Continual advancements in medical equipment and treatment are resulting in more and better treatment services and methods. This creates a special obligation on the part of healthcare professionals whose work is evidence based to update their professional knowledge and heighten their awareness.
In 2014, the specialist health service reported 414 adverse and/or serious incidents to the Norwegian Board of Health Supervision. Of these, 38 were classified as incidents related to surgical intervention (1). Some of the incidents were related to surgical complications that arose during or after the surgery. However, some complications arose from an injury caused by incorrect surgical positioning of the patient.
Incidents of sudden death due to a heart attack, blood clot or difficulties relating to the administration of anaesthesia were reported as well (1). We can therefore state that such incidents occur relatively often. Surgery-related injuries or death are often cited as examples when adverse incidents in the health service are discussed in general (1, 5, 6).
Within the sphere of ‘evidence-based practice’ (EBP), it is important to base clinical decisions on up-to-date, research-based knowledge when it is available. Furthermore, the concept of EBP includes experience-based knowledge, i.e. clinical expertise and judgment, reflection and tacit knowledge. Acquisition of knowledge from health service users is also a crucial dimension of EBP (7).
Multiple studies have identified various barriers that impede evidence-based practice (3, 7–10). These barriers are related to, for example, a lack of knowledge that nursing research is available and can be used to change practice, as well as to limited experience with acquiring relevant, up-to-date knowledge from research. Another barrier is that research is perceived as unclear and difficult to read (8, 9, 11, 12).
Other noteworthy findings are a shortage of time during working hours, professional and research literature that is not compiled in a single location, a lack of rooms with access to PCs, and difficulties in implementing new measures due to resistance from managers and doctors (3, 7–9, 12). Recent research shows a positive attitude towards EBP. However, there are challenges relating to a time shortage and lack of support from managers in the effort to assess and implement new measures (10, 13–15).
Purpose of the study
This article describes the results from a qualitative study based on focus group interviews of surgical nurses from different parts of Norway. The purpose of this study was to gain insight into surgical nurses’ understanding of the concept of ‘evidence-based practice’ (EBP), as well as their experiences with evidence-based practice. On this basis, we formulated two research questions:
- What is surgical nurses’ understanding of the concept of evidence-based practice?
- To what degree and in what way do surgical nurses work in an evidence-based manner?
The study has a qualitative design, and we assembled four focus groups. We chose to use focus groups because the dynamic that arises from this method makes it well-suited to revealing the participants’ knowledge about, experiences with and attitudes towards the application of EBP (16). The focus group interviews were conducted between October and November 2012 and each group consisted of four to six surgical nurses.
We took a strategic decision to include three hospitals from different parts of the country. By including various hospitals, we were able to uncover a variety of practices based on different educational backgrounds or educational institutions, or systemic differences within the hospitals, e.g. time allocated to professional development.
We phoned the administrative managers of the various surgical departments. The managers were informed of the study’s purpose and method, and they were asked to help with recruitment. We recruited participants with 2 to 40 years of work experience in a surgical department. Most of them worked in full-time positions, and none of them worked in a position of less than 70 per cent. The sample consisted of women because there were no male surgical nurses in the respective departments.
The surgical departments provided a venue for the interviews, and all the focus group discussions were therefore held in the respective hospitals. We conducted one of the interviews during working hours and three at the end of the work day. The focus group discussions lasted from 60 to 80 minutes. Based on our research questions, we created an interview guide. The main questions in the interview guide were as follows:
- What is your understanding of the concept of evidence-based practice?
- In what way and how often do you acquire new knowledge?
The first author served as the moderator for the interviews. In addition to broad, open-ended questions related to EBP and professional development, we asked questions about procedures and structures in the department. It can be beneficial for the moderator to have adequate background knowledge of the topic being discussed, as that individual may have different perspectives on the topic being discussed and can follow up on important aspects of the topic (16).
In our view, the moderator’s background in surgical nursing laid a good foundation for the interviews. However, because the moderator was knowledgeable about the field, what is regarded as ‘common knowledge’ among surgical nurses may not have been integrated into the discussion.
It was not necessary to apply for permission from the Regional Committees for Medical and Health Research Ethics to conduct this study. The application to the Norwegian Social Sciences Data Service, now called the Norwegian Centre for Research Data, was approved prior to project start-up. The managers of the respective departments informed all the participants about the study, both verbally and in writing.
Prior to the interview, the moderator reiterated information about the study and the participants’ right to withdraw. Ethical guidelines on confidentiality and anonymisation of data were complied with (17). The data were encrypted and stored on a password-protected PC.
We analysed the findings using Malterud’s (18) modified version of Giorgi’s phenomenological analysis. The objective of the analysis was to illuminate the surgical nurses’ own perceptions and experiences, and we focused on both the group and each individual surgical nurse. In the analysis process, we sought to identify the surgical nurses’ understanding of the concept of EBP, and to what degree and in what way they work in an evidence-based manner. Consequently, we had to gather information about their work, or lack of work, with EBP in the surgical departments, as well as identify connections and contradictions in the information conveyed.
In the first phase of the analysis, we thoroughly read the transcribed texts several times. In so doing, we gained an overall impression of the opinions and patterns that predominated. In the next phase, we conducted a systematic review of the interviews. We focused on identifying meaning units of phenomena that the focus groups revealed and that resulted in knowledge about the research problem.
The main points of the interview guide were used to create codes, i.e. labels to gather extracts of text that had commonalities. Such extracts were systematised and placed in the following columns:
- What is surgical nurses’ understanding of the concept of evidence-based practice?
- In what way and how often is new knowledge acquired?
Then we compared and assessed the meaning units from the same column from each focus group interview to gain a deeper understanding of the important patterns and nuances that came to light. We formulated the following categories:
- professional development versus EBP
- promotes professional development
- impedes professional development
- departmental culture
In this phase of the analysis, the concept of EBP was put in the context of ‘professional development’, as very few nurses used or had a clear understanding of EBP, which in itself represented a finding. In the third phase, we critically assessed the codes that represented the basis for the categories. Potential topics were developed, and connections between meaning units, codes, categories and topics were brought to light. In the fourth phase, we critically assessed the meaning connections within the topics in relation to the data as a whole. We identified three main topics:
- structural factors
- attitudes and responsibility for one’s own profession
- competence and knowledge related to evidence-based practice
The findings show some lack of knowledge about, understanding of and use of the concept or term ‘EBP’. By the same token, the findings show that the participants are already working with aspects of the concept of EBP. Experiential knowledge such as reflection and sharing clinical experience with others stand out as key strategies that are used to enhance competence and increase patient safety. A focus group participant stated the following:
‘We learn from each other’s experiences. We can have different experiences with different things, and if you’re unsure about something, then you go and find the person who dealt with it last and you ask, “How did you do that exactly?”.’