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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 125-131

The theory of evidence-based practice among clinical teaching assistants at a college of nursing in Jeddah, Saudi Arabia


Department of Nursing, College of Nursing, King Saud bin Abdul Aziz University for Health Sciences; King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Jeddah, Kingdom of Saudi Arabia

Date of Submission24-Feb-2021
Date of Decision01-Apr-2021
Date of Acceptance22-Apr-2021
Date of Web Publication16-Aug-2021

Correspondence Address:
Hawazen Omar Rawas
College of Nursing at King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, National Guard Health Affairs, King Abdulaziz Medical City, Jeddah, Saudi Arabia.

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_35_21

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  Abstract 


Background: Evidence-based practice (EBP) is an integration of the research evidence with clinical expertise and the values of patients to assist the health profession in clinical decision-making. Recent studies indicate that education on EBP is considered a core component in the learning curricula for all health-care professions. In addition, it has been recommended to use a variety of teaching strategies to enhance EBP knowledge and skills. Aims: The aim of this study is to develop an explanatory theory to guide the process of EBP among clinical teaching assistants (CTAs) within the Saudi context that is characterized by a multicultural environment. Setting and Design This study used grounded theory approach by Strauss and Corbin (1990), and was conducted in a college of nursing, Jeddah, Saudi Arabia. Materials and Methods: The study participants included 22 CTAs. Initially, three participants were conveniently sampled. As data collection and data analysis continued, sampling changed from conveniently to theoretical until data saturation was reached. The data collection was through in-depth interviews and was recorded with the permission of the participants. Analysis: The data were analyzed by following the coding in grounded theory, namely open, axial, and selective coding. Results: Twenty two CTAs participated in this study. The average age of participants was 46 years with average years of experience of 7.5 years. The theory that emerged from this study was the “theory of EBP among CTAs.” There were one core concept emerged from the study (confident to care) and four subconcepts (teamwork, forcing inquiry, EBP champions, and formal education). Conclusion: This study provided insight into the process of EBP among CTAs and provided a middle range theory for CTAs toward becoming confident in caring through adopting EBP approach to care.

Keywords: Clinical teaching instructors, confident to care, evidence-based practice, grounded theory, Saudi Arabia


How to cite this article:
Rawas HO. The theory of evidence-based practice among clinical teaching assistants at a college of nursing in Jeddah, Saudi Arabia. Saudi J Health Sci 2021;10:125-31

How to cite this URL:
Rawas HO. The theory of evidence-based practice among clinical teaching assistants at a college of nursing in Jeddah, Saudi Arabia. Saudi J Health Sci [serial online] 2021 [cited 2021 Dec 7];10:125-31. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/2/125/323879




  Introduction Top


There are different definitions in the literature about evidence-based practice (EBP). Most of those definitions include three areas: research-based information, clinical expertise, and patient preferences.[1] Winter and Echeverri, for example, defined EBP in a simple way as an integration of the research evidence with clinical expertise and the values of patients to assist the health profession in clinical decision-making.[2] EBP is a process of examining all evidence available such as research findings, which are accompanied with scientific theories. The definition has been expanded to include the practice context.[3] According to Hoffmann, Bennett, and Del Mar, the ability to make decisions on patients' care which are based on EBP depends on achieving four elements: using evidence from research by health professionals; and combining that with education, values, skills, and clinical experience; considering patients' values and situation; and gaining information about the practice context. The Sigma Theta Tau International defined EBP in nursing as an “integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.”[4] Therefore, all aspects of patient care should be based on EBP. The process of EBP can be divided into five steps: turning the problem in the clinic into questions; searching for evidence in the literature to answer this question; evaluating this evidence for validity and applicability; implementing the best evidence into a practice with consideration of clinical experience, patients' value, and practice context; and finally, evaluating the change in the practice.[5]

Many studies have argued that EBP allows the combination of education with clinical practice and the use the most effective available care.[6],[7],[8] In other words, health professionals become more aware of EBP processes and how they can adapt them directly to their clinical practice.[9] For instance, the clinicians generate questions from the patients' problems and search the relevant literature to find answers. Therefore, EBP can help the clinician to keep their practice up-to-date and motivate them to explore recent research findings.

Implementing EBP can help health professionals to use the best available evidence to make their decisions in clinical practice.[10] Involving staff nurses in EBP has many advantages for them, such as developing their confidence in using research findings, developing their leadership skills, improving their critical thinking for them, and increasing their ability to provide safe, cost-effective, and valid practices for patients.[10] Another example of the benefits of implementing EBP for staff nurses is that EBP improves the decision-making for nurses, which can improve patients' care and outcomes, reduce the cost of unnecessary interventions or treatments, and reduce the risk of medical error and patient mortality.[11] Although it is argued that EBP does not reduce costs, it does help to prevent unnecessary and ineffective interventions.

Researchers recognize the role of the implementation of EBP for patients.[11] For example, EBP increases the patients' expectations which leads health professionals to become more responsible for their practice. It is argued that the available resources have increased the awareness and education of patients regarding their diseases, interventions, and medical tests.[3] Furthermore, available evidence is a good source for patients to provide them with consistent information and answer any questions about their procedures or care.

It is evident from previous studies that there are a number of factors which obstruct or promote the utilization of EBP in the clinical practice.[12] These factors operate at the level of the individual health-care professional and a level of a health-care system as well. Individual health-care professional barriers consist of a lack of knowledge, negative attitudes, or underdeveloped skills. Factors at level of a health-care system comprise structured barriers (financial arrangement), organizational barriers (lack of facilities), peer group barriers, and professional–patient interaction barriers (communication).[12]

Recent research indicates that education on EBPs is considered a core component in the learning curricula for all health-care professions.[8] In addition, a variety of teaching strategies to enhance EBP knowledge and skills are recommended. For example, the teaching and learning methods for EBP have been described in three levels of hierarchy.[13] In the first level, the teaching method should be based on the interactive clinical activities. The classroom didactics through using the clinical and interactive activities is the second level of that hierarchy. The third level is the stand-alone teaching or the classroom didactics. There are different engaging teaching strategies that have been adopted by nursing educators such as small group work, journal club, interactive lecture, workshops, clinical case presentation, and problem-based learning.[5] However, it has been argued that it is important for the educators to keep the teaching strategies very simple, and that the faculty and clinical monitors should act as role models for the students because what is learned comes from observed behavior.[14]


  Materials and Methods Top


Study design

This study is a qualitative study used the Strauss and Corbin's grounded theory approach.[15] This approach was chosen, as limited research has been conducted on EBP within Saudi Arabia.[15] In addition, the researcher followed a constructivist research paradigm, which emphasizes that reality is a constructed between the researcher and the participants.

Study setting

The study was conducted at the College of Nursing, Jeddah, which offers an undergraduate and postgraduate program. The staff profile of the College of Nursing, Jeddah, consists of the Nursing Faculty members (Lecturers and Assistant Professors and Clinical Teaching Assistants [CTAs]). CTAs are employed by the professional nursing program to assist the program faculty with the supervision of students during clinical learning experiences. Working under the supervision of a master's or doctoral prepared nursing faculty member, CTAs function in the role of clinical supervisor and are responsible for supervision of students “skills performance, student evaluation, and other aspects of student learning in the clinical setting.”

Study participants and sampling

The study participants included 22 CTAs. Initially, three participants were conveniently sampled. As data collection and data analysis continued, sampling changed from conveniently to theoretical until data saturation was reached.

Data collection process

The data collection process commenced as soon as the necessary permission was obtained. Therefore, CTAs were approached to arrange convenient times for data collection. Once this is completed, all CTAs contacted and requested to take part in this study. Data collection begun after the written consents were obtained. The data collection was commenced at a time that is convenient for the CTAs. The data collection was through in-depth interviews in area that is private and was tape recorded with the permission of the participants.

Data collection

Data collection took place over a period of 6 months during the year 2020. Data collection included four individual interviews and two focus groups with all 22 CTAs. The focus groups were conducted first, and as theoretical sampling occurred, individual in-depth interviews were conducted. Participants were asked some questions such as: What does EBP means to you? Can you tell me about your experiences with EBP? What are the challenges for applying EBP? And what are the factors that facilitate applying EBP? Data collection occurred in a private space within the Clinical Affairs Department. All interviews were audio recorded with permission being obtained from participants. Individual interview ranged from 30 to 45 min, and the average length of both focus groups was 110 min.

Data analysis

Data analysis followed the coding in grounded theory, namely open, axial, and selective coding.

As data collection is a reiterative process in grounded theory, the data collection and analysis occurred simultaneously. Open coding commenced with listening to the audio recordings of the interviews for the purpose of transcribing. Thereafter, data were broken down into incidents and compared with other incidents and other data in order to develop the concepts. Thereafter, common themes were grouped together to form categories called categories, thereby reducing the number of concepts. Thereafter, axial coding involved looking at the full list of categories produced at the end of open coding further analyzing them in terms of their dimensions and properties, allowing subcategories to emerge on the basis of how they related to the category in question. Finally, selective coding involved selecting a core category and relating it to other categories. Further selective coding involved integrating and linking the main categories into a conceptual framework that represents the theory grounded in the data.

Ethical considerations

Permission to conduct the research was obtained from the Research Unit at the College of Nursing, Jeddah, thereafter ethical approval was granted by the Institutional Review Board (Approval No. RJ20/137/J). Participants were assured that confidentiality and anonymity will be maintained. The data were managed with uttermost privacy, and only the researchers and two qualitative experts had access to the data.

Academic rigor

The principle of credibility, dependability, confirmability, and transferability of academic rigor were undertaken. Credibility included member checking which involved the researcher providing feedback about the emerging data and interpretations to participants to ensure it was a true reflection of their reactions. Dependability was ensured by a dependability audit which involved using an expert in qualitative research to review the tapes, transcripts, and filed notes that the researcher used during the duration of this study. A confirmability trail was also established by the researcher recording the research activities over time so that others can follow the research process undertaken. Transferability included researcher provided sufficient thick descriptions by providing detailed descriptions of the research settings, participants, data collection methods, and time frame of data collection.


  Results Top


A total of 22 CTAs participated in the study. The average age of participants was 46 years. The average years of experience of participants were 7.5 years. Majority (36.5%) of CTAs were from the medical-surgical discipline, followed by the discipline of pediatrics (22.7%), maternity (13.6%) and community (9.1%), critical care (9.15), and psychiatry (9.1%) [Table 1].
Table 1: Number of the clinical teaching assistants per dripline

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The theory that emerged was the “theory of EBP among CTAs.”

The concepts and definitions of the theory

One core concept (confident to care) and four subconcepts (teamwork, forcing inquiry, EBP champions, and formal education) emerged.

The core concept

confident to care

Confident to care refers to a state whereby CTAs are able to move from feeling unsure, unskilled and overcoming challenges to feeling safe, and confident in providing safe patient care. CTAs are able to mobilize resources to reach a state of feeling confident to care.

The core processes that facilitate a state of confident to care include teamwork, forcing inquiry, EBP champions, and formal education.

EBP is fostered by teamwork to achieve common goals and shared ideas. Without the collective effort of all stakeholders within the health-care context, EBP becomes a disjointed effort. EBP within the health-care context is challenging and often health-care professionals are faced with a variety of barriers. Further to this, forcing inquiry involves the individual be cognizant of the fact that in order to become confident to care, taking responsibility to having an inquiry approach toward searching for the best evidence. Identifying the best evidence is not an easy task, however, having an enquiring mind will help gain an understanding in research and hence promote best care. In addition, fostering a state of confident to care can be achieved by EBP champions, which includes having support systems in place that are willing to offer teaching and guidance. Finally, confident to care is achieved also through formal education in EBP. This includes education around the core knowledge and skills to practice in a manner than that promotes EBP.

Subconcept

Teamwork

Teamwork involves health-care professional working together to achieve common goals toward safe patient care. EBP is not an individual approach and it involves people working in teams. Working in teams fosters a culture of shared interests and a sense of community of practice:

We come together as a team to share what we each know, and through this sharing, the process of EBP is facilitated.

Being unified is more effective…we collaborate so that we implement the best evidence….we are working towards the same thing at the end of the day…doing it in a team makes more sense than being alone.

According to Kowalski (2017, p 14), teamwork in EBP provides an opportunity to ignite nurse's passion for the EBP process and outcomes.[16] Further to this, teamwork assists health-care professionals to develop the ability to evaluate evidence and amend practice accordingly. Teamwork also provides the opportunity to question, discuss, and reflect could involve practitioners questioning their basic assumptions about practice which could be discomforting. Reflecting and changing practice as members of a team can be supportive and ease fears.[17]

Forcing inquiry

Reaching a state of confident to care is also achieved through the individual having and enquiring mind. This creates opportunity for engaging in research with multiple resources developing critical thinking skills:

You know one has to want to do research…you should have an attitude that questions…always enquire which will expose you to gain more.

A culture of inquiry is required for EBP in which professional nurses develop and practice clinical decision-making and critical thinking skills.[18]

An enquiring mind is the first step in the EBP process.[19] Further to this, making inquiry with a supportive EBP culture allows an individual to routinely ask questions about care that is being delivered.[20]

Evidence-based practice champions

In order to become confident to care, EBP champions as support and guidance are needed. This provides mentorship in order to facilitate professional development needs and implementing EBP changes:

We need people that are expert in the field to help us and guide us…resource people.

It is important to have people that are competent in EBP to show us the way…having them guide us and support us makes it easier to get the knowledge and skills needed.

Champions of change are staff who promote EBP in their clinical areas. The role of facilitation with the champions of change model is a significant strategy in successful EBP implementation.[21] In addition, an EBP champion helps facilitate transition in the organization.[22] An EBP Change Champion is “a charismatic individual who throws his or her weight behind an innovation, thus overcoming indifference or resistance that the new idea may provoke in an organization … [and] can play an important role in boosting a new idea”[23] however, despite the benefits of champions, there are few studies that describe the clarity of the role.[24]

Formal education

Formal education regarding EBP is a vital tool toward ensuring that a practitioner is confident in caring. Formal education should focus on educational framework that should be adaptable to the learners' needs to reflect interdisciplinary nature of care.

I need the skills to search for research, how to access articles, what type of journals should I look at, where to go to find the journals…how to critic an article…I need to be taught all these skills.

Without the proper education it will be very difficult to be familiar with EBP, off course training is very important…we didn't have this in our training in those days so we don't have the skills.

EBP is necessary for health-care systems to improve quality, safety, patient outcomes, and costs. Yet, EBP competency is lacking in many nurses and clinicians across the country.[25] Even though EBP has be included in undergraduate and graduate curriculum in the recent years, many nursing leaders have never received formal education on the skills and knowledge for EBP competency. It takes an average of 17 years for research translation to practice despite the national recommendations for clinicians to use EBP for all clinical decisions. Further to this, literature also highlights that leaders can be barriers to EBP when they do not have the knowledge and skills of EBP to support staff and create a culture of EBP. EBP is a key competency that has been identified to facilitate the improvement of the quadruple aim in health care.[26]


  Discussion Top


Description of the theory

[Figure 1 is a diagrammatic representation of the theory.
Figure 1: The theory of evidence-based practice among clinical teaching assistants

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In describing the structural layout of the theory, the outer section of the theory depicts the context of the “theory of EBP among CTAs.” This is depicted by an outer solid line forming a rectangular diagram. The context of EBP does not represent a physical but rather a context relevant to the process of EBP. The context within which EBP takes place is one of dynamic health care. The ever-changing health needs of the population, keeping abreast of times in terms of practice and care provided, and working in environment that is collaborative and supportive provide a context for which EBP care is driven. The arrows between the boxes depicting the context show that there is a relationship between these concepts related to the context. The arrows leading from the boxes indicating the context moving on to the broken line forming the circle indicate that there is a relationship between the context and the core concept and subconcepts.

Assumptions of the theory of evidence-based practice among clinical teaching assistants

The assumptions underlying this theory include:

  • EBP is collaborative effort and there is a link between all members of the multidisciplinary team
  • EBP is a culture and environment that support the integration of EBP. This allows for access to information, support, and resources that are necessary for skills and knowledge necessary for EBP. The EBP environment is empowering to problem-solving and clinical decision-making
  • The process of novice to expert is time bound
  • EBP requires an enquiring mind and motivation
  • Focused EBP education is facilitate competence.


The context theory of evidence-based practice among clinical teaching assistants

Theory of EBP among CTAs is an explanatory theory to guide the process of EBP among CTAs within the Saudi Context that is characterized by a multicultural environment. The Saudi Arabian health workforce relies largely on expatriate nurses that carry varying education backgrounds, languages, and cultures. However, Strauss and Corbin refer to a context as not being only the physical environment but rather being a particular set of conditions within which action/interaction strategies are taken to manage, handle, carry out, and respond to a specific phenomenon.[15] The context of this theory, therefore, also encompasses stress, a sense of feeling lost, and lacking skills in caring with patients without the necessary EBP skills. Further to this, if an individual has a sense of incompetence and lacks the necessary skills in EBP, then teaching becomes compromised as one lacks the skills to impart onto students.

The purpose of the theory of evidence-based practice among clinical teaching assistants

The purpose of a theory is important because it specifies the context and situations in which the theory applies.[27] This theory provides knowledge and guidance into the process of EBP among CTAs and its overall purpose is to facilitate the process of EBP. It will equip CTAs with the necessary support that will encourage them to shift from traditional approach to care to one that uses the best evidence in practice. It will allow for collaboration among the multidisciplinary team who will work together toward shared ideas and common goals.

In addition to this, a further purpose of this theory is to promote an environment that is conducive and supportive of EBP. EBP is not an individual effort but rather the effort of everyone within the health-care context. Top management to people on the floor should support a culture of EBP. Even though this theory was developed in the context for CTAs, it is not restricted to this area but can be extended and applied to other health-care educators including student.

Evaluation of the theory

A theory is evaluated by its fittingness, understandability, generality, and control.[14] The fittingness was achieved by describing the context of the study and the participants involved. Providing information about the context will help the reader visualize the concepts and subconcepts and assess the fittingness of the findings. Understandability was achieved by using the participant's guidance in the data collection. Data collection commenced initially with purposiveness sampling and proceeded to theoretical sampling based on the participants' responses or words. Generality was achieved by writing conceptually about the findings. Control was achieved by using a specific school of thought, namely the Strauss and Corbin's school of thought.[28]

Limitations and recommendations

The study included just one college in one area within Saudi Arabia. In addition, only one category of faculty was included in the study. Even though qualitative research does not aim to generalize findings, further research includes other colleges and other categories of faculty.


  Conclusion Top


This study provided insight into the process of EBP among CTAs and provided a middle range theory for CTAs toward becoming confident in caring through adopting EBP approach to care.

Acknowledgement

We are extremely grateful to all participants of this research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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