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doi:10.1111/j.1744-1609.2012.00263.x

EVIDENCE

Int J Evid Based Healthc 2012; 10: 117–125

UTILISATION

Evidence-based practice in a multiprofessional context

jbr_263

117..125

Kristina Areskoug Josefsson MSc RPT,1 Ann-Sofi C Kammerlind PhD RPT2 and Martha Sund-Levander PhD RPN2 1

Samrehab, Värnamo Hospital, Värnamo and 2Futurum – The Academy of Healthcare, Jönköping, Sweden

Abstract Background Healthcare today is a complex system with increasing needs of specific knowledge of evaluation of research and implementation into clinical practice. A critical issue is that we all apply evidence-based practice (EBP) with standardised methods and continuing and systematic improvements. EBP includes both scientific and critical assessed experience-based knowledge. For the individual, this means applying evidence-based knowledge to a specific situation, and for the organisation, it means catering for a systematic critical review and evaluation and compiling research into guidelines and programmes. In 2009, the County Council of Jönköping had approximately 335 000 inhabitants and the healthcare organisation had more than 10 000 employees. As the County Council actively promotes clinical improvement, it is interesting to explore how healthcare employees think about and act upon EBP. The aim of this survey was therefore to describe factors that facilitate or hinder the application of EBP in the clinical context. Method A quantitative study was performed with a questionnaire to healthcare staff employed in the County Council of Jönköping in 2009. The questionnaire consisted of questions concerning which factors are experienced to affect the development of evidence-based healthcare. There were 59 open and closed questions, divided into the following areas: • Sources of knowledge used in practice • Barriers to finding and evaluating research reports and guidelines • Barriers to changing practice on the basis of best evidence • Facilitating factors for changing practice on the basis of best evidence • Experience in finding, evaluating and using different sources of evidence The participants were selected using the county council’s staff database and included medical, caring and rehabilitative staff within hospitals, primary care, dentistry and laboratory medicine. The inclusion criteria were permanent employment and clinical work. Invitations were sent to 5787 persons to participate in the study and 1445 persons answered the questionnaire.

Results Knowledge used in daily clinical practice was mainly based on information about the patient, personal experience and local guidelines. Twenty per cent answered that they worked ‘in the way they always had’, and 11% responded that they used evidence from research as a basis for change. The participants experienced that EBP was not used enough in clinical healthcare and explained this with practical and structural barriers, which they thought should be better monitored by the organisation and directors. Conclusion Overall, the results indicate that the scientific evidence for healthcare is not used sufficiently as a base for decisions in daily practice as well as for changing practice. This is more prominent among assistant staff. As a consequence, this might affect the care of the patients in a negative way. Increased awareness of EBP and a stronger evidence-based approach are keys in the ongoing improvement work in the county. Local guidelines seem to be a way to implement knowledge. But, as the arena of activities is complex and the employees have diverse education levels, different strategies to facilitate and promote EBP are necessary.

Key words: evidence-based practice, implementation, management, multiprofessional.

Correspondence: Mrs Kristina Areskoug Josefsson, Samrehab, Värnamo Hospital, 33185 Värnamo, Sweden. Email: [email protected]

© 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

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Background Healthcare today is a complex system1 with increasing needs of specific knowledge of evaluation of research and implementation into clinical practice.2,3 A critical issue is that we all apply evidence-based practice (EBP)4 with standardised methods and continuing and systematic improvements.3,5 EBP includes both scientific and critically assessed experience-based knowledge.6 For the individual, this means applying evidence-based knowledge to a specific situation (approach), and for the organisation, it means catering for a systematic critical review and evaluation and compiling research into guidelines and programmes (process).7 To achieve this, it is necessary to have organisational structures and management that support critical assessment of procedures and facilitate research, development and implementation of new knowledge.8 Others have found that personal experience, discussions with co-workers and patients and local guidelines more than scientific publications are the basis for clinical practice9 and that lack of time, resources and influence of work, insufficient facilities and inadequate authority are crucial for applying EBP.9–15 Learning opportunities, culture building and availability and simplicity of resources have been reported to be facilitators.16 Personal attitudes, level of education and profession also affect EBP.13 In 2009 the County Council of Jönköping had approximately 335 000 inhabitants and the healthcare organisation had more than 10 000 employees. Their mean age was 48 years, 81% were women and about 50% had a college or university education. National evaluations have shown that patients experience good availability and have great confidence in the healthcare given in the county.17 The management of the county states a continuous, ongoing process based on research,2 with a clear focus on assessment and evaluation of whether a change in clinical practice is in fact an improvement or not. Hence, awareness of EBP would be a key for improvement of healthcare services. As the County Council actively promotes clinical improvement, it is interesting to explore how healthcare employees think about and act upon EBP. The aim of this survey was therefore to describe factors that facilitate or hinder the application of EBP in the clinical context.

tions.9 It was translated to Swedish by Heiwe and Säflund in 2005 and revised in 2007.18 The final questionnaire consists of 59 open and closed questions, divided into the following areas: • Sources of knowledge used in practice • Barriers to finding and evaluating research reports and guidelines • Barriers to changing practice on the basis of best evidence • Facilitating factors for changing practice on the basis of best evidence • Experience in finding, evaluating and using different sources of evidence The closed questions are written as claims with five optional answers from ‘absolutely do not agree’ to ‘agree completely’ and from ‘never’ to ‘always’. The 5-grade scale was dichotomized in order to clarify the tendencies and to refine the presentation of the results.

Participants Participants were selected using the County Council’s staff database and included medical, caring and rehabilitative staff within hospitals, primary care, dentistry and laboratory medicine. The inclusion criteria were permanent employment and clinical work. Persons who answered positively to the first question, ‘Is clinical patient care included in your work’, were included in the study. The staff working in laboratory medicine were included due to their expressed wish to participate in this study, even if all of them did not have clinical patient care in their regular work. Exact numbers of staff working with clinical patient care were not available, but 5787 persons from the database were invited to participate in the study. In total, 1445 persons answered the questionnaire. The participants had the following work place distribution: 904 (62%) hospital, 363 (25%) primary care, 111 (8%) dentistry and 67 (5%) laboratory medicine. The age distribution was 19% aged 19–35 years, 41% aged 36–50 years and 40% aged 51 years or older. The number of women was 1188 (84%) and 61% had full time employment. The distribution of the participants’ professions is described in Table 1.

Method A quantitative study was performed with a questionnaire to healthcare staff employed in the County Council of Jönköping in 2009. At the time of the survey, the county had three hospitals with 1063 beds, 32 primary care centres and 29 centres for dental care. Questionnaire The questionnaire18 consisted of questions concerning which factors are experienced to affect the development of evidence-based healthcare and was originally developed by Gerrish and Clayton.9 Their questionnaire was in turn based on a Canadian instrument19 as well as the Barriers questionnaire20 and was further developed with additional ques-

Procedure The study consisted of two steps. We first carried out a pilot study at a geriatric clinic in order to test the Internet-based questionnaire. Thereafter, the questionnaire was distributed to the remaining healthcare staff employed in the County Council of Jönköping in 2009, according to the inclusion criteria. The results of the pilot study were included in the final results. The questionnaire was distributed and compiled electronically by the Internet-based program Esmaker (Entergate AB, Halmstad, Sweden). The participants received a personal letter of information about the study and an invitation to participate. The questionnaire was answered anonymously.

© 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

EBP in a multiprofessional context Table 1 Description of participants’ professions Profession Nurse Nursing assistant Physician Physiotherapist Occupational therapist Biomedical analysts Dentist Psychologist Dental nurse Counsellor Audiologist, dietician, speech therapist Dental hygienist Not specified Total

Number of participants 620 191 143 91 70 69 58 39 34 31 20 18 61 1445

Analysis Quantitative analysis of closed questions Demographic data are described using descriptive statistics, frequencies and proportions. Professions with 10 persons or less are not described separately but are included in the presentation of the whole group. Qualitative analysis of open questions In two of the questions, the participants had the opportunity to describe in their own words barriers and facilitators concerning working with EBP. Those answers were analysed using content analysis.21 Each question was analysed separately and the content analysis was made by two researchers, who followed the same procedure: • Reading and rereading of all answers to get a sense of the material • Sorting the material into meaning units • Coding meaning units • Comparing codes as concerns similarities and differences • Differences between the two researchers concerning coding and categorisation were discussed from the view of the question and the completion of the answer • Categorising codes and comparing similarities and differences • Differences between the two researchers concerning coding and categorisation were discussed from the view of the question and the completion of the answer • Transforming the categories into themes All the researchers discussed the categories and themes together to gain consensus. The analysis of each question resulted in a theme with underlying categories.

Results We present the results of the quantitative analysis of the closed questions both for the total group and for the different professions. There were no differences in results between the different forms of care (hospital, primary care, dentistry and laboratory medicine) or between the three geographic

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areas of the County Council. We then present the results of the qualitative analysis of the open questions for the total group. Results of the closed questions for the total group Sources of knowledge used in practice The participants stated that the information they learned about the patient as an individual was the most important source of knowledge. Personal experience and information from local guidelines were also ranked highly (Fig. 1). Barriers to finding and evaluating research reports and guidelines A lack of time to search for research reports was stated to be the greatest barrier. The barriers to finding and using research reports were greater than the barriers to finding and using guidelines (Fig. 2). Barriers to changing practice on the basis of best evidence The five barriers to changing practice on the basis of best evidence had generally low rankings. Twenty-nine per cent agreed or agreed completely that there was insufficient time, and 19% said that there were insufficient resources (equipment, for example) to implement changes in practice. Fifteen per cent stated that they lacked authority, 9% said that the team was not receptive and 5% said that they did not feel confident to make a change in their practice. Facilitating factors for changing practice on the basis of best evidence Fifty-nine per cent stated that their superiors encouraged them, 51% said that their colleagues encouraged them and 38% said that doctors always or often encouraged them to change practice. Experiences in finding, evaluating and using different sources of evidence Less than 40% reported great or very great experiences in each of the questions about finding, evaluating and using different sources of evidence (Fig. 3). Results of the closed questions by professions Overall time for searching literature was barriers for EBP, while understanding the scientific text and the practical meaning of it was more prominent among assistant staff, for example, nursing assistants and dental nurses. However, local guidelines were considered easy to find and understand, irrespective of profession. Sources of knowledge used in practice Nurses reported to a higher degree than other professions that they based their knowledge on information from physicians (questions (q) 8 and 9 in Fig. 1). Nursing assistants answered more often than others that they trusted their intuition (q 2) and used information from colleagues (q 6). Dental nurses used information about the individual patient to a lower degree (q 1) but their own experience to a higher degree (q 4). Physicians and dental hygienists stated to a

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1. Information that I learn about the patient as an individual 3. My personal experience of caring for patients over time 14. Information I get from local guidelines, procedure manuals and care programs 12. Information I learned during my education 13. Information I get when attending courses / conferences 7. Information from colleagues with special knowledge 15. Information from national guidelines or equivalent 4. What has worked for me for years 6. Information from colleagues 8. What doctors discuss with me 2. My intuition about what seems to be right for the patient 19. Information in textbooks 9. New treatments and medications I learn about when doctors prescribe them to patients 20. Information I get from the Internet 17. Articles published journals for my profession 18. Articles published in scientific journals 5. In the manner I have always done 11. Information I get from product information 10. Medications and treatments I learn about from pharmacists or representatives from companies 16. Articles published in journals for doctors 21. Information I get from media (newspapers, television)

Figure 1 The percentage share of participants answering that they always or often used different sources of knowledge in their practice.

higher degree that they used national guidelines (q 15) and many professions often used local guidelines (q 14). Physiotherapists and psychologists used professional journals (q 17) to a higher degree than others. Psychologists also often used textbooks and scientific journals (q 18 and 19). Nursing assistants, occupational therapists and biomedical analysts did not use information from their education (q 12) as often as other groups. Nursing assistants and dental nurses used textbooks and professional journals (q 17 and 19) to a lower degree than others. Barriers to finding and evaluating research reports and guidelines Nursing assistants, dental nurses, dental hygienists and biomedical analysts agreed to a higher degree than others to statements about finding research reports and guidelines (q 22 and 27 in Fig. 2). Dental nurses and dental hygienists more often answered that they did not have sufficient time to search for research reports and guidelines (q 24 and 25). Nursing assistants and dental nurses experienced more difficulties understanding and judging the quality of research reports and identifying the significance of research reports and guidelines for their own practice (q 28–31). Psychologists on the other hand agreed to a lower degree that

research reports were difficult to find and understand (q 26 and 28). Barriers to changing practice on the basis of best evidence Dental nurses and dental hygienists agreed more than others that they lacked the authority in the workplace to be able to change practice. Occupational therapists stated more often than other groups that there were insufficient resources and time at work to implement changes. Facilitating factors for changing practice on the basis of best evidence Answers to the statements about facilitating factors varied the most regarding the statement that physicians encouraged them to change practice. Physicians and dental nurses agreed more often with this statement. Experiences in finding, evaluating and using different sources of evidence Physicians reported to a higher degree than other groups that they had great experience of searching for research evidence and guidelines, using Internet, evaluating guidelines and using guidelines (q 42, 43, 45, 47 and 49 in Fig. 3). Psychologists reported greater experience than others of

© 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

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24. I do not have sufficient time to search for research reports

29. I do not feel confident in judging the quality of research reports

26. Research reports are not easy to find

25. I do not have sufficient time to search for guidelines (pm / protocols etc.)

30. I find it difficult to identify the significance of new research for my own practice

28. I find it difficult to understand research reports

22. I do not know how to find appropriate research reports

27. It is not easy to find guidelines (pm / protocols etc.) 31. I find it difficult to identify the significance of guidelines, pm and care programs for my own practice 23. I do not know how to find guidelines (pm / protocols etc.)

Figure 2 The percentage share of participants that agreed or totally agreed to the barriers to finding and evaluating research reports and guidelines.

searching for research evidence, using the library and the Internet and evaluating research reports and guidelines (q 42 and 44–47). Nursing assistants, dental nurses and biomedical analysts described less experience than other groups in using the library (q 44). Results of the open questions for the total group In two open questions, ‘Please identify additional barriers for you to be able to conduct EBP’ and ‘Please identify three factors that you think would facilitate your conducting EBP’, the participants were offered the opportunity to supplement the answers to the closed questions. The analysis resulted in a theme with two underlying categories for each question. The theme for the question about barriers was unclear responsibilities hinder EBP, and the theme for the question about opportunities was learning organisation facilitates EBP. The underlying categories are illustrated with citations. Unclear responsibilities hinder EBP This theme resulted from the analysis of the answers to the question about barriers to EBP. The theme describes uncertainties about whether the individual employee is responsible for the healthcare given being evidence based or whether it is a responsibility of the organisation/leadership

to organise such that the healthcare is evidence based. The uncertainties covered clinical practice, support structures and acquisition of knowledge. The participants considered personal factors to be a large proportion of the barriers present. They also believed that there were barriers at all levels of organisation and operational management. The theme consists of two underlying categories: individual factors and organisational factors.

Individual factors. This category includes personal attitudes and characteristics that the participants perceived among colleagues in the workplace. It also included an understanding of their own role in the organisation and in implementation, as well as their own knowledge of EBP. A large proportion of the answers were about resistance to changes needed to make the practice more evidence based, but also that EBP means constant readiness for change. ‘Evidence-based care changes and develops all the time, that is hard for the personnel to accept and keep up with.’ The participants mentioned personal barriers both in managers, colleagues, patients and themselves. They stated that other persons were more negative to change than they were themselves. One example of personal bar-

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45. To use Internet to search for information

49. To use guidelines, pm and care programs

43. To search for guidelines, pm and care programs

44. To use the library to search for information

47. To evaluate policy guidelines, pm and care programs

46. To evaluate research results

42. To search for research evidence

48. To use research evidence to change practice

Figure 3 The percentage share of the participants stating great or very great experiences in finding, evaluating and using different sources of evidence.

riers was lack of energy because of a high workload. Barriers in other persons were lack of interest in development, territorial thinking among professionals, different ages and low motivation. The participants pointed out a lack of evidence in many areas of healthcare. Examples were given of numerically small patient populations and about generalisation, which does not take the specific needs of individual patients into account. Taking the specific treatment preferences of individual patients into account was also considered to be a barrier. There were views that EBP increases the demands on patients and sometimes impairs their care. ‘Many methods require extensive regular monitoring of the patients. Besides that, it is time consuming and expensive, it means inconveniences for the patients in the form of costs of time, travel and expenses.’ Insufficient knowledge about and understanding of the EBP concept was considered to hinder the implementation of EBP. The participants mentioned for example insufficient knowledge about searching for evidence and difficulties in understanding both the scientific and the English language and translating the evidence to one’s own practice. Other barriers were insufficient professional knowledge and varying levels of knowledge in the team. ‘It seems to me that it is a barrier that we on the staff are on different levels concerning knowledge and competence. Especially in small units. It is often difficult to meet each other in the discussion. We have

different missions and are differently educated and often there is not the time to clarify what we mean. I mean to get someone to jump on the bandwagon on the train.’

Organisational factors. This category has to do with shortages in the organisation that originate from management functions. This includes planning and managing the content of business adjusted to temporal and economic conditions as well as priorities on an overall level. EBP was perceived to be difficult to apply in the clinical setting, and guidelines were perceived to be too extensive or hard to apply in the own workplace. The participants experienced that they lacked sufficient resources to be able to engage in change management because patient work takes time. Examples given were lack of time and lack of investments in equipment, competence and facilities. ‘Many times it is easier to do as you have always done and when there is insufficient time and resources then so be it. With a growing waiting list and prolonged understaffing there is also a decrease of endurance and motivation to search for new findings and to change/renew practice.’ The participants also described barriers of insufficient knowledge about and understanding of EBP at various levels of management. This was one example of how this could hinder EBP: when the management had insufficient knowledge of EBP, the staffs’ possibilities to work in an evidence-based way was smaller. The management was perceived as incompetent by

© 2012 The Authors International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute

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showing a low and inactive interest in the presence of EBP in practice. ‘Slow to change something. No response from the management. No one questions how we work.’ The management was criticised for not connecting EBP to the goals and for not discussing EBP in relation to performance monitoring and improvements. Participants also missed a job description that included EBP. ‘It would make it easier if the management level stressed that it is a part of the job.’ The information, available at the internal Internet, was considered to hinder EBP in several ways. The amount of information was considered insufficient and to give an abundance of information from several sources, resulting in difficulties sorting out information and spreading the ‘right’ knowledge. The information was also considered to be contradictory and to leave room for different interpretations in different groups, as well as between different professions, such as between the patient and therapist. ‘Too many places where information is located and spread.’ Lack of priority was considered another barrier. The participants lacked support from the management in prioritising the work in relation to change processes. Heavy workload and a continuous stream of new patients were considered to contribute to the need for, and the difficulties in, prioritising. ‘It is mostly about that it is hard in the middle of clinical practice to take the time to search for new evidence and to understand it.’ Economic factors were considered to be common and to hinder possibilities for evidence-based education. Furthermore, facilities were not always optimised to EBP. ‘Staffing shortages result in a booked clinic and time statistics, only patient visits are prioritised, no space to take a closer look at why we do what we do with all these patients that we see so many of on the same day’. Learning organisation facilitates EBP This theme emerged in the analysis of the answers to the question about facilitators for EBP. The theme describes factors that are considered to contribute to create conditions for EBP. The theme consists of two underlying categories: process of change and management process.

Process of change. This category includes willingness to change related to individual functions and group dynamics. The participants in the study thought that both their own and their colleagues’ willingness to change was of great importance to how the individual workplace managed practicing evidence-based care. By colleagues we mean persons within one’s own as well as in other workplaces and individual patients. ‘An open approach in the team – that we always openly discuss our way to care and try to get it together with new research findings.’ The ability of employees and patients to influence the change processes was considered to be an important factor. The participants suggested how this influence could be strengthened, for example by presenting people’s own proposals, by participating in development work and by one’s own research that aims to further develop insufficient evidence. Examples were given that the work environment needs to be changed with friendly ambience and that an

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understanding of change processes and a positive attitude with encouragement and support from both management and the team are needed. This view applied to cooperation in the own unit, between units and between different principals. ‘The whole system at the unit needs to be characterized by change. Everyone must feel that if they see something that may be possible to change they have the opportunity to make a small project and implement a change.’

Management process. This category includes factors that the participants of the study thought could be influenced by the healthcare management. Management here means different levels from the participants’ own workplace/clinic to the top management of the County Council. Via effective and clear systems and structures, the management was expected to influence the work. The participants felt that they needed clear structures for how to conduct evidence-based work. Especially, they asked for structures for prioritisation between administrative and patient-related work, and a reasonable workload. ‘Help to prioritise away other duties/patient populations when new duties/patient populations are introduced.’ Factors considered to influence this were sufficient economy and staffing. Those who specifically stated time to be an important factor stressed that time is needed to search for evidence and how to use it to get the best result. A good economy was considered to contribute to possibilities to participate in educations, to buy the best equipment available and to adjust facilities according to the practice. A well developed information technology (IT) structure was considered to facilitate the access to and search for evidence. Another suggestion was that individual co-workers could have the opportunity to get support from key persons responsible for finding and spreading evidence-based knowledge in practice. ‘Resource persons in the clinic with knowledge about research and development who can support the units in their development of EBP.’ The participants also believed that there is a need for a basic, well-functioning system for daily practice to make the daily care work with good routines for patient care. ‘Good routines for the daily work lead to security, save time and create space for change and improvements to a more evidence-based care.’ Clearly formulated goals and visions including EBP make it possible for the management to guide the direction of the practice. Following up the outcome of the care according to current evidence strengthens the system. To make this possible, the management and the co-workers need to have the same level of knowledge of EBP and the management needs to encourage and support the co-workers to carry out evidence-based care. This should happen by a prioritisation of duties so that the workload decreased instead of increasing. Another suggestion was to support a good information flow within the practice by well-functioning IT support and a well-functioning forum where knowledge can develop and be spread. The participants believed that the co-workers’ plans for development could be more systematic and include the knowledge needed for EBP. ‘That the managers understand the need for evidence-based care and that this can lead to changes.’

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Discussion The results explore factors that facilitate or hinder planning and executing the implementation of new knowledge and the removal of inefficient methods. The participants felt that an evidence-based approach was not applied on a sufficiently large scale and explained this with practical and structural barriers, which they felt should be governed in a better way by the leadership/organisation. The results show that the knowledge employees used in their daily clinical activities was primarily based on information about the patient as an individual, personal experience and local guidelines. This is on the whole a good basis for clinical assessments and decisions, but the answers also show that 20% always or often worked ‘in the way I have always done’ and that only 11% said they had great or very great experience in using research evidence to change practice. This indicates that the scientific basis for the care might be weak, which in turn may imply that patients receive different treatments and that the care given might be based on methods whose evidence is not known. The results also reveal that the practice of applying guidelines tended to increase with higher education, in line with an earlier study in which speech therapists had the highest education level and a maximum degree of research uptake compared with physiotherapists and occupational therapists.22 The finding that information from guidelines, policy papers and the like was used to a greater extent than scientific publications is supported in previous research, as is that a lack of time, resources and influence to change working method affected the use of different sources of evidence.9 Two proposals that emerged in the investigation were a better IT structure so that the right knowledge could be found and access to resources that can find, review, adapt and disseminate correct knowledge. The responses indicated uncertainty about whether it is the individual’s or the management’s/organisation’s responsibility to ensure that the care is evidence based. The opinion of personal responsibility varied depending on occupation, missions and competence. An evidence-based approach entails scientific and critically reviewed knowledge being used by the individual in clinical practice.6 This does not mean that everyone must search for and critically review scientific papers, but more that everyone has the responsibility to practise evidence-based methods and to employ a critical approach to current routines. A critical approach leads to reflection about what, how and why we do what we do and to expressing thoughts to employees and management. The approach also entails a responsibility to seek guidance in local guidelines. It is therefore notable that only 30% of participants indicated that they had great/very great experience of searching for guidelines and promemoria (PM), which is supported by previous studies.7,13,23–27 This could be due to a lack of knowledge in scientific methodology and procedures to find and evaluate research reports. The County Leadership has the ultimate responsibility for knowledge management and for evidence-based guidelines being developed and applied in clinical activities.28 Health-

care should be knowledge based and efficient, secure and standardised.3,5 To achieve this, there is a great need to develop guidelines that are coordinated nationally and are then systematically adapted and integrated in the control and management of local processes.28 Our results show that the staff of the County Council expected the management to create the conditions for evidence-based medicine (EBM). They also expressed that the managers show relatively little interest in the evidence-based approach. The respondents wished that goals and vision would be more clearly based on EBPs. Obstacles to this were perceived to be related to the time perspectives and priorities of the management, which has also been found in earlier studies.7,23,25–27 A common expression seen in the responses was ‘sufficient resources’, but what participants meant by this is not clear and should be investigated further. The replies revealed a desire for the management to prioritise between administrative, bedside and improvement work to create conditions for a reasonable workload. In summary, this indicates a need for both management and staff having knowledge of what evidence is and what an evidence-based approach involves. The results reveal a feeling of insecurity among employees about who is responsible for supporting structures and gathering knowledge. The participants wanted clearer directives from management and a better structure to find knowledge support on paper and websites. This may be related to the fact that responsibility for the current national knowledge base is divided into different authorities and that the methods for how a systematic knowledge base can be integrated in management processes are unclear.28 Participants also indicated that they have limited experience in using evidence from research, guidelines and PM in clinical improvement. As the County Council in their policy promotes clinical improvement, this is important for improving the quality of implementation and clinical improvement processes. Barriers to EBP were attributed to different levels of importance of the participants, depending on whether they were considered to be related to one’s own person, in the working group or in the sense of the patient. Participants indicated that they had a great desire to work on improvements. Sixty per cent also indicated that their managers encouraged changes in practice and 50% felt the encouragement of colleagues. It is also apparent that negative attitudes to each other’s willingness to change can affect the will of the work groups for change. In addition, the respondents claimed that the process of change may be adversely affected when persons involved in the changes have different perceptions. This might show a negative culture, as a positive culture sees different opinions as promoting creative discussions and as a prerequisite for the implementation of an evidence-based approach.9 Method discussion The open and closed questions in the questionnaire complement and support each other, which is a strength in our survey. There are some limitations in the study that must be considered. The questionnaire was originally designed for

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the nursing staff, but we broadened its use and included further professions. The answers to the question about the Internet (question 20) were difficult to evaluate because, while the Web based information may be unscientific, it may also have good scientific quality. Because the title of ‘doctor’ was used by the respondents, both as a term for the completion of medical training and the academic degree of doctor, we have not been able to analyse the results on the basis of the educational level (question 55). The low response rate gives reason for caution in the interpretation of the results. Other studies concerning attitudes about EBM have had similar response rates, 40%,11 25%24 and 27%.14 We have therefore only reported trends and not made statistical analyses. The survey excludes patient participation, although care should be designed and implemented in consultation with the patient.29 As others have pointed out,4 the participation of the patient must be taken into account to a greater extent in the development of EBP in clinical practice.

Conclusion Overall, the results indicate that the scientific evidence for healthcare is not used sufficiently as a base for decisions in daily practice as well as for changing practice. This is more prominent among assistant staff. As a consequence, this might affect the care of the patients in a negative way. Increased awareness of EBP and a stronger evidence-based approach are keys in the ongoing improvement work in the county. Local guidelines seem to be a way to implement knowledge. But, as the arena of activities is complex and the employees have diverse education levels, different strategies to facilitate and promote EBP are necessary.

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