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Application of a Q Method Study to Understanding Nurses' Perspective of Adopting Evidence-Based Nursing

Open AccessPublished:October 22, 2017DOI:https://doi.org/10.1016/j.anr.2017.09.001

      s u m m a r y

      Purpose

      This study applied the Q method to identify and describe the various types of nurse perceptions that are crucially associated with their engagement in evidence-based nursing (EBN).

      Methods

      The study participants were nurses at a medical center and a regional teaching hospital. A series of Q sorts was performed by nurses to subjectively rank the Q statements. Q statements were constructed based on the literature related to EBN adoption by nurses and face-to-face interviews.

      Results

      A total of 60 participants were invited to rank 44 Q statements related to EBN. Factor analysis was conducted on the rankings of the Q statements. The following are the five prominent shared perspectives: (1) emphasized the obstacles to evidence searching and reading ability; (2) emphasized the organizational promotive strategies; (3) emphasized the available supportive resources; (4) emphasized the significance of EBN; and (5) emphasized the evidence-searching ability and external incentives. The five identified groups of perspectives can enhance hospital administrators to acknowledge the barriers and incentives associated with EBN practices.

      Conclusion

      The exploration of clustering nurses' perceptions may facilitate the development of customized strategies to enable more appropriate training.

      Keywords

      Introduction

      Evidence-based nursing (EBN) has become one of the most effective methods for improving patient outcomes and the quality of care as well as delivering cost-efficient health care [
      • Melnyk B.M.
      • Fineout-Overholt E.
      • Giggleman M.
      • Cruz R.
      Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system.
      ,
      • Wallen G.R.
      • Mitchell S.A.
      • Melnyk B.
      • Fineout-Overholt E.
      • Miller-Davis C.
      • Yates J.
      • et al.
      Implementing evidence-based practice: effectiveness of a structured multifaceted mentorship programme.
      ]. EBN emphasizes integrating the most valid research evidence with nursing expertise and findings from research on specific clinical concerns of nursing care. EBN has been recognized as an excellent approach for reducing variations and improving the quality of care; it considers patient preferences, context, health care systems, and clinician judgment [
      • Pearson A.
      • Wiechula R.
      • Court A.
      • Lockwood C.
      The JBI model of evidence-based healthcare.
      ]. Despite its many benefits, EBN may not be the prevailing standard in current health care practices, and its integration with nursing practice has been challenging.
      The application of evidence-based practices is considered the optimal method for enhancing nurses' ability to identify and resolve clinical problems. This implies that nurses have developed the skills and knowledge to search for, appraise, and use research evidence for clinical decision-making and to facilitate approaches to deliver high-quality care [
      • Adib-Hajbaghery M.
      Factors facilitating and inhibiting evidence-based nursing in Iran.
      ,
      • Hsu L.-L.
      • Hsieh S.-I.
      • Huang Y.-H.
      A study of the evidence-based nursing practice competence of nurses and its clinical applications.
      ]. Nurses have numerous subjective perspectives that influence their motivation to promote and execute EBN. Nurses generally report the following: having limited time for executing evidence-based practices during scheduled working hours [
      • Chau J.P.
      • Lopez V.
      • Thompson D.R.
      A survey of Hong Kong nurses' perceptions of barriers to and facilitators of research utilization.
      ,
      • Majid S.
      • Foo S.
      • Luyt B.
      • Zhang X.
      • Theng Y.-L.
      • Chang Y.-K.
      • et al.
      Adopting evidence-based practice in clinical decision making: nurses' perceptions, knowledge, and barriers (EC).
      ], lacking knowledge related to finding and understanding research reports and data [
      • Breimaier H.E.
      • Halfens R.J.
      • Lohrmann C.
      Nurses' wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria.
      ,
      • Dalheim A.
      • Harthug S.
      • Nilsen R.M.
      • Nortvedt M.W.
      Factors influencing the development of evidence-based practice among nurses: a self-report survey.
      ] and how to change clinical practices, receiving inadequate support from the organization in executing evidence-based practices [
      • Gerrish K.
      • Clayton J.
      Promoting evidence-based practice: an organizational approach.
      ,
      • Grant H.S.
      • Stuhlmacher A.
      • Bonte-Eley S.
      Overcoming barriers to research utilization and evidence-based practice among staff nurses.
      ], and having limited autonomy in changing their practice and other nurses' resistance to change [
      • Brown C.E.
      • Wickline M.A.
      • Ecoff L.
      • Glaser D.
      Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center.
      ,
      • Hart P.
      • Eaton L.
      • Buckner M.
      • Morrow B.N.
      • Barrett D.T.
      • Fraser D.D.
      • et al.
      Effectiveness of a computer-based educational program on nurses' knowledge, attitude, and skill level related to evidence-based practice.
      ].
      Most EBN-related studies have applied Likert-type scale format questions to measure participants' levels of propensity [
      • Breimaier H.E.
      • Halfens R.J.
      • Lohrmann C.
      Nurses' wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria.
      ,
      • Kim S.C.
      • Stichler J.F.
      • Ecoff L.
      • Brown C.E.
      • Gallo A.M.
      • Davidson J.E.
      Predictors of evidence-based practice implementation, job satisfaction, and group cohesion among regional fellowship program participants.
      ,
      • Levin R.F.
      • Fineout-Overholt E.
      • Melnyk B.M.
      • Barnes M.
      • Vetter M.J.
      Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.
      ,
      • Mollon D.
      • Fields W.
      • Gallo A.M.
      • Wagener R.
      • Soucy J.
      • Gustafson B.
      • et al.
      Staff practice, attitudes, and knowledge/skills regarding evidence-based practice before and after an educational intervention.
      ]. A limitation of this type of measure is that a midpoint can be an easy option when participants are uncertain or do not take time to weigh the merit of each item [
      • Shabila N.P.
      • Al-Tawil N.G.
      • Al-Hadithi T.S.
      • Sondorp E.
      Using Q-methodology to explore people's health seeking behavior and perception of the quality of primary care services.
      ]. Whether the midpoint is a true neutral option is questionable. The Q method is a technique to identify patterns based on opinions rather than to test the proportional distribution of opinions among participants [
      • Lobo V.M.
      • Fisher A.
      • Baumann A.
      • Akhtar-Danesh N.
      Effective retention strategies for midcareer critical care nurses: a Q-method study.
      ]. The major objective of this method is to examine individual perceptions of a designed topic by categorizing participants according to the similarity of their opinions [
      • Akhtar-Danesh N.
      • Baumann A.
      • Cordingley L.
      Q-Methodology in nursing research a promising method for the study of subjectivity.
      ]. To avoid the mentioned limitation, the Q method uses distinguishing statements that are ranked at the extremes of the composite Q-sort to interpret the characteristics of the identified patterns. Because of the forced distribution of Q sorts, the extremes can be interpreted as representing a participant's opinions with more confidence. Using this procedure, personal perspectives regarding a specific issue can be systematically evaluated [
      • Absalom-Hornby V.
      • Hare D.
      • Gooding P.
      • Tarrier N.
      Attitudes of relatives and staff towards family intervention in forensic services using Q methodology.
      ]. Patterns of shared opinions emerge from Q sorts, and such analyses may provide novel insights that would otherwise not have been elicited using conventional Likert scaling techniques.
      Successful EBN implementation requires effective teamwork. Promoting teamwork and cooperation, further EBN studies may not only identify the barriers and facilitators, but also understand patterns of shared opinions emerging from nurses' perspectives toward these factors. Because of the strengths of grouping people according to their attitude tendency, we adopted the Q method to investigate nurses' perspectives toward EBN. The aim of this study was to identify and describe the various types of nurses' perceptions that are crucially associated with their engagement in EBN.

      Methods

      Study design

      The Q method was used in this study to investigate the various common perspectives among nurses.

      Setting and sample

      We enrolled eligible participants from a medical center and a regional hospital in Taiwan. Sixty clinical staff members were recruited from a medical center (n = 30) and regional hospital (n = 30). The following were the inclusion criteria: nurses who are currently employed, have at least 1 year of clinical experience, have general awareness and understanding of the five steps of EBN, and are willing to participate in the study and provide written informed consent. The Q method is a type of exploratory factor analysis. To effectively determine diversity in perspectives, 40 to 60 participants are required in a group [
      • Watts S.
      • Stenner P.
      Doing Q methodology: theory, method and interpretation.
      ]. In this study, 60 nurses participated in the Q-sort evaluation of the designed Q statements.

      Ethical considerations

      The study protocol was approved by the institutional review boards of the National Yang-Ming University Hospital (NYMUH IRB No. 2013A016) and MacKay Memorial Hospital (Approval no. 13MMHIS200) before the study commencement. After ethical approval was obtained for this study, the participants were informed and invited to voluntarily participate in the study. The Q sorts were identified by numbers alone; therefore, participant identity and the collected information were not associated, thereby ensuring anonymity. All the participants signed informed consent before participating in the study.

      Instruments

      This section described the developing process of Q statements. Initial categories specific to barriers to and facilitators of EBN adoption by nurses were developed through data extraction from published nursing research and a review nursing of the literature. These categories included skills and ability associated with EBN, attitudes associated with EBN, practicability associated with EBN practices, and working conditions and supportive resources. Table 1 presents detailed descriptions of each category. Fifteen nurses were interviewed to obtain their concerns related to EBN, and subsequently, a list of sentences under each category was prepared. We revised these sentences several times until a consensus was reached. Five experts and scholars with related specialties were invited to examine the representative Q statements. The content validity index was used to evaluate the Q statements. Only statements with content validity index values >.80 were retained for further Q sorting. A modified list of 44 Q statements was obtained by clarifying the semantics of individual statements and eliminating duplication.
      Table 1Categories of the Factors Associated with EBN Adoption from Published Literatures.
      CategoriesSkills and ability associated with EBNAttitudes associated with EBNPracticability associated with EBN practicesWorking conditions and supportive resources
      First author (publication yr)Description
      • -
        Knowledge about research utilization
      • -
        Mentoring
      • -
        Learning opportunity
      • -
        EBN training
      • -
        Skills in retrieving and evaluating research publication
      • -
        Skills on managing research-based evidence
      • -
        Meaning
      • -
        Beliefs about benefits of EBN
      • -
        Nursing confidence
      • -
        Nursing responsibility
      • -
        Nursing autonomy
      • -
        Adequate organizational support
      • -
        Managerial support
      • -
        Hospital policy
      • -
        Culture adoption
      • -
        Supports from colleagues and other collaborators
      • -
        Time constrain
      • -
        Heavy workload
      • -
        Opportunities for working with a computer
      • -
        Internet use in the workplace
      • -
        Availability of professional support
      • -
        Availability of library assistance
      Gerrish (2004)
      Melnyk (2004)
      Adib-Hajbaghery (2007)
      Chau (2008)
      Gerrish (2008)
      Hart (2008)
      Koehn (2008)
      Brown (2009)
      Chien (2010)
      Breimaier (2011)
      Eizenberg(2011)
      Majid (2011)
      Dalheim(2012)
      Grant (2012)
      Note. EBN = evidence-based nursing.

      Procedure of data collection

      After obtaining their permission to participate, the nurses performed a series of Q sorts to subjectively rank the Q statements. This technique is a relatively novel approach for identifying the divergent concerns of nurses regarding barriers to and facilitators of EBN adoption. The Q-sorting procedure enables participants to rank Q statements in a normally distributed 44-cell grid, according to the extent to which each statement represents their perspectives. We developed an E-platform for the participants to perform the Q sorting online. An example of the user interface was reported in our previous study [
      • Huang C.M.
      • Hung W.S.
      • Lai J.N.
      • Kao Y.H.
      • Wang C.L.
      • Guo J.L.
      Maternity staff perspectives regarding resource demands of breastfeeding supportive practices in accordance with the Baby-Friendly Hospital Initiative accreditation: a Q methodology approach.
      ]. The screen was divided into two panels. The left panel displayed a list of the final Q statements, and the right panel showed the scoring system in the form of a Q-sort grid (−4 to +4). The participants were asked to place the statements most and least crucial to them in the right (+4; positively labeled) and left (−4; negatively labeled) columns, respectively. The participants used a mouse to move each statement from the left panel to the Q-sorting grid in the right panel until all statements were on the grid.

      Data analysis

      We performed factor analysis on the rankings (Q sorts) of the Q statements, which were developed according to previous studies. The PQMethod 2.35 program was used to analyze the Q sorts [
      • Schmolck P.
      PQMethod manual [Internet].
      ] (PQMethod 2.35 program was developed by John Atkinson at Kent State University, Kent, OH, USA in 1992). By-person factor analysis, rather than traditional item factor analysis, was used to form participant groups (factors) according to the similarities in their Q sorts. The prominent shared perspectives, known as factors, were extracted using principal component analysis with varimax rotation. Rotation was ensured to maximize similarities within factors and differences between them. Participants with Q sorts that were significant for a factor, but not significant for any other factors were classified into that particular factor. Participants who significantly loaded on a factor represented similar perspectives of EBN adoption. An eigenvalue conceptually represented the relative contribution of the corresponding factor in explaining the total variance in the data set [
      • Shabila N.P.
      • Al-Tawil N.G.
      • Al-Hadithi T.S.
      • Sondorp E.
      Using Q-methodology to explore people's health seeking behavior and perception of the quality of primary care services.
      ]. A combination of eigenvalues and a screen plot was used to determine the number of retained factors.
      The results and interpretation of each factor are presented according to the characterizing and distinguishing statements. The characterizing statements, ranked at both ends of the composite sorting of each factor (−3, −4, +3, and +4), were used to provide an initial description. The distinguishing statements, statistically significant at p < .05, were used to highlight the differences between the factors examined in this study.

      Results

      The participants were aged 27 to 54 years, with a mean ± standard deviation of 37.63 ± 6.65 years. The participants had an average clinical experience of 14.78 ± 7.10 years. Principal component analysis yielded 18 factors with eigenvalues exceeding 1 (1.00–11.25). After the screen plot analysis, five factors were retained in the final model. Table 2 shows the corresponding category, Q statements, and factor arrays of the five factors.
      Table 2Q Statements and Factor Arrays across the Five Factors.
      CategoriesFactor arrays
      F1F2F3F4F5
      Skills and ability associated with EBN
       Difficulty in searching for appropriate empirical literature3−1−304
       Using EBN steps to solve patient problems−1−2101
       Attending EBN training13142
       Learning opportunity for new information22221
       Using competition as a training method of EBN1021−4
       Lack of confidence in assessing the quality of empirical literature1−3−1−4−2
       Difficulty in understanding English-language literature42−2−22
       Lack of professional guidance for EBN21303
       Requires mentorship of EBN guidance−200−10
       Using group discussion as a training method of EBN102−40
      Attitudes associated with EBN
       Willingness in adopting EBN3−1342
       Appreciating the importance of EBN1−2−122
       EBN promotes critical thinking31233
       EBN enhances quality of care20131
       EBN promotes autonomy in nursing practice−1−3000
       Offering a scientific explanation for nursing care10111
       EBN enhances nursing care efficiency−2−1020
       EBN enhances patient comfort0−1010
       Care procedures can be altered according to EBN−2−200−1
       EBN enhances nursing authority01010
       EBN enhances nursing competence0100−1
       EBN demonstrates nursing uniqueness to other professionals0−11−2−1
       EBN enhances the respects of colleagues−200−1−1
      Practicability associated with EBN practices
       Difficulty in implementing EBN practices that require a doctor's order0431−1
       Lack of teamwork cooperation across disciplines−1312−3
       Applied EBN practices as a mandatory policy0−2−2−2−4
       Require recognition and support from colleagues01200
       Require support from the hospital management and administrators−12−1−11
       EBN practices against current medical practices−3−2−2−3−3
       Require tangible rewards (e.g., leave and allowances) for EBN practices−14−213
       Promote EBN practices through publication of implementation process and results−400−21
       Regarding the time spending on EBN practices as flexible working hours−23−1−20
       Provision of supports and reinforcement−4−1−200
       Initiating EBN practices on a trial basis for testing feasibility101−11
       Incorporation of EBN knowledge into evaluation for nursing competence advancement−3−4−2−3−2
      Working conditions and supportive resources
       Lack of time at the workplaces to search and read research articles40−324
       EBN practice increasing in clinical workload22−33−2
       Time constrains because of too many family responsibilities−3−1−1−3−2
       Slow computers and limitations on the number of internet users0−4−41−3
       Difficulty in obtaining the full text of empirical literature−1−3−4−1−1
       Availability of professional supports for research skills21401
       Availability of library staff to consult with024−20
       Time constrains because of multiple roles010−1−2
       Inadequate staffing (large number of patients, heavy workloads)−10−102
      Factor 1 emphasized the obstacles to evidence searching and reading ability, Factor 2 emphasized the organizational promotive strategies, Factor 3 emphasized the available supportive resources, Factor 4 emphasized the significance of EBN, and Factor 5 emphasized the evidence-searching ability and external incentives.
      Note. EBN=evidence-based nursing.
      Table 3 presents the distinguishing statements ranked at both ends of each factor. The following are the five prominent shared perspectives: (1) Factor 1 emphasized the obstacles to evidence searching and reading ability; (2) Factor 2 emphasized the organizational promotive strategies; (3) Factor 3 emphasized the available supportive resources; (4) Factor 4 emphasized the significance of EBN; and (5) Factor 5 emphasized the evidence-searching ability and external incentives.
      Table 3Distinguishing Statements at Both Extreme Ends across the Five Factors.
      CategoriesResult of Q-sort factor analysis
      Emphasized the obstacles to evidence searching and reading abilityEmphasized the organizational promotive strategiesEmphasized the available supportive resourcesEmphasized the significance of EBNEmphasized the evidence-searching ability and external incentives
      Skills and ability associated with EBNMost importanceDifficulty in searching for appropriate empirical literature (3, 1.25)

      Difficulty in understanding English-language literature (4, 1.86)
      Attending EBN training (3, 1.43)Attending EBN training (4, 1.96)Difficulty in searching for appropriate empirical literature (4, 2.34)
      Least importanceLack of confidence in assessing the quality of empirical literature (−3, −1.39)Difficulty in searching for appropriate empirical literature (−3, −1.36)Lack of confidence in assessing the quality of empirical literature (−4, −1.99)

      Using group discussion as a training method of EBN (−4, −1.66)
      Using competition as a training method of EBN

      (−4, −2.51)
      Attitudes associated with EBNMost importanceEBN promotes critical thinking (3, 1.82)

      EBN enhances quality of care (3, 1.57)
      Least importanceEBN promotes autonomy in nursing practice (−3, −1.33)
      Practicability associated with EBN practicesMost importanceLack of teamwork cooperation across disciplines (3, 1.39)

      Requires tangible rewards (e.g., leave and allowances) for EBN practices (4, 2.38)

      Regarding the time spending on EBN practices as flexible working hours (3, 1.53)
      Requires tangible rewards (e.g., leave and allowances) (3, 1.14)
      Least importancePromote EBN through publication of implementation process and results (−4, −1.54)

      Provision of supports and reinforcement (−4, −1.66)
      Lack of teamwork cooperation across disciplines (−3, −1.47)

      Applied EBN as a mandatory policy (−4, −1.99)
      Working conditions and supportive resourcesMost importanceAvailability professional supports for research skills (4, 1.75)

      Availability of library staff to consult with (4, 1.91)
      Least importanceDifficulty in obtaining the full text of empirical literature (−3, −1.41)Lack of time at the workplaces to search and read research articles (−3, −1.27)

      Difficulty in obtaining the full text of empirical literature (−4, −2.36)
      Slow computers and limitations on the number of internet users (−3, −1.30)
      Both the factors Q-sort value and Z-Score are shown in parentheses. The numbers in the parentheses were identified by Q-sort factor analysis. They represent that the statements were the most/least accurately reflected the experience of participants who loaded significantly onto the given factor.
      Note. EBN=evidence-based nursing.

      Factor 1 emphasized the obstacles in evidence searching and reading ability

      Fourteen participants were significantly loaded on this factor. They strongly emphasized EBN-associated skills and abilities, particularly the difficulty in evidence searching (+3) and reading (+4), which affected their engagement in EBN. They were not highly concerned about organizational strategies such as promoting EBN through the publication of the implementation processes and results (−4) or the provision of support and reinforcement (−4) (Table 3).
      Among all the participants, those associated with Factor 1 were relatively young (35.71 years), with an average clinical experience of 13.07 years. Most of them were employed at a regional hospital (78.6%), and 92.9% of the participants had an education level equivalent to an undergraduate degree. Only 35.7% of the participants had a higher level of nursing competency (N3 and N4). Most of them attended EBN training (71.4%) (Table 4).
      Table 4Background Information.
      Participant backgroundEmphasized the obstacles to evidence searching and reading abilityEmphasized the organizational promotive strategiesEmphasized the available supportive resourcesEmphasized the significance of EBNEmphasized the evidence-searching ability and external incentives
      (n = 14)(n = 10)(n = 6)(n = 9)(n = 8)
      n
      Types of hospital
       Medical center39604
       Regional hospital111094
      Education level
       College/baccalaureate136296
       Graduate14402
      Job position
       Nurse109265
       Administer41433
      Level of nurse career advancement
       N101100
       N292075
       N336503
       N421020
      Work unit
       Emergency and critical care66176
       Surgical and medical wards84522
      Attended EBN training
       Yes1010675
       No40023
      Age (yr)
       Mean ± SD35.71 ± 7.4136.20 ± 5.6342.33 ± 3.4537.78 ± 6.3036.50 ± 7.59
      Clinical experience (yr)
       Mean ± SD13.07 ± 7.6113.30 ± 7.5720.50 ± 4.4613.44 ± 5.2514.75 ± 7.15
      Note. EBN=evidence-based nursing; N=level of nursing competency; SD=standard deviation.

      Factor 2 emphasized the organizational promotive strategies

      Ten participants were significantly loaded on this factor. These participants favored tangible rewards (leave and allowances) for EBN practices (+4) and considered the time spent on EBN practices as flexible working hours (+3). This group emphasized attending EBN training (+3). The participants were concerned about the lack of teamwork across disciplines (+3). By contrast, they were not highly concerned about obtaining the full text of empirical literature (−3), promoting nursing autonomy by using EBN practices (−3), or their literature appraisal ability (−3) (Table 3).
      The average age of the participants associated with Factor 2 was 36.20 years, with an average clinical experience of 13.30 years. Most of the participants were employed at medical centers (90.0%), 60.0% of the participants had an education level equivalent to an undergraduate degree, and 70.0% had a higher level of nursing competency (N3 and N4). All the participants attended EBN training (100.0%) (Table 4).

      Factor 3 emphasized the available supportive resources

      Six participants were significantly loaded on this factor. These participants emphasized the availability of professional support for research skills (+4) and availability of library staff for consultation (+4). Compared with the participants in the other groups, these participants were less concerned about conditional barriers such as the lack of time at workplaces to search and read research articles (−3) and difficulty in obtaining the full text of empirical literature (−4). They placed less emphasis on the difficulty in searching for appropriate empirical literature (−3) (Table 3).
      Among all the participants, those associated with Factor 3 were relatively old (42.33 years), with an average clinical experience of 20.50 years. These participants were employed at medical centers (100.0%); 33.3% of the participants had an education level equivalent to an undergraduate degree, and 83.3% had a higher level of nursing competency (N3 and N4). All the participants attended EBN training (100.0%) (Table 4).

      Factor 4 emphasized the significance of EBN

      Nine participants were significantly loaded on this factor. These participants supported the value of EBN. They considered that EBN promotes critical thinking (+3) and enhances the quality of care (+3). This group of participants emphasized attending EBN training (+4). By contrast, these participants were not highly concerned about the ability or training method associated with EBN, such as the lack of confidence in assessing the quality of empirical literature (−4) or conducting group discussion as a training method of EBN (−4) (Table 3).
      The average age of participants associated with Factor 4 was 37.78 years, with an average clinical experience of 13.44 years. All the participants were employed at a regional hospital (100.0%) and had an education degree equivalent to an undergraduate degree. Only 22.2% of the participants had a higher level of nursing competency (N3 and N4). Most of them attended EBN training (77.8%) (Table 4).

      Factor 5 emphasized the evidence-searching ability and external incentives

      Eight participants were significantly loaded on this factor. These participants were concerned about self-ability and external incentives such as the difficulty in searching for appropriate empirical literature (+4) and provision of tangible rewards (leave and allowances) for EBN practices (+3). These participants were not highly concerned about the practicability of EBN practices, such as the lack of teamwork across disciplines (−3) or application of EBN as a mandatory policy (−4). They did not prefer using competition as a training method of EBN (−4). They were not concerned about slow computers or a limited number of internet users (−3) (Table 3).
      The average age of the participants associated with Factor 5 was 36.50 years, with an average clinical experience of 14.75 years. Half of the participants were employed at medical centers (50.0%), 75.0% of the participants had an education degree equivalent to an undergraduate degree, and 37.5% had a higher level of nursing competency (N3 and N4). Most of the participants attended EBN training (62.5%) (Table 4).

      Consensus statements

      Consensus (a similar magnitude of agreement or disagreement with the Q statements provided by all participants) was achieved for only one statement. The study groups ranked the following statement as relatively neutral: “offer a scientific explanation for nursing care (1, 0, 1, 1, and 1).”

      Discussion

      This study identified five shared perspectives regarding the factors relevant for nurses to adopt EBN. The following are the five prominent shared perspectives: (1) the obstacles to evidence searching and reading ability; (2) the organizational promotive strategies; (3) the available supportive resources; (4) the significance of EBN; and (5) the evidence-searching ability and external incentives. Previous studies have identified factors facilitating and hindering EBN [
      • Chien W.T.
      A survey of nurses' perceived barriers to research utilisation in Hong Kong.
      ,
      • Solomons N.M.
      • Spross J.A.
      Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review.
      ] and reported nurses' perceived knowledge, attitude, and skills regarding EBN [
      • Brown C.E.
      • Wickline M.A.
      • Ecoff L.
      • Glaser D.
      Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center.
      ,
      • Mollon D.
      • Fields W.
      • Gallo A.M.
      • Wagener R.
      • Soucy J.
      • Gustafson B.
      • et al.
      Staff practice, attitudes, and knowledge/skills regarding evidence-based practice before and after an educational intervention.
      ,
      • Melnyk B.M.
      • Fineout-Overholt E.
      • Fischbeck Feinstein N.
      • Li H.
      • Small L.
      • Wilcox L.
      • et al.
      Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: implications for accelerating the paradigm shift.
      ]. Our finding contributes to the literature by revealing different perspectives and a novel approach to EBN studies. The factors associated with EBN adoption by nurses in previous studies were organized as a framework to construct the Q statements in this study. In addition, this study integrated qualitative interviews into a framework to develop the Q statements for Q sorting. Using this procedure, a combination of a literature review and face-to-face interviews, concerns related to EBN adoption could be adequately addressed and illustrated.
      The participants associated with Factor 1 shared an experience of being discouraged by their evidence searching and reading abilities. A lack of confidence in retrieving and evaluating nursing practice evidence was not an unusual barrier to adopting EBN in non–English-speaking countries [
      • Hsu L.-L.
      • Hsieh S.-I.
      • Huang Y.-H.
      A study of the evidence-based nursing practice competence of nurses and its clinical applications.
      ,
      • Wang L.-P.
      • Jiang X.-L.
      • Wang L.
      • Wang G.-R.
      • Bai Y.-J.
      Barriers to and facilitators of research utilization: a survey of registered nurses in China.
      ]. Similarly, Dalheim et al [
      • Dalheim A.
      • Harthug S.
      • Nilsen R.M.
      • Nortvedt M.W.
      Factors influencing the development of evidence-based practice among nurses: a self-report survey.
      ] identified a difficulty in understanding English-language publications. Our finding implied that EBN training alone may not adequately empower this group of participants because most of them (more than 70%) attended EBN training. A systematic review found that lectures/didactic presentations were the most frequently used training methods [
      • Häggman-Laitila A.
      • Mattila L.R.
      • Melender H.L.
      A systematic review of journal clubs for nurses.
      ]. The findings suggested that not many nurses could perform EBN independently with confidence after receiving lecture-type training [
      • Mollon D.
      • Fields W.
      • Gallo A.M.
      • Wagener R.
      • Soucy J.
      • Gustafson B.
      • et al.
      Staff practice, attitudes, and knowledge/skills regarding evidence-based practice before and after an educational intervention.
      ,
      • Häggman-Laitila A.
      • Mattila L.R.
      • Melender H.L.
      A systematic review of journal clubs for nurses.
      ]. It may be more effective to help and support these nurses by a provision of interactive activities, such as small group discussion or establishing a mentorship model on EBN in clinical practice [
      • Kim S.C.
      • Stichler J.F.
      • Ecoff L.
      • Brown C.E.
      • Gallo A.M.
      • Davidson J.E.
      Predictors of evidence-based practice implementation, job satisfaction, and group cohesion among regional fellowship program participants.
      ,
      • Levin R.F.
      • Fineout-Overholt E.
      • Melnyk B.M.
      • Barnes M.
      • Vetter M.J.
      Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.
      ,
      • Pravikoff D.S.
      • Tanner A.B.
      • Pierce S.T.
      Readiness of US nurses for evidence-based practice: many don't understand or value research and have had little or no training to help them find evidence on which to base their practice.
      ].
      Factor 1 emphasized individual abilities, but participants who loaded on Factor 2 favored organizational promotive strategies. They emphasized tangible rewards for their efforts on EBN practices. Necessary organizational incentives were expected as effective strategies for the participants who loaded on Factor 2. The appreciation and reward would promote nurses feeling energized and a stronger sense of professionalism [
      • Levin R.F.
      • Fineout-Overholt E.
      • Melnyk B.M.
      • Barnes M.
      • Vetter M.J.
      Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.
      ]. If organizations could provide them external rewards and support, nurses would be able to engage in EBN and work with satisfaction [
      • Adib-Hajbaghery M.
      Factors facilitating and inhibiting evidence-based nursing in Iran.
      ,
      • Kim S.C.
      • Stichler J.F.
      • Ecoff L.
      • Brown C.E.
      • Gallo A.M.
      • Davidson J.E.
      Predictors of evidence-based practice implementation, job satisfaction, and group cohesion among regional fellowship program participants.
      ,
      • Levin R.F.
      • Fineout-Overholt E.
      • Melnyk B.M.
      • Barnes M.
      • Vetter M.J.
      Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.
      ]. The participants who loaded on Factor 3 emphasized the availability of supportive resources. They were relatively old (42.33 years), with an average clinical experience of 20.50 years. All of them attended EBN training. The findings suggest that EBN training may not satisfy these experienced nurses. The nurses preferred library assistance and professional support for research skills while engaging in EBN. Difficulty navigating online data systems or lacking confidence in library skills were barriers for nurses [
      • Gerrish K.
      • Clayton J.
      Promoting evidence-based practice: an organizational approach.
      ,
      • Solomons N.M.
      • Spross J.A.
      Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review.
      ]. A previous study [
      • Brown C.E.
      • Wickline M.A.
      • Ecoff L.
      • Glaser D.
      Nursing practice, knowledge, attitudes and perceived barriers to evidence-based practice at an academic medical center.
      ] suggested that provision of guidance by knowledgeable people (advanced practice nurses and researchers) is effective in overcoming these barriers.
      The participants who loaded on Factor 4 emphasized the value of EBN. They accredited that EBN is an essential element of nursing and enhances critical thinking and the quality of care. An integrative review revealed that nurses could not be isolated from organizational and social factors that affect EBN [
      • Solomons N.M.
      • Spross J.A.
      Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review.
      ]. However, these nurses emphasized the value of EBN rather than external barriers. Positive attitudes associated with EBN enhance nurses' readiness for engaging in EBN practices [
      • Adib-Hajbaghery M.
      Factors facilitating and inhibiting evidence-based nursing in Iran.
      ]. Recognition of nurses with positive attitudes would be a benefit to construct a supportive environment for EBN implementation. The participants who loaded on Factor 5 emphasized both individual ability and external incentives. They can be appropriately assisted by integrating individual and external strategies. Provisions of training programs and related tangible rewards were needed to foster EBN implementation [
      • Adib-Hajbaghery M.
      Factors facilitating and inhibiting evidence-based nursing in Iran.
      ,
      • Levin R.F.
      • Fineout-Overholt E.
      • Melnyk B.M.
      • Barnes M.
      • Vetter M.J.
      Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.
      ].

      Implication for the nursing practice

      Responsive approaches, according to each group, may be beneficial for attaining more effective collaboration. Educational training is the most common strategy for motivating nursing staff to engage in EBN. However, our findings suggest that EBN training alone may not be sufficient for some nurses. Alternative strategies, such as providing translation to reduce language barriers to English literature, are necessary to assist nurses who associate with Factor 1. Our findings highlight the need for strategies to ensure that evidence-based information is readily available to nurses in a form that they can easily understand [
      • Gerrish K.
      • Clayton J.
      Promoting evidence-based practice: an organizational approach.
      ].
      For some experienced nurses (Factor 3), provision of supportive resources, such as library assistance and professional support for research skills, is desired in addition to EBN training. Insufficient library assistance may hinder nurses from adopting EBN. Promotive strategies to engage these nurses in EBN should equip them with sufficient assistance to search and retrieve evidence-based literatures [
      • Häggman-Laitila A.
      • Mattila L.R.
      • Melender H.L.
      A systematic review of journal clubs for nurses.
      ,
      • Pravikoff D.S.
      • Tanner A.B.
      • Pierce S.T.
      Readiness of US nurses for evidence-based practice: many don't understand or value research and have had little or no training to help them find evidence on which to base their practice.
      ].
      Nurses who associated with Factor 4 appreciated the value of EBN and could be appropriate advocates of an organizational policy to implement EBN. Their inclusion as a representative presence on hospital-wide committees helped to promote EBN practices within institutions. This can be considered both a strategic and cultural intervention that enhances nursing authority and autonomy [
      • Solomons N.M.
      • Spross J.A.
      Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: an integrative review.
      ].
      Finally, for some nurses (Factors 2 and 5), provision of organizational support and rewards or incentives was more effective than EBN training. Positive reinforcement (exact rewards) of identified behaviors is perceived as organizational support [
      • Grant H.S.
      • Stuhlmacher A.
      • Bonte-Eley S.
      Overcoming barriers to research utilization and evidence-based practice among staff nurses.
      ]. Organizational culture must recognize and reward those who adopt EBN in nursing practice.

      Limitation

      The generalizability of results obtained using the Q method is slightly limited. The study used a purposive sample; therefore, nonrandom sampling of participants may hinder the generalizability of the findings. Hence, the findings may not reflect the perspectives of nurses in other divisions or disciplines. To confirm the validity of these patterns and perspectives, the replication of the study is required. However, the Q method is useful for exploring diverse perspectives rather than potential generalizable studies.

      Conclusion

      This study comprehensively presents an understanding of nurses' perceptions of what they crucially associate with engagement in EBN. Q statements are constructed based on the literature related to EBN adoption by nurses and face-to-face interviews. Patterns of shared perspectives emerge from nurses' rankings of these statements. The five identified groups of perspectives can facilitate the development of customized strategies to meet nurses' preferences. The exploration of clustering nurses' perceptions may enable more appropriate training and assistance.

      Conflict of interest

      The authors declare that they have no conflicts of interest.

      Acknowledgments

      This work was supported by a grant from the National Yang-Ming University Hospital Hospital, Yilan, Taiwan ( RD2014-026 ). The authors would like to express their gratitude to the nursing staff and the care units that participated in this study.

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