| Objectives: It is a national requirement to focus on building a nursing norm and technical standard system based on evidence and clinical needs,and effectively improve the level of inter-regional and inter-institutional nursing homogeneity.Nurse’s evidencebased practice(EBP)is a clinically operable path to accomplish this task.Based on patient needs,nurses integrate scientific research into the best evidence for clinical application,evaluate and disseminate the effect of nursing practice,so as to achieve the homogeneity of nursing services.However,at present,the behavior level of clinical nurses implementing EBP in my country is relatively low,and exploring the mechanism of EBP behavior is of great significance to formulate accurate EBP promotion strategies for nurses.This study adopts a mixed method to investigate the associated factors and the pathways to behavior of EBP of Nurses from the individual factors of clinical nurses(EBP competence,work control,passive defensive nursing behavior,intention to adopt EBP),organizational factors(organizational climate for EBP implementation)and environmental factors(opportunity perception,threat perception).Methods: This study adopted a mixed research method:(1)Qualitative research:(1)Indepth interviews: 12 clinical nurses and nursing managers were selected to conduct in-depth interviews on the opportunities and threats of the EBP implementation,and elements of opportunities and threats scales were formed;(2)Focus group interview: 8 clinical nurses and nursing managers were selected for focus group interview,and explored the organizational climate for EBP implementation;(3)Delphi method: 7EBP experts were select to construct content validity test of the scale(passive defensive nursing behavior,organizational climate for EBP implementation,EBP opportunity perception and threat perception).(2)Quantitative research:(1)Pilot test: Convenience sampling method was used to select 116 clinical nurses from tertiary hospitals in Beijing,Shanghai,Guangzhou,Hangzhou,Tianjin and Shenyang for investigation,using Cronbach’α,exploratory factor Analysis to test of the reliability and validity of the scales;(2)Formal survey: According to the differences in geographical and socioeconomic development levels,Shenyang,Beijing,Zhengzhou,Shanghai,Guangzhou,Wulumuqi were selected by purposive sampling,6 tertiary hospitals with the highest competitiveness in each city were selected as the survey hospitals.A questionnaire survey was conducted among 641 nurses in the departments who had implemented EBP,including the demographic and sociological characteristics of nurses,EBP behavior and associated factors(EBP competence,work control,passive defensive nursing behavior,intention to adopt EBP,organizational climate for EBP implementation,EBP opportunity perception,threat perception,job satisfaction and work pressure,etc.).Descriptive statistical analysis,univariate analysis,multivariate analysis,path analysis,mediation effect analysis,moderating effect analysis were conducted by IBM SPSS 26.0,AMOS 24.0,PROCESS 3.5 software;(3)Random forest analysis was used to analyze the importance of the associated factors of EBP behavior,and IPA analysis(ImportancePerformance Analysis,IPA)was used to construct a priority improvement matrix of EBP associated factors to identify the factors with priority improvement value.Results:(1)A total of 130 questionnaires were distributed in pilot test,and 116 valid questionnaires were recovered,with an effective recovery rate of 89.23%.After verification,the total Cronbach’α of passive defensive nursing behavior,EBP organizational climate,EBP opportunity perception,and EBP threat perception were 0.910,0.939,0.919,and 0.918.Using principal component factor analysis,androtating the factor matrix by the maximum variance method,the cumulative variance contribution rates of each measurement tool were 69.228%,73.303%,67.350%,and 74.768%,respectively.(2)Associated factors of behavior of EBP 1)The score of EBP behavior of nurses was 4.16±1.32(score range from 1 to 7),which is at a medium level.The average score of the item of clinical integration was rated the highest at 4.16±1.56,followed by evaluating evidence(4.16±1.55),converting problems(4.13±1.61),evaluating effects(4.12±1.59),and sharing results(4.12±1.63).2)The influences of individual factors on EBP behavior:(1)Demographic and sociological characteristics: The level of EBP behavior for nurses in economically developed areas(4.37±1.37)were higher than nurses in less developed areas(3.98±1.25),and that of management nurses(4.82±1.31)was higher than general nurses(4.12±1.31),nurses with bachelor degree or above(4.22±1.31)were higher than nurses with junior college and below(3.87±1.34),nurses with formal staffing(4.52±1.39)were higher than those with informal staffing(4.08±1.29),nurses with teaching experience(4.27 ± 1.33)were higher than those without teaching experience(4.04 ± 1.29),nurses with scientific research experience(4.59 ± 1.33)were higher than those without scientific research experience(4.02 ± 1.29),those of nurses working years ≥ 21 years(4.60±1.37)were higher than those of other working years group nurses,and those with no children(4.32±1.29)and 1 child(4.21±1.25)were higher than nurses who had 2 children nurses at least(3.69±1.46)(P<0.05).(2)Other influences of individual factors: The score of intention to adopt EBP was 3.90±0.81 which ranged from 1 to 5.The score of EBP competence was 2.65±0.55 which ranged from 1 to 4.The score of work control was 3.48 ± 0.60,which ranged from 1 to 5.The score of passive defensive nursing behavior was 3.73 ± 0.77,which ranged from 1 to 5.After controlling for demographic and sociological variables,clinical nurses’ EBP competence(B=0.856),work control(B=0.686),and intention toadopt EBP(B=0.561)had a positive impact on EBP behavior(P < 0.001),while passive defensive nursing behavior(B=-0.386)had a negative impact on EBP behavior(P < 0.001).3)The influences of organizational factors on EBP behavior: The score of organizational climates for EBP implementation was 3.66±0.57(score range was from 1 to 5),of which the scores of each dimension from high to low were leadership effectiveness(3.71±0.71),resource provision(3.70±0.77),environmental climate(3.69±0.75),organizational philosophy(3.63±0.77),teamwork(3.63±0.76),work style(3.62±0.75),learning and growth(3.62±0.72).After controlling for demographic and sociological variables,organizational climate(B=0.972)had a positive impact on EBP behavior(P<0.001).4)The influences of environmental factors on EBP behavior: The score of EBP opportunity perception is 3.76±0.63(score range was from 1 to 5),which is at a high level,and the scores of each dimension from high to low were opportunity for patients(3.80±0.75),opportunity for organization(3.80±0.73),opportunity for nurses(3.67±0.71);The score of EBP threat perception was 3.41±0.66(score range was from 1 to 5),and the scores of each dimension from high to low were social threat(3.50±0.70),nurse threat(3.45±0.76),patient threat(3.40±0.82)and organizational threat(3.28±0.92).After controlling for demographic and sociological variables,clinical nurses’ perception of EBP opportunity(B=0.643)had a positive impact on EBP behavior(P<0.001),and EBP threat perception(B=-0.623)had a negative impact on EBP behavior(P<0.001).5)Ranking of the importance of the factors of EBP behavior: A random forest regression was conducted to analyze the factors of EBP behavior.The results showed that the factors included EBP competence,organizational climate,opportunity perception,threat perception,intention to adopt EBP,work control,passive defensive nursing behavior,and demographic sociological characteristics.6)At present,the factors that need to be solved urgently among the influencingfactors of EBP behavior were EBP competence(skills,application),EBP threat perception(patient threat),and passive defensive nursing behavior.What needs to be maintained were organizational climate(teamwork,resource provision),perception of opportunity(organizational opportunity,nurse opportunity).(3)Pathways to behavior of EBP 1)The path and indirect effect of organizational factors→ individual factors of nurses→ EBP behavior:(1)EBP competence/work control/ intention to adopt EBP played a partial mediating role in the influence of EBP organizational climate on EBP behavior(P<0.001).EBP competence and intention to adopt EBP,work control and intention to adopt EBP played a chain mediating role in the influence of EBP organizational climate on EBP behavior(P<0.001).Organizational factors(organizational climate)had a positive impact on nurses’ individual factors(EBP competence,work control,and intention to adopt EBP)(B=0.446,0.615,0.228,P<0.001),Nurses’ individual factors(EBP competence,work control,and intention to adopt EBP)have a positive impact on EBP behavior(B=0.276,0.170,0.140,P<0.01),organizational factors(organizational climate)had a positive impact on EBP behavior(B=0.254,P<0.001).(2)The indirect effect of the path of "organizational climate →work control →EBP behavior" was 0.105,accounting for 18.99% of the total effect;the indirect effect of the path of "organizational climate →EBP competence →EBP behavior" was 0.123,accounting for 22.24% of the total effect;the indirect effect of the path of "organizational climate →intention to adopt EBP→EBP behavior" was 0.032,accounting for 5.79% of the total effect;the indirect effect of the path of "organizational climate → work control → intention to adopt EBP→EBP behavior" was 0.021,accounting for 3.80% of the total effect;the indirect effect of the path of "organizational climate → EBP competence → intention to adopt EBP→ EBP behavior" was 0.018,accounting for 3.25% of the total effect.The total effect,direct effect,and indirect effect in this path were 0.553,0.254,and 0.299,and the totalindirect effect accounted for 54.07% of the total effect.(3)Job satisfaction played a negative moderating role between the direct effect of “organizational climate →EBP behavior”(B=-0.296,P<0.001)and between the “intention to adopt EBP→ EBP behavior”(B=-0.131,P<0.05).3)The path and indirect effect of environmental factors →individual factors of nurses →EBP behavior:(1)Passive defensive nursing behavior/ intention to adopt EBP played a partial mediating role in the impact of EBP opportunity perception/threat perception on EBP behavior(P<0.001).EBP opportunity perception had a negative impact on nurses’ passive defensive nursing behavior(B=-0.255,P<0.001),and had a positive impact on nurses’ intention to adopt EBP(B=0.388,P<0.001);EBP threat perception had a positive impact on nurses’ passive defensive nursing behavior(B=0.491,P<0.001),and a negative impact on intention to adopt EBP(B=-0.482,P<0.001).Nurses’ passive defensive nursing behavior had a negative impact on EBP behavior(B=-0.151,P<0.01),and intention to adopt EBP had a positive impact on EBP behavior(B=0.430,P<0.01).P<0.001);the EBP opportunity perception had a positive effect on EBP behavior(B=0.529,P<0.001),and EBP threat perception had a negative impact on EBP behavior(B=-0.607,P < 0.001).(2)The indirect effect of the path of "EBP opportunity perception →passive defensive nursing behavior →EBP behavior" was 0.039,accounting for 9.61% of the total effect;the indirect effect of the path of "EBP opportunity perception →intention to adopt EBP →EBP behavior" was 0.112,accounting for 27.58% of the total effect;the total effect,direct effect,and indirect effect were 0.406,0.250,and 0.156,the total indirect effect accounted for 38.42% of the total effect;the indirect effect of the path of " EBP threat perception →passive defensive nursing behavior →EBP behavior" was-0.051,accounting for 12.14% of the total effect;the indirect effect of the path of "EBP threat perception →intention to adopt EBP→EBP behavior" was-0.121,accounting for 28.81% of the total effect;the total effect,direct effect,and indirecteffect were-0.420,-0.245,-0.175,and total indirect effect accounted for 41.67% of the total effect.(3)Work stress negatively moderated the impact of EBP threat perception on passive defensive nursing behavior(B=-0.129,P < 0.01)and passive defensive nursing behavior on EBP behavior(B=-0.144,P < 0.05).Work stress negatively moderated the impact of EBP threat perception on the intention to adopt EBP(B=0.097,P<0.05).Conclusions:(1)The level of EBP behavior of clinical nurses in tertiary hospitals surveyed in this study was at a moderate level.It was speculated that the level of EBP behavior of clinical nurses in other regions and hospitals may be lower,suggesting that health policy makers,clinical nursing managers should attach great importance to EBP,actively intervene in the influencing factors of EBP behavior,and promote clinical nurses to implement EBP.(2)Individual factors(demographic and sociological characteristics,EBP competence,work control,intention to adopt EBP,passive defensive nursing behavior),organizational factors(EBP organizational climate),and environmental factors(EBP opportunity perception,EBP threat perception)were the key factors for clinical nurses to implement EBP practice.This suggests that nursing managers can identify priority improvement factors as early as possible through evaluation and give targeted intervention,which can actively promote clinical nurses to implement EBP.(3)Nursing managers should pay attention to the organizational factors that can affect the behavior of EBP through the individual factors of nurses.Managers can constantly improve nurses’ EBP competence and level of work control by creating a friendly working environment,providing leadership support,encouraging team cooperation,relaxing nurses’ work authority and decision-making power,ensuring accessibility of EBP resources,optimizing post level settings,implementing hierarchical management and education of EBP,creating career growth space etc,to promote the EBP implementaion.(4)Nursing managers should pay attention to the environmental factors that can affect the behavior of EBP through the individual factors of nurses.They can improve the quality of evidence,transform the evidence into a form convenient for use,equip sufficient nursing human resources,improve the management system and norms for clinical nurses to implement EBP,establish an incentive system for nurses to implement EBP,and improve patients’ recognition of EBP,accelerate the integration of evidence and nursing standards,to increase nurses’ perception of opportunities and reduce their threat perception,thus reducing nurses’ passive defensive nursing behavior,and stimulate clinical nurses’ EBP behavior.(5)The moderating effect of work pressure and job satisfaction suggested that nursing managers should adjust work pressure and job satisfaction appropriately,stimulate work enthusiasm,and promote EBP according to the actual level influencing factor of nurses’ EBP behavior. |
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