools and outcomes
research, the Center for EBP has begun to transform the cul-
ture of MUSC into one that incorporates best evidence into
clinical practice on both an individual and system level.

One of the strategies implemented by the Center for EBP
to promote cultural change is an educational course: the EBP
Nurse Scholars course, where nurses are taught about the the-
ory, practice, and dissemination of EBP.

DETAILED DESCRIPTION OF STRATEGY
Nurses serve on the frontline of health care, and have a
unique opportunity to improve patient care through EBP
(Hockenberry, Walaen, Brown, & Barrera, 2008). The staff
nurse is a critical link in bringing evidence-based changes into
clinical practice. Best practice only occurs when staff continu-
ally ask questions about treatment and care, have the resources
and skills necessary to search for and appraise research ev-
idence, implement the evidence in practice, and evaluate its
effectiveness (Dawes et al., 2005; Hockenberry et al., 2008).

MUSC’s experience in preparing practicing nurses to do
EBP was limited. To address this, the Center for EBP, in part-
nership with the Center for Professional Excellence, developed
a 12-week, project-based course to prepare nurses to engage in
EBP. The Center for Professional Excellence collaborates with

internal and external customers to create growth and devel-
opment opportunities for registered nurses. Additionally, the
center is responsible for Magnet application and designation.
The EBP Nurse Scholars course provides nurses with a com-
prehensive overview of EBP, prepares them to frame clinical
questions, perform literature searches, analyze and evaluate
evidence, and translate that knowledge into something clini-
cally meaningful. Members of the Center for EBP staff and
library faculty provided lectures and individual consultations
on framing clinical questions, conducting comprehensive lit-
erature searches, understanding statistics commonly reported
in research articles, and appraising and summarizing evidence
using the GRADE criteria. As part of the course, nurses se-
lected a specific hospital policy and applied their knowledge
to evaluating the evidence base for it. They then updated the
policy to ensure it reflected current evidence and best practice.

RESULTS
The EBP Nurse Scholars course resulted in successful com-
pletion of 15 projects related to nursing care and practice, and
led to significant practice improvements (Table 1). In addition,
several nurses have presented their findings at regional and
national conferences.

Pre- and post-course surveys demonstrated that the course
improved nurses’ confidence with EBP methods and skills re-
lated to research tools, statistical concepts, and study designs.
Data collected included responses from students from two EBP
Nurse Scholars courses: Spring 2013 and Spring 2014.

Participant Demographics
The majority of students who participated in the course were
BSN-level nurses working with adult populations at MUSC.

172 Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175.
C© 2016 Sigma Theta Tau International

Implementing EBP Column

0

1

2

3

4

5

Use of
research

Cochrane
Database of
Systema�c

Reviews

CINAHL Na�onal
Guideline

Clearinghouse

PubMed UpToDate

(1= Never, 2= Once per month, 3= Once per week, 4= Few
�mes per week, 5= Once per day, 6= Mul�ple �mes per day )

Median (Pre) Median (Post)

Figure 1. Use of research tools in practice.

Table 1. Examples of Completed EBP Nurse Scholars
Course Projects

Abdominal X-Ray forNG/OGTubePlacement

ClosedArterial Line LabSamplingSystem forPCICUPatients

DischargePlanning for Psychiatric Patients

ImprovingCare of Elderly in theAcuteCareSetting

InternationalNormalizedRatioCut-Off forHeart Catheterizations

Lidocaine4% forNonemergent IVStarts

Oral Care for Infants

Peripheral Administration ofChemotherapyAgents

Postoperative Education

Postpyloric Feeding toReduceRisk of AspirationPneumonia

PreoperativeBathing

PreventingTurniquet-Related Injuries inPatientsUndergoingTKA

Safety of “QuickStart”DepoProvera

ThermoprotectiveWraps inVery LowBirthWeight Infants

The majority of participants were ICU nurses, and students
typically had 0–5 years of experience.

Survey Results
Study data were collected and managed using Research
Electronic Data Capture (REDCap) electronic data capture
tools, hosted at MUSC. Due to the continuous nature of the

variables assessed in the pre- and post-tests for the EBP Nurse
Scholars course, we used pre- and post-test median scores and
the Mann-Whitney U test to measure significant changes in
confidence with EBP methods, use of research tools in clinical
practice, and understanding of statistical concepts and study
designs. A complete listing of the survey questions can be
found in Appendix 1, available with the online version of this
article.

After the course, there were significant increases in nurses’
confidence in critically reviewing literature (p < .001), their belief that EBP was necessary in nursing practice (p = .052), and their interest in improving skills necessary to use EBP in practice (p = .002). There were also significant increases in the use of EBP resources in clinical practice, including the Cochrane Database of Systematic Reviews (p < .001), CINAHL (p < .001), National Guideline Clearinghouse (p = .049), PubMed (p = .005), and UpToDate (p = .018), as well as in the understanding of statistical concepts and study design methods (p < .001). Pre- and post-test median scores representing the improvements in EBP resource utilization and understanding of research concepts are included in Figures 1 and 2.

The success of the EBP Nurse Scholars course led to
the development of a project-based course for interprofes-
sional teams of pediatric clinicians, all of which included
a nurse. These teams received EBP education and worked
together during this Interprofessional EBP course to frame
clinical questions, systematically search for, and critically ap-
praise and synthesize a body of research evidence for a par-
ticular disease topic. Based on their review of the evidence,
teams developed clinical practice recommendations for each
of the clinical questions they framed. These recommenda-
tions were used to develop admission and emergency depart-
ment order sets which were integrated into MUSC’s electronic

Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175. 173
C© 2016 Sigma Theta Tau International

Improving Care through EBP

0
1
2
3

(1= Do not understand, 2= Understand somewhat,
3= Understand completely)

Median (Pre) Median (Post)

Figure 2. Understanding of Research Concepts.

medical record. Finally, participants who completed either
the EBP Nurse Scholars course or the Interprofessional EBP
course were invited to participate in an EBP Leadership Pro-
gram. This program focused on implementation of their EBP
project, evaluation of results, outcomes, and dissemination of
findings.

Through these courses, the Center for EBP is transforming
the institution’s culture into one that builds EBP capacity, and
incorporates best evidence into clinical practice on both an
individual and system level.

DISSEMINATION
The Center for EBP staff has supported nurses in translating
their projects into scholarly work. The EBP Leadership
Program, the follow-up to the EBP Nurse Scholars course,
provided nurses with the skills to both implement and evaluate
practice change projects, but it also provided nurses with tools
and resources for developing abstracts for poster and podium
presentations. As a result of these efforts, numerous course
participants have had their work accepted for presentation
at regional and national conferences. The Center for EBP
applied for and received a competitive, internally funded
grant to support nurses in attending conferences where
they present the results of their EBP projects. The grant
covers the cost of printing a poster for nurses who have
had abstracts accepted. Funding the printing cost of the
posters further encouraged nurses to attend conferences, and
present their work, and motivated departments and units to
provide support for nursing engagement in EBP scholarly
work.

Supporting professional growth and development is a
nursing strategic priority at MUSC. To support and promote

nursing clinicians, three EBP Nurse Scholar projects were
highlighted in MUSC’s Magnet document. Additionally,
videos of nurses engaging in the EBP process were produced
and disseminated internally. The videos highlighted scholars
performing a literature search, analyzing and evaluating evi-
dence, and translating that knowledge in to changes in nursing
practice. WVN

LINKING EVIDENCE TO ACTION

� Organizational cultures can be transformed
through provision of EBP education and mentored
implementation of EBP knowledge and skills.

� A project-based EBP education program can re-
sult in an increase in utilization of EBP resources,
and in improvements in knowledge and attitudes
related to EBP.

� The implementation and dissemination of EBP
projects creates opportunities for nurses to partici-
pate in the development of scholarly products, and
results in professional growth and development.

Author information

Elizabeth Crabtree, Director of Evidence-Based Practice, Qual-
ity, Management, and Assistant Professor, Library & Infor-
matics, Medical University of South Carolina, Charleston,
SC; Emily Brennan, Informationist, Research Librarian, and
Assistant Professor, Library & Informatics, Medical Univer-
sity of South Carolina, Charleston, SC; Amanda Davis,

174 Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175.
C© 2016 Sigma Theta Tau International

Implementing EBP Column
Clinical Evidence-Based Practice Analyst, Medical University
of South Carolina, Charleston, SC; Andrea Coyle, Professional
Excellence Coordinator, Clinical, Services Administration,
Medical University of South Carolina, Charleston, SC

Address correspondence to Elizabeth Crabtree, Library
& Informatics, Medical University of South Carolina, 171
Ashley Avenue, Library, Suite 408, Charleston, SC 29425;
crabtr@musc.edu

Accepted 15 August 2015
Copyright C© 2016, Sigma Theta Tau International

References
Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Mar-

tin, J., Hopayian, K., & . . . Osborne, J. (2005). Sicily statement
on evidence-based practice. BMC Medical Education, 5, 1.

Hockenberry, M., Walaen, M., Brown, T., & Barrera, P. (2008).
Creating an evidence-based practice environment: One hospi-
tal’s journey. Journal of Trauma Nursing, 15(3), 136–142.

doi 10.1111/wvn.12126
WVN 2016;13:172–175

Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175. 175
C© 2016 Sigma Theta Tau International

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articles for individual use.

Original Article

Predictors of Evidence-Based Practice
Implementation, Job Satisfaction, and Group
Cohesion Among Regional Fellowship
Program Participants
Son Chae Kim, RN, PhD • Jaynelle F. Stichler, DNS, RN, NEA-BC, FACHE, FAAN •
Laurie Ecoff, RN, PhD, NEA-BC • Caroline E. Brown, DEd, CNS •
Ana-Maria Gallo, PhD, CNS, RNC-OB • Judy E. Davidson, DNP, RN, FCCM

Keywords

evidence-based
practice,

fellowship,
EBP beliefs,

EBP
implementation,
job satisfaction,

group cohesion,
group attractiveness

ABSTRACT
Background: A regional, collaborative evidence-based practice (EBP) fellowship program utiliz-
ing institution-matched mentors was offered to a targeted group of nurses from multiple local
hospitals to implement unit-based EBP projects. The Advancing Research and Clinical Practice
through Close Collaboration (ARCC) model postulates that strong EBP beliefs result in high EBP
implementation, which in turn causes high job satisfaction and group cohesion among nurses.

Aims: This study examined the relationships among EBP beliefs, EBP implementation, job satis-
faction, group cohesion, and group attractiveness among the fellowship program participants.

Methods: A total of 175 participants from three annual cohorts between 2012 and 2014 com-
pleted the questionnaires at the beginning of each annual session. The questionnaires included
the EBP beliefs, EBP implementation, job satisfaction, group cohesion, and group attractiveness
scales.

Results: There were positive correlations between EBP beliefs and EBP implementation (r = 0.47;
p <.001), as well as EBP implementation and job satisfaction (r = 0.17; p = .029). However, no statistically significant correlations were found between EBP implementation and group cohesion, or group attractiveness. Hierarchical multiple regression models showed that EBP beliefs was a significant predictor of both EBP implementation (β = 0.33; p <.001) and job satisfaction (β = 0.25; p = .011). However, EBP implementation was not a significant predictor of job satisfaction, group cohesion, or group attractiveness.

Linking Evidence to Action: In multivariate analyses where demographic variables were taken
into account, although EBP beliefs predicted job satisfaction, no significant relationship was
found between EBP implementation and job satisfaction or group cohesion. Further studies are
needed to confirm these unexpected study findings.

BACKGROUND
The adoption and implementation of evidence-based practice
(EBP) in nursing and other healthcare disciplines are recog-
nized as essential in ensuring optimal patient outcomes and
quality of care (Aarons, Ehrhart, & Farahnak, 2014). Although
EBP is considered to be the gold standard in nursing practice,
the actual implementation of EBP has been inconsistent due
to barriers related to nursing workload, lack of organizational
support, lack of EBP knowledge and skills, and poor attitudes
toward EBP (Brown et al., 2010; Ramos-Morcillo, Fernandez-
Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015; Squires,
Estabrooks, Gustavsson, & Wallin, 2011). Although many hos-
pitals have used professional development courses individually

to encourage nurses’ implementation of EBP through im-
proved nurses’ knowledge and attitudes about EBP, successful
outcomes have been elusive (Melnyk, Gallagher-Ford, Long,
& Fineout-Overholt, 2014; Pryse, McDaniel, & Schafer, 2014;
Underhill, Roper, Siefert, Boucher, & Berry, 2015).

A regional, collaborative EBP fellowship program, the EBP
Institute, was founded in 2006 by nurse leaders from multi-
ple hospitals and academia in San Diego County, California, to
promote implementation of EBP by hospital nurses. The fel-
lowship program utilized institution-matched mentors to assist
in executing unit-based EBP projects, and included didactic as
well as interactive learning experiences in six daylong educa-
tional sessions over a 9-month period. A formal graduation day

340 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
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Original Article
completed the learning experience, with the fellows present-
ing their EBP projects in poster and podium presentations. A
previous report on this program showed improvements in the
participants’ knowledge, attitudes, and practice associated with
EBP, as well as a reduction in barriers to

EBP implementation

(Kim et al., 2013).

LITERATURE REVIEW
The literature is replete with evidence and opinions that ef-
forts to educate nurses regarding EBP have improved nurses’
knowledge and attitudes. However, these efforts have not nec-
essarily resulted in actual improvements in EBP implementa-
tion, nor have they changed clinical practices (Aarons et al.,
2014; Melnyk et al., 2014; Pryse et al., 2014). Although barri-
ers to EBP implementation have been well-documented, some
authors have also cited the importance of organizational cul-
ture and leadership in reducing barriers and fostering EBP
implementation.

Organizational Culture and Leadership for EBP
An organizational culture that emphasizes making clinical de-
cisions based on evidence is critical for improving and sus-
taining safe and high-quality patient care (Melnyk, Fineout-
Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010). Al-
though leaders influence the organizational culture, they also
play an important role in supporting implementation of EBP
and other innovative practices. Supportive leaders obtain fund-
ing, provide resources, allow the time necessary for nurses
to engage in EBP implementation, and reward those nurses
who participate in evidence-based change projects in perfor-
mance evaluations (Aarons et al., 2014; Ehrhart, Aarons, &
Farahnak, 2015). Ehrhart, Aarons, and Farahnak (2015) have
reported that clinical nurses with the greatest clinical exper-
tise and EBP knowledge were most helpful in advancing EBP
skills and positive EBP attitudes among their coworkers. This
finding supports the importance of mentorship in improving
nurses’ knowledge, attitudes, and practice of EBP (Abdullah
et al., 2014; Green et al., 2014; Magers, 2014).

Furthermore, organizations that engage in the Magnet
Recognition Program have been recognized for nurse engage-
ment in EBP and implementation of clinical practice changes.
The Magnet journey transforms organizational cultures, and
ensures leadership support and resources necessary to facili-
tate nurses’ engagement in EBP (American Nurses Credential-
ing Center, 2014; Black, Balneaves, Garossino, Puyat, & Qian,
2015; Wilson et al., 2015).

Educational Processes to Enhance EBP in
Healthcare Settings
A number of studies have described the structures, processes,
and outcomes of programs to enhance nurses’ appreciation,
knowledge, competencies, and practice of EBP (Kim et al.,
2013; Magers, 2014; Mollon et al., 2012; Ramos-Morcillo et al.,
2015; Underhill et al., 2015; Wong & Myers, 2015). Although

most EBP educational programs emphasize EBP contents re-
lated to asking relevant clinical questions, and searching for
and appraising forms of evidence, less emphasis is put on
actual EBP implementation (Wyer, Umscheid, Wright, Silva,
& Lang, 2015). The Advancing Research and Clinical Practice
through Close Collaboration (ARCC) model emphasizes EBP
implementation as the final focal point of the entire model,
through which all of the beneficial outcomes of EBP diffusion
flow (Melnyk et al., 2010). These outcomes include benefits
to patients with improved patient outcomes as well as bene-
fits to nurses such as higher job satisfaction and group cohe-
sion, along with lower nurse turnover, with the ultimate out-
come of decreased hospital costs. Using the ARCC model to
educate nurses, previous studies have reported that partici-
pants’ beliefs about EBP were significantly correlated with
perceived organizational culture for EBP, implementation of
EBP, group cohesion, and job satisfaction (Melnyk et al., 2010;
Wallen et al., 2010). However, there has not been a full ex-
amination of the strength of relationships among EBP beliefs,
EBP implementation, job satisfaction, and group cohesion that
takes the demographic variables into account.

The purpose of the study was to examine the relation-
ships among EBP beliefs, EBP implementation, job satisfac-
tion, group cohesion, and group attractiveness among nurses
participating in a regional, collaborative EBP fellowship pro-
gram. The specific aims were to examine: (a) EBP beliefs as a
predictor of EBP implementation; and (b) EBP beliefs and EBP
implementation as predictors of job satisfaction, group cohe-
sion, and group attractiveness above and beyond the influence
of demographic variables.

METHODS
Design and Participants
Three annual cohorts of nurses attending the 9-month re-
gional, collaborative EBP fellowship program in San Diego,
California, from 2012 to 2014 were invited to participate in
the study. The program attendees were selected nurses repre-
senting each participating institution as a dyad of mentor and
fellow. The fellows, in general, were staff nurses who would be
implementing unit-based EBP projects under the mentorship
of advanced practice nurses, nurse educators, or other nurses
with experience in implementing EBP projects.

Instruments
EBP beliefs scale. This 16-item scale measures respondents’
beliefs about the importance of EBP and their EBP competence
in a five-point Likert response format, ranging from strongly
disagree ( = 1) to strongly agree ( = 5). Possible total scores
range from 16 to 80, with higher scores indicating stronger
EBP beliefs. The internal consistency reliability was reported
as Cronbach’s alpha of 0.90, and validity testing has also been
reported in the previous study (Melnyk, Fineout-Overholt, &
Mays, 2008). The Cronbach’s alpha for the instrument in this
study was 0.87.

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 341
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Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

EBP implementation scale. This 18-item scale assesses the
frequency of performing EBP-related activities in the past
8 weeks (Melnyk et al., 2008). Examples of items include gener-
ating a PICO question, critically appraising research evidence,
and collecting data, as well as sharing EBP guidelines with oth-
ers. Response options range from 0 times ( = 0) to greater than
or equal to 8 times ( = 4), and the total summation score ranges
from 0 to 72, with a higher score indicating greater participa-
tion in EBP-related activities. The internal consistency reliabil-
ity was Cronbach’s alpha of 0.96, and validity testing was also
reported. The Cronbach’s alpha in this study was 0.96.

Job satisfaction scale. Respondents are asked to rate their
perception of job satisfaction in a five-point Likert response
format, ranging from strongly disagree ( = 1) to strongly agree
( = 5). This scale contains four items and the total summation
score ranges from 4 to 20, with a higher score indicating higher
job satisfaction (Mueller, Boyer, Price, & Iverson, 1994). The
Cronbach’s alpha was reported as 0.88 in the previous study
and it was 0.89 in this study.

Group cohesion and attractiveness scales. These are two
scales that measure group cohesion and group attractiveness
in a seven-point Likert response format (Good & Nelson, 1973).
The four-item Group Cohesion scale rates respondents’ percep-
tion about their work group’s productivity, efficiency, feeling
of belongingness, and morale from very much above average
( = 1) to very much below average ( = 7). The two-item Group
Attractiveness scale assesses respondents’ perception of their
enjoyment in working with the group. Responses range from
like/enjoy very much ( = 1) to dislike very much ( = 7). In this
study, the scores were reversed so that higher scores indicate
positive perceptions. The reported split-half reliabilities were
0.77 and 0.82, whereas the Cronbach’s alphas in this study
were 0.90 and 0.85, respectively.

Demographic data form. General demographic information,
such as age, educational background, ethnicity, years of RN
experience, and nursing position, was obtained.

Data Collection Procedures
This study was approved by the institutional review boards
of the participating academic and healthcare institutions. A
consent letter was provided to and reviewed by all potential
participants. Written documentation of consent was waived,
because minimal risk was involved in this study and partici-
pants’ anonymity was protected. Completion of the study ques-
tionnaires indicated consent to participate in the study. The
participants completed the study questionnaires at the begin-
ning of each 9-month program.

Data Analyses
Descriptive statistics, including mean, standard deviation, fre-
quency, and percentage, were calculated. Independent t-tests
were performed to compare the mean scores of EBP be-
liefs, EBP implementation, job satisfaction, group cohesion,

and group attractiveness between the mentors and the fel-
lows. Bivariate Pearson’s correlations were performed to exam-
ine the relationships among demographic variables and other
variables. To examine EBP beliefs as a predictor of EBP im-
plementation, the demographic variables that had significant
correlations with EBP implementation were entered in the first
step of the hierarchical multiple regression model. The EBP be-
liefs was then entered in the second step as a predictor of EBP
implementation above and beyond the demographic variables.

To examine EBP beliefs and EBP implementation as pre-
dictors of job satisfaction, group cohesion, and group attrac-
tiveness, the demographic variables that correlated with job
satisfaction, group cohesion, or group attractiveness were en-
tered in the first step of the hierarchical multiple regression
models. This was followed by entry of the EBP beliefs and
EBP implementation in the second step as predictors above
and beyond the demographic variables. The assumptions of
normality, linearity, and homoscedasticity in the hierarchical
multiple regression models were met. SPSS version 21.0 (IBM
SPSS Statistics, Armonk, NY) was used for data analyses and
the level of significance was set at p < .05.

RESULTS
Sample Characteristics
A total of 175 participants (101 fellows and 74 mentors) from
the three annual cohorts between 2012 and 2014 completed the
questionnaires at the beginning of the program. The fellows
comprised 57.7% of all participants. A majority of the partic-
ipants were white (69.7%) and had graduate degrees (52%).
The mean age was 42 years and average RN experience was
15 years (Table 1).

The mentors had statistically significant higher scores for
EBP beliefs (66.6 vs. 59.3; p < .001) and EBP implementation (24.2 vs. 11.0; p < .001) in comparison with the fellows. How- ever, there were no statistically significant differences in job satisfaction, group cohesion, or group attractiveness between the mentors and the fellows (Table 2).

Bivariate Correlations among Demographics and
Other Variables
Table 3 shows that the demographic variables of being a
mentor, clinical nurse specialist, nurse educator, or nurse
practitioner, as well as having a graduate-level education, had
statistically significant positive correlations with both EBP
beliefs and EBP implementation. Length of RN experience also
correlated with EBP implementation and having a graduate-
level education was the only demographic variable that corre-
lated with job satisfaction. None of the demographic variables
had positive correlations with either group cohesion or group
attractiveness.

For EBP implementation, positive correlations were ob-
served with EBP beliefs (r = 0.47; p < .001) and job satisfaction (r = 0.17; p = .029). However, no statistically significant cor- relations were found between EBP implementation and group

342 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
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Table 1. Demographic Characteristics (N = 175)

Total Fellows Mentors

Variables (N = 175) (n = 101) (n = 74)
Cohorts

2012 cohort 42 (24.0) 20 (19.8) 22 (29.7)

2013 cohort 60 (34.3) 40 (39.6) 20 (27.0)

2014 cohort 73 (41.7) 41 (40.6) 32 (43.2)

Age,mean (year), range 42 (23-68) 39 (23-68) 46 (27-67)

Ethnicity

White (non-Hispanic) 122 (69.7) 66 (65.3) 56 (75.7)

Black 5 (2.9) 3 (3.0) 2 (2.7)

Hispanic 11 (6.3) 6 (5.9) 5 (6.8)

Asian/Pacific Islanders 29 (16.6) 19 (18.8) 10 (13.5)

Other 8 (4.5) 7 (6.9) 1 (1.4)

Educational level

Diploma/associate 8 (4.6) 8 (7.9) 0 (0.0)

Baccalaureate 76 (43.4) 70 (69.3) 6 (8.1)

Master/doctorate 91 (52.0) 23 (22.8) 68 (91.9)

Nursingposition

Clinical nurse 73 (41.7) 67 (66.3) 6 (8.1)

Leadnurse 20 (11.4) 13 (12.9) 7 (9.5)

Nursemanager 12 (6.9) 1 (1.0) 11 (14.9)

CNS/nurse educator/NP 64 (36.6) 15 (14.9) 49 (66.2)

Non-nursing 6 (3.4) 5 (5.0) 1 (1.4)

RNexperience,mean (year), range 15 (1, 42) 12 (1, 35) 20 (2, 42)

ANCCcertification in specialty 94 (53.7) 48 (47.5) 46 (62.2)

Note. Values are expressed as n (%) unless otherwise indicated. Percentagesmay not add up to 100% because of missing data or rounding. ANCC = American
NursesCredentialingCenter; CNS = clinical nurse specialist; NP = nursepractitioner; RN = registerednurse.

cohesion or group attractiveness. For job satisfaction, there
were positive correlations with EBP beliefs (r = 0.26; p = .01)
and group attractiveness (r = 0.23; p = .003). There was also a
positive correlation between group cohesion and group attrac-
tiveness (r = 0.49; p < .001; Table 3).

Multivariate Analysis: EBP Beliefs as a Predictor of
EBP Implementation
In the first step of a hierarchical multiple regression model,
the demographic variables, including being a mentor, edu-
cational level, years of RN experience, and nursing position
accounted for 22.5% of the variance in EBP implementation

(R2 = 0.225; Table 4). The entry of the EBP beliefs in the
second step increased the R2 by .075, indicating that the EBP
beliefs explained a small fraction of the variance in the EBP
implementation above and beyond the demographic variables
(7.5%). Being a mentor (β = 0.27; p = .012) and EBP beliefs
(β = 0.33; p < .001) were statistically significant predictors of EBP implementation.

Multivariate Analyses: Predictors of Job Satisfac-
tion, Group Cohesion, and Group Attractiveness
Table 5 shows that demographic variables in the first step
of a hierarchical multiple regression model accounted for 6.2%

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Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

Table 2. Comparison of Mean (± SD) of Variables
Between Mentors and Fellows (N = 170)

P value

Fellows Mentors independent

(n = 98) (n = 72) (t test)
EBPbeliefs 59.3 (6.38) 66.6 (6.91) < .001***

EBP implementation 11.0 (10.6) 24.2 (16.9) < .001***

Job satisfaction 16.6 (2.18) 17.0 (2.34) .215

Groupcohesion 20.1 (4.39) 20.6 (4.67) .479

Groupattractiveness 11.7 (1.67) 11.8 (1.83) .653

Note. ***p < 0.001. SD = standard deviation. The higher the scores, the higher the EBP beliefs, EBP implementation, job satisfaction, group cohesion, andgroupattractiveness.

of the variance in job satisfaction (R2 = 0.062). The entry of
EBP beliefs and EBP implementation in the second step in-
creased the R2 by 0.050, indicating that these two variables ex-
plained a small fraction of the variance in job satisfaction above
and beyond demographic variables (5.0%). EBP beliefs was
a statistically significant positive predictor of job satisfaction
(β = 0.25; p = .011), but EBP implementation was not a
predictor of job satisfaction.

For group cohesion, the demographic variables in the
first step explained 1.8% of the variance of group cohesion
(R2 = 0.018). The EBP beliefs and EBP implementation in the
second step explained 0.2% of the variance of group cohesion
(R2 = 0.002), indicating that these two variables explained
only a minimal fraction of variance in group cohesion above
and beyond the demographic variables.

For group attractiveness, the first entry of demographic
variables accounted for 1.0% of the variance of the group at-
tractiveness (R2 = 0.010). The entry of EBP beliefs and EBP
implementation in the second step changed the R2 by 0.038,
indicating that they explained a minimal fraction of the vari-
ance in group attractiveness (3.8%). EBP implementation was
a statistically significant negative predictor for group attractive-
ness (β = -0.22; p = .021; Table 5).

Table 3. Bivariate Correlations Among Variables

EBP
beliefs

EBP
implementation

Job
satisfaction

Group
cohesion

Group
attractiveness

Mentors 0.48*** 0.43*** 0.10 0.06 0.04

Educational level

Diploma/associate −0.19* −0.03 −0.02 −0.19* 0.01
Baccalaureate −0.43*** −0.37*** −0.15* −0.002 −0.06
Master/doctorate 0.51*** 0.38*** 0.16* 0.01 0.07

Years of RNexperience 0.13 0.16* 0.02 0.04 0.04

Nursingposition

Clinical nurse −0.33*** −0.28*** 0.04 −0.01 −0.07
Leadnurse −0.02 −0.001 −0.19* −0.04 −0.02
Nursemanager 0.07 −0.02 −0.07 0.11 0.04
CNS/nurse educator/NP 0.34*** 0.32*** 0.09 −0.02 0.01

EBPbeliefs 1 0.47*** 0.26** −0.02 0.09
EBP implementation 0.47*** 1 0.17* −0.02 −0.11
Job satisfaction 0.26** 0.17* 1 0.09 0.23**

Groupcohesion −0.02 −0.02 0.09 1 0.49***

Groupattractiveness 0.09 −0.11 0.23** 0.49*** 1
Note. *p < .05; ** p < .01; *** p < .001 byPearson’s correlations.

344 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
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Table 4. Multivariate Analysis: Predictors of EBP Im-
plementation

EBP implementation

Predictors B β

Step 1

Constant demographic variables a 15.4

R2 = 0.225***

Step2

Constant −27.0
Mentor 8.25* 0.27*

EBPbeliefs 0.66*** 0.33***

R2 � = 0.075***

F� (1, 160) = 17.22***

Note. *p < 0.05; *** p < 0.001. aDemographic variables of being amen- tor, educational level, years of RN experience, and nursing position were entered.

DISCUSSION
The study findings indicate that EBP beliefs had a signifi-
cant correlation with EBP implementation in bivariate anal-
ysis, and was a positive predictor of EBP implementation in
multivariate analysis. In addition, EBP beliefs showed a signif-

icant correlation with job satisfaction in bivariate analysis and
was also a positive predictor of job satisfaction in multivariate
analysis. These results are consistent with previous findings
and support the ARCC model, which postulates that strong
EBP beliefs result in high levels of EBP implementation
(Melnyk et al., 2010).

Although these study findings indicate that EBP implemen-
tation has some correlation with job satisfaction in a bivariate
analysis, the multivariate analysis showed a surprising finding
that EBP implementation was not a predictor of job satisfac-
tion. In addition, EBP implementation was not a significant
predictor of group cohesion or group attractiveness in mul-
tivariate analyses. Furthermore, EBP implementation was a
significant negative predictor of group attractiveness, indicat-
ing that high levels of EBP implementation are associated with
lower group attractiveness. These unexpected findings from
multivariate analyses appear to conflict with the ARCC model,
which postulates that high levels of EBP implementation re-
sult in high job satisfaction as well as high group cohesion
(Melnyk et al., 2010). However, these findings are consistent
with a previous report showing no statistically significant cor-
relations between EBP implementation and job satisfaction or
group cohesion (Melnyk et al., 2010). Also, an interventional
study of implementing the ARCC model showed no signifi-
cant effect on job satisfaction, in spite of improvements in EBP
implementation (Levin, Fineout-Overholt, Melnyk, Barnes, &
Vetter, 2011). It is possible that these findings showing no
significant relationship between EBP implementation and job
satisfaction or group cohesion are due to small sample sizes,
which could have prevented detection of small effects. Further
studies are needed to confirm this study findings.

Table 5. Multivariate Analyses: Predictors of Job Satisfaction, Group Cohesion, and Group Attractiveness

Job satisfaction Groupcohesion Groupattractiveness

Predictors B β B β B β

Step 1

Constant 17.0 19.3 12.1

demographic variables a

R2 = 0.062 R2 = 0.018 R2 = 0.010
Step2

Constant 12.2 20.9 10.2

EBP implementation 0.01 0.06 −0.01 −0.03 −0.03* −0.22
EBPbeliefs 0.07* 0.25* −0.02 −0.04 0.04 0.16

R2 � = 0.050* R2 � = 0.002 R2 � = 0.038*

F� (2, 157) = 4.47* F� (2, 162) = 0.16 F� (2, 157) = 3.12*

Note. *p < 0.05. aDemographic variables of being amentor, educational level, years of RNexperience, andnursingpositionwere entered.

Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348. 345
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Predictors of EBP Implementation, Job Satisfaction, and Group Cohesion

It was not surprising that mentors, given their longer years
of RN experience, higher levels of education, and nursing
positions as advanced practice nurses (clinical nurse special-
ists, nurse educators, or nurse practitioners), had significantly
stronger EBP beliefs and greater EBP implementation. These
findings are consistent with previous reports showing that
higher levels of education correlated with higher EBP be-
liefs and EBP implementation (Underhill et al., 2015). It is
interesting that the mentors did not have higher job satis-
faction, group cohesion, or group attractiveness, in spite of
having higher EBP implementation. This is consistent with
the aforementioned findings from this study, as well as previ-
ous reports that EBP implementation is not necessarily asso-
ciated with higher job satisfaction or group cohesion (Melnyk
et al., 2010).

Since its inception in 2006, our regional collaborative EBP
fellowship program has been in continuous operation, and has
successfully educated more than 400 nurses and nurse lead-
ers from 12 local hospitals to date. With solid and consistent
organizational support from local hospitals and academic insti-
tutions, the fellowship program has been able to pool resources
and expertise from these organizations to empower participat-
ing nurses to execute unit-based EBP projects (Kim et al., 2013).
The fellows and mentors, equipped with EBP knowledge and
skills, along with strong EBP beliefs, become EBP champi-
ons in their own hospital units and serve as role models for
their colleagues (Melnyk, 2007). We believe that our regional
EBP fellowship program in Southern California can serve as
a template for other regional organizations to come together
and collaborate in fostering EBP implementation across mul-
tiple hospitals in their own regions, with the ultimate aim of
improving quality of care and patient outcomes.

Limitations
There are several limitations to this study. First, the study find-
ings of EBP beliefs as a significant predictor of EBP implemen-
tation and job satisfaction should not be taken as cause-and-
effect relationships in this descriptive cross-sectional study.
Second, the subjective self-reporting methods of the study
questionnaire may have overestimated respondents’ percep-
tions about their beliefs in the value of EBP, EBP implemen-
tation, and job satisfaction. Third, the fellowship participants
were selected from a group of staff nurses who had already
demonstrated high motivation for EBP adoption. Due to the
potential sample selection bias, the study findings may not be
generalizable to other nursing staff. Fourth, although the in-
struments used in this study have been validated previously,
the items may not have fully captured the intended concepts.
Further refinements of the instruments could show differ-
ent results. Finally, even though the study population came
from multiple institutions, the findings are from one region
in Southern California and may not be generalizable to other
regions.

Future studies are needed to conduct an interventional
study to evaluate the beneficial effects of regional fellowship

programs on EBP beliefs, EBP implementation, job satisfac-
tion, and group cohesion. There is a need for further empir-
ical research evidence to support relationships in the ARCC
model.

CONCLUSIONS
The baseline data collected from the participants of a regional
collaborative fellowship program involving multiple local hos-
pitals and academic institutions over a 3-year period indicated
that strong EBP beliefs was a positive predictor of EBP imple-
mentation and job satisfaction. However, no significant rela-
tionships were found between EBP implementation and job
satisfaction or group cohesion when demographic variables
were taken into account. Further studies are needed to evalu-
ate the impact of regional collaborative fellowship programs on
EBP beliefs, EBP implementation, job satisfaction, and group
cohesion among the participants, as well as to generate addi-
tional evidence for the ARCC model. WVN

LINKING EVIDENCE TO ACTION

� A regional, collaborative EBP fellowship program
utilizing institution-matched mentors should be
encouraged to advance EBP because such pro-
grams may be effective in improving EBP beliefs,
EBP implementation, and job satisfaction.

� Support from participating institutions is essential
for the success of a regional, collaborative EBP
fellowship program.

� Strong beliefs in the value of EBP appear to be
associated with high levels of EBP implementation
and job satisfaction among the fellowship program
participants.

� No significant relationship was found between
EBP implementation and job satisfaction or group
cohesion when demographic variables were taken
into account; further studies are needed to confirm
these unexpected study findings.

Author information

Son Chae Kim, Professor, St. David’s School of Nursing, Texas
State University, Round Rock, TX; Jaynelle F. Stichler, Pro-
fessor Emerita, San Diego State University; Consultant, Re-
search and Professional Development, Sharp Memorial Hos-
pital and Sharp Mary Birch Hospital for Women & Infants, San
Diego, CA; Laurie Ecoff, Director of Research, Education, and
Professional Practice, Sharp Memorial Hospital, San Diego,
CA; Caroline E. Brown, Research Consultant, Bonita Springs,
FL; Ana-Maria Gallo, Director of Nursing Education, Research
and Professional Practice, La Mesa, CA; Judy E. Davidson,

346 Worldviews on Evidence-Based Nursing, 2016; 13:5, 340–348.
C© 2016 Sigma Theta Tau International

Original Article
EBP/Research Nurse Liaison, University of California San
Diego Health System, San Diego, CA

Address correspondence to Dr. Son Chae Kim, Professor, St.
David’s School of Nursing, Texas State University, 1555 Univer-
sity Blvd., Round Rock, TX 78665; sck30@txstate.edu

Accepted 14 November 2015
Copyright C© 2016, Sigma Theta Tau International

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articles for individual use.

The Quadruple Aim: care, health,
cost and meaning in work

Rishi Sikka,1 Julianne M Morath,2 Lucian Leape3

1Advocate Health Care, Downers
Grove, Illinois, USA
2Hospital Quality Institute,
Sacramento, California, USA
3Harvard School of Public
Health, Boston, Massachusetts,
USA

Correspondence to
Dr Rishi Sikka, Advocate
Health Care, 3075 Highland
Avenue, Suite 600, Downers
Grove, Il 60515, USA;
rishi.sikka@advocatehealth.com

Received 5 March 2015
Revised 6 May 2015
Accepted 16 May 2015

To cite: Sikka R, Morath JM,
Leape L. BMJ Qual Saf
2015;24:608–610.

In 2008, Donald Berwick and colleagues
provided a framework for the delivery of
high value care in the USA, the Triple
Aim, that is centred around three over-
arching goals: improving the individual
experience of care; improving the health
of populations; and reducing the per
capita cost of healthcare.1 The intent is
that the Triple Aim will guide the redesign
of healthcare systems and the transition to
population health. Health systems glo-
bally grapple with these challenges of
improving the health of populations while
simultaneously lowering healthcare costs.
As a result, the Triple Aim, although ori-
ginally conceived within the USA, has
been adopted as a set of principles for
health system reform within many organi-
sations around the world.
The successful achievement of the

Triple Aim requires highly effective
healthcare organisations. The backbone of
any effective healthcare system is an
engaged and productive workforce.2 But
the Triple Aim does not explicitly acknow-
ledge the critical role of the workforce in
healthcare transformation. We propose a
modification of the Triple Aim to acknow-
ledge the importance of physicians, nurses
and all employees finding joy and
meaning in their work. This ‘Quadruple
Aim’ would add a fourth aim: improving
the experience of providing care.
The core of workforce engagement is

the experience of joy and meaning in the
work of healthcare. This is not synonym-
ous with happiness, rather that all
members of the workforce have a sense
of accomplishment and meaning in their
contributions. By meaning, we refer to
the sense of importance of daily work.
By joy, we refer to the feeling of success
and fulfilment that results from meaning-
ful work. In the UK, the National Health
Service has captured this with the notion
of an engaged staff that ‘think and act in
a positive way about the work they do,
the people they work with and the organ-
isation that they work in’.3

The evidence that the healthcare work-
force finds joy and meaning in work is
not encouraging. In a recent physician
survey in the USA, 60% of respondents
indicated they were considering leaving
practice; 70% of surveyed physicians
knew at least one colleague who left their
practice due to poor morale.2 A 2015
survey of British physicians reported
similar findings with approximately 44%
of respondents reporting very low or low
morale.4 These findings also extend to
the nursing profession. In a 2013 US
survey of registered nurses, 51% of
nurses worried that their job was affect-
ing their health; 35% felt like resigning
from their current job.5 Similar findings
have been reported across Europe, with
rates of nursing job dissatisfaction
ranging from 11% to 56%.6

This absence of joy and meaning experi-
enced by a majority of the healthcare
workforce is in part due to the threats of
psychological and physical harm that are
common in the work environment.
Workforce injuries are much more frequent
in healthcare than in other industries. For
some, such as nurses’ aides, orderlies and
attendants, the rate is four times the indus-
trial average.7 More days are lost due to
occupational illness and injury in health-
care than in mining, machinery manufac-
turing or construction.7

The risk of physical harm is dwarfed
by the extent of psychological harm in
the complex environment of the health-
care workplace. Egregious examples
include bullying, intimidation and phys-
ical assault. Far more prevalent is the psy-
chological harm due to lack of respect.
This dysfunction is compounded by pro-
duction pressure, poor design of work
flow and the proportion of non-value
added work.
The current dysfunctional healthcare

work environment is in part a by-product
of the gradual shift in healthcare from a
public service to a business model that
occurred in the latter half of the 20th

EDITORIAL

608 Sikka R, et al. BMJ Qual Saf 2015;24:608–610. doi:10.1136/bmjqs-2015-004160

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjqs-2015-004160&domain=pdf&date_stamp=2015-09-09

http://www.health.org.uk/

http://qualitysafety.bmj.com

century.8 Complex, intimate caregiving relationships
have been reduced to a series of transactional demand-
ing tasks, with a focus on productivity and efficiency,
fuelled by the pressures of decreasing reimbursement.
These forces have led to an environment with lack

of teamwork, disrespect between colleagues and lack
of workforce engagement. The problems exist from
the level of the front-line caregivers, doctors and
nurses, who are burdened with non-caregiving work,
to the healthcare leader with bottom-line worries and
disproportionate reporting requirements. Without joy
and meaning in work, the workforce cannot perform
at its potential. Joy and meaning are generative and
allow the best to be contributed by each individual,
and the teams they comprise, towards the work of the
Triple Aim every day.
The precondition for restoring joy and meaning is

to ensure that the workforce has physical and psycho-
logical freedom from harm, neglect and disrespect.
For a health system aspiring to the Triple Aim, fulfill-
ing this precondition must be a non-negotiable, endur-
ing property of the system. It alone does not
guarantee the achievement of joy and meaning,
however the absence of a safe environment guarantees
robbing people of joy and meaning in their work.
Cultural freedom from physical and psychological
harm is the right thing to do and it is smart economics
because toxic environments impose real costs on the
organisation, its employees, physicians, patients and
ultimately the entire population.
An organisation focused on enabling joy and

meaning in work and pursuit of the Triple Aim needs
to embody shared core values of mutual respect and
civility, transparency and truth telling and the safety
of the workforce. It recognises the work and accom-
plishments of the workforce regularly and with high
visibility. For the individual, these notions of joy and
meaning in healthcare work are recognised in three
critical questions posed by Paul O’Neill, former chair-
man and chief executive officer of Alcoa. This is an
internal gut-check, that needs to be answered affirma-
tively by each worker each day:2

1. Am I treated with dignity and respect by everyone,
everyday, by everyone I encounter, without regard to
race, ethnicity, nationality, gender, religious belief, sexual
orientation, title, pay grade or number of degrees?

2. Do I have the things I need: education, training, tools,
financial support, encouragement, so I can make a con-
tribution this organisation that gives meaning to my life?

3. Am I recognised and thanked for what I do?
If each individual in the workforce cannot answer

affirmatively to these questions, the full potential to
achieve patient safety, effective outcomes and lower
costs is compromised.
The leadership and governance of our healthcare

systems currently have strong economic and outcome
motivations to focus on the Triple Aim. They also
need to feel a parallel moral obligation to the

workforce to create an environment that ensures joy
and meaning in work. For this reason, we recommend
adding a fourth essential aim: improving the experi-
ence of providing care. The notion of changing the
objective to the Quadruple Aim recognises this focus
within the context of the broader transformation
required in our healthcare system towards high value
care. While the first three aims provide a rationale for
the existence of a health system, the fourth aim
becomes a foundational element for the other goals to
be realised.
Progress on this fourth goal in the Quadruple Aim

can be measured through metrics focusing on two
broad areas: workforce engagement and workforce
safety. Workforce engagement can be assessed through
annual surveys using established frameworks that
allow for benchmarking within industry and with
non-healthcare industries.9 Measures should also be
extended to quantify the opposite of engagement,
workforce burn-out. This could include select ques-
tions from the Maslach Burnout Inventory, the gold
standard for measuring employee burn-out.10 In the
realm of workforce safety, metrics should include
quantifying work-related deaths or disability, lost time
injuries, government mandated reported injuries and
all injuries. Although these measures do not com-
pletely quantify the experience of providing care, they
provide a practical start that is familiar and allow for
an initial baseline assessment and monitoring for
improvement.
The rewards of the Quadruple Aim, achieved within

an inspirational workplace could be immense. No
other industry has more potential to free up resources
from non-value added and inefficient production
practices than healthcare; no other industry has more
potential to use its resources to save lives and reduce
human suffering; no other industry has the potential
to deliver the value envisioned by The Triple Aim on
such an audacious scale. The key is the fourth aim:
creating the conditions for the healthcare workforce
to find joy and meaning in their work and in doing
so, improving the experience of providing care.

Contributors All authors assisted in the drafting of this
manuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externally
peer reviewed.

REFERENCES
1 Berwick DM, Nolan TW, Whittington J. The triple aim: care,

health and cost. Health Aff 2008;27:759–69.
2 Lucian Leape Institute. 2013. Through the eyes of the

workforce: creating joy, meaning and safer health care. Boston,
MA: National Patient Safety Foundation.

3 NHS employers staff engagement. http://www.nhsemployers.
org/staffengagement (accessed 4 May 2015).

4 BMA Quarterly Tracker Survey. http://bma.org.uk/working-
for-change/policy-and-lobbying/training-and-workforce/

Editorial

Sikka R, et al. BMJ Qual Saf 2015;24:608–610. doi:10.1136/bmjqs-2015-004160 609

http://dx.doi.org/10.1377/hlthaff.27.3.759

http://www.nhsemployers.org/staffengagement

http://www.nhsemployers.org/staffengagement

http://www.nhsemployers.org/staffengagement

http://bma.org.uk/working-for-change/policy-and-lobbying/training-and-workforce/tracker-survey/omnibus-survey-january-2015

http://bma.org.uk/working-for-change/policy-and-lobbying/training-and-workforce/tracker-survey/omnibus-survey-january-2015

http://bma.org.uk/working-for-change/policy-and-lobbying/training-and-workforce/tracker-survey/omnibus-survey-january-2015

tracker-survey/omnibus-survey-january-2015 (accessed 4 May
2015).

5 AMN Healthcare 2013 survey of registered nurses. http://www.
amnhealthcare.com/uploadedFiles/MainSite/Content/
Healthcare_Industry_Insights/Industry_Research/2013_
RNSurvey (accessed 4 May 2015).

6 Aiken LH, Sermeus W, Van Den HeedeKoen, et al. Patient
safety, satisfaction and quality of hospital care: cross sectional
surveys of nurses and patients in 12 countries in Europe and
the United States. BMJ 2012;344:e1717.

7 US Department of Labor Bureau of Labor Statistics.
Occupational injuries and illnesses (annual) news release.

Workplace injuries and illnesses 2009. 21 October 2010.
http://www.bls.gov/news.release/archives/osh_10212010.htm
(accessed 4 May 2015).

8 Morath J. The quality advantage, a strategic guide for health
care leaders. AHA Press, 1999:225.

9 Surveys on Patient Safety Culture. Agency for Healthcare
Research and Quality. http://www.ahrq.gov/professionals/quality-
patient-safety/patientsafetyculture/index.html (accessed 4 May
2015).

10 Maslach C, Jackson S, Leiter M. Maslach burnout inventory
manual. 3rd edn. Palo Alto, CA: Consulting Psychologists
Press, 1996.

Editorial

610 Sikka R, et al. BMJ Qual Saf 2015;24:608–610. doi:10.1136/bmjqs-2015-004160

http://bma.org.uk/working-for-change/policy-and-lobbying/training-and-workforce/tracker-survey/omnibus-survey-january-2015

http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey

http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey

http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey

http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey

http://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Healthcare_Industry_Insights/Industry_Research/2013_RNSurvey

http://dx.doi.org/10.1136/bmj.e1717

http://www.bls.gov/news.release/archives/osh_10212010.htm

http://www.bls.gov/news.release/archives/osh_10212010.htm

http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

• The Quadruple Aim: care, health, cost and meaning in work

References

Guest Editorial

Nurse Educators: Leading Health Care to
the Quadruple Aim Sweet Spot

E
ighteen years ago, an alarming
report on preventable deaths from
medical errors was released by

the Institute of Medicine (IOM, 2000).
That report featured the estimate that
approximately 100,000 people in the
United States die each year because of
preventable medical errors. A subse-
quent IOM report (2003) called for all
health professionals to be better pre-
pared to keep patients safe, focusing
on five core competencies for health
professions education: patient-centered
care, interprofessional collaboration,
evidence-based practice, quality im-
provement, and informatics.

Visionary leaders in nursing educa-
tion were ahead of the curve, responding
to the call for safer and more effective
care via the Quality and Safety Education
for Nurses (QSEN) project (Cronenwett
et al., 2007). In 2008, the Institute for
Healthcare Improvement announced a
major initiative—the Triple Aim—which
focuses on “simultaneous pursuit of three
aims: improving the experience of care,
improving the health of populations, and
reducing per capita costs of health care”
(Berwick, Nolan, & Whittington, 2008,
p. 759). Subsequently, Bodenheimer
and Sinsky (2014) proposed a fourth—a
quadruple—aim to improve the work life
of health care providers, both clinicians
and staff.

What progress has been made during
the past 19 years since the IOM report,
with 10 years of QSEN education, and
9 years after the Triple Aim was launched?
Improvements in some health outcomes
have been reported. For instance, the
United States has seen a 15% reduction in
infant mortality rates compared with 2005

(Kochanek, Murphy, Xu, & Tejada-Vera,
2014). Numbers of hospital-acquired con-
ditions, such as central line-associated
bloodstream infections (CLABSIs), pres-
sure ulcers, and falls with injuries have
significantly decreased from 2010 to
2013, according to a recent report from the
American Hospital Association (2015).
However, in terms of better care and lower
costs, we are not yet there. James (2013)
has estimated annual hospital patient
deaths due to preventable harm to be over
400,000 per year. Reports from consumers
of health care continue to include stories
of poor care experiences, including lack
of compassion and frustrations in navigat-
ing the complexities of the care system.
Further, the aim of lower costs per capita
has yet to become reality. Although an
estimated 20 million people were newly
insured through the Patient Protection
and Affordable Care Act (ACA, 2010),
political challenges to the ACA remain,
including rising costs, high out-of-pocket
expenses, and access to affordable insur-
ance.

In the world of leadership, there is a
term referred to as the sweet spot, where
economic health and the common good
coexist and are the keys to achieving vi-
able and sustainable solutions (Savitz &
Weber, 2008). Is it possible to reach the
sweet spot of the Quadruple Aim? Acad-
emy Health and the Robert Wood John-
son Foundation are partnering to pursue
this formidable aim, proposing that care
delivery systems collaborate across mul-
tiple sectors to provide an affordable ap-
proach to improving population health
(Hacker, 2017).

Are we as a profession just going to
sit back and wait for that to happen? I be-

lieve that nurse educators are well posi-
tioned to lead the way to this lofty sweet
spot goal. Nursing schools and nurse
educators already work across multiple
sectors to prepare nurses at all levels,
from prelicensure to doctoral education.
Nurse educators are already in all settings
across the care continuum as practitioners
themselves and as mentors to nursing stu-
dents applying theory in practice. Many,
if not most, prelicensure through DNP
nursing students have been well prepared
with the QSEN competencies. Those at
the graduate level are leading evidence-
based systems improvement initiatives
as a part of their practice immersion and
culminating projects.

I have seen the power of what nurses
can do to bring the multiple sectors to-
gether in the interest of patient safety,
quality, population health, and affordable
care. Faculty and students have taken
a Quadruple Aim approach. Working
in communities and across the globe,
they have engaged with community and
global leaders and local health advocates,
such as Promotores (lay Hispanic health
advocates), to partner for better health
outcomes. Faculty and students have con-
ducted community needs assessments to
identify health priorities. They have pro-
vided health education and health screen-
ing. They have applied the processes and
tools of the science of improvement to
community-based projects to facilitate
collaboration across sectors to improve
health outcomes. They have been part of
teams who have provided resources that
communities often cannot afford alone.
They have gathered and analyzed the
metrics to measure results. The response
from local leaders and health advocates

707Journal of Nursing Education • Vol. 56, No. 12, 2017

GUEST EDITORIAL

is consistently positive, acknowledging
their contributions. And both students
and faculty have benefitted from these
practice experiences.

My greatest concern is that those
who lead national associations in both
education and practice have not found a
way to rise above their respective self-
interests with a genuine commitment to
work in partnership towards the Qua-
druple Aim sweet spot. Some have not
yet learned what visionary 20th century
organizational leadership pioneer Mary
Follett Parker taught about the distinc-
tion between power with versus power
over (Briskin, Erickson, Ott, & Callahan,
2009). Power over depends on relation-
ships of polarity, suspicion, and differ-
entials in power. Power with relies on
relationships of respect, stakeholder en-
gagement, and multisector approaches,
resulting in co-created power.

Faculty and students typically work
in collaboration with their patients and
families, as well as their clinical partners
across sectors, to improve health care
and health outcomes. That is what QSEN
has taught us. Through care coordina-
tion models, we typically collaborate in a
power with stance to reach both optimal
learning and optimal health outcomes,
contribute to cost-effectiveness, and con-
tribute to quality of life. Coordination
of care, including patients as partners in
care, is one evidence-based strategy for
reaching the Triple Aim. Care coordina-
tion is a philosophy and attitude as much
as it is a process. We need to teach our
politicians and public officials about the
care coordination model and how it ad-

dresses gaps in care in order to achieve
optimal health outcomes. I have seen this
facilitative education around care coordi-
nation take place when students and fac-
ulty are present at the policy table as im-
portant health care issues are addressed,
specifically relating to homelessness and
care for children and families who are at
high risk for foster care. Conversations
have moved beyond debate to generative
dialogue because nurses (faculty, stu-
dents, nurse leaders, and nurses as board
members) have been at the table.

Faculty, students, and their precep-
tors could teach many organizational and
political leaders by modeling how lever-
aging a power with approach is a viable
pathway to the Quadruple Aim’s sweet
spot. Power with is what makes clinical
nurses, nurse educators, and nurse lead-
ers so effective and so special. With a
rising emphasis on population health, we
have many more opportunities to com-
municate with political leaders and other
policy makers. We must believe in our-
selves as leaders of the Quadruple Aim
and act accordingly if we are ever going
to reach the sweet spot.

Power with and power ahead. What a
concept!

References
American Hospital Association. (2015). Zeroing

in on the Triple Aim. Retrieved from http://
www.aha.org/content/15/brief-3aim

Berwick, D.M., Nolan, T.W., & Whittington, J.
(2008). The Triple Aim: Care, health, and
cost. Health Affairs, 27, 759-769. doi:10.1377/
hlthaff.27.3.759

Bodenheimer, T., & Sinsky, C. (2014). From
Triple to Quadruple Aim: Care of the patient
requires care of the provider. Annals of Family

Medicine, 12, 573-576. doi:10.1370.afm.1713
Briskin, A., Erickson, S., Ott, J., Callanan, T.

(2009). The power of collective wisdom and
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Cronenwett, L., Sherwood, G., Barnsteiner, J.
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Hacker, K. (2017, March 27). Bridging the di-
vide: The sweet spot in health care and pub-
lic health. [Web log post]. Retrieved from
http://www.academyhealth.org/blog/2017-
03/bridging-divide-sweet-spot-health-care-
and-public-health

Institute of Medicine. (2000). To err is human:
Building a safer health system. Washington,
DC: The National Academies Press. https://
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Institute of Medicine. (2003). Health professions
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Jan Boller, PhD, RN
Adjunct Associate Professor

College of Nursing
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The author has disclosed no potential
conflicts of interest, financial or otherwise.

doi:10.3928/01484834-20171120-01

708 Copyright © SLACK Incorporated

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

Implementing EBP Column

Improving Patient Care Through Nursing
Engagement in Evidence-Based Practice
Elizabeth Crabtree, MPH • Emily Brennan, MLIS • Amanda Davis, MPH, RD •
Andrea Coyle, MSN, MHA, RN, CMSRN

This column shares the best evidence-based strategies and innovative ideas on how
to facilitate the learning of EBP principles and processes by clinicians as well as
nursing and interprofessional students. Guidelines for submission are available at
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787

INTRODUCTION AND BACKGROUND
The Medical University of South Carolina (MUSC) is a large
academic health science center, with a 700-bed medical cen-
ter (MUSC Health), and six colleges that train approximately
2,600 healthcare professionals annually. The MUSC Center
for Evidence-Based Practice (EBP), housed jointly in the Li-
brary and the Quality Management department of the MUSC
Hospital, aims to promote scientific inquiry, EBP, and quality
outcomes at MUSC. Through education, the development of
evidence-based clinical decision support tools and outcomes
research, the Center for EBP has begun to transform the cul-
ture of MUSC into one that incorporates best evidence into
clinical practice on both an individual and system level.

One of the strategies implemented by the Center for EBP
to promote cultural change is an educational course: the EBP
Nurse Scholars course, where nurses are taught about the the-
ory, practice, and dissemination of EBP.

DETAILED DESCRIPTION OF STRATEGY
Nurses serve on the frontline of health care, and have a
unique opportunity to improve patient care through EBP
(Hockenberry, Walaen, Brown, & Barrera, 2008). The staff
nurse is a critical link in bringing evidence-based changes into
clinical practice. Best practice only occurs when staff continu-
ally ask questions about treatment and care, have the resources
and skills necessary to search for and appraise research ev-
idence, implement the evidence in practice, and evaluate its
effectiveness (Dawes et al., 2005; Hockenberry et al., 2008).

MUSC’s experience in preparing practicing nurses to do
EBP was limited. To address this, the Center for EBP, in part-
nership with the Center for Professional Excellence, developed
a 12-week, project-based course to prepare nurses to engage in
EBP. The Center for Professional Excellence collaborates with

internal and external customers to create growth and devel-
opment opportunities for registered nurses. Additionally, the
center is responsible for Magnet application and designation.
The EBP Nurse Scholars course provides nurses with a com-
prehensive overview of EBP, prepares them to frame clinical
questions, perform literature searches, analyze and evaluate
evidence, and translate that knowledge into something clini-
cally meaningful. Members of the Center for EBP staff and
library faculty provided lectures and individual consultations
on framing clinical questions, conducting comprehensive lit-
erature searches, understanding statistics commonly reported
in research articles, and appraising and summarizing evidence
using the GRADE criteria. As part of the course, nurses se-
lected a specific hospital policy and applied their knowledge
to evaluating the evidence base for it. They then updated the
policy to ensure it reflected current evidence and best practice.

RESULTS
The EBP Nurse Scholars course resulted in successful com-
pletion of 15 projects related to nursing care and practice, and
led to significant practice improvements (Table 1). In addition,
several nurses have presented their findings at regional and
national conferences.

Pre- and post-course surveys demonstrated that the course
improved nurses’ confidence with EBP methods and skills re-
lated to research tools, statistical concepts, and study designs.
Data collected included responses from students from two EBP
Nurse Scholars courses: Spring 2013 and Spring 2014.

Participant Demographics
The majority of students who participated in the course were
BSN-level nurses working with adult populations at MUSC.

172 Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175.
C© 2016 Sigma Theta Tau International

Implementing EBP Column

0

1

2

3

4

5

Use of
research

Cochrane
Database of
Systema�c

Reviews

CINAHL Na�onal
Guideline

Clearinghouse

PubMed UpToDate

(1= Never, 2= Once per month, 3= Once per week, 4= Few
�mes per week, 5= Once per day, 6= Mul�ple �mes per day )

Median (Pre) Median (Post)

Figure 1. Use of research tools in practice.

Table 1. Examples of Completed EBP Nurse Scholars
Course Projects

Abdominal X-Ray forNG/OGTubePlacement

ClosedArterial Line LabSamplingSystem forPCICUPatients

DischargePlanning for Psychiatric Patients

ImprovingCare of Elderly in theAcuteCareSetting

InternationalNormalizedRatioCut-Off forHeart Catheterizations

Lidocaine4% forNonemergent IVStarts

Oral Care for Infants

Peripheral Administration ofChemotherapyAgents

Postoperative Education

Postpyloric Feeding toReduceRisk of AspirationPneumonia

PreoperativeBathing

PreventingTurniquet-Related Injuries inPatientsUndergoingTKA

Safety of “QuickStart”DepoProvera

ThermoprotectiveWraps inVery LowBirthWeight Infants

The majority of participants were ICU nurses, and students
typically had 0–5 years of experience.

Survey Results
Study data were collected and managed using Research
Electronic Data Capture (REDCap) electronic data capture
tools, hosted at MUSC. Due to the continuous nature of the

variables assessed in the pre- and post-tests for the EBP Nurse
Scholars course, we used pre- and post-test median scores and
the Mann-Whitney U test to measure significant changes in
confidence with EBP methods, use of research tools in clinical
practice, and understanding of statistical concepts and study
designs. A complete listing of the survey questions can be
found in Appendix 1, available with the online version of this
article.

After the course, there were significant increases in nurses’
confidence in critically reviewing literature (p < .001), their belief that EBP was necessary in nursing practice (p = .052), and their interest in improving skills necessary to use EBP in practice (p = .002). There were also significant increases in the use of EBP resources in clinical practice, including the Cochrane Database of Systematic Reviews (p < .001), CINAHL (p < .001), National Guideline Clearinghouse (p = .049), PubMed (p = .005), and UpToDate (p = .018), as well as in the understanding of statistical concepts and study design methods (p < .001). Pre- and post-test median scores representing the improvements in EBP resource utilization and understanding of research concepts are included in Figures 1 and 2.

The success of the EBP Nurse Scholars course led to
the development of a project-based course for interprofes-
sional teams of pediatric clinicians, all of which included
a nurse. These teams received EBP education and worked
together during this Interprofessional EBP course to frame
clinical questions, systematically search for, and critically ap-
praise and synthesize a body of research evidence for a par-
ticular disease topic. Based on their review of the evidence,
teams developed clinical practice recommendations for each
of the clinical questions they framed. These recommenda-
tions were used to develop admission and emergency depart-
ment order sets which were integrated into MUSC’s electronic

Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175. 173
C© 2016 Sigma Theta Tau International

Improving Care through EBP

0
1
2
3

(1= Do not understand, 2= Understand somewhat,
3= Understand completely)

Median (Pre) Median (Post)

Figure 2. Understanding of Research Concepts.

medical record. Finally, participants who completed either
the EBP Nurse Scholars course or the Interprofessional EBP
course were invited to participate in an EBP Leadership Pro-
gram. This program focused on implementation of their EBP
project, evaluation of results, outcomes, and dissemination of
findings.

Through these courses, the Center for EBP is transforming
the institution’s culture into one that builds EBP capacity, and
incorporates best evidence into clinical practice on both an
individual and system level.

DISSEMINATION
The Center for EBP staff has supported nurses in translating
their projects into scholarly work. The EBP Leadership
Program, the follow-up to the EBP Nurse Scholars course,
provided nurses with the skills to both implement and evaluate
practice change projects, but it also provided nurses with tools
and resources for developing abstracts for poster and podium
presentations. As a result of these efforts, numerous course
participants have had their work accepted for presentation
at regional and national conferences. The Center for EBP
applied for and received a competitive, internally funded
grant to support nurses in attending conferences where
they present the results of their EBP projects. The grant
covers the cost of printing a poster for nurses who have
had abstracts accepted. Funding the printing cost of the
posters further encouraged nurses to attend conferences, and
present their work, and motivated departments and units to
provide support for nursing engagement in EBP scholarly
work.

Supporting professional growth and development is a
nursing strategic priority at MUSC. To support and promote

nursing clinicians, three EBP Nurse Scholar projects were
highlighted in MUSC’s Magnet document. Additionally,
videos of nurses engaging in the EBP process were produced
and disseminated internally. The videos highlighted scholars
performing a literature search, analyzing and evaluating evi-
dence, and translating that knowledge in to changes in nursing
practice. WVN

LINKING EVIDENCE TO ACTION

� Organizational cultures can be transformed
through provision of EBP education and mentored
implementation of EBP knowledge and skills.

� A project-based EBP education program can re-
sult in an increase in utilization of EBP resources,
and in improvements in knowledge and attitudes
related to EBP.

� The implementation and dissemination of EBP
projects creates opportunities for nurses to partici-
pate in the development of scholarly products, and
results in professional growth and development.

Author information

Elizabeth Crabtree, Director of Evidence-Based Practice, Qual-
ity, Management, and Assistant Professor, Library & Infor-
matics, Medical University of South Carolina, Charleston,
SC; Emily Brennan, Informationist, Research Librarian, and
Assistant Professor, Library & Informatics, Medical Univer-
sity of South Carolina, Charleston, SC; Amanda Davis,

174 Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175.
C© 2016 Sigma Theta Tau International

Implementing EBP Column
Clinical Evidence-Based Practice Analyst, Medical University
of South Carolina, Charleston, SC; Andrea Coyle, Professional
Excellence Coordinator, Clinical, Services Administration,
Medical University of South Carolina, Charleston, SC

Address correspondence to Elizabeth Crabtree, Library
& Informatics, Medical University of South Carolina, 171
Ashley Avenue, Library, Suite 408, Charleston, SC 29425;
crabtr@musc.edu

Accepted 15 August 2015
Copyright C© 2016, Sigma Theta Tau International

References
Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Mar-

tin, J., Hopayian, K., & . . . Osborne, J. (2005). Sicily statement
on evidence-based practice. BMC Medical Education, 5, 1.

Hockenberry, M., Walaen, M., Brown, T., & Barrera, P. (2008).
Creating an evidence-based practice environment: One hospi-
tal’s journey. Journal of Trauma Nursing, 15(3), 136–142.

doi 10.1111/wvn.12126
WVN 2016;13:172–175

Worldviews on Evidence-Based Nursing, 2016; 13:2, 172–175. 175
C© 2016 Sigma Theta Tau International

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Original Article

The Establishment of Evidence-Based
Practice Competencies for Practicing
Registered Nurses and Advanced Practice
Nurses in Real-World Clinical Settings:
Proficiencies to Improve Healthcare Quality,
Reliability, Patient Outcomes, and Costs
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FNAP, FAANP, FAAN •
Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC • Lisa English Long, RN, MSN, CNS •
Ellen Fineout-Overholt, RN, PhD, FAAN

Keywords

evidence-based
practice,

competencies,
healthcare quality

ABSTRACT
Background: Although it is widely known that evidence-based practice (EBP) improves healthcare
quality, reliability, and patient outcomes as well as reduces variations in care and costs, it is still
not the standard of care delivered by practicing clinicians across the globe. Adoption of specific
EBP competencies for nurses and advanced practice nurses (APNs) who practice in real-world
healthcare settings can assist institutions in achieving high-value, low-cost evidence-based health
care.

Aim: The aim of this study was to develop a set of clear EBP competencies for both practicing
registered nurses and APNs in clinical settings that can be used by healthcare institutions in their
quest to achieve high performing systems that consistently implement and sustain EBP.

Methods: Seven national EBP leaders developed an initial set of competencies for practicing
registered nurses and APNs through a consensus building process. Next, a Delphi survey was
conducted with 80 EBP mentors across the United States to determine consensus and clarity
around the competencies.

Findings: Two rounds of the Delphi survey resulted in total consensus by the EBP mentors,
resulting in a final set of 13 competencies for practicing registered nurses and 11 additional
competencies for APNs.

Linking Evidence to Action: Incorporation of these competencies into healthcare system ex-
pectations, orientations, job descriptions, performance appraisals, and clinical ladder promotio

n

processes could drive higher quality, reliability, and consistency of healthcare as well as reduce
costs. Research is now needed to develop valid and reliable tools for assessing these competen-
cies as well as linking them to clinician and patient outcomes.

BACKGROUND
Evidence-based practice (EBP) is a life-long problem-solving
approach to the delivery of health care that integrates the best
evidence from well-designed studies (i.e., external evidence)
and integrates it with a patient’s preferences and values
and a clinician’s expertise, which includes internal evidence
gathered from patient data. When EBP is delivered in a context
of caring and a culture as well as an ecosystem or environment
that supports it, the best clinical decisions are made that

yield positive patient outcomes (see Figure 1; Melnyk &
Fineout-Overholt, 2011).

Research supports that EBP promotes high-value health
care, including enhancing the quality and reliability of health
care, improving health outcomes, and reducing variations in
care and costs (McGinty & Anderson, 2008; Melnyk, Fineout-
Overholt, Gallagher-Ford, & Kaplan, 2012; Pravikoff, Pierce, &
Tanner, 2005). Even with its tremendous benefits, EBP is not
the standard of care that is practiced consistently by clinicians
throughout the United States and globe (Fink, Thompson, &

Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15. 5
C© 2014 Sigma Theta Tau International

EBP Competencies for Practice

Figure 1. The merging of science and art: EBP within a context of caring and an EBP culture and environment
results in the highest quality of healthcare and patient outcomes. Reprinted from Melnyk, B. M., & Fineout-
Overholt, E. (2011). Evidence-based practice in nursing and healthcare. A guide to best practice. Philadelphia:
Lippincott Williams & Wilkins. Reprinted with permission.

Bonnes, 2005; Melnyk, Grossman, et al., 2012). Tremendously
long lag times continue to exist between the generation of re-
search findings and their implementation in real-world clinical
settings to improve care and outcomes due to multiple barri-
ers, including: (a) misperceptions by clinicians that it takes
too much time, (b) inadequate EBP knowledge and skills, (c)
academic programs that continue to teach the rigorous pro-
cess of how to conduct research instead of an evidence-based
approach to care, (d) organizational cultures that do not sup-
port it, (e) lack of EBP mentors and appropriate resources, and
(f) resistance by colleagues, managers or leaders, and physi-
cians (Ely, Osheroff, Chambliss, Ebell, & Rosenbaum, 2005;
Estabrooks, O’Leary, Ricker, & Humphrey, 2003; Jennings &
Loan, 2001; Melnyk, Fineout-Overholt, Feinstein, et al., 2004;
Melnyk, Fineout-Overholt, et al., 2012; Titler, 2009).

The Seven-Step EBP Process and Facilitating
Factors
The seven steps of EBP start with cultivating a spirit of inquiry
and an EBP culture and environment as without these ele-
ments, clinicians will not routinely ask clinical questions about
their practices (see Table 1). After a clinician asks a clinical
question and searches for the best evidence, critical appraisal
of the evidence for validity, reliability, and applicability to prac-
tice is essential for integrating that evidence with a clinician’s
expertise and patient preferences to determine whether a cur-
rent practice should be changed. Once a practice change is
made based on this process, evaluating the outcomes of that

Table 1. The Seven Steps of Evidence-Based Practice

Step0:Cultivate a spirit of inquiry alongwith anEBPculture
andenvironment

Step 1: Ask thePICO(T) question

Step2: Search for thebest evidence

Step3:Critically appraise the evidence

Step4: Integrate the evidencewith clinical expertise and
patient preferences tomake thebest clinical decision

Step5: Evaluate the outcome(s) of theEBPpractice change

Step6:Disseminate theoutcome(s) (Melnyk&
Fineout-Overholt, 2011)

change is imperative to determine its impact. Finally, dissemi-
nation of the process and outcomes of the EBP change is key so
that others may learn of practices that produce the best results.

The systematic seven-step process of EBP provides a plat-
form for facilitating the best clinical decisions and ensuring the
best patient outcomes. However, consistent implementation of
the EBP process and use of evidence by practicing clinicians
is challenging. Typical barriers to EBP cited by clinicians in-
clude: time limitations, an organizational culture and philoso-
phy of “that is the way we have always done it here,” inadequate

6 Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15.
C© 2014 Sigma Theta Tau International

Original Article
EBP knowledge or education, lack of access to databases that
enable searching for best evidence, manager and leader resis-
tance, heavy workloads, resistance from nursing and physician
colleagues, uncertainty about where to look for information
and how to critically appraise evidence, and limited access to
resources that facilitate EBP (Gerrish & Clayton, 2004; Mel-
nyk, Fineout-Overholt, et al., 2012; Pravikoff, Pierce, & Tanner,
2005; Restas, 2000; Rycroft-Malone et al., 2004).

There are also factors that facilitate EBP, including: beliefs
in the value of EBP and the ability to implement it, EBP men-
tors who work with direct care clinicians to implement best
practices, supportive EBP contexts or environments and cul-
tures, administrative support, and assistance by librarians from
multifaceted education programs (Melnyk et al., 2004; Mel-
nyk & Fineout-Overholt, 2011; Melnyk, Fineout-Overholt, &
Mays, 2008; Newhouse, Dearholt, Poe, Pugh, & White, 2007;
Rycroft-Malone, 2004). The concept of healthcare context (i.e.,
the environment or setting in which people receive health-
care services), specifically organizational context, is becoming
an increasingly important factor in the implementation of ev-
idence at the point of care (Estabrooks, Squires, Cummings,
Birdsell, & Norton, 2009; Rycroft-Malone, 2004). Strategies
to enhance system-wide implementation and sustainability of
evidence-based care need to be multipronged and target: (a)
the enhancement of individual clinician and healthcare leader
EBP knowledge and skills; (b) cultivation of a context and cul-
ture that supports EBP, including the availability of resources
and EBP mentors; (c) development of healthcare leaders who
can spearhead teams that create an exciting vision, mission,
and strategic goals for system-wide implementation of EBP;
(d) sufficient time, resources, mentors, and tools for clinicians
to engage in EBP; (e) clear expectations of the role of clini-
cians and advanced practice nurses (APNs) in implementing
and sustaining evidence-based care; (f) facilitator characteris-
tics and approach; and (f) a recognition or reward system for
those who are fully engaged in the effort (Dogherty, Harri-
son, Graham, Vandyk, & Keeping-Burke, 2013; Melnyk, 2007;
Melnyk, Fineout-Overholt, et al., 2012).

Competencies for Nurses
Although there is a general expectation of healthcare systems
globally for nurses to engage in EBP, much uncertainty exists
about what exactly that level of engagement encompasses. Lack
of clarity about EBP expectations and specific EBP competen-
cies that nurses and APNs who practice in real-world healthcare
settings should meet impedes institutions from attaining high-
value, low-cost evidence-based health care. The development of
EBP competencies should be aligned with the EBP process in
continual evaluation across the span of the nurses’ practice, in-
cluding technical skills in searching and appraising literature,
clinical reasoning as patient and family preferences are con-
sidered in decision making, problem-solving skills in making
recommendations for practice changes, and the ability to adapt
to changing environments (Burns, 2009).

Competence is defined as the ability to do something well;
the quality or state of being competent (Merriam Webster Dic-
tionary, 2012). Competencies are a mechanism that supports
health professionals in providing high-quality, safe care. The
construct of nursing competency “attempts to capture the myr-
iad of personal characteristics or attributes that underlie com-
petent performance of a professional person.” Competencies
are holistic entities that are carried out within clinical contexts
and are composed of multiple attributes including knowledge,
psychomotor skills, and affective skills. Dunn and colleagues
contend that competency is not a “skill or task to be done, but
characteristics required in order to act effectively in the nurs-
ing setting.” Although a particular competency “cannot exist
without scientific knowledge, clinical skills, and humanistic
values” (Dunn et al., 2000, p. 341), the actual competency tran-
scends each of the individual components. The measurement
of nurses’ competencies related to various patient care activi-
ties is a standard ongoing activity in a multitude of healthcare
organizations across the globe, however, competencies related
to the critical issue of how practicing nurses approach decision
making (e.g., whether it is evidence-based vs. tradition-based)
is limited and needs further research.

Recently, work has been conducted to establish general
competencies for nursing by the Quality and Safety Educa-
tion for Nurses (QSEN) Project, which is a global nursing
initiative whose purpose was to develop competencies that
would “prepare future nurses who would have the knowl-
edge, skills, and attitudes (KSAs) necessary to continuously
improve the quality and safety of the healthcare systems
within which they work” (QSEN, 2013). This project has
developed competency recommendations that address the
following practice areas:

� Patient-centered care

� Teamwork and collaboration

� Evidence-based practice

� Quality improvement

� Safety

� Informatics

Further work in competency development has been spear-
headed by the Association of Critical Care Nurses, which de-
veloped the Synergy Model. The goal of the model was to assist
practicing nurses in decision making. An example of the model
in action would be the use of the model by charge nurses in
their decisions to match patients and nurses to achieve best
outcomes of evidence-based care processes promulgated by
the American Association of Critical Care Nurse (2013). Kring
(2008) wrote about how clinical nurse specialists, when com-
petent in EBP, can leverage their unique roles as expert prac-
titioners, researchers, consultants, educators, and leaders to
promote and support EBP in their organizations.

Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15. 7
C© 2014 Sigma Theta Tau International

EBP Competencies for Practice

In addition, competencies related to the academic setting
have been developed. The National League for Nurses (NLN)
developed competencies for program levels within nursing ed-
ucation. Definitions, guides to curricular development, and
criteria for use in developing certification and continuing ed-
ucation programs is a focus for faculty and administrators in
academic settings (NLN, 2013).

Stevens and colleagues defined essential competencies for
EBP to be incorporated into nursing education programs to
serve as a helpful guide to faculty in teaching and preparing
students for EBP and to “provide a basis for professional com-
petencies in clinical practice” (Stevens, 2009, p. 8). However,
to our knowledge, there has never been a systematic research-
based process used to develop contemporary EBP competen-
cies for practicing registered professional nurses and APNs
who are delivering care in real-world clinical settings defined
by leaders and mentors responsible for facilitating and sustain-
ing evidence-based care in today’s healthcare systems.

AIM
The aim of this study was to develop a clear set of competen-
cies for both practicing registered nurses and APNs in clinical
settings. These competencies can be used by healthcare insti-
tutions in their quest to achieve high performing systems that
consistently implement and sustain evidence-based care.

METHODOLOGY
The first step in formulating the competencies involved seven
national experts from both clinical and academic settings across
the United States, who were identified and invited to participate
in developing EBP competencies through a consensus build-
ing process. These experts were chosen because they were rec-
ognized national experts in EBP, having influenced the field
or being widely published in the area. Through a consensus
building process, the EBP expert panel produced two lists of
essential EBP competencies, one set for practicing registered
nurses and one for APNs. For registered nurses, the experts
identified 12 essential EBP competencies. For APNs, there were
11 additional essential EBP competencies (23 total).

The next step in developing the competencies involved uti-
lizing the Delphi survey technique, which seeks to obtain con-
sensus on the opinions of experts through a series of struc-
tured rounds. The Delphi technique is an iterative multistage
process, designed to transform opinion into group consensus.
Studies employing the Delphi technique make use of individ-
uals who have knowledge of the topic being investigated who
are identified as “experts” selected for the purpose of applying
their knowledge to a particular issue or problem. The literature
reflects that an adequate number of rounds must be employed
in a Delphi study in order to find the balance between produc-
ing meaningful results without causing sample fatigue. Rec-
ommendations for Delphi technique suggest that two or three
rounds are preferred to achieve this balance (Hasson, Keeney,
& McKenna, 2000).

Inclusion Criteria
The expert participants for this Delphi survey of EBP compe-
tencies were individuals who attended an intensive continuing
education course or program in EBP at the first author’s aca-
demic institution within the last 7 years and who identified
themselves as EBP mentors. The EBP mentors were nurses
with in-depth knowledge and skills in EBP along with skills
in organizational and individual behavior change, who work
directly with clinicians to facilitate the rapid translation of re-
search findings into healthcare systems to improve healthcare
quality and patient outcomes. EBP mentors guide others to
consistently implement evidence-based care by educating and
role modeling the use of evidence in decision making and ad-
vancement of best practice (Melnyk, 2007).

An important design element of a Delphi study is that the
investigators must determine the definition of consensus in
relation to the study’s findings prior to the data collection
phase (Williams & Webb, 1994). Although there is no uni-
versal standard about the proportion of participant agreement
that equates with consensus, recommendations range from
51% to 80% agreement for the items on the survey (Green,
Jones, Hughes, & Williams, 2002; Sumsion, 1998). Data anal-
ysis involves management of both qualitative and quantitative
information gathered from the survey. Qualitative data from
the first round group similar items together in an attempt
to create a universal description. Subsequent rounds involve
quantitative data collected to ascertain collective opinion and
are reported using descriptive and inferential statistics.

In preparation for the Delphi survey of EBP mentors across
the United States, the study was submitted to the first author’s
institutional review board and was deemed exempt status. Prior
to the survey being disseminated electronically to the EBP men-
tors for review, the study team determined the parameters of
consensus. The EBP mentors were asked to rate each com-
petency for: (a) clarity of the written quality of the competency
and (b) how essential the competency was for practicing nurses
and APNs. The criterion for agreement set was that 70% of the
EBP mentor respondents would rate the EBP competency (e.g.,
“Questions clinical practices for the purpose of improving the
quality of care”; “Searches for external evidence to answer fo-
cused clinical questions”) between 4.5 and 5 on a five-point
Likert scale that ranged from 1 not at all to 5 very much so. The
study team also decided that competencies which EBP mentors
identified as not clearly written would be reworded taking in
consideration their feedback and resent to the participants in
a second round of the Delphi survey. The essential EBP com-
petencies were sent via e-mail to the EBP mentors for review,
rating, and feedback in July 2012.

Each EBP mentor participant was contacted through an
e-mail and invited to participate in the anonymous Delphi
survey. An introduction to the study and its parameters was
included in the introductory e-mail along with the planned
timeline for the study. The survey consisted of three sections:
(a) demographic data, (b) rating of essential EBP competencies
for practicing registered nurses, and (c) rating of essential EBP

8 Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15.
C© 2014 Sigma Theta Tau International

Original Article
Table 2. Participant Characteristics (N = 80)

Mean Median Max Min

Age 52 54 70 25

Years in active clinical practice 26 29 43

1

Years as anadvancedpractice nurse 9 5 40 0

Number of years as anEBPmentor 3 3 15 0

competencies for practicing APNs. The survey was open for 2
weeks from the first contact date. A reminder e-mail was sent
1 week following the first contact and a second reminder was
issued a day before the survey closed. Consent was obtained
by virtue of the participant completing the survey.

The EBP mentors were asked to respond to two questions
about each of the EBP competencies on the survey using a five-
point Likert scale with 1 = Not at all, 2 = A little, 3 = Somewhat,
4 = Moderately so, and 5 = Very much so. The first question
was related to how essential the competency was for nurses
and APNs and was stated as “To what extent do you believe the
above EBP competency is essential for practicing registered
professional nurses.” The second question was focused on the
clarity of the competency and was stated as, “Is the competency
statement clearly written?” If participants answered “no” in
response to whether the statement was clearly written, they
were asked how they would rewrite it. Only the EBP mentors
who identified themselves as APNs were permitted to rate the
APN competencies.

FINDINGS
Of the 315 EBP mentors originally contacted to participate in
the survey, 80 responded indicating a 25% response rate. De-
mographic data collected reflected that all 80 participants were
female with a mean age of 52 years and an average of 26 years in
clinical practice. Fifty of the 80 respondents were self-reported
as APNs and the average number of years as an EBP mentor
was reported as 3 (see Table 2). The majority of the partici-
pants had a Master’s or higher educational degree and was
currently serving in an EBP mentor role. The participants re-
ported holding both clinical positions and academic positions
(see Table 3). There was a relatively even distribution of partic-
ipants who worked in Magnet (n = 36; 45%) and non-Magnet
institutions (n = 44; 55%). The sample represented a variety of
primary work settings (see Table 4).

In the competency rating section of round 1 of the survey,
all of the practicing registered nurse and APN competencies
achieved consensus as an essential competency, based on the
preset criteria. However, in the clarity portion of the rating
section, there was feedback provided by participants regarding
refining the wording of four of the competencies. Each of these

Table 3. Race, Ethnicity, Education, and Role
(N = 80)

n

Race White 75

Black orAfricanAmerican 2

NativeHawaiian or other Pacific
Islander

1

Asian 2

Ethnicity NotHispanic or Latino 79

Hispanic or Latino 1

Education Bachelor’s 9

Master’s 48

PhD 18

DNP 4

Other 1

Current position Staff nurse 5

Nursepractitioner 2

Clinical nurse specialist 12

Clinical nurse leader 0

Nurse educator 18

Nursemanager/administrator 8

Academic faculty 10

Academic administration 3

Other 22

Currently serving inan
EBPmentor role

Yes 63

No 17

four competencies was reworded and included in a second
round of the Delphi study. None of the competencies were
eliminated (see Tables 5 and 6).

Based on the feedback received from the participants in
round 1 related to the clarity of the competencies, the following
process was operationalized. In the single case where clarity
feedback was related simply to consistency in terminology, the
competency was reworded to incorporate the feedback and was
included in round 2 for the reviewers to see that their feed-
back had been integrated. However, they were not asked to
revote on the competency. In the cases where the clarity feed-
back was related to the action described (such as Formulates a
PICOT question vs. Participates in formulating a PICOT ques-
tion), the competencies were reworded and included in round

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EBP Competencies for Practice

Table 4. Organization (N = 80)

n

Typeof primary
work setting

Community hospital 21

Academicmedical center 33

Academic institution 21

Primary carepractice 1

Community health setting 0

Other 4

Work in aMagnet
designated
institution

Yes 36

No 44

Table 5. Round 1 Registered Nurse (RN) Competen-
cies (N = 80)

Consensus Reword Revote

Competency Mean ± SD (Yes–No) (Yes–No)
1 4.9 ± 0.3 No No
2 4.7 ± 0.5 No No
3 4.7 ± 0.5 Yes Yes
4 4.8 ± 0.4 No No
5 4.6 ± 0.5 Yes Yes
6 4.6 ± 0.5 Yes* Yes*

7 4.7 ± 0.5 No No
8 4.7 ± 0.5 No No
9 4.8 ± 0.4 No No
10 4.7 ± 0.4 No No
11 4.7 ± 0.5 No No
12 4.8 ± 0.4 No No

Note.*Competency6wassplit into twoseparatecompetencystatements
basedon round 1 feedback.

2 for the reviewers to see that their feedback had been inte-
grated and they were asked to revote on the whether the revised
competency still rated as an essential EBP competency. Only
registered nurse competencies received feedback that required
revoting. All of the APNs competencies reached consensus
with only minor clarifications in terminology needed.

Table 6. Round 1 APN Competencies (N = 50)

Consensus Reword Revote

Competency Mean ± SD (Yes–No) (Yes–No)
1 4.8 ± 0.4 No No
2 4.9 ± 0.3 No No
3 4.9 ± 0.3 No No
4 4.9 ± 0.3 No No
5 4.9 ± 0.2 No No
6 5.0 ± 0.2 No No
7 4.9 ± 0.3 No No
8 4.9 ± 0.3 No No
9 4.9 ± 0.3 No No
10 4.9 ± 0.2 No No
11 5.0 ± 0.2 No No

Three registered nurse competencies required rewriting
and revoting. Two competencies (#3, #5) required rewording
and one competency (#6) required splitting into two separate
competencies. Competency 3, formulates focused clinical ques-
tions in PICOT (i.e., Patient population; Intervention or area of
interest; Comparison intervention or group; Outcome; Time), was
revised to be: participates in the formulation of clinical ques-
tions using PICOT* format (*PICOT = Patient population;
Intervention or area of interest; Comparison intervention or
group; Outcome; Time). Competency 5, conducts rapid critical
appraisal of preappraised evidence and clinical practice guidelines
to determine their applicability to clinical practice, was revised to
be: participates in critical appraisal of preappraised evidence
(such as clinical practice guidelines, evidence-based policies
and procedures, and evidence syntheses).

The EBP mentor responses and feedback resulted in the
number of competency statements being increased when com-
petency 6 was split into two separate competency statements.
The additional competency statement was generated based on
feedback related to the clarity of the competency, which re-
flected that more than one idea or action was expressed in
the single competency statement. Competency 6, participates
in critical appraisal (i.e., rapid critical appraisal, evaluation, and
synthesis of published research studies) to determine the strength and
worth of evidence as well as its applicability to clinical practice, was
reworded as new competency 6, participates in the critical ap-
praisal of published research studies to determine their strength and
applicability to clinical practice, and new competency 7, partici-
pates in the evaluation and synthesis of a body of evidence gathered
to determine its strength and applicability to clinical practice.

10 Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15.
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Original Article
Table 7. EBP Competencies

Evidence-basedpractice competencies for practicing registeredprofessional nurses

1. Questions clinical practices for thepurposeof improving thequality of care.

2. Describes clinical problemsusing internal evidence.* (internal evidence* = evidencegenerated internallywithin a clinical
setting, suchaspatient assessment data, outcomesmanagement, andquality improvement data)

3. Participates in the formulation of clinical questions usingPICOT* format. (*PICOT = Patient population; Intervention or areaof
interest; Comparison intervention or group;Outcome; Time).

4. Searches for external evidence* to answer focusedclinical questions. (external evidence* = evidencegenerated from research)
5. Participates in critical appraisal of preappraised evidence (suchas clinical practice guidelines, evidence-basedpolicies and
procedures, andevidence syntheses).

6.Participates in thecritical appraisal ofpublished researchstudies todetermine their strengthandapplicability toclinicalpractice.

7. Participates in the evaluation and synthesis of a bodyof evidencegathered todetermine its strength andapplicability to clinical
practice.

8. Collects practice data (e.g., individual patient data, quality improvement data) systematically as internal evidence for clinical
decisionmaking in the care of individuals, groups, andpopulations.

9. Integrates evidencegathered fromexternal and internal sources in order to plan evidence-basedpractice changes.

10. Implements practice changesbasedonevidenceandclinical expertise andpatient preferences to improve careprocesses and
patient outcomes.

11. Evaluates outcomesof evidence-baseddecisions andpractice changes for individuals, groups, andpopulations todetermine
best practices.

12. Disseminatesbest practices supportedby evidence to improvequality of care andpatient outcomes.

13. Participates in strategies to sustain an evidence-basedpractice culture.

Evidence-basedpractice competencies for practicing advancedpractice nurses
All competencies of practicing registeredprofessional nursesplus:

14. Systematically conducts anexhaustive search for external evidence* toanswer clinical questions. (external evidence*: evidence
generated from research)

15. Critically appraises relevant preappraised evidence (i.e., clinical guidelines, summaries, synopses, synthesesof relevant
external evidence) andprimary studies, including evaluation and synthesis.

16. Integrates abodyof external evidence fromnursing and relatedfieldswith internal evidence* inmakingdecisions about patient
care. (internal evidence* = evidencegenerated internallywithin a clinical setting, suchaspatient assessment data, outcomes
management, andquality improvement data)

17. Leads transdisciplinary teams inapplying synthesizedevidence to initiate clinical decisionsandpracticechanges to improve the
health of individuals, groups, andpopulations.

18.Generates internal evidence throughoutcomesmanagement andEBP implementationprojects for thepurposeof integrating
best practices.

19.Measuresprocesses andoutcomesof evidence-basedclinical decisions.

20. Formulates evidence-basedpolicies andprocedures.

21. Participates in the generation of external evidencewith other healthcareprofessionals.

22.Mentors others in evidence-baseddecisionmaking and theEBPprocess.

23. Implements strategies to sustain anEBPculture.

24. Communicates best evidence to individuals, groups, colleagues, andpolicymakers.

Copyright:Melnyk,Gallagher-Ford, andFineout-Overholt (2013).

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EBP Competencies for Practice

Table 8. Round 2 Registered Nurse (RN) Competen-
cies (N = 59)

CompetencyConsensusMean ± SDConsensusMet (Yes–No)
3 4.6 ± 0.5 Yes
5 4.6 ± 0.5 Yes
6 4.6 ± 0.5 Yes
7 4.5 ± 0.5 Yes

This process rendered a revised set of EBP competencies
that included 13 competencies for registered nurses and an
additional 11 EBP competencies (for a total of 24) for APNs
(see Table 7).

In October 2012, the second round of the Delphi study was
conducted. The revised set of EBP competencies was e-mailed
to the EBP mentors who responded in the first round of the
study in October 2012. The round 2 survey provided feedback to
the EBP mentors about the process that had been conducted by
the study team to render the revised competencies and asked
them to rate the three revised and the two new (split) EBP
competency statements using the same five-point Likert rank-
ing scale used in round 1. Fifty-nine of the 80 original EBP
mentors responded to the second round of the study (74%)
by the response deadline. In round 2 of the study, each of the
13 registered nurse competencies achieved consensus (based
on the preset criteria) as an essential EBP competency (see
Table 8). Throughout the process, none of the EBP mentors
articulated additional competencies, indicating a high level of
consensus about the completeness of the list of EBP compe-
tencies identified in the study. The final list of consensus-built
EBP competencies is included in Table 7.

DISCUSSION
Competencies are a mechanism that supports health profes-
sionals in providing high-quality, safe care (Dunn et al., 2000).
The issue of nursing competence in implementing EBP is im-
portant for individual nurses, APNs, nurse educators, nurse
executives, and healthcare organizations. Regardless of the sys-
tem, the culture and context or environment in which nurses
practice impact the success of engagement in and sustainabil-
ity of EBP. Therefore, it is imperative for nurse executives and
leaders to invest in creating a culture and environment to sup-
port EBP (Melnyk, Fineout-Overholt, et al., 2012). One action
toward investment in a culture of EBP is to provide a mecha-
nism for clarity in expectations for evidence-based care. Devel-
opment of evidence-based competencies provides a key mech-
anism for engagement in EBP and the delivery of high-quality
health care. Through a Delphi survey process, EBP competen-
cies were developed by EBP experts working in a variety of

settings, for registered professional nurses and APNs practic-
ing in real-world healthcare settings. These EBP competencies
can be used by healthcare systems to succinctly establish ex-
pectations regarding level of performance related to EBP by
registered professional nurses and APNs.

Multiple strategies can be used to incorporate competen-
cies into healthcare systems to improve healthcare quality, re-
liability, and patient outcomes as well as reduce variations in
care and costs. These strategies range from implementation of
competencies developed by the AACN, NLN, QSEN, and the
Institute of Medicine (IOM) from an organizational perspective

LINKING EVIDENCE TO ACTION

� Practice: Incorporation of EBP competencies into
healthcare system expectations and operations
can drive higher quality, reliability, and consis-
tency of healthcare as well as reduce costs. Support
systems in healthcare institutions, including edu-
cational and skills building programs along with
availability of EBP mentors, should be provided
to assist practicing nurses and APNs in achieving
the EBP competencies.

� Research is needed to develop valid and reliable
instruments for assessing these competencies. Al-
though the Fresno tool has been developed as
a valid and reliable tool for assessing EBP com-
petence in medicine (Ramos, Schafer, & Tracz,
2003), it has not been tested with nursing or al-
lied health professionals. Future research should
also determine the relationship between imple-
mentation of these EBP competencies with both
clinician and patient outcomes.

� Policy: Organizations that set standards for prac-
tice should embrace and endorse the EBP compe-
tencies as a tool to build and sustain acquisition of
EBP knowledge, development of EBP skills, and
incorporation of a positive attitude toward EBP to
promote best practices.

� Management: Nursing leaders should integrate
EBP competencies into multiple processes that
impact nurses across their clinical lifespan includ-
ing; interview questions, onboarding/orientation,
job descriptions, performance appraisals, and
clinical ladder promotion programs.

� Education: EBP competencies should be inte-
grated into both academic and clinical education
programs to establish and continuously reinforce
EBP as the foundation of practice.

12 Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15.
C© 2014 Sigma Theta Tau International

Original Article
Table 9. Strategies for Integration of the EBP Competencies

Category Organizational Strategies Individual Strategies

Promote a culture and
context or environment
that supports EBP

• Assess theorganization’s andemployee’s
readiness for implementation of EBP
competencies prior to implementation to
promotedevelopmentof aneffective strategic
plan for their integration.

• Beanevidence-basedclinicianby integrating
EBPcompetencies into daily practice to
deliver thebest carepossible to patients and
families.

• IncludeEBPcompetency language in the
mission and vision statements for nursing as
well as sharedgovernance council charters.

• Bea rolemodel for othersbymakingdecisions
basedonevidence every day.

• Provide systemsand resources that support
the integration anduseof EBPcompetencies,
suchas a criticalmassof EBPmentors,
access to library services including a
dedicated librarian, andavailability of aPhD
preparednurse scientist.

• IncludeEBPcompetencies in role expectations
of nurse leaders to support the
implementation of EBP in all aspects of care.

• Provide educational and skills building
programs to support clinicians’ attainment of
theEBPcompetencies.

• Support thedevelopmentof EBPmentors,who
meet/exceed theEBPcompetencies to
support practicing nurses andAPNs in EBP
projects.

Establish EBPperformance
expectations for all nurse
leaders andclinicians:

• IncludeEBP-competency-relatedquestions in
interviewprocesses

• Expect evidence-baseddecisionmaking from
others to promote awork environmentwhere
thebest care is possible.

• Designonboarding/orientationprograms that
specifically alignwith EBPcompetencies

• Rewrite jobdescriptions to include theEBP
competencies

Sustain EBPactivities and
culture

• IncludeEBPcompetencies in performance
appraisals and clinical ladder programs

• BecomeanEBPmentor andhelp others to
developand integrate theEBPcompetencies
into their daily practice.

• ImbedEBPcompetencies in practice policy
andguideline development processes

to actions and decisions made by point of care nurses (AACN,
2013; NLN, 2013; IOM, 2003). In addition, strategies can be
developed to integrate the scientifically derived, specific EBP
competencies developed in this study. EBP competencies can
be used as tools to guide the development of individuals
and organizations. Strategies for integration of the competen-
cies require both organizational and individual actions (see
Table 9).

LIMITATIONS
The main limitation of this study is that it used a convenience
sample of nurses who attended an EBP immersion workshop
at the first author’s institution, which may have biased the re-
search findings. In addition, some of the respondents were
not currently in an EBP mentorship role in practice settings.
Despite these limitations, the use of an expert EBP leader-
ship panel to first draft the competencies along with a Delphi

Worldviews on Evidence-Based Nursing, 2014; 11:1, 5–15. 13
C© 2014 Sigma Theta Tau International

EBP Competencies for Practice

survey technique with individuals who had EBP mentorship
experience in real-world practice settings were strengths in the
development of this set of contemporary EBP competencies for
practicing and APNs.

SUMMARY
A national consensus process and Delphi study was conducted
to establish contemporary EBP competencies for practicing
registered nurses and APNs. Incorporation of these EBP com-
petencies into healthcare systems should lead to higher quality
of care, greater reliability, improved patient outcomes, and re-
duced costs.

ACKNOWLEDGMENTS
The authors would like to thank the following national expert
panel who participated in the first phase of achieving consensus
in the development of these EBP competencies: Dr. Karen Bal-
akas, Dr. Ellen Fineout-Overholt, Dr. Anna Gawlinski, Dr. Mar-
ilyn Hockenberry, Dr. Rona F. Levin, Dr. Bernadette Mazurek
Melnyk, and Dr. Teri Wurmser. WVN

Author information

Bernadette Mazurek Melnyk, Associate Vice President for
Health Promotion, University Chief Wellness Officer, Dean
and Professor, College of Nursing, Professor of Pediatrics and
Psychiatry, College of Medicine, The Ohio State University,
Columbus, OH; Lynn Gallagher-Ford, Clinical Associate Pro-
fessor and Director, Center for Transdisciplinary Evidence-
based Practice, College of Nursing, The Ohio State Univer-
sity, Columbus, OH; Lisa English Long, Expert Evidence-based
Practice Mentor, Clinical Instructor, College of Nursing, The
Ohio State University, Columbus, OH; Ellen Fineout-Overholt,
Dean and Professor, Groner School of Professional Studies,
Chair, Department of Nursing, East Texas Baptist University,
Marshall, TX.
Address correspondence to Dr. Bernadette Mazurek Melnyk,
College of Nursing, The Ohio State University, 1585 Neil Av-
enue, Columbus, OH 43210, USA; Melnyk.15@osu.edu

Accepted 28 October 2013
Copyright C© 2014, Sigma Theta Tau International

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