Nursing managers' perspectives on facilitators of and barriers to evidence‐based practice: A cross‐sectional study

Abstract Aim This study aimed to determine the facilitators and barriers to evidence‐based practice (EBP) from the perspective of Iranian nursing managers. Design Cross‐sectional study. Methods Data were collected from 335 top nursing managers of Iran. The research instruments included three electronic questionnaires for demographics, facilitators and barriers of evidence‐based practice. Descriptive statistics and appropriate analysis tests were used to clarify the strength of relationships between the factors. Results A total of 277 nursing managers participated in the study (response rate of 82%). Iranian nursing managers believed that organizational factors were the most important domain for both facilitators (34.7 ± 9.2) and barriers (28.37 ± 6.2) to EBP. Regarding the Perspectives of nursing managers on Necessity and Extent of EBP implementation, 79.8% (n = 221) considered EBP to be essential, while 45.8% (n = 127) regarded its implementation as moderate.


| INTRODUC TI ON
Evidence-based practice (EBP) is a decision-making method that has become an important component of health care in recent decades (Adib-Hajbaghery, 2006) and is recognized as a way to improve healthcare standards and excellence in nursing care (Azami et al., 2020). As a problem-solving method, EBP integrates the best available scientific evidence with clinical expertise, situational conditions, available resources and patient preferences (Renolen et al., 2018). Since nurses are the largest group of specialized staff in healthcare systems, their performance statistically significantly impacts the quality of health care, and this leads to reduced costs, family satisfaction, nurses' personal and professional development and improvement of organizational performance (Heydari et al., 2014).
Facilitators and barriers to EBP in clinical settings have been the focus of research for many years. Factors that have a great impact on the implementation of EBP in several studies are related to organizational support, especially leadership and support by managers (Cheng et al., 2018;Li et al., 2019). Healthcare system leaders need to create an organizational culture to support their staff to implement EBP (Gallagher-Ford et al., 2020). The perspectives and performance of nursing managers play an effective role in the process of accepting the use of EBP by nurse (Tuppal et al., 2019).

| BACKG ROU N D
Health care has changed a lot in the past decade due to the evolutions in technology, provision of services, increased elderly population, need for the management of the increasing population with chronic diseases and an increase in the public knowledge about high quality and affordable healthcare services (Pittman, 2019).
These changes have made healthcare systems improve and update their service provision, especially in the field of nursing (Pittman, 2019). Based on the available statistics all the graduated nurses are employed in hospitals and treatment centres in Iran (de Las Heras-Rosas et al., 2021;Raeissi et al., 2019). It was previously stated that EBP has been neglected in the healthcare system and nursing education in Iran (Mohammadi et al., 2018).
Adoption of EBP by nurses was found to be related to the innovation, knowledge and attitude of the nurses and their perception of EBP attributes. It was also shown that attitudes had the most statistically significant effect on the adoption of EBP (Mohammadi et al., 2018). It was also shown that nursing managers have an important role in the adoption of EBP in the nurses (Hasanpoor et al., 2019).
Nursing managers, especially top nursing managers, are a statistically significant force in the success of EBP because they understand the importance of evidence-based interventions and policies, have the potential to change healthcare system, and allocate human and material resources to nurses' work environment (Azami et al., 2020;Farokhzadian et al., 2016). Hence, it is necessary to investigate nursing managers' perspectives on EBP and how to implement it. In Iran, Hassanpour et al. conducted a study to examine the perspectives of nursing managers at one of the universities of medical sciences in relation to facilitators and barriers to evidence-based management (EBMgt) (Hasanpoor et al., 2019). The currently available data indicated that training and research systems and discordance between universities and stakeholders were considered as the barriers to, while personal interest in the adoption of scientific management and interpersonal and social factors were reported as the facilitators for EBP in Iranian nursing managers. To the best of our knowledge the perspectives of Iranian nursing managers on EBP has not been fully evaluated and due to the number and diversities in nursing managers, the current study findings may not be generalizable to the whole population of nursing managers in Iran. As much is not known on this topic, the facilitators and barriers to EBP among nursing managers have not been determined. The first step in implementing successful interventions in improving EBP among nursing managers is to identify its facilitators and barriers. Therefore, the present study was designed and implemented with the aim to learn about facilitators and barriers to EBP from the perspective of Iranian Nursing Managers.
The present study also aimed at examining the relationship between managers' demographic characteristics and facilitators and barriers to EBP. Another aim of this study was to determine the necessity and extent of EBP implementation by nurses from the perspective of nursing managers.

| Study design
The present cross-sectional study was conducted at Iranian universities of medical sciences. The research population included top nursing managers, comprising two categories in Iran, chief nursing officers (matrons) of hospitals and nursing managers of medical universities.

| Sampling method
Considering the aim of this study, two groups of nursing managers were identified; (1) university nursing managers and (2) hospital matrons. As the number of university nursing managers were small (n = 55), all of them were included in the study based on census sampling. However, as the population of matrons was 750, sample size was calculated using the Morgan table. Therefore, the sample size was 254 participants that was increased to 280 participants considering 10% dropout. Matrons were recruited using stratified random sampling by classifying Iranian universities of medical sciences into three levels according to the ranking system of the Ministry of Health.
Then the number of affiliated hospitals to each university was identified. Sampling in each university was performed proportionate to the number of that university affiliated hospitals. Therefore, the total estimated sample size for this study was 335 participants (Figure 1).

| Measures
Three electronic questionnaires were used to collect information in this study. included 11 items related to personal and educational information, work experience, familiarity with EBP and the level of research activity. In addition, two items asked about the necessity and extent of EBP implementation, scored from zero to ten and were classified into three levels of low (score 0-3), medium (score 4-6) and high (score 7-10).

F I G U R E 1
2. Facilitators of Evidence-based practice Questionnaire: This Persian questionnaire, designed by Chehrzad et al. in 2015, includes 16 items for reviewing facilitators if EBP (Chehrzad et al., 2015). The criteria for assessing the score in this questionnaire are based on a five-point Likert scale (nothing, little, no opinion, moderate and high), which are assigned scores of one to five, respectively. Thus, the total score of this questionnaire ranges from 16 to 80. The reliability of the instrument was determined with Cronbach's alpha coefficient of 0.89 (Chehrzad et al., 2015). In the present study, items were classified into three domains based on their similarities: nursing factors (3 items), organizational factors (9 items) and quality and research presentation factors (4 items) in order to facilitate its assessment (Table 1). The overall Cronbach's alpha of the facilitators of EBP questionnaire in this study was 0.96.

Barriers to Evidence-based practice Scale (BARRIER Scale): The
Persian version of BARRIER Scale was used, which was translated into Persian by Salemi et al. and its reliability was determined with Cronbach's alpha coefficient of 0.71 (Salemi et al., 2010).
The BARRIER Scale includes 29 items that investigate the barriers to implementation of EBP in four domains: barriers to nurses' values, skills and awareness (8 items), organizational barriers and limitations (8 items), barriers to research quality (6 items) and barriers to presentation and accessibility of research results (7 items) ( Table 1). The scoring criteria are based on a five-point Likert scale (nothing, little, no opinion, moderate and high), which are given scores one to five, respectively, with the total score ranging from 29 to 145. The overall Cronbach's alpha for the barriers to EBP scale in this study was 0.90.

| Data collection
First, necessary permissions were obtained. Phone numbers of the nursing managers were given to the researcher by the nursing offices of the universities of medical sciences. Then, consent to participate in the study was obtained by phone and the questionnaires were sent to them by e-mail or social networks.

| Data analysis
As all the questionnaire items were set as compulsory, participants could not end the sessions with leaving unanswered items. Therefore, there was no missing data in this study. Data were stratified and analysed with SPSS, version 22. Descriptive statistics were reported using mean and standard deviation (SD) for continuous variables and frequency and percentage for categorical variables. Comparison of the mean scores for facilitator and barrier questionnaire domains between gender and work place groups was performed using the student t-test, while comparison of mean scores for the domains between education level and university rank was performed using the one-way analysis of variance (ANOVA). Correlation between domain scores and continuous study variables was evaluated using the Pearson's correlation coefficient. Linear regression analysis with backward correction was performed to identify the predictors of domain scores.
The level of statistical significance was considered as p < 0.05.

| Ethics
The study protocol was approved by the ethics committee of Gonabad University of Medical Sciences (code of ethics: IR.GMU. REC.1397.041).

| Demographic characteristics of the participants
Of the 335 questionnaires sent, 277 were returned, indicating an 82% response rate. The participants included 31 university nursing manager and 246 matrons, 51.6% of the managers (n = 143) were female. The mean working experience and nursing management experience of the participants were 20.05 ± 7.38 years and 42.05 ± 47.38 months, respectively. Table 2 shows participants' demographic and professional characteristics.

| Facilitators of EBP
Among the three domains of facilitators, nursing managers believed organizational factors were the most important (34.7 ± 9.2) followed by factors related to quality and presentation of research results and factors related to nursing. The most important facilitating factors were 'increased support and encouragement by managers' and 'establishing an evidence-based nursing committee' to apply research findings in clinical settings, each receiving medium to high scores of by 78.7% of managers (Table 3).
In this study, among the facilitators of EBP, the mean score for nursing factors domain was only statistically significantly different between categories of university ranking (p = 0.006) with highest scores in first rank universities followed by third ranked and second ranked universities. The mean score for organizational factors was statistically significantly different between categories of education level (p = 0.001) and university ranking (p < 0.0001). This finding indicated that the mean score for organizational factors domain decreased from bachelor's degree to PhD degree, while the highest score was recorded for first third rank universities followed by first TA B L E 1 Domain constructs of the study questionnaires.

Questionnaire Domain Items
Facilitators of EBP questionnaire degree to PhD degree, while the first ranked and third ranked universities had similar mean scores; they were higher than that for the second ranked universities (Table 4).
The correlation between domains of facilitators of EBP and age, work experience and nursing management experience are shown in Table 5.   Table 4).

| Barriers to EBP
The correlation between scores of barriers to EBP domains and age, work experience and nursing management experience are shown in Table 5 (Mehrdad et al., 2007). The role of evidence-based nursing committees as a training resource is important because nurses' education is considered as one of the most important facilitators in various studies (Almaskari, 2017;Hasanpoor et al., 2019). In the present study, this item held the second place among facilitating factors.  (Jordan et al., 2016). However, some studies have reported this factor to rank fourth among barriers (Amini et al., 2011;Salemi et al., 2010). Since this factor is highly dependent on organizational culture, differences in study results can be justified. Physicians and nurses have different understandings of patient needs, thus, correcting the physician-nurse relationship strengthens the planning based on common goals and increases the sense of participation and cooperation in the treatment team (Futami et al., 2020). The second barrier from the perspective of nursing managers is nurses' unawareness of research findings. To remove this barrier, there are suggestions such as continuing training, holding a journal club and hiring research-oriented nurses who can serve as role models. In this regard, the results of Malik's study strongly support education as a tool to enhance nurses' inquiry and appraisal skills, create positive attitudes and to overcome EBP barriers (Malik et al., 2016).
Another important barrier is 'insufficient time on the job to implement new ideas'. In sum, 60% to 75% of nurses in different countries considered not having enough time to try new ideas as a barrier with a moderate or high impact (Alatawi et al., 2020;Hasanpoor et al., 2019;Youssef et al., 2018). Lack of time can be caused by a shortage nurse in addition to too much workload in each shift. The previous research suggests that nurses are reluctant to EBP because they are too tired and overworked (Ahlers et al., 2021;Hamilton, 2019;Treviño-Siller et al., 2020). Although some believe that not having time is an acceptable excuse in the society, which can reflect the lack of interest, need and knowledge for applying research results (Hasanpoor et al., 2019;Mthiyane & Habedi, 2018 TA B L E 5 Correlation between facilitators and barriers to EBP and age, work experience and nursing management experience. Mudderman et al., 2020;Youssef et al., 2018). However, when it comes to EBP implementation, nursing managers believe EBP was moderately implemented for care giving at medical centers, which is consistent with other studies (Mohsen et al., 2016;Saunders & Vehviläinen-Julkunen, 2014). The findings of this part show that despite the strong positive attitude towards EBP, its implementation in clinical performance is moderate or low.

| Study strengths and limitations
This study was conducted on a large sample of nursing managers using an online questionnaire. Utilizing social media and internet has facilitated conducting studies in a wide geographical region especially during the coronavirus disease 2019 (COVUD-19) pandemic. To the best of our knowledge, no study has yet combined the perception of nursing managers in terms of EBP between various regional universities in Iran. These findings could also be used in countries and societies that share similar values, culture and education systems, especially countries that have matrons, a nurse with minimum undergraduate degree in nursing whose duty is to supervise the performance of nurses in the hospital and clinic and oversee the standard of care.
However, due to the difficulty in accessing the contact number of all nurses and also due to their busy working hours, the minimum sample size was calculated and used for this study. The findings of this study provide evidence for conducting further studies in this field. Another limitation of this study was performing the study based on self-report and relying solely on the replies of the items to be answered dishonestly as the participants might not be willing to give a faire response to some questionnaire items.
Although statistically significant correlations were found in this study, the correlation coefficients were small and indicated small effect size. Similar issue was present for the regression findings (adjusted R squared ranged from 0.04 to 0.07). Therefore, these findings should be interpreted with caution. It is suggested that studies with larger sample sizes be conducted to evaluate the relevance of these findings.

| Study implications and recommendations for further research
The findings of this study can have managerial, clinical and education applications. In terms of managerial application, this study findings emphasized the key role of organizational conditions and nursing managers for evidence-based practice. Supportive performance of managers and nursing organization is necessary to provide evidence-based performance. The support of the organization requires a positive attitude towards EBP among nursing managers.
This study showed that this attitude was present among the highlevel the nursing managers. In terms of clinical application, the findings of this study can be used by nurse managers to improve the quality of nursing services by facilitating EBP and improve treatment outcomes in the hospitals. In terms of education application, the findings of this study indicated that nursing managers had insufficient the level of knowledge and skills in adopting EBP. Therefore, there is a need for education interventions to fill the existing educational gap. Currently, research method has been included in the nursing bachelor's education program and higher levels, but it seems that this education alone was not enough. Therefore, nursing managers and nurses may require practical education of the searching, comprehension and interpretation of academic documents.
As mentioned in the limitations, the findings of this study documented the need for extreme evaluating the facilitators and barriers and to identify the triggers and related factors to these barriers and facilitators prior to designing interventions. Therefore, there is a need for large multicentre studies with the aim of identifying the mechanism of action of each barrier and facilitator. The findings of these studies can be further used in updating the education curricula and continuing nursing education programs.

| CON CLUS ION
This study analysed the facilitators and barriers to EBP from the perspective of Iranian nursing managers. Nursing managers valued organizational factors and nursing factors as the prominent barriers to EBP. The findings of this study may help nursing educators, healthcare decision-makers and nursing managers design interventions to empower nurses in adapting EBP. However, these findings should be evaluated in larger and multicentre studies and in other fields of healthcare system.

AUTH O R CO NTR I B UTI O N S
All authors read and approved the final manuscript. Hosseini-Moghaddam F and Mohamadpour A contributed in designing the study, Hosseini-Moghaddam F collected the data and data analysed by Hosseini-Moghaddam F, Bahri N and Mojalli M. All authors participated in the writing and review of the manuscript.

ACK N O WLE D G E M ENTS
This research is derived from a Master's thesis on Internal Surgical Nursing. Hereby, the authors wish to thank the professors of REDACTED and all Nursing Managers who sincerely participated in this study.

FU N D I N G I N FO R M ATI O N
This study is not financially supported.

CO N FLI C T O F I NTE R E S T S TATE M E NT
No conflicts of interest have been declared by the authors.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.