Primary healthcare nurse managers’ perceptions in relation to evidence-based practice and their role in further extension: A qualitative study

Abstract

Objective

To explore the perceptions of primary healthcare nurse managers in relation to evidence based practice (EBP) and their role for further EBP extension.

Design

Bradshaw's qualitative descriptive approach.

Site

Primary Healthcare Centres in the Basque Country, Spain.

Participants

12 nurse managers in Primary Healthcare Centres.

Methods

Data were collected through semi-structured interviews in 2024, transcribed and analysed following qualitative content analysis.

Results

Three categories were elaborated during the analysis. The first one, ‘Somehow contradictory perceptions around EBP’ describes how participants considered EBP at the core of nursing while at the same time perceived it to be something abstract, difficult to achieve and to implement. The second category, ‘The tortuous pathway to EBP competence’ reflects how participants understood that acquiring EBP competence was not a straightforward process, but dependent on individual willingness and motivation of each nurse. Finally, the third category ‘EBP implementation: whose responsibility?’ covers participants’ reflections on their role in further EBP expansion as nursing supervisors along with reflections on institutional barriers and responsibility and action in this regard.

Conclusions

There was a great consensus among participants in this study about EBP being essential to provide quality healthcare but, at the same time, they perceived EBP as something abstract and difficult to implement and dependent on individual nurses’ willingness and motivation. Although participants extensively described organisational barriers for further EBP implementation, their role in EBP implementation was never described as advocating for an organisational change in favour of EBP but down the hierarchy towards the nurses under their management.

Resumen

Objetivo

Explorar las percepciones de enfermeras en puestos de gestión de centros de atención primaria sobre la práctica basada en la evidencia (PBE) y su rol en la extensión de la misma.

Diseño

Enfoque descriptivo cualitativo de Bradshaw.

Emplazamiento

Centros de atención primaria en el País Vasco, España.

Participantes

12 enfermeras gestoras de Centros de Atención Primaria.

Métodos

Se recogieron los datos en 2024 mediante entrevistas semiestructuradas, transcritas y analizadas posteriormente mediante un análisis de contenido cualitativo.

Resultados

Se elaboraron tres categorías; la primera, “Percepciones contradictorias en torno a la PBE”, describe cómo las participantes consideran la PBE como algo fundamental, pero, al mismo tiempo, la perciben como algo abstracto, difícil de lograr e implementar. La segunda categoría, “El intrincado camino hacia la competencia en PBE”, refleja cómo las participantes entienden que la adquisición de la competencia en PBE no es un proceso sencillo, sino que depende de la voluntad y motivación individual de cada enfermera. Por último, la tercera categoría “Implementación de la PBE: ¿de quién es la responsabilidad?” abarca las reflexiones de las personas participantes sobre su rol en la implementación de la PBE, junto con reflexiones sobre las barreras institucionales y su responsabilidad y capacidad de acción al respecto.

Conclusiones

Existe un gran consenso entre las participantes de este estudio al describir la PBE como esencial para proporcionar una asistencia sanitaria de calidad, pero, al mismo tiempo, la PBE se percibe como algo abstracto, difícil de implementar y dependiente de la voluntad y motivación de cada profesional de enfermería. A pesar de que las participantes describen ampliamente las barreras organizacionales para una mayor implementación de la PBE, su papel en la implementación de la PBE no se describe buscando un cambio institucional a favor de la PBE, sino hacia las enfermeras bajo su gestión.

Introduction

Evidence-based practice (EBP) is a lifelong problem-solving approach to clinical decision-making in healthcare that integrates the best evidence from well-designed studies with a clinician's expertise and a patient's preferences and values.¹ EBP is a key strategy to ensure quality care provision and the achievement of best health results for patients.^2,3 Despite its relevance, evidence-based practice adoption and implementation in nursing always face relevant barriers that have been extensively reported in literature.^4–7 Along with individual-level barriers, lack of institutional support – specifically investment in training and professional development, or lack of organisational culture that values and rewards evidence-based innovation – can seriously jeopardise evidence-based practice implementation.^2,8

Nurse managers’ leadership and support are essential for overcoming the barriers described in the literature and ensuring full implementation of EBP.⁹ Besides, they have the potential to advocate for changes in the policies and practices that facilitate EBP, and to shape organisational culture in their services in favour of EBP.^9,10 To achieve this, they must, on the one hand, identify their role and responsibilities in the process,² and on the other, know where their organisation is in relation to EBP beliefs, knowledge, competency and implementation.⁹ Consequently, their knowledge about EBP, their awareness about existing barriers for its implementation and their understanding of the role they can play to address those barriers are essential to hinder or facilitate EBP implementation.²

The study

This study aimed to explore the perceptions of primary healthcare nurse managers in relation to EBP and their role for further EBP extension.

Methods

Design

This research followed a qualitative descriptive analysis approach.¹¹ This study design was deemed the most appropriate to achieve the aim of this study, as qualitative descriptive research seeks to discover and understand phenomena, processes or perspectives of those involved in the issue under study. It is considered particularly relevant when information is required directly from those experiencing the phenomenon under investigation and when there is an interest in deriving practical implications for practitioners and policymakers.¹¹

Context and participants

Participants were nurses in supervisory positions in primary healthcare centres belonging to the public healthcare organisation of the Basque Country, Spain. In February 2024, the first author sent an email to the corporate accounts of nurse managers working at primary healthcare centres to invite them to participate in the study. Two additional invitation messages were sent in March. Twelve of the 27 nurses contacted responded to the invitation and participated in the study.

Inclusion criteria

Inclusion criteria were having a university degree in nursing and working as a nurse manager at primary healthcare services for at least six months at the time of the recruitment.

Data collection

Data collection took place between March and April 2024 through individual semi-structured interviews, which were recorded and professionally transcribed. All the interviews were conducted by the first author, a male nurse with a master's degree and currently a doctoral student, who also works in a primary healthcare centre in a managerial position. Interviews were conducted at the participants’ workplaces for their convenience. The mean duration of the interviews was 27 min (range: 15–49 min).

The interview guide was specifically developed for this study. It included questions related to the meaning and relevance of EBP in the context of the challenges that nurses are currently facing. It also included questions about participants’ perceptions of EBP implementation in their unit, their role in that implementation and the barriers and facilitators related to both their role and EBP implementation in general.

Data analysis

Transcriptions were analysed following qualitative content analysis as described by Graneheim, Lindgren and Lundman¹² with the support of the Atlas.ti software version 24 (GmbH, Berlin, Germany). The software was only used for the coding process and the retrieval of the quotations during the elaboration of the categories. The first and the last authors read all the transcriptions many times to familiarise themselves with the data and independently coded each interview in a double-coding process. The coding process was inductive; thus, all the codes were derived from the data. The first author performed a preliminary sorting of codes into categories, which were later discussed among the first, second and last authors and modified many times until a consensus was reached. The results were then presented to the other two authors of this paper and modified following the suggestions received.

Rigor

The demonstration of quality regarding the research process, and subsequently the findings and conclusions derived from qualitative studies, is always a concern and a challenge.¹¹ Consequently, many different recommendations and strategies have been developed to guide authors in achieving trustworthiness in qualitative studies.

The following lines describe how selected recommendations for establishing trustworthiness in qualitative descriptive studies, as proposed by Bradshaw, Atkinson and Doody, were implemented in this research.¹¹

To achieve credibility, great care was taken to establish rapport prior to and during the interviews. This was facilitated by the interviewer sharing the same nursing profession and managerial role as the interviewees, which enabled him to easily understand and empathise with the experiences described during the interviews.

To facilitate a trusting relationship and enhance participants’ willingness to share information, they were informed in detail about data management and measures to ensure confidentiality. The accuracy of the interview transcripts was ensured by hiring a professional service for this purpose and by the research team double-checking the accuracy of the transcriptions by listening to the audio. Finally, triangulation of the results among the five researchers improved credibility. Three of the researchers are currently nurses working in the same healthcare organisations as the participants, while the other two are nurses working full time at the university. These different positions enriched the credibility by combining these two different perspectives and minimising the risk of insider bias.

In relation to confirmability, along with representative direct quotations from participants included in the Results section, a table with examples of quotations, codes and categories has been included as supplementary material to illustrate the process of development of the categories. Furthermore, at the beginning of the Results section, participants’ relevant characteristics have been summarised.

All the procedures and processes followed during the research process are described in this section to ensure dependability.

To enhance transferability, this study followed a purposive sampling with the aim of finding participants who had enough experience of the issue under study. Variations and differences found in their discourses are described in the Results section of this paper. All the key aspects of the study have been explained to allow for recreation of this study in other settings.

Ethical considerations

The Ethics Committee for Research Involving Human Beings of the University of the Basque Country (UPV/EHU) granted ethical approval for this study (M10_2023_326). Ethical principles of written informed consent, confidentiality and right to withdraw were maintained throughout the study. Even though the first author is also a nurse in a managerial position, there was no previous relationship with any of the participants, as they all work in different primary healthcare centres.

Results

Seventy-five per cent of participants were women, with a mean age of 45.6 years, 22.3 years of average professional experience and 4.7 years in managerial positions. All but one participant had postgraduate official training, such as a master degree or a specialist nursing degree.

Three categories were elaborated during the analysis. The first one, ‘Somehow contradictory perceptions around EBP’, describes how participants viewed EBP as core to nursing, while at the same time perceiving it as abstract, difficult to achieve and challenging to implement. The second category, ‘The tortuous pathway to EBP competence’, reflects participants’ understanding that acquiring EBP competence, understood as the interpretation and application of EBP knowledge in clinical practice, is not a straightforward process but is dependent on individual willingness and motivation of each nurse. Finally, the third category, ‘EBP implementation: Whose responsibility?’, covers participants’ reflections on their role in further EBP expansion as nursing supervisors, along with reflections on institutional barriers and responsibility and action in this regard.

Somehow contradictory perceptions around EBP

There was a strong consensus among the interviewees in highlighting that EBP is relevant, essential and at the core of not only nursing but also all healthcare-related professions, and for patients, mainly as a way to ensure patient safety (Table 1).

Table 1.

Quotations for the first category.

Category	Quotations
Somehow contradictory perceptions around EBP	‘Evidence-based practice seems to me to be fundamental.’ (P8)
	‘[EBP] makes our work valued. That is to say, that in the end… That it has value and that it is recognised.’ (P11)
	‘Well, to carry out our day-to-day work, putting into practice everything we know and which has been proven to be the best way to carry out our work.’ (P7)
	‘All the protocols that we have, all the ways of working that we have, we have to have a backing behind, an evidence-based protocol that uses the scientific method and that is used on a scientific basis. Not because ‘I don’t want to’, ‘not because we have always done it thatway’.’ (P8)
	‘Something abstract comes to my mind (when hearing EBP) because it does not correspond to something that I have had well defined or well-structured in my head from the beginning.’ (P1)
	‘But I think it is something that is still a little bit distant from day-to-day practice and how professionals deal with their daily work.’ (P3)
	I think we have come a long way in that, in thinking a bit more and looking for more evidence than ‘it has been done that way all my life, all my life, we have cured it that way and we continue to do it’…’ (P5)
	‘If you have a unit like when I came here, which was a unit for the elder (nurses), all of them, I was one of the young ones, it was horrible, horrible, you couldn’t innovate anything.’ (P8)
	‘I hope that in the future with the new advances and with artificial intelligence and all those things, all that can be reduced, because it is very difficult that currently nurses can deal all the work behind [searching for evidence]. So I am confident that this ease will exist in the future.’ (P1)
	‘In the end, the workload often doesn’t allow you to stop and think. It's a bit like that, survival…’ (P5)

Thus, EBP was considered every nurse's task, closely linked to daily work and described as doing a good job every day and as the appropriate way to address problems that arise in daily practice. In this sense, EBP was linked, and sometimes equated, to having updated clinical guidelines, norms and standardising procedures, based on research utilisation and in contrast to ‘We’ve always done things this way.’ Similarly, doing EBP was associated with having updated knowledge, being engaged in continuous training activities, going to seminars and conducting research.

In contrast with this unanimous discourse in relation to its relevance, EBP was also extensively described as abstract, something that nurses lack knowledge of, difficult to apply and disconnected from day-to-day reality. Implementing EBP was seen as linked to the necessity of making changes in current practice and its implementation as a continuous work in progress. In general, older nurses were associated with discourses such as ‘I’ve always done things this way’ and were perceived as resistant to change and opposed to EBP.

EBP was also described as something unattainable – on the one hand, due to the immeasurable amount of information being generated constantly, and on the other, due to the perception that changes and discoveries in healthcare happen at a frantic pace, causing clinical guidelines and practice to become outdated permanently. In this scenario, for one participant, AI was seen as the hope that could solve the need for immediate answers when facing clinical doubts.

These challenges to EBP implementation were embedded in a broader context of strain on the nursing profession, as workloads and responsibilities have steadily increased in recent years, without a corresponding increase in staffing, and turnover rates are higher than ever.

All these varied and sometimes contradictory perceptions around EBP can be exemplified in the following quotation, in which a participant brought up the idea that maybe sometimes what nurses do is already EBP even if they are not aware of: ‘Perhaps without knowing it, we do evidence-based nursing, without knowing that we work with it.’ (P11)

The tortuous pathway to EBP competence

Despite defining EBP as the core of the profession, and thus, something every nurse should master, the pathway described by the participants to acquire necessary competences to implement EBP was described as a difficult and not straightforward process (Table 2).

Table 2.

Quotations for the second category.

Category	Quotations
The tortuous pathway to EBP competence	‘The information continues to be passed on [from one nurse to another], you might have a doubt and you go to your colleague… Yes, we do that a lot, from one to another and then if something has worked well, you implement it.’ (P4)
	‘When we were running from ward to ward, we were the messengers, because when there was a change of practice in one unit, in one ward, you took it to the other’ (P8)
	‘We are still, I think, a bit stuck in this learning by imitation.’ (P3)
	‘In the end, right? You can make a huge effort to do everything as well as possible, you can dedicate many hours of your free time to reading, studying… and you will obviously have the personal satisfaction that this will probably have an impact, probably not, certainly, it will have an impact in how you manage your patients, but for the organisation, what difference will be between you and your colleague next door, who while you are reading the latest issue of Clinical Nurse, is out having a drink with her colleagues? Well, there won’t be any. So in the end I also think that this kind of thing… demotivates a bit, at least it doesn’t encourage people to get more involved. That's at least what we see.’ (P3)
	‘Yes, they have much more training, […], and these are some of the competences they have, the subject of research.’ (P9)
	‘Now nurses in the specialisation training have research work with the teaching unit, with methodologists, statisticians… In the end, I think they are incorporating the subject of research into their daily work.’ (P11)

For interviewees, acquiring EBP competence was mainly an autonomous learning process in which professional colleagues play a key role. In the words of one of the participants, ‘We (nurses) learn fromus’ (P8). This knowledge transmission usually happened through informal and barely structured or systematised means. Consistently, there were multiple examples of how good nursing practices were informally transmitted between nurses, such as seminars organised at the unit in which the speaker was someone from the same work group, or working at different units/services as a valuable way of acquiring new knowledge/information.

In this context of barely structured information transmission that was dependent on each service/unit organisation, acquiring or enhancing EBP competence was understood as an individual and autonomous process, and thus dependent on each nurse's motivation and willingness. Moreover, participants complained about the absence of incentives, support and encouragement at the institutional level for nurses with greater implication in EBP.

Most participants saw training in EBP as the university's responsibility. Yet there were discrepancies in the discourses about the role the university currently plays and/or should play in relation to the implementation of EBP. Although for many participants, EBP was considered absent at the university, new generations of nurses were overall described as better prepared to search for information and were identified, in some cases, as a source of information. More specifically, the final-year bachelor's project and the master's thesis were identified as a first approximation to research and to EBP. There was more consensus on the relevance of nursing specialisation training programmes for EBP.

EBP implementation: whose responsibility?

Participants found it difficult to identify and explain their role in relation to EBP implementation (Table 3). One of them mentioned that supervisors did not have any specific role in relation to EBP. The difficulty in identifying their role was linked to the understanding of nurses as professionals with great autonomy, along with the previous description of EBP as an individual responsibility dependent on individual willingness described earlier. Therefore, their role in relation to EBP was described as providing information, motivating, encouraging or facilitating anything that could enhance EBP, such as organising or facilitating continuous training courses, understanding nurses’ interests and needs or trying to give them some time without patients, but never from an imposition or punitive perspective. Participants considered their main responsibility, in relation to themselves, to be serving as role models by staying updated.

Table 3.

Quotations for the third category.

Category	Quotations
EBP implementation: whose responsibility?	‘So well, you can’t be on top of everyone watching how they do everything and at all times supervising absolutely everything, so well I trust my staff, you have to trust them. We do sessions, we implement things that we can change, things that we can improve, but then each one in her practice does what she can or what she wants or so…’ (P2)
	‘But, well, I do think it is important, on the one hand, to lead becoming an example and, on the other hand, that you make life easier for them for these concerns, for these… whatever they want to do, either training, projects, studies or whatever each one wants to do.’ (P5)
	‘If I am going to receive a mail about evidence based nursing monthly, among another hundred of more important things, that is going to go missing. And after two weeks I’ve forgotten about it. If they don’t push it from above, we can’t push it ourselves.’ (P12)
	‘I believe that the process of change should be much more defined, planned and with a great deal of support at an institutional level.’ (P6)
	‘First, lack of time, overload of urgent work for yesterday, of millions of administrative procedures, which are all urgent and not dealing with them makes it difficult for me to work on a daily basis, for the patients and my colleagues, therefore they are a priority.’ (P12)
	‘But if I work in the afternoon on Monday, from early morning I’m already being called with things. With things… it's not about managing agendas, it's that the painter is coming, that the cleaning lady is coming, I mean, do I have to control even the cleaning lady?’ (P8)

When describing their role in EBP extension, many participants pointed to the healthcare institution as the one that should be mainly responsible. Yet, instead of assuming that responsibility, many barriers to a wider EBP implementation described by the participants were, in fact, organisational barriers that hinder EBP. Among them, different issues were remarked upon, including (a lack of) decision-making, excessive organisational fragmentation, lack of information transmission systems, an overwhelming workload for nurses and supervisors, multiple tasks placed on the shoulders of nursing supervisors and excessive bureaucracy.

Discussion

This study aimed to explore the perceptions of nurse managers in relation to EBP, its implementation and their role for further EBP extension. The main findings of this study are that while participants considered EBP essential in nursing, they also described it as abstract, unattainable and difficult to achieve. Acquiring EBP competence and its implementation were described as strongly dependent on personal willingness and effort. Therefore, their role was mainly understood as enhancing that personal willingness and individual ability for EBP implementation among the nurses under their management.

One of this study's findings is the confirmation of the persistent misunderstanding about EBP's meaning, with a strong tendency to conflate EBP with research utilisation, which has been widely reported previously in the literature.¹³ In this sense, it is noteworthy how clinical experience was seen as valueless or even negative and a barrier for EBP in the discourses. Thus, younger nurses were considered better equipped to implement EBP despite having almost no clinical experience, while older nurses with vast experience were perceived as resistant to EBP implementation, with no nuances. Each patient's preferences and values were overlooked, taking for granted that their preferences would always match what the best evidence says. The concern about patients’ references and values getting lost in the process of applying ‘the best evidence’ goes far back in time, and our results seem to justify this concern.^14,15 Furthermore, the progressive incorporation of AI into clinical decision-making, pointed out by one participant as the solution for better research utilisation, has the risk of further disregarding patient preferences.¹⁶

This study's participants’ perception of EBP as abstract and far from daily practice has been associated with a lack of institutional support and unfavourable organisational climate for EBP implementation.^5,17-19 More specifically, organisational factors and structural barriers – such as lack of clarity in tasks and responsibilities, also identified in this study – deter the effective implementation of EBP among nurse managers. The absence of institutional incentives for nurses promoting EBP, as described in the results, has also been identified as a critical barrier for EBP implementation in nursing practice.²⁰ Yet, when describing their role in EBP implementation, there was no mention of anything related to using their position to challenge or advocate for organisational changes. All their efforts were instead directed towards nurses lower down in the organisational hierarchy.

Limitations

Nurse managers who participated in this study might have a specific interest in the topic under study and may differ in their perceptions from those who declined participation. Even if the consistency of this study's findings with existing literature suggests this was not the case, this is a limitation to bear in mind.

Conclusions

There was a great consensus among participants in this study about EBP being essential to provide quality healthcare, but at the same time, they perceived EBP as abstract, difficult to implement and dependent on individual nurses’ willingness and motivation. EBP was exclusively described as the application of best evidence in clinical decision-making, disregarding clinical experience and patients’ preferences as part of it. Although participants extensively described organisational barriers for further EBP implementation, their role in EBP implementation was never described as advocating for organisational change in favour of EBP but rather directed down the hierarchy towards the nurses under their management. To develop their potential to enhance EBP implementation, nurse managers would need specific training to build EBP skills so they can become role models. More importantly, they would also need advocacy skills to ensure their organisations support EBP by mobilising funds and human resources and by establishing policies and regular assessment systems that favour EBP.

What is known about the topic

• •

  EBP implementation in nursing remains limited by individual and organisational barriers.

• •

  Nurse managers can play an essential role in EBP extension by promoting an organisational change to create EBP supportive environments.

What this study adds

• •

  Nurse managers’ role was mainly understood as related to motivating and facilitating training and research related activities for the nurses they were managing.

• •

  There was no mention to their role or potential to change the organisation, even though the majority of barriers they identified for further EBP were at the organisational level and not the individual one.

• •

  Therefore, nurses in managerial positions should receive appropriate training and support to become aware of their potential in changing organisations and to develop necessary advocacy skills.

Ethical considerations

This project was approved by the Ethics Committee for Research Involving Human Beings of the University of the Basque Country (ref. M10_2023_326). Ethical principles of written informed consent, confidentiality and right to withdraw were maintained throughout the study.

Generative AI statement

No generative AI or AI-assisted technologies were used in the writing process.

Funding

APC funding provided by University of the Basque Country, UPV/EHU. The funding organisation had no involvement in the research study design, data collection, the analysis or manuscript elaboration.

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgements

The authors thank all the participants for the willingness for contribute to this study.