Assessment of Evidence-Based Practice Knowledge, Utilization of Practice and Associated Factors on Nurses Working in the Adult Intensive Care Unit of Federal Public Hospital in Addis Ababa

Critical care nurses face several challenges in providing safe, evidence-based care for critical patients. Evidence-based practices are important to improve the overall quality of patient care, enhance nursing practice, and increase condence in evidence-based decision-making. Thus, this study was intended to assess evidence-based practice knowledge and utilization of the practice on nurses working in the adult intensive care units. Institutional based cross-sectional study was employed on 135 randomly selected nurses working in adult intensive care units of federal public hospitals in Addis Ababa, Ethiopia, from April 3 to December 21, 2020. Data were collected using a structured questionnaire through face-to-face interviews. Then, it was entered into Epi data version 4.4.2.1, and exported to SPSS version 25 for analysis. In the bivariate logistic regression analysis, predictors variables with p< 0.25 were tted to multivariate analysis. Then, the adjusted odds ratio with 95% CI was used to report the association at P< 0.05.


Introduction
Evidence-based practice (EBP) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients, and the integration of best research evidence with clinical expertise and patient practice to predict patient outcomes, improve care quality, and contain costs. [1][2][3][4] The EBP process includes ve elements: formulating an appropriate question, performing an e cient literature search, critically appraising the best available evidence, applying the best evidence to clinical practice, and assessing outcomes of care. [5][6][7] In the 21-century, low implementation of EBP among nurses show substantial serious health problem and medical errors for patients in many places worldwide: In the United States, more than 800,000 Americans require invasive mechanical ventilation in the intensive care unit (ICU) each year, many of these patients do not receive care via evidence-based practices. About 65.5% of the nurses could not regularly implement EBP in treating patients. 8 A study report conducted in East Africa, Ethiopia and Kenya shows that, 17.5% and 92% of nurses do not fully utilize research evidence when providing nursing care respectively. 9,10 Due to the lack of implementation of evidence-based practice during patient care, about 20-25% of treatments may be unnecessary or even harmful. 11 Research ndings suggest that nurses perceived a lot of barriers or factors to implement evidence-based practice in the clinical setting such as lack of time, heavy workload, lack of knowledge about EBP, limited access to literature, computer skills, lack of training in information seeking and critical appraisal skills. [12][13][14][15] Furthermore, in the intensive care unit, applying of evidence-based practice implementation can be challenging, also factors, such as dramatic changes in the health care system, increasing emphasis on quality of care, cost limitations, increasing patient and professional expectations, pressure for patient centered care and transparency in delivering clinical care increasingly push the health care industry towards the utilization of more scienti c research globally. [16][17][18][19] Therefore, the nursing profession as a practical discipline is expected to be accountable for integrating the best research evidence into the decision-making process with the aim of improving care. To achieve this goal, evidence-based practice (EBP) was introduced as an important initiative to health care system. 15,20,21 Therefore, this study was aimed to identify a gap related to evidence-based practice knowledge, utilization of practice and associated factors on nurses working in the adult intensive care units.

Methods And Materials Study Design and Setting
An institutional-based cross-sectional study design was conducted at selected federal public hospitals of Addis Ababa city from April 3 to December 21, 2020. Addis Ababa is the capital city of Ethiopia and the largest city in Ethiopia, with a population of 3

Eligibility Criteria
All adult ICU nurses were included part in the study, while ICU Nurses who were on annual leave were excluded from the study.

Sample Size Determination and Sampling Procedure
The required sample size for the study was calculated using a single population proportion formula with the assumption of con dence interval 95%, the margin of error 5%, and proportion 51.8% ≈ 52%. 4 Initial sample size (ni) = (Zα/2)2p (1-p)/d2=384; where Z= Standard error of the mean which is corresponding to 95% con dence level (1.96) were considered. The source populations of the study area were 189 adult ICU nurses who were working in Federal Public Hospitals. Since the total sources of the study population they were less than 10,000, the sample size correction formula was used, (1+ n/N) (1+ 384/189) = 127.
Finally, after adding a 10% nonresponse rate, a total of 140 nurses were targeted for the study.
The number of study participants for each hospital was proportional to the size allocated and those who had been part of the nal sample size were selected by using a simple random sampling technique from those found in the adult ICU department during the data collection period.

Data Collection Tools and Procedure
Pilot tested English version tool developed from up-to-date similar literature, which had contained sociodemographic characteristics, knowledge, utilization of EBP, and barriers for EBP was used to collect data. 4,9,10,23,24 Data collection was facilitated by ve BSc nurses through distributing a structured selfadministered questionnaires.

Data Quality Assurance
The data quality was assured by daily checking for completeness and consistency throughout the data collection period. Additionally, training was provided for data collectors. The tool was checked for reliability (internal consistency) using the Cronbach's alpha coe cient was 0.77.

Data Processing and Analysis
The collected data was checked for its completeness and entered into EPI data version 4.2. Then, it was exported into (SPSS) version 25.0 software to analyze using descriptive statistics and inferential statistics. A bivariate and multivariable analysis was done using a binary logistic regression model to see the outcome association between the dependent and independent variables. Those variables with a pvalue of ≤ 0.25 were transferred to multivariate analysis for identi cation of independent predictors. The Hosmer and Lemeshow goodness of t was considered to check model tness with p=0.225. An adjusted odds ratio with 95% C.I was used to measure the strength of association between dependent and independent variables. P-value < 0.05 was used to determine the level of statistical signi cance.

Ethical Consideration
Ethical clearance was obtained from the Institution Review Board (IRB) of St. Paul hospital Millennium Medical College to carry out the study. A letter of permission was secured from the administrative body of a hospital to communicate with relevant bodies in the health institution. The facilitator was explained the purpose of the study, and then written consent was obtained from the study participants before data collection and con dentiality was maintained at each level of purpose.

Result
Socio-demographic characteristics of the respondents From a total of 135 nurses included in the study, 74 (54.8%) of them were under the age of 25-29 with a median age of 26 years with an interquartile range (IQR) of 4 years. Among the study participants, 69 (51.1%) were females and the rest were male by sex. Concerning the marital status of the study participants, a majority, 79 (58.5%), were single. The vast majority, 118 (87.4%) of the respondents had BSc degree in nursing, whereas 17 (12.6%) of the nurses had a master's degree in emergency and critical care nursing (EMCCN). The highest proportion of poor knowledge was recorded among those aged between 20-24 years, which was 41.6% (15/36). Male participants were found to have the highest proportion of good knowledge and utilization in which 78.8% (52/66), 87.8% (58/66) were reported to have good knowledge and good utilization of EBP respectively. (Table 1) Knowledge, utilization of evidence-based practices and factors related with EBP Among the study participants, 103(76.3%), 87(64.4%), and 86(63.7%) of them reported insu cient resources to change practices, severity of critically ill patients and inability to properly interpret the results of research in uence were the factors that affect the utilization of EBP respectively. (Table 2) Furthermore, among those who agreed to have lack of con dence in judging the quality of research (n=68), 45.6% (31/68) had poor knowledge of EBP. Again, among those who were con dent in judging the quality of research (67), about 21% (14/67) had good utilization of EBP. About 65.2% (62/95) participants among those who responded that nurse managers were supportive had good knowledge of EBP, whereas 75% (30/40) participants among those who disagreed with nurse managers' support had poor knowledge of EBP. Concerning the utilization of EBP, 84.2% (80/95) of those agreed with having nurse manager's support were found to have good utilization, whereas 87.5% (35/40) of those disagreed with nurse manager's support had good utilization of EBP. (Table 2) Of the total study subjects, 92(68.1%) were found to have good knowledge about EBP and the rest 43 (31.9%) had poor knowledge of EBP. The study ndings also revealed that 115 (85%) of the study subjects had good utilization of EBP. (Table 2) Factors associated with knowledge of EBP among study participants Knowledge of EBP was dichotomized into good and poor knowledge. The, in logistic regression model tness was checked using Hosmer and Leme show tness test. In bivariate logistic regression, predictors with p value <0.25 were candidates for multivariate logistic regression. In multivariate logistic regression, those predictors having p-value <0.05 were considered statically signi cant associations. Variables transferred to multivariate analysis include sex, inability to understand, di culty in judging, inability to properly, no con dent, di cult to understand, EBP has little bene t, nurse managers, nurse colleagues, physicians are supportive, organization, severity of critically ill patient in uence, and insu cient resources. (Table 3) In multivariate logistic regression, participants who had di culty to properly interpret research terms were 11.36 times more likely to have poor knowledge compared to their counterparts (AOR=11.36; 95% CI: 1.86-69.39). Similarly, the odds of poor knowledge among ICU nurses who did not receive support from their colleagues were 7 times greater than those who received support from nursing colleagues (AOR=6.96; 95% CI: 1.01-47.90). Additionally, nurses who had reported insu cient resources to implement changes in practice were 4.4 times at an increased risk to have poor knowledge of EBP than their counterparts (AOR=4.44; 95% CI: 1.05-18.80). (Table 3) Factors associated with utilization of EBP Finally, inability to properly interpret the research, lack of con dence in judging the quality of research, support from nursing colleagues, and having insu cient time were independently associated with the utilization of EBP.

Discussion
The evidence-based practice is thorough and explicit use of current best evidence in making decisions about the care of individual patients, and the integration of best research evidence with clinical expertise and patient practice to predict patient outcomes, improve care quality, and contain costs. [1][2][3][4] Therefore, this study was aimed to determine the level of knowledge and utilization of adult ICU nurses on EBP and its associated factors. About 68.1% of the participants were found to have good knowledge about EBP, whereas 115 (85.2%) of them had utilization of EBP. Predictors like inability to properly interpret results, support from nursing colleagues, and insu cient time were found to be independently associated with knowledge of EBP. Predictor variables like lack of con dence in judging research, unable to interpret research results, nursing colleague's support, and insu cient time for practice changes were found to be signi cantly associated with utilization of EBP.  28 The possible explanation for this discrepancy might be due to several reasons. Firstly, most of the nurses assigned in the ICU were highly experienced. Additionally, in our settings, nurses received short term ICU training and are expected to be frequently exposed to new evidence and practices since they are participating in daily round and bed-side sessions with senior physicians and staff. Moreover, the recent shift in the current curriculum in our country that strengthened and focused on specialty programs such as emergency medicine and critical care training were provided at the BSc and MSc levels. This could contribute to better care provision and increased understanding of EBP applications.
Participants who had di culty to properly interpret the research results were 11.36 times more likely to have poor knowledge compared to their counterparts. Similarly, the odds of ICU nurses who were not able to interpret the research results were 7.44 times greater than their counterparts. This nding was supported by a former study conducted in South Africa. 2 This could be justi ed that nurses who failed to interpret the research ndings could face di culty in applying the ndings so that might in turn lead to poor knowledge and utilization of the concept of EBP in their daily activities.
Moreover, ICU nurses who had no support from their colleagues were 6.2 times at an increased risk to have poor utilization of EBP compared to nurses having support from colleagues. This nding is conformable with the ndings of studies conducted in Ghana 29 , Nigeria, FETHA II in 2016 28 , and Saudi Arabia. 25 The possible reason could be nurses who lacked support from their colleagues and senior staff were more likely to face di culties in accessing literature and resources that could enhance the understanding of EBP. Senior staff and nurse managers could have more chances to get these resources and the way to get access to related services easily. The other factor that independently associated with the knowledge of ICU nurses on EBP was the insu ciency of time for implementation. Nurses who had insu cient time to implement changes in practice were 4.4 times at an increased risk to have poor knowledge of EBP than their counterparts. This study nding was consistent with studies conducted in Iran, Norway, Saudi Arabia, and Nigeria which revealed that lack of time to practice EBP was associated with knowledge of EBP. 3,25,28,30 The possible evidence for this could be nurses having insu cient time might face di culty in searching and reading new evidence and protocols. Furthermore, they would not be able to participate in research projects and innovative ideas. Hence, this could in turn lead to lack of knowledge and understanding of new evidence and practices as well as poor utilization of these protocols. This nally could result in poor utilization of EBP.

Conclusion
The knowledge and utilization of evidence-based practice (EBP) among nurses working in the adult ICU in this study was found to be high compared to former studies conducted in the area of EBP. Inability to properly interpret research results, lack of con dence in judging the quality of research, insu cient time for implementation of new practices, as well as lack of support from nursing colleagues were factors that were independently associated with poor knowledge and utilization of evidence-based practice among nurses working in adult ICU.

Strength and Limitations of the study
Since, this study was the rst report that was conducted among ICU nurses in which every task is expected to be implemented by protocols. Hence, it will provide more accurate data on evidence-based practice in the eld compared to previous studies conducted among nurses working in wards or other departments.
The study might have inaccurate statistical estimations because of the small sample size used in the study, although it was believed to be representative of the source population.

Declarations Ethics declarations
Ethics approval and consent to participate Ethical clearance was obtained from the Institution Review Board (IRB) of St. Paul hospital Millennium Medical College to carry out the study. A letter of permission was secured from the administrative body of a hospital to communicate with relevant bodies in the health institution. The facilitator was explained the purpose of the study, and then written consent was obtained from the study participants before data collection and con dentiality was maintained at each level of purpose.

Consent for publication
Not applicable.

Availability of data and materials
The datasets generated and analyzed during the current study are not publicly available due to these data were used under license for the current study but are available from the corresponding author on reasonable request.

Funding
This study was funded by Saint Paul Hospital Millennium Medical College. Other than funding, this institution had not taken part in the design of the study and collection, analysis, interpretation of data, and writing of this manuscript.

Authors' contributions
The rst two authors (Zerihune Alene,Negat W/Hawariat) wrote the introduction literature and review methods and material part, Helina Bogale was did the analysis part,Ayele Fikadu wrote the discussion section and Abdata Workina wrote the conclusion part of the manuscript. Finally all authors participated to nalize and review the manuscript.    Table 4: Binary and multivariate logistic regression analysis for adult ICU nurse's utilization on EBP who had been working in federal public hospitals, Addis Ababa, Ethiopia, 2020 (n=135).