Methods
Following the sequential mixed-methods design, the initial results from
the surveys were further explained by data gathered through the focus
group. In both, we examined the
participants’ relationships to EBP beliefs, values, and behaviors while
assessing factors
like years of education, employment, age, and years of research
experience.
The study was approved by the Seattle University Institutional Review
Board (file number FY2017-003). The participants signed an informed
consent agreement (in Spanish) prior to participating, which expressed
the voluntary nature of their participation, their right to refuse to
participate or answer questions, and the measures taken to ensure the
privacy of their responses.
Setting and Participant Recruitment . Professional nurses
(Licenciadas en Enfermeria )
in three hospitals and five public health centers (Redes de
Salud ) in La Paz, who had worked for at least two years were invited to
participate in the study. Hospitals A, B, and C were all tertiary
hospitals with approximately 358, 345, and 160 beds, respectively. The
health centers, collectively referred here as D, were located in
marginalized neighborhoods. The participants were recruited during brief
visits to the study’s settings by two Bolivian-trained research
assistants (RAs). During the survey period, the RAs could begin to
identify the formal and informal leaders, who were to comprise the focus
group. These leaders were later invited by e-mail and mail to
participate in the focus group. No participant was excluded by any
demographic variable (e.g., age, marital status, or sex). The focus
group was configured to be homogenous in terms of experience and focus
of practice, although each person’s characteristics, e.g., age and years
of employment, provided for a diversity of opinion during the group
sessions, which always had at least seven participants. Participants
received means for transportation to motivate attendance and they were
also offered small gifts as a gesture of appreciation.
Measures . The survey included: a) demographic questions (Table
1), b) EBP Beliefs (EBPB), c) EBP Implementation (EBPI), and d) the
BARRIERS scales. The EBPB scale measures a provider’s belief about the
value of EBP.19 This
scale had 16 items, gauged on a five point Likert-type scale, ranging
from ”strong disagreement = 1” to ”strong agreement = 5”. Total
responses could thus range from 16 to 80. The EBPI scale, containing 18
items, measures the belief and confidence in implementing EBP. It asked
the frequency of each item performed, ranging from ”0” (zero times)” to
“4,” (> 8” times). Total scores could range from 0 to 72.
The scales establish appropriate face, content, and construct validity
with internal consistency reliabilities of Cronbach’s alpha coefficients
> 0.90.19The BARRIERS scale assesses the provider’s perceived barriers to
research utilization. This Likert-type scale is comprised of 29 items
under four factors (Table 2), on which they can respond to potential
barriers, from 1 (to no extent) to 4 (to a great extent), as well as a
non-opinion option. This scale has demonstrated to have high face and
content validity with a Cronbach’s alpha of
0.65-0.80.20The BARRIERS survey was translated
into Spanish following an acceptable
process,21 and
pretested, along with the Spanish version of the EBPB and EBPI survey
questionnaires with a group of nurse volunteers (N = 12) having similar
characteristics to the study’s target population. Similarly, five nurses
validated the focus group questions to produce discussion sessions of
approximately two hours moderated by a skilled facilitator. The
discussion questions were: a) What does evidence-based practice mean to
you? b) How do you identify
evidence-based interventions? c) What barriers make it difficult to
implement EBP? and d) What
changes (personal or institutional) do you think are necessary to
implement EBP?
Data Analysis . Quantitative data were analyzed in SPSS 19 (IBM,
2010). Here, the descriptive statistics regarding the nurses’
demographic and professional characteristics and survey questionnaires
were analyzed. The relationships between nurses’ demographics and
professional characteristics and their identified barriers and
facilitators for EBP were examined using chi-square tests for
categorical measures and Pearson’s r for interval or ratio
measures. For the qualitative part, all sessions dialogues, field notes,
and the principal investigator’s (PI) personal notes were transcribed.
The analysis used an inductive approach, beginning close to the data and
moving through levels of more abstract analysis to identify the patterns
and relationships explaining the phenomena under
review.22 ATLAS.ti 8.0
was used to identify the repetition of phrases and words using in vivo
coding to determine themes, as well as to provide verbatim statements
made about those themes. The results were consistent across the three
sources of data. For cross-language trustworthiness, the analysis was
completed in Spanish—the participants’ language. Additionally,
transcripts were reviewed by the PI and a doctorate-prepared Bolivian
nurse, who negotiated differences. Furthermore, two strategies for
validation of data analysis were used: a) investigator triangulation by
two bilingual investigators, who independently analyzed the same data;
and b) a review of the description of findings by the participants
themselves.