Evidence-Based Practice Competency of registered nurses in the Greek National Health Service

1. Introduction

Evidence-based practice (EBP) results in improved healthcare quality and health outcomes, enhances the reliability of healthcare and reduces variations in care and costs [1-4]. Nurses’ competency is defined as “an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations in nursing practice’’ [1,5]. For this reason, researchers stress the need for cultivating nurses’ EBP competencies even from the undergraduate level and focus on designing educational programs and digital tools for undergraduate and postgraduate students and professional nurses as well [6-13]. In this direction, health organizations aim to reach a high level of practice and the best quality patient outcomes while they highlight the necessity to evaluate nurses’ EBP in order to provide evidence-based, high-quality, and cost-effective care [1]. Healthcare systems and hospitals should provide the proper equipment and educational support in order to develop EBP competencies in their clinicians and nurses [14].

An increasing number of different scales have been used to evaluate nurses’ EBP across Europe. One of those, the EBP-COQ Prof by the Spanish National Survey [15], showed that it could be a beneficial tool when evaluating factors such as levels of education and years of training post-degree, along with active scientific interest such as reading articles and attending seminars. These factors were considered to enhance and develop EBP competency [16]. However, a systematic review by Saunders et al. (2019) has stated that EBP competencies alone are not sufficient and cannot be used exclusively in order to reach a high level of EBP in healthcare practice [17]. The same review concludes that competency assessment should be used as an aspect of the development and evaluation of clinical practice as well as that there is a need for validated tools in order to measure EBP competency that can be more accurate than mere self-assessments [17].

Based on an updated literature review, in a European context, a consensus of experts from the Czech Republic, Greece, Italy, Poland, Slovenia, and Spain, 24 EBP competencies and 120 learning outcomes for general nurses and advanced practice nurses were identified in order to conclude a common tool that can be used in order to assess nursing competency, which it will be used for educational intervention and the integration of EBP into daily clinical practice [10].

According to the literature, there seems to be a lack of validated questionnaires in Greek health systems. Major strategies to evaluate nurses’ competency are required so as to focus on training programs and practices in order to improve everyday health practice. There has been an attempt by Patelarou et al. (2021) to translate and validate the EBP-COQ questionnaire to evaluate EBP competency in nursing students [18].

In a recent study conducted by Schetaki et al. (2022) in Greece [19], as precisely defined by Melnyk [2], it was shown that the EBP-COQ Prof questionnaire, translated and validated in Greek, is able to measure and evaluate the competency of nurses in the National Health System (NHS) in Greece. This was confirmed in terms of knowledge, skills, and attitude but also in the utilization of EBP in their daily clinical settings.

The purpose of this study is to measure and evaluate the competence of NHS nurses in Greece using the valid questionnaire EBP-COQ Prof [19] as well as assessing the variables that can influence that competence in terms of EBP.

2. Materials and Methods

2.1. Aim

The aims of this study were: a) to investigate the practice, attitude, knowledge, and skills of Greek nurses towards EBP, and b) to determine relationships between the EBP competency and nurses’ demographic characteristics (personal and professional factors).

2.1.2. Study Desing and Sample

The study was a cross-sectional survey and utilized a descriptive study design to investigate Greek nurses’ practice, attitude, knowledge, and skills towards EBP and the demographic factors associated with them. A convenience sample was recruited from nurses employed by ten hospitals in Greece (4 from Athens and 6 from the island of Crete). The sample was recruited from different types of nursing units with the following inclusion criteria: 1) registered nurse as professional role, 2) age > 18 years, and 3) ability to read in Greek.

2.1.3. Data Collection Tools

The study used two tools to collect data – the Evidence-Based Practice Competency Questionnaire for Professional Registered Nurses (EBP-COQ Prof) and a demographic survey which was developed specifically for the purposes of the present study.

The EBP-COQ Prof was developed and psychometrically-tested to measure Spanish-speaking nurses’ attitudes towards evidence-based practice [20]. Schetaki et al. (2022) translated the EBP-COQ Prof into Greek, establishing the scale’s validity and reliability for Greek nurses (Cronbach-α: Attitudes (8 items; α = 0.89), Knowledge (11 items; α = 0.94), Skills (6 items; α = 0.82), and Utilization (10 items; α = 0.87) [19]. The EBP-COQ Prof scale consists of 35 items that attempt to assess the competence of nursing staff by focusing on the attitudes, skills, and knowledge around EBP, as well as the utilization of EBP in clinical practice. These 35 items are in the form of a 5-point Likert scale (1 corresponding to totally disagree, 2 to disagree, 3 to neither agree nor disagree, 4 to agree, and 5 to agree completely), with higher scores indicating a higher positive attitude towards EBP.

In order to determine factors that are associated with different attitudes about EBP, we developed a form to gather personal and professional information from each of the subjects (age, biological sex, possession of a master’s degree, years of nursing experience, writing academic/professional nursing articles in the last 5 years, level of English language knowledge, level of computer knowledge).

2.1.4. Ethical Consideration

This research was reviewed and approved by the Hellenic Mediterranean University Ethics Committee (No 28/18.01.21). This survey was carried out in full compliance with the new General Data Protection Regulation (GDPR) [EU 2016/679] 25.5.2018 on sensitive personal data. Prior to its implementation, the relevant licenses were secured by the respective services. The data collected were anonymous; their use was made solely for the purposes of the survey and for access to them by the lead researcher. The participants consented in writing, having been fully informed that the procedure was anonymous, that their personal data and answers would be used exclusively for research purposes, and that at any time, they would be able to leave.

2.1.5. Data Analysis

We performed the statistical analysis using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA) [21]. Continuous variables were expressed as mean ± standard deviation (sd) and categorical variables were expressed as absolute numbers (n) and percentages (n%). Normality of the variables was tested by the Shapiro-Wilks test, and through the study “Normal Q-Q plot”, “Detrended Normal Q-Q plot”, and “Box Plot”. For all tests, statistical differences were determined to be significant at p < 0.05. We used the independent t-test when are interested to compare two group means, and One-way ANOVA to compare of more than two group means. To correlate two continuous variables, we used the Pearson coefficient. To correlate a continuous variable with an ordinal variable, we used the Point Biserial coefficient. For the purposes of the analysis of confounding factors associated with EBP-COQ Prof subscales, we used a multiple linear regression model. In the univariate analysis, the criterion for the initial entry of variables into multiple regression models was p < 0.25.

3. Results

3.1. Descriptive analysis

The study sample consists of 473 participants (402 women and 71 men), average age 44.7 years (SD = 9.2). The average time of nursing experience is 17.3 years (SD = 10.1), and one hundred seventy-one (36.5%) were working in a university clinic.

One hundred eighteen nurses (25.0%) held a Master’s degree, and fifty-three (11.2%) they had written at least one academic or professional nursing article in the last 5 years. Twenty nurses (4.3%) had no knowledge of English at all and eighty-six (18.3%) had excellent knowledge. Three nurses (0.6%) had no knowledge of computer at all and one hundred nineteen (25.4%) had excellent knowledge [Table 1].

As for the EBP-COQ Prof, the mean of Attitudes was 3.9 (SD = 0.6), Knowledge was 3.1 (SD = 0.8), Skills was 3.7 (SD = 0.6), and Utilization was 3.4 (SD = 0.7) [Figure 1].

The subscales Attitudes (8 items; α = 0.89), Knowledge (11 items; α = 0.94), Skills (6 items; α = 0.82), and Utilization (10 items; α = 0.87) were found to be highly reliable.

3.1.1. Correlations of EBP-COQ Prof subscales

3.1.1.1. Bivariate analysis

The Table 2 summarizes the results of the correlations of the subscales of the EBP-COQ Prof questionnaire with the studied factors. According to the results, older ages correspond to higher values of Skills’ (r = 0.153, p = 0.001) and Utilization’s (r = 0.132, p = 0.004) subscale. The level of Attitudes (t = -4.86, p < 0.001), Knowledge (t = -9.17, p < 0.001), Skills (t = -5.29, p < 0.001), and Utilization (t = -3.29, p < 0.001) were statistically significant higher for nurses who have a master’s degree than nurses who haven’t. Moreover, the level of Attitudes (t = -3.87, p < 0.001), Knowledge (t = -6.50, p < 0.001), and Skills (t = -4.00, p < 0.001) were statistically significant higher for nurses who have written at least one academic or professional nursing article in the last 5 years than nurses who haven’t. higher level of computer knowledge corresponds to higher values of Attitudes’ (rpb = 0.138, p = 0.003), Knowledge (rpb = 0.290, p < 0.001), Skills’ (rpb = 0.161, p < 0.001), and Utilization’s (rpb = 0.113, p = 0.015) subscale. More years of nursing experience corresponds to higher values of Skills’ (r = 0.179, p < 0.001) and Utilization’s (r = 0.140, p = 0.002) subscale. The level of Attitudes (t = -3.25, p = 0.001), Knowledge (t = -3.72, p < 0.001), Skills (t = -2.88, p = 0.004), and Utilization (t = -4.32, p < 0.001) were statistically significant higher for nurses who works in a university clinic. English language knowledge were significant higher in the level of attitude (rpb=469, p = 0.012), knowledge (rpb=469, p < 0.001), and skills (rpb=469, p = 0.012) subscale. The findings revealed no significant correlation between biological sex and EBP-COQ Prof subscales.

3.1.1.2. Multivariable analysis

The multiple regression model statistically significantly predicted the subscale Attitudes, F(6, 457) = 7.163, p < .001, adj. R² = 0.074. The variables “Master’s degree” (p = 0.003), “Work in a university clinic” (p = 0.008), and “Writing academic/professional nursing articles in the last 5 years” (p = 0.024) added statistically significantly to the prediction. Regression coefficients and standard errors are presented in Table 3.

The multiple regression model statistically significantly predicted the subscale Knowledge, F (6, 457) = 23.306, p < .001, adj. R² = 0.224. The variables “Master’s degree” (p < 0.001), “Writing academic/professional nursing articles in the last 5 years” ( p = 0.001), “Computer knowledge” (p = 0.002), and “Work in a university clinic” (p = 0.006) added statistically significantly to the prediction. Regression coefficients and standard errors are presented in detail in Table 4.

The multiple regression model statistically significantly predicted the subscale Skills, F (7, 449) = 9.598, p < .001, adj. R² = 0.117. The variables “Computer knowledge” (p = 0.002), “Master’s degree” (p = 0.011), “Writing academic/professional nursing articles in the last 5 years” (p = 0.019), and “Work in a university clinic” (p = 0.028) added statistically significantly to the prediction. Table 5 presents the regression coefficients and standard errors.

The multiple regression model statistically significantly predicted the subscale Utillization, F (7, 449) = 6.299, p < .001, adj. R² = 0.075. The variables “Work in a university clinic” (p < 0.001) and “Computer knowledge” (p = 0.017) added statistically significantly to the prediction. Regression coefficients and standard errors can be found in Table 6.

5. Strengths and limitations of the study

It is noteworthy that no other scale has been used in the Greek language that can investigate and assess the competence of nurses in the NHS toward EBP. This is the first study revealing results about Greek nurses’ attitudes, skills, knowledge and utilization. The questionnaire is self-administered, and therefore there should be a degree of caution as to the validity of the responses, but a sufficiently large sample and convenience sampling tend to eliminate this disadvantage.

6. Conclusion

The study reveals that Greek NHS nurses have a positive attitude, moderate levels of skills and lower levels of utilization and knowledge. The factors influencing these variables are educational level, writing an academic article in the last five years, level of computer knowledge as well as the type of clinic they work. The limited literature in the Greek area around the specific subject confirms the requirement for further research in order to identify the needs. For this reason, educational programs should be developed that will aim at continuous training to enhance and improve the appropriate culture and guarantee a favorable climate towards EBP.