Discussion
Our results indicate that, overall, nurses have positive beliefs towards EBPBs,
similar to nurses from HICs,23,24low income,25 and other LMICs.26 This work also provided unique findings. For example, even though the participants strongly believed in their abilities to implement EBP—seeing it as neither difficult nor time consuming—the rate of the behaviors under review concerning EBP was low, reflecting their lack of EBP understanding. This finding was explained by the nurses’ dialogues as the disconnect between what nurses say and what they do . This disconnect—which needs to be addressed—is a well-known concern between nursing care discourse and practice,27 and it slows the progress of EBP in the nursing field globally. For Bolivian nurses, this disconnect, in addition to the identified organizational barriers associated to EBP resources development and support by both administrators and medical staff, does not only nullify nurses’ involvement with EBP, but also affects important dimensions in their profession, for instance, the relational work dimension, by which nurses learn about one another, gain trust and respect, collaborate, and work as a team28 to accomplish goals. The focus group noted that this dimension was absent in their work. The respondents also referred to “destructive criticism,” “egoism,” and “resistance to change” by seasoned nurses occupying most leadership positions. Those on the focus group also faulted nurses’ lack of “altruism and commitment,” in fostering relational work. The core values of altruism, commitment, cleanliness, and orderliness have been inculcated29 in Bolivia nurses since the 1930s—via an educational model copied from Western countries. However, those values alone would not be enough to improve the needed relational work for effective collaboration among the multidisciplinary teams (including nurses) to deliver safe, quality, evidence-based care. The participants also expressed the “loss of credibility” about “how nurses operate” by the care-team professionals, resulting in a lack of respect and trust by others and a lack of visibility within team-care decision-making processes. In this scenario, the relationship nurses have with patients—their most important source of professional pride,30—is vulnerable to fallibility as well.
Another dimension affecting nurses is power. In nursing, power, has been
defined as “power to” achieve objectives effectively, and “power over” as the ability to influence
others’ behaviors.31The nurses in this study shared successful nursing initiatives, by which they achieved their objective of influencing practices. However, these influencing practices were short-lived, and their power in these settings was unsustainable due to the lack of organizational support for EBP. In the last decade, researchers have suggested that certain measures, such as changing nurses’ perceptions to consider EBP as part of their clinical practice, training supervisors in EBP,32 and targeting contextual factors of an organization in terms of its culture, structure, or resources,33 have the ability to empower nurses. However, none of these measures were present in our participants’ workplaces. Contrary to recent findings about nurses having limited power in relation to controlling environments, resources, and over supervisors’ competency compared to power on achieving their professional goals,31 the nurses in our study were primarily concerned with the latter. They repeatedly discussed that their hospital education committees were led by physicians, and thus the continuing education offered tended to benefit the doctors the most. Perceptions of power among nursing professionals are also affected by other aspects, including age. For instance, studies have reported that younger professionals under 30 years of age31 perceive higher levels of group power than those over 30. Our sample consisted mostly of older nurses, and so their responses were the result of an enduring lack of continuing nursing education.
The high scores on items associated with lack of collaboration with physicians and
other staff to implement EPB suggest that collaboration is another affected dimension in the nurses’ work environments. Collaboration focuses on the process of collective action to integrate themes and schemes shared by various disciplines with the goal of proposing solutions to complex care problems.34 The nurses in this study have called out for more collaboration, not only among themselves but also among the multidisciplinary teams and administrative departments in which they worked. They maintained that they were not valued on par with other health professionals, and therefore, their perspective was discounted. They also felt that they did not have the support from Bolivian professional and scientific organizations to increase their visibility within the care team that would lead to greater integration and collaboration for them. The automatous-like perception physicians have about nursing—a general feeling expressed by the participants—is likely the result of prevalent traditional medical and nursing education in Bolivia.
Having at least some graduate-level education and having research work experience were both correlated with the belief that patients’ care would be improved through EBP. The difficulty of accessing data (e.g., from the Cochrane database) was associated with the challenge of implementing EBP. These findings were consistent with other studies.9,15,24The fact that no other associations were found between the participants’ demographics and the identified facilitators and barriers might be due to the lack of EBP knowledge and experience among them, thus resulting in contradictory results. However, this study allowed the nurses to voice their own views on their current practices and what they might do differently. They called upon each other to be proactive in getting themselves noticed within the multidisciplinary teams, as well as to strive for more active roles on those teams. Overall, they celebrated the tripartite effort it took to complete this study and expressed their desire to participate in more dialogues to discuss the difficulties they face. In other words, these nurses were looking for assistance to advance the nursing profession as a whole. This help should be one of commitment to investing the necessary time in investigating nursing phenomena in Bolivia, as well as having bilingual researchers, ideally, who come from various collaborating countries. In the present study, the RAs were UMSA faculty, who as part of the research team, received trainings throughout the study process, e.g., instruction offered by the U.S. National Institutes of Health on protecting human research participants (which is found online in Spanish),35 which allowed the tripartite collaborative to achieve its goal of capacitating nurses in research.
Several limitations of this study should be discussed. First, there was an underrepresentation of staff nurses in the focus groups, as opposed to nurses in leadership positions. There was also a lack of male nurse participants. When engaging nurses as study participants, it is common that researchers generally get a low response rate.36,37Although this study reached its proposed sample, it is important that specific regional and culturally-based strategies should be applied to update the traditional practice of involving only nurse supervisors. Second, the study was limited in terms of geographical area. Nurses’ demographics and attitudes toward EBP can vary in different regions, and this could have affected this study’s findings. Thus, the results of this study should not be generalized to other areas or populations. Lastly, the statistical significance was set at 0.05. Adjustments for a Type I error in multiple comparisons were not implemented. Nonetheless, we reported all the test statistics and exact p values for an accurate report.
Further research on this topic should unveil the EBP preparedness of nurses at a national level, since regional environmental, socioeconomic, and disease profiles regionally may vary nursing research needs. This could be accomplished using via Web-based surveys, which would likely save data collection time and cost. Investigating the needs of educators and clinical nurses to jointly create institutional EBP cultures could enhance the education of future nurses. Additionally, involving scholars from the host country throughout the research process could help to achieve this goal. Creating an entity embracing educators, clinicians, and nursing organizations to develop strategies for nurses to stay current on their EBP skills is one viable recommendation. Ultimately, the success of nurses can benefit from: a) assessing their internal forces of change to propose EBP activities implementation while maximizing the utilization of current resources and allowing for the smooth adoption of new ones; b) working on a policy proposals to be submitted to the Bolivian Health Ministry to increase leadership in the profession throughout the health-care system; c) creating initiatives to prepare doctoral-level nurses to lead the change; d) enhancing relationships with the global EBP community; e) using social media platforms to inform the public and other health professionals about nursing practices, thus increasing the appreciation, visibility, and reputation of their work; and f) seeking financial support to accomplish various nursing goals through national or foreign grants.