To the best of our knowledge, this is the first study to describe RNMs knowledge, attitude and use of EBP among registered nurses and midwives in central hospitals in Malawi.
This study has shown that RNMs’ attitude towards EBP had the highest mean score followed by the knowledge/skills and then practice. This shows that the RNMs viewed EBP positively and their attitude towards EBP seemed to be more positive than their knowledge/skills and use of EBP. This result is consistent with previous studies describing attitude, practices and knowledge/skills associated with EBP(1, 2, 34–36). Over 80% of the respondents agreed that EBP was ‘fundamental to professional practice’. They also reported ‘welcoming questions in own practice’ and ‘changing practice due to evidence found’. These findings suggest that the nurses and midwives realize the importance of EBP and need for implementing it. The positive attitude as Van Achterberg, Schoonhoven and Grol(37) observed allows for better strategies pertaining to EBP dissemination and implementation.
In this study, the RNMs showed that they had some knowledge about EBP. An overall mean score 5.46 ± 1.49 was received in the section of self-rated knowledge on EBP. However, knowledge was lacking relating to EBP skills, for instance, critical analysis of evidence against set standards (4.87 ± 1.52), retrieving evidence (4.77 ± 1.65), awareness of major information sources (4.57 ± 1.44%), information technology (4.53 ± 1.43), appropriate research skills (4.34 ± 1.53) and converting information needs into research questions (4.11 ± 1.56). As depicted in the results (Table 2) the RNMs scored high mean scores on identifying the research problem and sharing ideas and information with colleagues rather than the actual skills of obtaining the evidence. A similar response was also observed in previous studies(2, 9, 38–40). Hansen and Severinsson(9) support the view in their study that EBP is the way to clinical decision making. They emphasize the use of scientific research, sound judgment and patient preference in respective contexts using various expertise. Brown et al (2) also observed that although participants understood EBP as a new way of clinical decision making, it required skills in its application to practice and also skills to research further on evidence that is relevant to the context of the investigation. It is important, therefore, that helping RNMs improve such aspects of their knowledge and/or skills in order to improve the overall EBP of RNMs in Malawian central hospitals. The central hospital managers should consider recruiting hospital librarians in their hospitals to promote EBP among RNMs and other staff. Where librarians have been used, they have introduced various programs on information literacy, importance of EBP, and implementation of EBP(41). Nurse leaders and nurse and midwife specialists should also intensify the use of performance appraisals so that specific needs of the nurses and midwives can be identified and applied during the continuing professional development programs.
There was a moderate relationship between knowledge levels and practice (r = 0.487).An improvement in the knowledge levels of RNMs could translate into their improved practice and thus again improve the overall EBP amongst RNMs in Malawian central hospitals. These results therefore demonstrate that EBP amongst RNMs can be improved most rapidly and significantly by improving primarily their knowledge levels, followed by improving their practical skills and lastly their attitude to the discipline. This explains the results presented in Table 3 which have shown that higher education qualifications are associated with high scores in knowledge levels amongst RNMs, whereas available work (research) experience is associated also with higher scores in nursing and midwifery practice. In the end, both educational qualification and research experience affect the overall EBP.
The female participants dominated the study (79.2%), a finding that is consistent with other international results especially in the nursing and midwifery professions where more females are reported than males(42). The current study has revealed no statistically significant differences in RNMs’ practice, attitude, knowledge levels and overall EBP based on gender (P > 0.05). Even though AbuRuz, Hayeah, Al-Dweik and Al-Akash(3) reported that female nurses conduct research less, have less positive and less knowledge about research compared to their male counterparts, Hasheesh and Ruz, (43) reported contrary results.
In this study, EBP amongst RNMs was not influenced by administrative roles or positions held by nurse-midwives in hospitals. This finding is consistent with a study done in Ethopia(15). This may be due to lack of managerial skills and EBP training. However, leadership is described as a key for creating an environment for generation and implementation of EBP(44). Leaders have a responsibility to engage staff at all levels, support an EBP culture and allocate resources to provide the necessary infrastructure to promote clinical decision making based on best available evidence (10). These leaders should introduce (where necessary) and motivate the RNMs to participate in research activities like research trainings, scientific conferences and journal clubs to strengthen EBP in the clinical area. Nursing and midwifery leaders at the central hospitals need to understand the EBP process and be able to clearly articulate its meaning, use and impact on patient care(45). It is time RNMs in this country had a shared vision and developed a model consisting of clinical bedside nurse midwives and leaders at an individual hospital that can be used to standardize and support EBP.
This study has found that RNMs who had masters' degrees in nursing or midwifery tended to perceive fewer barriers to finding research compared to nurses-midwives with diplomas. This is consistent with recent studies (3, 36, 46, 47). For instance, a study by Grant, Stuhmacher and Bonte-Eley(47), found that RNMs with masters degrees often promoted EBP among their clinical nursing colleagues. Al Qadire(46) observed that teaching of EBP and its related skills are emphasized during postgraduate studies. This is supported by AbuRuz, Hayeah, Al-Dweik and Al-Akash (3) who indicated that the masters degree curricula often contains more specialized courses about nursing and midwifery research methodology than those below them. At masters level, RNMs are required to find significant clinical problems, perform integrated literature reviews, read and implement research findings, critique previous research, write proposals and publish scientific papers. This preparation makes the students at masters level apply the steps of research and learn how they can effectively implement EBP. RNMs with Master qualifications should, therefore, take an upper hand in facilitating a culture of EBP in the clinical area. This suggests that RNMs who have diplomas or even bachelor degrees who have not received any research or EBP training need additional education. This could be done by initiating comprehensive in-service training programmes on EBP (48) and/or offering scholarships for those who wish to complete a Bachelors or Masters degree(49). There is need to incorporate a course on EBP into RNMs training programs in higher educational institutions to enable these cadres to integrate EBP into their work after graduation.
This study found that RNMs who acquired their current qualification within 5 years perceived fewer barriers to finding research than those who obtained their current qualifications more than 5 years ago. This is consistent with previous studies(45, 50). This greater knowledge of EBP with novice RNMs, when compared to experienced RNMs, is most likely attributable to modern-day nursing curriculums that include EBP which most seasoned RNMs lack(45). Majid, Foo, Luyt et.al (51) also found that when nurses graduated from higher levels, including the baccalaureate programme, they were more capable to benefit from EBP activities. These RNMs are exposed to research process before they graduate. The main purpose of EBP is to recognize, appraise and apply the best available research finding(35). This is probably why RNMs who had research experience had better knowledge, attitude and practice due to exposure. As Chen, Wu, Zhou et al.(36) observed, there is need to offer EBP training programs in form of workshops, conferences and lectures to those who had not received EBP education in college for them to obtain knowledge and skills about EBP at the workplace
Failure to “make time in a work schedule for research” in the attitude subscale was identified as the main barrier to using EBP among RNMs in Malawi. This study also concurs with several previous studies(1, 18, 33, 38). In a study by Majid, Foo, Luyt et al. (51), more than half of study participants reported perceived lack of time at their workplaces as one of the priority barrier to accessing and reviewing literature. According to Cummings, Estabrooks, Midodzi, Wallin and Hayduk(52), a better understanding of the nursing practice environment is crucial to the understanding and development of interventions to advance EBP. Hospital management and policy decision makers, therefore, should consider making adjustments to RNMs work schedules or recruiting more so that they have additional time to attend classes on conducting EBP, reviewing relevant literature and planning practice changes(30). However, previous researchers argued that lack of knowledge and skills in EBP could be underlining aspects of lack of time(18, 29, 33). Without proper knowledge and skills for critically analyzing evidence against set standards, retrieving evidence, determining the validity of material and converting information needs into research questions scored very low in this study (refer Table 2) might be too time consuming. Clinical integrated teaching on evidence based processes would improve the knowledge, skills, attitude and practice on EBP. Capacity building of RNMs on EBP processes is required to increase their knowledge on EBP to reduce time for searching for EBP information. This calls for cooperation between academic faculty and clinical RNMs.
The results of this study also showed that RNMs practicing at QECH and ZCH have higher levels of knowledge, attitude and practice on EBP compared to MCH and KCH. QECH is the biggest hospital in Malawi and better resourced in terms of human resource and medical equipment than any other central hospital in the country. The proximity of University of Malawi’s constituent colleges namely College of Medicine and Kamuzu College of Nursing, and Malawi College of Health Sciences to the facility makes it a better teaching facility than the rest. Since the EBP means scores observed among the four care settings in this study were small, future EBP educational programs should target RNMs practicing in all the four settings including those in the academia for better results.
Strengths and Limitations of the study
The study has some strengths. First, the study had a response rate of 87.14% which makes the results to be generalised to the study population. Secondly, the study used an adopted validated instrument. The instrument was developed in the UK (33) with the aim of reporting development and validation of a self report measure of knowledge practice and attitude of EBP among nurses. Reliability was established using Cronbach Alpha. Validity was established using construct and discriminant validity. The tool has been extensively used previously in USA(2, 40)
However, this study needs to be considered in light of certain limitations. First, the study is cross-sectional in nature. As such, the ability to infer cause and effect conclusions between study variables was hindered. Secondly, this study was based on self reported data which may be less accurate than other forms of measurement due to an inherent bias. Participants may answer scale items in a socially desirable manner. Thirdly, the study used convenient sampling as a recruitment method and may not be truly representative of the nursing population in Malawi although four different sample groups strengthen the external validity. Fourthly, the study was conducted with RNMs of public hospitals and cannot be generalized to non-governmental hospitals (i.e. private, Christian Health Association of Malawi (CHAM) facilities and other populations). Despite the mentioned limitations, this study provides some into insight in knowledge, attitude and use of EBP among RNMs in Malawi.
For future research, we propose that a Delphi study regarding the continuing professional needs of nurses and midwives on EBP should be done which should be followed by an education intervention. Replication of this study involving other nongovernmental hospitals in all regions of the country is recommended as some private hospitals have better resources than public facilities.