Actions and activities of promoting and implementing evidence-based practice among nurses: a systematic review

Introduction

Evidence-based practice (EBP) was defined as the integration of the best research evidence with clinical expertise, patient values, and circumstances (1). EBP assists nurses in providing holistic and high-quality care based on the most up-to-date research and knowledge rather than traditional methods, personal beliefs, or colleagues’ advice (2).

The drive for EBP comes from pressure from taxpayers and healthcare facilities to contain costs, increase the availability of information, and increase consumer awareness about treatment and care options (3). EBP focuses on patients, expands nurses’ knowledge, and improves their clinical practice experience by collecting, processing, and implementing research findings (2). It also provides opportunities for nursing care to be more individualized, effective, streamlined, and dynamic in enhancing the effects of clinical judgment (3). EBP also had a significant role in the effectiveness, quality of healthcare, confidence, and empowerment of healthcare professionals, including nurses (4-6). Furthermore, EBP empowers nurses to be strong leaders and influencers of change (6). However, a systematic literature review disclosed that various EBP projects implemented by nurses and physicians are limited to infection prevention, reimbursement, and measuring return on investment (ROI) (7).

The literature also disclosed several models of implementing EBP. First, the Promoting Action on Research Implementation in Health Services (PARiHS) framework interplays three core elements: evidence, the context of the research, and facilitation, or the method or way of implementation (8,9). Second, the Advancing Research and Clinical Practice through Close Collaboration (ARCC) Model focuses on the system-wide implementation of EBP and sustainability by implementing five steps: assessment of culture and organizational readiness, identification of facilitators and barriers, identification of EBP mentors, implementation, and evaluation of outcomes (10). Seven steps of EBP were also proposed: cultivating a spirit of inquiry, asking clinical questions, searching, appraising, integrating evidence with clinical practice, evaluating outcomes, and disseminating the EBP results (11). Third, the Joanna Briggs Institute (JBI) model of EBP involves four phases: (I) generation of evidence through research, expertise, and discourse, (II) evidence synthesis by systematic reviews, evidence summaries, and guidelines, (III) evidence or knowledge transfer, and (IV) sustainment (12). Fourth, the IOWA Model of EBP, which provides a systematic approach for translating research into practice, focuses on problem and knowledge triggers to initiate changes, emphasizes team approaches, and stakeholders’ involvement. It involves identifying a topic, forming a team, searching for and evaluating evidence, piloting change, assessing the trial, implementing change, and sustaining it (13).

Several factors positively influenced the EBP, i.e., the clinical nurse educators, advanced practice nurses, nurse leaders, and mentorship programs (14-17). Several factors are needed to improve healthcare through enhanced teaching and application of EBP, particularly EBP curriculum, teaching EBP, and stakeholder engagement in EBP education, enhancing the local environment of EBP, guiding staff using a shared EBP model, facilitating teams by knowledgeable nurses, and encouraging EBP culture and leadership (18,19). The literature also disclosed several barriers to EBP among nurses. For example, barriers were more prevalent in non-magnet hospitals than in Pathways and Magnet hospitals; young nurses were more competent than senior nurses; and nurses in tertiary hospitals were better than those in primary and secondary hospitals. It also identified other barriers, including lack of support, supervision, training, education, resources, time, knowledge, skills, awareness of using the EBP, professional characteristics, attitude, experience, and language barrier (20-22).

The consistent translation of EBP at the point of care remains elusive despite its necessity for delivering quality and safe healthcare and maintaining positive attitudes towards it (18). The literature highlighted a critical gap in EBP implementation among nurses and midwives in various contexts and cultures (23). The EBP gap has been identified in several countries, including the USA, United Arab Emirates, Shanghai, and Egypt (5,21,24,25). A qualitative study in public hospitals in Ethiopia found that nurses and midwives rarely utilized research findings in health services (26). On the other hand, a systematic literature review disclosed significant gaps in EBP work in addressing major healthcare concerns, e.g., obesity, oncology and cancer care, neonatal and child health, mental health, maternal health, and geriatric populations, and a gap in the consistent application of research and EBP methodology (7). Nursing must engage in reporting and applying research and stop limiting it to specific methods, phenomena, or levels of discovery for a better future (27). Leaders, clinicians, publishers, and educators are also responsible for improving the state of EBP and taking action to help clinicians understand the differences between quality improvement, implementation science, EBP, and research, and strengthening EBP across various organizational contexts (4,28).

One effective method utilized for implementing EBP among clinicians in healthcare is action research. Lewin was the first to propose action research to improve conditions and practices in healthcare environments (29,30). In other words, it aims to bring about change in specific contexts, generate solutions to practical problems, and empower practitioners by engaging them in research and implementation activities (31,32). Action research usually includes three phases: (I) analysis of the current situation phase, (II) initiating an action plan, and (III) drawing a conclusion and recommendation for further improvement (33). It empowers practitioners by engaging them in research and implementation activities (32). However, the researchers are part of the project and users of the findings (34).

According to many scholars, the action research paradigm is congruent with qualitative research (35-37). Other scholars argued that the knowledge built into action research depends on the validity of the research outcomes (38). Furthermore, action research is a holistic approach to problem-solving rather than a single method for collecting and analyzing data; it allows the use of several different research tools, which are common in the qualitative research paradigm, such as document collection, participant observation, questionnaire surveys, structured and unstructured interviews, and case studies (39). Action research is distinct from quality projects. It typically focuses on a specific problem or informs individuals and community-based knowledge in a way that influences teaching, learning, and other related processes, emphasizing the involvement of practitioners in a local context. In contrast, quality projects focus on continuous improvements of a process or product.

Action research includes two types: (I) participatory action research, which aims to improve the quality of organizations, communities, and family lives by empowering individuals and groups, and (II) practical action research, which aims to address and solve specific problems by focusing on the “how to” approach (40). Participatory action research has a social and community orientation, contributing to emancipation or change in our society, for example, classroom interactions that silence or quiet the voices of minority students (41). Practical action research involves a small-scale research project, narrowly focused on a specific problem or issue, and is undertaken by individuals or teams. For example, a researcher chooses an area of focus, collects data, analyses and interprets data, and develops action plans (41).

Nurses play critical roles in identifying problems, preparing an action plan, implementing solutions, observing and evaluating the process and outcomes, and initiating a new action (42). Using action research to implement EBP is promising. However, action research lacks detailed descriptions of implementation strategies and their intensity and frequency, which prevents readers from making conclusions (43). The review is the first to focus on action research related to EBP. It could identify the actions used to implement EBP, such as the extent of action research use, the actions and activities, the outcome, and the benefits and limitations. The study can guide nursing managers and educators in adopting practical actions and activities to promote and implement EBP culture among nurses in their facilities, empowering nurses to control practice, be confident, improve decision-making, assume leadership roles, and be directly involved in improving patient care (44,45).

This review aimed to search a specific database to identify the most common actions and activities for promoting and implementing EBP among nurses and to summarize the evidence regarding their effectiveness. The study objectives are:

• To search for literature applying action research to promoting and implementing EBP among nurses.
• To identify the most common actions, which are the processes of doing something to achieve specific objectives or solve a problem, and the activities, i.e., particular pursuits or tasks, to promote and implement EBP among nurses.
• To summarize the evidence related to the effectiveness of the utilized actions and activities in promoting and implementing EBP among nurses.

We present this article in accordance with the PRISMA reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-30/rc).

Methods

Systematic literature review

A systematic literature review is a systematic approach based on a clearly formulated question, forming criteria, search strategy, searching databases, identifying, screening, and appraising the quality of relevant studies, extracting and summarizing data using a selected explicit methodology, and writing, revising, and submitting the manuscript to a journal (46). It is a way of synthesizing a high level of scientific evidence placed at the top of the evidence-based pyramid to answer a particular research question transparently with the minimum risk of bias (47-50).

The number of peer-reviewed journal articles is significantly increasing (51). The systematic literature review comprehends the literature and identifies where contributions are needed to avoid unnecessary research duplication (52). Accordingly, the study employed the systematic literature review method to achieve its goal.

Search strategy

The authors searched PubMed, a well-known and easily accessible database, which is the most comprehensive database for medical, nursing, and healthcare literature. It comprises more than 38 million citations from several sources, including the MEDLINE database, PubMed Central, and other records. It is incredibly reliable and the gold standard for biomedical research. The authors also searched other well-known databases, including EBSCOhost, which is a broad database that provides access to various research databases, including CINAHL, a specific database of nursing and allied health literature, and Scopus, which offers a comprehensive coverage of global interdisciplinary scientific information, such as technology, medicine, and social sciences.

The authors used “AND & OR” as the basic Boolean operators, which are used in most information databases to combine keywords, e.g., synonyms and variant concepts in a search to access relevant items to reduce the overall number of documents retrieved while increasing the number of relevant documents identified, thereby representing a considerable reduction in effort required by systematic reviewers (53,54). The authors conducted the search process from September to December 2024. Detailed information about the search strategy is provided in Table 1.

Inclusion and exclusion criteria

The study included pre-prepared inclusion and exclusion criteria to prevent the researcher from bias. The study included papers that met the following criteria:

• The study was an action research that aimed to promote and/or implement EBP in a specific context.
• The study population was nurses.
• The research was conducted at a healthcare facility.
• The article was published in a peer-reviewed journal between 2000 and 2024.
• The article was in English.

The study excluded all non-action, non-English, non-peer-reviewed articles. They also excluded studies conducted among or included other healthcare professionals and published before 2000. Moreover, the study excluded interventional studies, i.e., randomized controlled and quasi-experimental studies, as those research designs are distinct from action research. For instance, action research involves a collaborative, cyclical process that emphasizes practical solutions for empowering stakeholders to contribute to meaningful change in their context. On the other hand, interventional studies aim to assess causal relationships between interventions and outcomes. Moreover, the study excluded pilot studies, as they only implement the plan in a pilot phase, in contrast to action research, which extends further during the pilot and scale-up stages.

Data extraction, quality assessment, and coding

The review process started by reviewing the titles and abstracts of the selected articles against the inclusion and exclusion criteria to minimize the chance of including non-relevant articles. The authors determined specific criteria relevant to action research: they should be participatory, completed at least one cycle of actions, and include reflection. They also considered studies that were not participatory, did not complete a complete cycle, or lacked reflection as unsuitable for this study.

Then, review the included articles for the research question, method, and findings, and organize the information into tables, including the author, year of publication, journal, country, sample type, actions, outcomes, evaluation method, and limitations. Scholars recommended three authors to review, summarize the articles, and organize findings (55). In the event of any conflict regarding a study among the authors, they reassessed and discussed it in depth until they reached an agreement. They employed a narrative synthesis approach, using a textual method to analyze, summarize, and report the results and relationships between the studies. Ultimately, the review was not registered.

Results

PRISMA flow diagram of studies

The study used the PRISMA flow diagram, the preferred reporting items on systematic reviews and meta-analyses, which maps out the flow of information through the different phases of the systematic review (56). PRISMA maps out the number of records identified, screened for eligibility, included, and excluded as justified by the inclusion and exclusion criteria (Figure 1).

Figure 1 PRISMA maps out the number of records identified, screened, included, and excluded. EBP, evidence-based practice.

Quality of the included EBP action research

The authors assessed the included articles for quality, using specific criteria relevant to action research. It is worth highlighting that several scholars have proposed quality criteria for evaluating action research. Those criteria were established because action research prioritizes outcomes relevant to the local setting, the education of participants, and the achievement of action-oriented goals. For this study, the authors utilized criteria developed by Herr and Anderson that included five elements required for the quality of action research (57). First, outcome validity refers to the extent to which actions occur and lead to a resolution of the problem. Second, process validity, i.e., the extent to which the action research frames and solves problems in a manner that permits ongoing learning of the individual or system. Third, catalytic validity refers to the extent to which the research process reorients, focuses, and energizes participants. Fourth, democratic validity refers to the extent to which research is done in collaboration with all parties. Fifth, dialogic validity refers to the process by which the method, evidence, and findings resonate with a community of practice, such as through peer review (57). The three authors evaluated the quality of the included articles individually, ranking each element on a scale of 1 to 5, and then calculated the average for each article. Finally, they computed the average of all elements for each article.

All articles included in the study met the quality criteria, i.e., the averages were above 2.5. See Table 2 for the results of the quality assessment for each included study.

It is worth highlighting that all articles received a rating of “5 out of 5” for dialogic validity, as they were peer-reviewed and published in reputable academic journals.

Details of the included EBP action research

The searching and screening stages ended with 14 action research projects. The included articles were summarized in Tables S1,S2. Table S1 shows the names of the authors, publishing year, Journals, research theories used, countries, and sample details. Regarding the publication year, three of the action research papers were released between 2000 and 2014, while 11 were published between 2015 and 2024, indicating an upward trend over the last 10 years. Various authors and journals published those papers, the Worldviews on Evidence-Based Nursing published a quarter of those papers, and half were conducted in the USA.

Five adopted the ARCC model, while three used the PARIHS and i-PARIHS. Moreover, other models, including the IOWA Model of EBP, Grol et al.’s EBP implementation model, and the Johns Hopkins Nursing EBP Model, were used once. One used the coaching theory. However, two studies did not highlight any specific model. Table S1 also shows that researchers conducted action research among nurses in one unit in one study, across multiple units or a hospital-wide in seven studies, and in several hospitals in six studies. They primarily used convenience sampling techniques in 10 studies and purposive sampling in four. The samples included nurses from nine studies, nursing leaders from two studies, and various nursing positions across three studies (Table S1).

A summary of the included articles per EBP actions, activities, evaluation methods, and outcomes shows that nursing departments utilized education and training actions eight times, mentoring two times, facilitation four times, coaching one time, and utilization of evidence-based (EB) process for reviewing and revising nursing clinical standards, policies, procedures, and protocols once. The education and training actions included blended education four times, face-to-face education three times, and online education one time. Moreover, the analysis of evaluation methods revealed that the included studies used mixed methods, i.e., quantitative and qualitative, nine times, mono-qualitative method twice, and multi-qualitative methods three times for evaluating and monitoring action outcomes (Table S2).

Summary of the included EBP action research

The review found that education and training were used, either individually or with other actions, in 10 studies (25,58-62,64,65,67,69). The quantitative data analysis of seven studies on EBP education indicated increased belief and implementation of EBP among nurses, a shift toward EBP, enhanced confidence levels, and that the training was a positive learning experience (25,58,61,62,64,67,69). Moreover, the qualitative data analysis highlighted several advantages of EBP education and training. For instance, it led to an increase in research projects, EBP projects, decision-making skills, and submissions to regional and national research conferences (58,59,64,67,69). It also identified several challenges in implementing EBP. For instance, lack of time, staff, research knowledge and skills, EBP information, access to resources, such as online journals or databases, the need for mentoring, coaching, leadership support, and empowerment of nursing staff (25,61,62,67). Moreover, some studies identified several facilitators to implementation, including working in teams, engaged leadership, the presence of an EBP council, and recognition by other health care professionals (25,67).

Another four articles highlighted the role of facilitation. One study compared two types of internal facilitation approaches, A and B, to research evidence implementation (63), and the others described the implementation of the EBP facilitator role, such as drafting guidelines, teaching, and assisting participants in selecting EBP projects, developing EBP teams, organizing meetings, and tracking progress (58,66,69). The four articles summarized the role of EBP facilitators, such as drafting guidelines, helping nurses in selecting EBP topics, developing searchable questions, forming EBP teams, organizing meetings, reviewing and synthesizing literature, setting outcome measures, analysing and evaluating outcomes, and tracking progress, disseminating project results, and enabling collaborative, inclusive, and participative engagement of individuals and teams in the implementation (Table S2). However, the articles identified that the facilitator role could be challenged by selecting a facilitator with poor personal characteristics, confidence, and interpersonal skills, frequent staff turnover at all levels, and a lack of standardization in reviewing and approving EBP initiatives (63,66).

Three articles implemented mentorship programs. One found a positive effect of implementing the EBP mentorship program to revise and update the outdated content of the Nursing Policy and Procedure Manual (NPM); the qualitative findings disclosed significant improvements in eliminating the duplicated policies and procedures, making it more manageable and relevant and the quantitative data disclosed positive changes in nurse’s perceptions of the NPM, positive impact on nursing practices, and increased usage and satisfaction (65). The second showed that the program had a positive effect on participants’ EBP skills and practices, with significant improvements observed in their knowledge and implementation of EBP after participating in the program (17). The third article utilized mentoring to guide participants to successfully implement the EBP initiative associated with the educational program (67). Finally, one article used internal and external coaching. Quantitative data highlighted that coaching supported nurses in participating in the change process, the growth of evidence-based quality improvement (EBQI) in nursing, and overcoming constraints within the nursing community (68).

Discussion

Trends of the included EBP action research

Although nurses conducted a considerable amount of research related to EBP, this study disclosed that the number of action research studies conducted is limited. Nurses focused more on conceptual, theoretical, descriptive, and interventional research and searched more on nurses’ attitudes, knowledge, skills, enablers, and barriers to implementing EBP, adopting cross-sectional research surveys. This trend in nursing research influenced the maturity of nurses in achieving a well-established knowledge related to implementing and promoting EBP among nurses, and they missed the opportunity to empower and engage nurses with EBP implementation activities and to learn lessons from the actual implementation of EBP in various contexts. However, this systematic literature review found a minor improvement in action research related to EBP over the last 10 years compared to the period before 2015.

The possible reasons behind the delay in adoption of action research, including (I) the lack of nurses’ understanding of the value of action research, knowledge, and skills, (II) the lack of resources to implement long-term plans, including multiple cycles, and (III) the lack of serious intention towards implementing EBP.

Themes in the included EBP action research

The review disclosed that those studies implemented one or two of the four main identified actions, including education and training, facilitation, mentorship, and/or coaching. Each research implemented a set of activities guided by a well-known EBP model, such as ARCC, PARIHS, and Iowa, and successfully followed the phases of the action research cycle, i.e., analysis of the current situation, initiating an action plan, and drawing a conclusion and recommendation for further improvement (33). The included research adopted several education and training strategies, i.e., implementing a series of workshops, online courses, education modules, quick look learning posters, intensive face-to-face discussions between participants and experts in EBP, nursing scholarship day, patient case discussion meetings, establishing partnerships with a university, train-the-trainer workshops, and independent studying (Table S2). The facilitation action involved both internal and external roles, designating trained nurses to take on mentoring responsibilities and providing both internal and external coaching. However, the facilitating role, which is higher-order learning by making connections, dialogue, and sense-making, was challenged by selecting the right people for this role and the need to support and mentor them (63).

Moreover, those action research studies shared common critical success factors, such as the strategic decision by the Executives to implement EBP in their departments and the allocation of the required resources. One research study included the shared governance councils in EBP implementation (65). This could be an encouraging factor in promoting EBP implementation among nurses. It is also worthwhile to highlight that partnership with an external source was beneficial in guiding internal human resources, such as senior nurses and postgraduate nurses, or recruiting a permanent facilitator or mentor, as done by some of the included researchers.

The findings of the action research studies yielded beneficial information about the benefits of the action research in implementing EBP, including improvements in the knowledge and skills of participants, confidence levels, recognition from other health professionals, quality projects, EBP belief, and EBP implementation scores (17,25,61,67-69). It also provided information about enablers and barriers of implementing EBP specific to each research context based on actual and long-term implementation (61,62,66,67). In our view, that information and knowledge are more significant than that obtained from non-action research. Moreover, some of the included studies involved multiple research projects, initiated to address gaps in clinical research, and an increase in EBP projects was presented at conferences (59,64).

One noteworthy finding of this review is that the majority of those action researches utilized mixed methods, i.e., quantitative surveys and qualitative interviews, to understand the outcome of those researches and the reality from different views, contradicting to some extent the argument of Huberman (35), Lincoln and Guba (36), and Newton and Burgess (37), that action research is commensurable with qualitative research. Those action research studies successfully utilized the mixed-methods approach, raising a critical philosophical question about the nature of the action research paradigm. To answer this inquiry, scholars need to consider that pragmatism emphasizes that knowledge built in action research depends on the validity of the research outcomes (38). In addition, action research utilizes several tools commonly used in the qualitative research paradigm, including the mixed-methods approach for data collection (39).

Limitations of the included EBP action research

The review highlighted several limitations in the included action research; most of the researches were limited to one action cycle and time, which could not provide adequate time for end-users to gain the EBP knowledge and skills and to build meaningful relationships with EBP educators, mentors, and facilitators; most of those researches implemented one action^, such as training (24,61,62), which could influence the quality of the action research; and most of those researches were implemented in one site, e.g., one unit, one hospital, or one health system, which could influence generalizability of the results. Many of those studies did not involve frontline staff in the preparation and evaluation of the implemented EBP activities; one involved only nursing managers and charge nurses (25); another did not involve unit nurses in evaluating the outcomes (61), which could affect the level of participation that is essential in action research. Moreover, some of the included action research did not track the long-term impact of the implemented actions and the impact of EBP initiatives on patient outcomes over time (60,61,66). Finally, the action research identified challenges in selecting the right individuals for mentorship or facilitation roles (63); some key individuals were selected based on convenient opportunities for the researchers. However, the authors argue that action research should consider a purposive sampling technique, i.e., to select participants based on pre-prepared criteria.

Implications and recommendations

The results of this study could guide nursing executives in understanding the value of EBP and the role of action research in boosting EBP culture and enhancing employee knowledge and skills. Addressing the strengths and limitations of action research could help researchers improve the quality of action research by proposing a guiding criterion for future action research among nurses. Accordingly, executives and concerned scholars should adhere to the action research guiding criteria to ensure the quality and generalizability of the implemented actions and outcomes.

While the four primary actions of EBP—education, facilitation, mentoring, and coaching—are crucial for implementing EBP programs among nurses, this review found that no single program stands out as superior or can serve as a standardized EBP implementation model. The EBP programs examined varied significantly from one study to another. For example, some were conducted over extended periods, while others took place over shorter durations. However, any proposed EBP program should be in light of what is possible to achieve with the human, physical, and financial resources available in the local setting, which could result in the best available evidence, and consider the context of practice (58). Despite the limited resources available for organizations, several key factors can help mitigate these challenges: (I) transformational leadership style, (II) participation of motivated and highly self-efficacious nurses, and (III) collaboration with external academic institutes. Moreover, any proposed EBP programs should develop different skills in participants, such as academic writing, web searching, and computer skills. Participants should also learn change management skills, time management, and demonstrate teamwork.

The authors also recommend that future action research should track the EBP implementation on patient care and consider cost-effectiveness analysis of the implemented actions, i.e., education and training, facilitation, mentoring, and coaching, by adopting a well-established set of measures.

Limitations

The study has one limitation: it did not search some well-known databases, such as Web of Science. Moreover, it excluded EMBASE, another comprehensive biomedical database, which was recommended by Cochrane interventions reviews if access is available to the review team (70). However, access to EMBASE was not feasible for the authors, as it required a subscription.

Conclusions

Implementing EBP is critical and requires a well-prepared action plan to change nurses’ culture and develop their knowledge and skills. This review found limited research that utilized the action research design to achieve their goals related to implementing EBP. It identified four primary actions implemented in those studies to promote and implement EBP, including education and training, facilitation, mentorship, and coaching. Although education and training were used more in action research studies than facilitation and mentorship, the authors believe that action research should utilize as many of the identified actions as possible for successful EBP implementation. Moreover, an action plan should include various activities, such as blended education and multiple teaching, facilitation, and mentoring methods. Action research could provide the opportunity to plan actions based on available resources, identify the enablers and barriers specific to their local context, and modify the plan accordingly.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-30/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-30/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-25-30/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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