Nurses' experience of integrating evidence‐based changes into their practice: A qualitative study

Abstract

Aim

To explore the experiences of neonatal and NICU nurses on participating in evidence‐based changes in their neonatal pain management practice.

Design

It is a qualitative conventional content analysis.

Methods

A purposive sample with nurses working in neonatal and NICUs was used. The data were collected through 11 semi‐structured in‐depth individual interviews, five focused group discussions, and observations and analyzed using the conventional content analysis method based on the Elo and Kyngäs model. The COREQ checklist was used for writing the report.

Results

Analysis of gathered data led to the emergence of four themes, including ‘being in a supportive and encouraging atmosphere’, ‘a journey from resistance to adherence’, ‘achieving multi‐dimensional improvements’, and ‘facing obstructive challenges’.

1. INTRODUCTION

Evidence‐based practice (EBP) incorporates the best scientific evidence, clinical expertise and patient preferences and values to make decisions (McNett et al., 2022). It employs the best evidence to make decisions and provide efficient and effective patient care scientifically (Li et al., 2019). Studies have confirmed that EBP implementation results in desirable outcomes, reduction of unnecessary variations and standardization of care, provision of equivalent efficient care, improved patient satisfaction, increased clinicians' satisfaction and autonomy and higher health‐related quality of life (Dang et al., 2022). Hence, EBP is essential in planning and implementing healthcare services worldwide (Yoo et al., 2019). Nowadays, it is assumed that an evidence‐based approach should be used in clinical situations for care and decision‐making. Moreover, professional standards, regulatory agencies, health insurance companies and healthcare insurers have considered it a critical issue (Dang et al., 2022).

Despite the strong emphasis on EBP, studies show that the best available and relevant evidence is rarely utilized in healthcare, clinical decision‐making and practice (Dagne & Beshah, 2021; Lehane et al., 2019). In other words, even after comprehensive training and enabling the clinicians, creating and implementing a sustainable change in the routine practice is still the most challenging step in EBP implementation (McNett et al., 2022). It means, this is a multifaceted process involving changes in the behaviour, attitude and practice of clinicians and sometimes needs a significant alteration in the entire healthcare system (Melnyk et al., 2010). Translation of evidence into clinical practice is a dynamic and interactive process towards improving the quality of care (Spooner et al., 2018) which requires organizational support, human and material resources, and the commitment of individuals and inter‐professional teams. Context, evidence, communication, leadership and mentoring are the key factors for the dissemination and implementation of the best evidence in clinical practice (Dang et al., 2022). Among clinicians, nurses play a crucial role (Abraham, 2017) in translating evidence into practice and implementing sustainable changes because of their power in leadership, education, collaboration, communication, evaluation and giving feedback and compiling and adapting the best evidence (Ten Ham‐Baloyi, 2022).

The review of the literature showed that most of the existing studies on implementing evidence in clinical practice were based on quantitative approaches (Abraham, 2017), and primarily evaluated the barriers and facilitators of creating evidence‐based changes in practice (Baird & Miller, 2015; Li et al., 2019; Warren, Montgomery & Friedmann, 2016) and also the effectiveness of evidence‐based interventions (Muirhead & Kynoch, 2019; Rana et al., 2017). Few studies have addressed the nurses' experiences of participating and collaborating in evidence‐based changes (Dagne & Beshah, 2021; McNett et al., 2022). In developing countries such as Iran, there have been many years of studies on nurses' evidence‐based performance, which were largely quantitative or qualitative studies on nurses' knowledge, attitude and barriers to using evidence or end‐of‐grant interventions (Adib‐Hajbaghery, 2009; Moosavi et al., 2020; Shafiei et al., 2014). Therefore, so far, no study has been conducted in Iran that examines the experience of nurses from the time of problem formation, evidence collection, protocol design and its implementation and evaluation.

Studies show that the EBP implementation process is influenced by the interaction between facilitating factors, relevant evidence and the characteristics of the actual context in which the evidence is to be used (Glasgow et al., 2012; Rycroft‐Malone et al., 2013). Also, to achieve the desired results, this process should be evaluated locally and the results of that used to improve the process (Dagne & Beshah, 2021).

Playing multiple roles of nurses in implementing evidence and creating change, places them in the position of rich sources of information and experience in this matter, which can clarify a large part of this challenging process. This study aimed to explore the experiences of neonatal and NICU nurses participating in an evidence‐based implementation project for changing clinical practice in neonate pain management. Applying a qualitative approach to perceive this experience can illuminate latent aspects of the implementation process in our context and provide the basis for facilitating and sustaining the change.

2. AIM

To explore the experiences of neonatal and NICU nurses on participating in evidence‐based changes in their neonatal pain management practice.

3. METHODOLOGY

3.1. Study design

This qualitative content analysis was conducted in 2022 to explore the nurses' experiences participating in an evidence‐based change implementation project. The qualitative approach is appropriate for better understanding a less‐known situation and paying attention to the participants' experiences, beliefs and views (Polit & Beck, 2018). Using an inductive method allows the researcher to provide the necessary contextual knowledge about the phenomenon in question. The researchers used the consolidated criteria for reporting qualitative studies (COREQ; Tong et al., 2007) to design and report the methods and findings.

3.2. Setting

The study setting is a referral medical‐educational centre with 120 beds providing specialized and subspecialized services for children and neonates in Golestan, Northeast Iran. This centre provides care in levels 3 and 4 in neonatal and NICU departments with 6 and 17 active beds respectively. The average monthly bed occupancy rate in this centre is 85%.

3.3. Participants

The nurses working in the neonatal and NICU departments were recruited as key informants between April and August 2022. There were 23 nurses in both the neonatal and NICU departments, all of whom participated in the development, implementation and evaluation stages of the neonatal pain management protocol. Two of the investigators visited the setting and asked them to participate in the study. Then, they provided the participants with information about the evidence‐based practice study purpose, clinical protocol content, implementation process, their roles and tasks and the research team's responsibilities. Due to the educational activity of the researchers as a faculty members in the departments under study, the participants had sufficient knowledge about them.

Finally, 13 eligible nurses agreed to participate in the study and signed the informed consent form. A purposeful sampling method was used to recruit study participants. The inclusion criterion was being involved in developing and applying the neonatal pain management protocol. The protocol was developed by all stakeholders based on the Johns Hopkins evidence‐based model in three steps; defining the practice question, identifying the best evidence to answer the question and translating evidence into a clinical protocol for implementation into practice. All these three steps were conducted through the active involvement of the research team and all stakeholders including; head nurses, matron, clinical and educational supervisors, neonatologists and mothers. The head of neonatal departments was involved as an internal facilitator and mentor to enable the staff for changing their practice. Along with them, there were 3–4 nurses per unit who were responsible for training, evaluating and giving appropriate feedback on nurses' practice in managing the neonates' pain. Moreover, the researchers considered the maximum variation in age, work experience, education level and position in selecting participants. Two of the participants later withdrew due to their unwillingness to recount their experiences and a lack of time. Finally, following 11 interviews and five group sessions, data saturation was confirmed in the opinion of the research team.

3.4. Data collection

The data were collected through semi‐structured individual interviews, group discussion sessions and observation (field note). A sufficiently trained member of the research team conducted the individual face‐to‐face interviews. She started the interview with a warm up question to establish rapport and trust. Then, she asked the nurses to describe their experiences of participating in the development and implementation of an evidence‐based protocol in neonatal pain management and changes in routine clinical practice. In addition, she asked probing and follow‐up questions based on the participants' responses and descriptions to gain an in‐depth understanding of their experiences. The time and place of the interviews were determined based on the participants' preferences in a private hospital room. The group discussion sessions were held in the neonatal and NICU departments of the hospital with the participation of the nursing staff and research team. The nursing staff was encouraged to discuss their perceptions and experiences concerning the process of creating and implementing the evidence‐based protocol and the changes that occurred in their practice and setting. All interviews and group sessions were recorded after getting the participant's informed consent. Each individual and group session took about 40 and 70 min respectively. Then, the audio was transcribed verbatim using Microsoft Word 2010. During the data analysis for a better understanding of the context and concise interpretation of the interviews, the field notes of observations were considered, as needed. No pilot or repeated interview was conducted.

3.5. Data analysis

Data collection and analysis were done by two of the investigators and went on until reaching data saturation and emerging no new codes. Data analysis was done based on the Elo and Kyngäs model, including the preparation, organizing and reporting phases (Elo & Kyngas, 2008). In this way, they read the transcribed interviews several times to obtain a general understanding of the content and determine the meaning units. Data management and coding process to explore the meaning of the participant's experiences were done using MAXQDA V.10 software. During the data analysis process, three transcribed interviews were reviewed and modified by one investigator and the participant to remove ambiguity and more accurately understand. Data reduction and categorization were done by comparing similarities and differences in assigned codes and subsequently, forming the subthemes and main themes. After reviewing of data and reaching of consensus, the study findings were confirmed by the research team.

3.6. Data trustworthiness

The researchers used Goba and Lincoln's criteria to achieve data trustworthiness (Polit & Beck, 2018). To ensure scientific validity and credibility, they allocated adequate time to collect and analyse the data, created appropriate communication in a friendly atmosphere, had prolonged engagement with the participants and continuously reviewed the extracted codes with several participants. They stated the themes accurately reflected their experiences.

To increase the dependability of the findings, they transcribed the interviews as soon as possible, conducted peer review and continuously reviewed the data. To ensure the confirmability of the study, they discussed the research procedures, interview content, transcriptions, codes and categories and the research team agreement rate. The transferability of the findings was established by selecting the participants with maximum diversity and enriched and thorough descriptions of the research location, interactions and observed processes during the research. To maintain reflexivity during the stages of data collection, analysis and reporting, the research team held meetings to learn about their beliefs and experiences and discussed them. They also tried to analyse and interpret the data according to the context and experiences of the participants.

3.7. Ethics considerations

This study has been approved and granted by the Research and Technology deputy of Golestan University and confirmed by regional committee of ethics in research on 23rd May 2021 (Code: IR.GUMS.REC.1400.039). Before starting the study, the researchers provided the participants with the necessary explanations about the purpose, voluntary participation and confidentiality of information. They obtained informed consent for participating in the interview sessions and recording their descriptions.

4. FINDINGS

The study participants were 11 female nurses working in the neonatal and NICU departments of the subspecialty centre with a mean work experience of 12.7 ± 7.5 and a mean age of 37 ± 7.4 years (Table 1). The interviews and group sessions were conducted between April 2022 and August 2022. The content analysis of the data yielded 560 codes, 25 categories, 12 subthemes and four themes. The themes included ‘being in a supportive and encouraging atmosphere’, ‘a journey from resistance to adherence’, ‘achieving multi‐dimensional improvements’ and ‘facing obstructive challenges’, explaining the nurses' experience in an evidence‐based change in their clinical practice for hospitalized neonate pain management (Table 2).

TABLE 1.

The demographic characteristics of the participants.

Code	Age (years)	Marital status	Education	Position	Work experience (years)
P1	40	Married	Master in nursing	Head nurse of NICU	16
P2	47	Married	Bachelor in nursing	Head nurse of neonatal ward	24
P3	37	Married	Bachelor in nursing	Nurse of neonatal ward (mentor)	13
P4	44	Married	Bachelor in nursing	NICU nurse (mentor)	19
P5	43	Married	Bachelor in nursing	Nurse of neonatal ward	18
P6	42	Married	Bachelor in nursing	NICU nurse (mentor)	18
P7	37	Married	Bachelor in nursing	Nurse of neonatal ward (mentor)	14
P8	29	Single	Master in nursing	NICU nurse	3
P9	24	Single	Bachelor in nursing	Nurse of neonatal ward	2
P10	27	Single	Bachelor in nursing	Nurse of neonatal ward	1.5
P11	37	Single	Bachelor in nursing	NICU nurse	11

TABLE 2.

Theme, subthemes and categories extracted from the content analysis of the data.

Theme	Subtheme	Category
Being in a supportive and encouraging atmosphere	Continuous facilitation	Receiving integrated and collaborative training Supplying resources
	Diligent follow‐up and supervision	Regular evaluation Clarification and ambiguity resolution
	Encouraging and motivating	Role‐playing by influential people Receiving formal/informal incentives
A journey from resistance to adherence	Initial resistance	Different beliefs Insufficient knowledge and experience
	Attitude improvement	Obtaining successful experiences in the real environment Receiving positive feedbacks Perceiving pleasant feelings
	Adherence and commitment	Routinized care Finding a mental concern
Achieving multi‐dimensional improvement	Improving professional role‐playing	Safety and improvement of quality of care Favourable responsiveness
	Individual development and dynamics	Improving social–personal skills Self‐efficacy and self‐worth
	Improving inter‐professional skills	More involvement in decision‐making Inter‐professional education and learning
Facing obstructive challenges	Care complexities	Diversity of care needs Unstable clinical conditions of clients
	Resource limitations	Lack of human resources Unfavourable equipment and facilities
	Insufficient preparation of the organizational context	Management and supervision Staff characteristics

4.1. Being in a supportive and encouraging atmosphere

This theme indicates that participants experienced a supportive and encouraging atmosphere during the evidence‐based change process due to ‘continuous facilitation’, ‘diligent follow‐up and supervision’, and an ‘encouraging and motivating’ environment.

4.1.1. Continuous facilitation

Continuous facilitation was formed through receiving integrated and collaborative training from various influential people such as head nurses, mentors, colleagues and faculty members. In addition, features such as continuity and repetition of training, presenting it in various methods such as theoretical, practical and visual, constant availability of the educational content, sharing experiences with colleagues, implementing mentoring and learning in a group manner made the transfer of current knowledge and recommendations to them more optimal and effective.

Change requires training and experience. With training and experience, everything becomes perfect. Some things are elusive and should be repeated several times. You may do it and think it's right, but it's not. It is better if someone who is more skilled gives you more training. This process that was done in our department; that is, the presence of a mentor and the implementation of recommendation by the head nurse, was effective. Training and its continuation were also important. (P5).

The fact that faculty members and head nurses had permanent training, there were pamphlets in the department and materials were fixed, there were always classes, and a mentor was present in the department facilitated the implementation process. It was not a complicated and strange thing that was said once and finished. All staff participate and information and experiences are constantly exchanged. (P8).

As a head nurse, I played the role of model for the staff. Regarding the protocol, I implemented most of the recommendations as the first person in the department and gave them feedback on the good experience I gained. This motivated them to implement the protocol. Then, they shared their experiences, and we concluded that the recommendations are feasible and effective. (P2).

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Providing the necessary resources by the head nurses and hospital authorities, in addition to motivating the staff, provided the necessary conditions for implementing the recommendations in the real environment.

Providing the necessary equipment and supplies was very effective because the staff realized that the authorities also cared about this issue and tried to remove the barriers. For example, they convinced the hospital administrators to buy the topical anesthetic, sucrose solution, or other equipment needed for the protocol implementation. This support can also motivate the staff. (P4).

4.1.2. Diligent follow‐up and supervision

Diligent intra‐professional follow‐up and supervision by the head nurse, mentor, educational supervisor and faculty members and inter‐professional follow‐up and supervision by the physician and head of the department led to the strengthening of the sense of support in the department staff. Because it was an attempt to answer the questions, clear up ambiguities and make the evidence‐based recommendations more operational in the nurses' clinical practice.

The follow‐up done by the head nurse plays a great role. She follows up and checks whether we have done and recorded it or not. She also implements the protocol when performing the procedure. Another factor is the presence of the research team and faculty members by our side. We ask them our questions. They guide us, providing up‐to‐date information, removing our ambiguities, following up on the implementation of protocols, and monitoring. It has an important role in the progress of the evidence implementation. Another important point is the department's physician. When we do pain management, she is with us to monitor what we do. She also gives orders that are very effective in implementing the protocol. (P6).

4.1.3. Encouraging and motivating

The role modelling of influential people, such as the head nurses and physicians, and the implementation of recommendations by them led to encouraging and motivating the nurse to make changes in clinical practice. A feeling of inner satisfaction with one's practice and receiving formal/informal incentives, such as positive feedback and praise, opportunities to comment and express problems, lack of penalty and reprimands in case of mistakes or indolence, a friendly and cordial atmosphere and receiving incentives from the hospital authorities played an important role in inducing a sense of support in the staff during the change process.

The department physician is very helpful; she perform recommendation herself and follows up on its implementation by us. The head nurse performs and repeats the recommendations when we are on shift. She insists that we implement the protocol and encourages us when we do it. The department head's satisfaction makes you feel better and go on. Also, when I implement the recommendations and write them in my report, the positive feedback from the head nurse and faculty members encourages me. In addition, we also received an incentive from the matron for accurate reporting and neonate pain management. (P9).

The head nurse encourages all of us to implement the recommendations. When we try to conduct the procedure, she helps and supervises us. If we do not carry out the procedure correctly, she does not give a penalty or reprimand; she only trains us how to do it. If I make a mistake while working, she will give feedback privately only for improvement. This is very important and valuable and makes us accept it and become motivated to learn it. (P5).

4.2. A journey from resistance to adherence

This theme is formed based on three subthemes including ‘initial resistance’, ‘attitude improvement’ and ‘adherence and commitment’. It shows the experience of a type of gradual process in the participants, during which they passed a path from resistance to adherence and commitment in making changes for their clinical practice.

4.2.1. Initial resistance

The participants expressed that at the beginning of facing the condition of change, a sense of resistance was formed in them, which was caused by different beliefs such as the infeasibility of up‐to‐date knowledge in the clinical setting, time‐consuming and hard implementation of the recommendations, imposing extra work on nursing, lack of trust in the effectiveness of up to date knowledge and a desire for routine practice. In addition, insufficient knowledge and experience regarding the recommendations and lack of practical experience in applying them in a real situation strengthened this feeling in them.

Like any other change, there was resistance toward this change at first. Anyway, it was considered a burden and added work. I felt that my work was getting too much, and it was difficult for me to do or pay attention to it. (P8).

When a new work starts, everyone first resists it because it is unknown. That is, being unknown and not having the necessary experience or skills for it causes resistance. In addition, I thought it would be impossible to implement it in the department; it would not influence our practice. (P11).

4.2.2. Attitude improvement

A short time after the beginning of the change process and implementation of the recommendations by the mentors and head nurses, other staff were also encouraged to experience this new situation. Being in this situation and becoming mentally prepared provided the basis for nurses' attitude improvement through gaining successful experiences such as observing the effectiveness of interventions and favourable outcomes in neonates, performing more successful diagnostic–therapeutic procedures, reducing harm to the neonate, saving time and resources, the pleasant feeling of acquiring new knowledge, and the collaborative and non‐coercive nature of the change process. Receiving positive feedback such as reduced stress and anxiety, increased satisfaction, expressing gratitude and appreciation, increased trust from clients (mothers) and inner satisfaction and peace were other sources of creating a positive attitude in nurses.

When I performed the recommendations, I realized that the neonates were very calm and pleased, and the mothers were satisfied. It was an encouraging factor for me to do these interventions next time. When the neonate was not restless, we felt better. We did procedure once and with more precision. In fact, we do our tasks better in less time. In addition, because the procedure is done carefully and better, consumables are not wasted, and in this sense, it is also useful for the hospital. In general, our attitudes changed due to the good feel of mother and neonate, our attitude changed. (P9).

Now, the procedures is done with neonatal pain management, and the mothers are not stressed. In addition, they trust us more. I feel relieved because the procedure is done well and successfully, and I am doing an effective intervention for the neonate. I have also learned something new about neonates. The neonate is calm, and the procedure is done quickly. This made me change my attitude and be more willing to use protocol recommendations. (P10).

4.2.3. Adherence and commitment

After the nurses' attitude improvement towards changing their clinical practice based on evidence, applying the recommendations was introduced as a routine activity in the care plane of the client (neonate). Then, it was internalized in the mental structure of the staff; that is, it became a priority and mental concern for them. This issue established the participation and coordinated effort for the implementation of recommendations in all the staff. In this regard, the nurses began to support each other committedly and became adherent to implementing the recommendations. Finally, they put forth great effort to always provide the best performance based on the protocol in different clinical situations.

First, the mind must be prepared and then trained. The change starts little by little, and people experience it. The mind will definitely be receptive as a result of the experience. This was the thing that happened to us. Previously, I did not think much about the neonate's pain, but now I do. It is important to me, and I will do it. (P5).

In the beginning, we thought it was difficult, but it became routine over time. Now, I unconsciously implement the recommendations for the neonate before performing the painful procedure. I mean, it has become routine for me and is no longer difficult. In the work shift, we all try to carry out the recommendations under any circumstances and perform it well along with our other duties. If one of the colleagues did not perform it, we would remind and help her do it. (P9).

4.3. Achieving multidimensional improvements

Another extracted theme was the participants' achievement of multidimensional improvements, which consists of three categories ‘improving professional role playing’, ‘personal development and dynamics’, and ‘improving inter‐professional skills’.

4.3.1. Improving professional role playing

Participants declared that they experienced improvements in various dimensions during the evidence‐based change process. About their professional role‐playing, nurses reported the purposefulness and effectiveness of nursing interventions, increased effective interaction with clients (mothers), active client participation in the care and decision‐making, change in perspective towards the patient's care needs and providing specialized, comprehensive, safe and high‐quality care. These conditions, in addition to the client's satisfaction; it has caused a change in the nurse's perspective of their professional role, followed by a pleasant feeling.

Furthermore, the participants expressed that applying up‐to‐date knowledge in clinical practice increased their confidence, promoted their clinical decision‐making ability and client management in different situations, improved their ability to justify and favourable accountability regarding the performed interventions, and helped them provide safer and more effective care.

Before learning about the protocol and implementing it in the department, I thought I would not be able to do my nursing duties if the mother was present and participated during the nursing procedures. But after this experience and understanding its effects, I realized the benefits of the mother's cooperation in caring for the neonate. Especially, I noticed the effectiveness of the interventions and the mother's satisfaction because she was involved in the procedure. So, she realized that I did my best to reduce the pain in her neonate and give her relief. (P3).

I feel I am no longer the kind of nurse who only gives the medication or does her duty per se. I have to notice the issues deeply and pay more attention to the problems that are not tangible. I realized that there are more interventions that I can do to make my patients more comfortable. Now, I can learn a new task, change my attitude, and look more deeply at my patient. Consider his spiritual needs, not just paying attention to the tests, writing reports, and administering medication. I do something more to give a good feeling to both the patients and their families. (P8).

Now I have up‐to‐date scientific and documented backing, and I can present the reasons for the nursing interventions that I do for the pain management of the neonates and defend the staff practice in my department. On the other hand, the doctor's trust in the staff has increased a lot. The nurses have advanced in terms of scientific information in this field and can manage the baby well. The physician is also satisfied; this is very pleasing to me. (P1).

4.3.2. Individual development and dynamics

Individual development and dynamics were other aspects of the experienced improvements by the participants. Improving social–personal skills in areas such as time and resource management, group learning methods, intrapersonal/ interpersonal relationships, knowledge transfer and how to access up‐to‐date knowledge and use it were among the issues mentioned by the nurses. In addition, The statements of the participants revealed that, after improving their performance, they have perceived an increase in self‐confidence, competence, skill, usefulness, and in general, self‐efficacy and self‐worth. The outcome of these perceptions was the formation of pleasant feelings from the satisfaction of the client, physician and head nurse, increased job satisfaction, and peaceful mind/conscience.

One night, when I was on shift, I told my colleague I had forgotten the pain assessment method. Let's study and review it together so that we understand it. I used this technique and tried not to be bossy. When we were together, I suggested studying pain and how to score it together. Then, I asked her to look at the posters to review the educational content. We did the learning in groups. We did things in groups and together. Therefore, the procedures are done faster and better, and no work is done again. (P4).

When I followed the recommendations, the neonate calmed down, which helped me skillfully and once perform the painful procedures. It made me feel more skillful and increased my confidence at work; I felt well. Feeling efficient because I can resolve a neonate's problem and provide her with a safe environment. This feeling is very good and satisfies me. (P9).

4.3.3. Improving inter‐professional skills

Inter‐professional skills were another dimension that improved during the change process. Due to the formation of a shared goal between the physicians and nurses, inter‐professional cooperation and trust improved and facilitated their communication. Along with relationship improvement, their exchanges and joint activities increased. In this way, inter‐professional education and learning took place, and nurses were able to play an effective role in transferring up‐to‐date knowledge to their physician colleagues, especially neonatal assistants. Moreover, the inter‐professional trust provided the basis for increasing the participation of nurses in the client's clinical decision‐making by the physician and made it possible for nurses to play the role of consultant.

At the request of the senior physician, we taught the interns the neonatal pain management protocol practically and theoretically. This increased the value and importance of nursing practice. The interns realized that nurses are also capable of doing specialized work. I felt worthy and was satisfied because I could teach the physicians. (P3).

The collaboration between nurses and physicians has been very good and effective. They listen well to what we report and even ask for our advice. For example, when they wanted to perform a painful procedure for the neonate yesterday, she asked me and my other colleagues for our opinion on the recommendations that are useful for this neonate. Her behavior was friendly and intimate; we did not feel like we were talking to a specialist doctor. (P6).

What has happened is that the physician accepts my report as a nurse and accompanies us to implement the recommendations. Working in a team with the physicians caused a change. Because when we do it together and trust each other, better outcomes are achieved. Implementing the protocol strengthened this trust, and as a result, our motivation to practice change increased. (P4).

4.4. Facing obstructive challenges

This theme has three categories ‘care complexities’, ‘resource limitations’ and ‘insufficient preparation of the organizational context’, representing the challenges that have affected the change process and applying the up‐to‐date knowledge by nurses.

4.4.1. Care complexities

The participant's experience showed that in the clinical setting, an important factor such as the care complexities is a barrier to the implementation of recommendations and evidence in the real environment. This complexity is due to the various care needs of clients and their unstable clinical conditions.

4.4.2. Resource limitations

Resource limitations, such as the lack of nurses and the consequent high workload, high patient‐to‐nurse ratio, overcrowding, undesirable equipment and facilities due to wear, physical space limitations and the lengthy medication/device preparation and distribution process played an essential role in the implementation of evidence‐based recommendation by nurses.

Usually, the overcrowding of the department, the lack of staff, the critically ill neonates, and the need for much care meant that we could not use the recommendations to perform the procedures. Sometimes there were no necessary facilities; for example, buying sucrose or vinyl gloves and repairing the trolleys took a long time. (P4).

In some shifts, the number of patients rises, and we are busy, or the admission is high, and mothers need more support and help upon arrival. Managers sometimes reduce the number of nurses in one shift and send them to departments such as emergency because the hospital is crowded. These were the barriers that prevented us from implementing the protocol well. On the other hand, the physical space limitation of the department has also created problems. We tried to implement the recommendations as much as possible in this situation. (P7).

4.4.3. Insufficient preparation of the organizational context

The researchers also identified that insufficient preparation of the organizational context was another challenge for nurses. Despite the nursing manager's participation in the process of developing and implementing the protocol, the managerial and monitoring context still did not provide sufficient preparation and support for the practice change. The participants pointed out that some managers gave less priority to the up‐to‐date knowledge in the clinical setting, did not have enough information regarding evidence‐based changes, were not familiar with the nurses' duties in specialized departments and had no regular supervision.

We expected that the hospital authorities would understand more that we needed human resources if we wanted to implement the protocol, especially when the number of patients was high. Well, they did not prioritize this issue. It makes you feel like they're not with you and don't see what you're doing. (P7).

One of the problems was the clinical supervisors. They did not have enough information about the protocol, which made us unable to implement recommendations effectively. For example, they ignored the care needs of the neonates and reduced the number of department staff to meet the needs of other departments. This made the implementation of recommendations harder. (P6).

The researchers identified the organization's employees and their unique characteristics as influential factors in the readiness of the organization and change acceptance. In this regard, the experience of the participants showed that the presence of nurses with high resistance and non‐acceptance, lack of professional commitment, low self‐confidence, lack of motivation, age and high work experience can affect the evidence implementation process and act as a detrimental factor that reduces the motivation in other staff. In such a way that even with sufficient and continuous training, encouragement, participation and team approach, no noticeable change can be observed in the clinical performance of these people.

Of course, not all staff are at the same level. Some personnel have less acceptance and are feebler in implementing the new practice. They accept the changes hard and slowly. New personnel perform better and accept things more easily. But it is more difficult for me as a head nurse to change the attitude of high work experience employees. They share their negative attitude with others and negatively affect other personnel. (P2).

Well, each person's thoughts affect their actions. I sometimes work with colleagues who believe these recommendations are not effective, so they do not perform them. They even suggest I not do it and follow the routine practice. (P11).

5. DISCUSSION

This study reflects the neonatal and NICU nurses' experience of an evidence‐based change in their clinical practice for neonate pain management. During the protocol implementation and evidence‐based change, the participants experienced being in a supportive and encouraging atmosphere, a journey from resistance to adherence, achieving multidimensional improvements and facing obstructive challenges.

The theme of being in a supportive and encouraging atmosphere, which results from continuous facilitation, diligent follow‐up and evaluation, and encouragement and motivation, can be one of the requirements contributing to changes in the nurses' clinical practice. Based on the PARiHS framework by Kitson et al., the ideal conditions for successful change implementation require three factors: evidence, context and facilitation in favourable conditions. Access to the best available evidence in the form of clinical guidelines or protocols with patient partnership, along with making a learning organization, continuing education, effective teamwork, clear leadership and regular audit or feedback are necessary as important elements related to the evidence and context factors.

Authority, respect, change agenda, flexibility, consistent and permanent support and presence, facilitators (who make things easier and promote action), and local opinion leaders (who influence other individuals' attitudes or overt behaviour informally in a desired way with relative frequency) have also been considered as critical elements of the facilitation (Kitson et al., 1998). The participants' experience in this study confirms the factors emphasized in the PARiHS framework and their effects on the implementation of evidence and practice change.

Based on the results of this study, continuous education through different methods, in a collaborative, mentoring, role‐playing manner and sharing the experiences along with cooperating with the faculty members and clinical nursing staff can be effective strategies in transferring current knowledge and improving the nurses' clinical practice. Several studies have suggested that nurses' continuous training is essential for EBP implementation (Duff et al., 2016; Li et al., 2019; Pereira et al., 2018). Higuchi et al. have shown that interactive and collaborative workshop activities enable people to successfully choose a shared focus for change and identify feasible steps to start the evidence‐based change process. Moreover, sharing success stories is an effective way to help build self‐efficacy and initiate change because reflecting on successful strategies allows people to create an attitude of empowerment which is a requirement for sustainable evidence‐based change (Higuchi et al., 2015). Employing a combination of dynamic teaching/learning techniques that involve learners in their learning process is an effective strategy for knowledge transfer and evidence‐based changes (Patelarou et al., 2017; Turenne et al., 2016). Cheng et al. (2018) have recommended strengthening the relationship between academic and clinical nursing institutions along with mutual benefits and close collaboration during the EBP implementation. It is one of the requirements of a supportive environment for EBP (Whiteside et al., 2016); its absence, along with the weak research culture, is an inhibiting factor at the organizational level (Alison et al., 2017; Friesen & Comino, 2017; Shifaza & Hamiduzzaman, 2019). Supervision motivates employees to maintain their commitment to EBP and identify and address their individual learning needs (Whiteside et al., 2016). Hence, mentors and role models are required to demonstrate the application of EBP in clinical decision‐making and to facilitate the context for EBP within a specific organization or environment (Lehane et al., 2019) because in addition to promoting change, they can effectively motivate other staff.

Therefore, according to the study results, it seems that the combination of the mentioned factors can provide a supportive and encouraging environment to create sustainable change. Similarly, McNett et al. (2022) declare that the EBP implementation in healthcare settings will be more effective when it is carried out by an inter‐professional team with strong leadership, adequate resources and stakeholder involvement in a positive EBP organizational culture. Because the lack of these factors, even with the presence of trained clinicians, can be a resisting obstacle to EBP implementation.

The participant's experience in this study defined the theme of a journey from resistance to adherence as a reflection of the path taken to achieve change in the clinical practice. In his Diffusion of Innovation theory, Rogers states that the change diffusion occurs during a five‐step decision‐making process. In the knowledge stage, a person becomes aware of the innovation and tries to get information about why and how it happened. The persuasion stage occurs when the person has a positive or negative attitude towards change. A positive or negative attitude towards a change does not always directly or indirectly result in accepting or rejecting it. In the decision stage, the person understands the concept of change, assesses its advantages and disadvantages, and decides to accept or reject it. In the implementation stage, the person uses the change to different degrees depending on the situation and determines its usefulness. In the confirmation step, the person finalizes her decision to continue using the change (Shahin, 2006). A reflection on the participant's experiences in this study shows that they have gone through these steps, and after initial resistance and reluctance, they have achieved attitude improvement. This positive attitude has been achieved after obtaining positive experiences and feedback in a real situation and gaining more knowledge about change, which led to acceptance and group effort. According to Rogers's opinion, changes with more ‘relative advantages’, ‘compatibility’, ‘simplicity’, ‘trialability’ and ‘observability’ are accepted faster than other changes by people. Therefore, preparing these variables for change can accelerate its diffusion process (Shahin, 2006).

The results of this study have revealed that effective leadership by the head nurses and mentors of the department is a crucial factor in creating an accepting atmosphere and sustainable change. According to Barker, most people resist change because they are stuck in their ‘comfort zones’ (Jordan et al., 2016). Often exists an organizational culture that is resistant to change and EBP implementation. Therefore, fostering and improving the culture of EBP is necessary to ensure its implementation (Williams et al., 2015). Cultivating this culture is a leadership‐driven change that fundamentally challenges common beliefs about practice. Hence, an evidence‐based culture requires leaders at all levels to question the traditions, set expectations, use evidence as the basis for decision‐making and hold the employees accountable at all levels for this issue (Dang et al., 2022). Evidence shows that committed leadership improves the organizational context, work culture, clinical environment, encourages the research spirit and increases EBP throughout the organization, resulting in improved outcomes (Pittman et al., 2019; Shuman et al., 2020).

The third theme, achieving multidimensional improvements, expressed improvement in the nurses' professional, personal and inter‐professional dimensions during the evidence‐based change process. In line with these results, several evidence show that EBP leads to safe patient care, favourable outcomes, reduced the time spent on nursing procedures and treatment costs (Dang et al., 2022; Spruce, 2015; Wilson et al., 2015) and it improves job satisfaction and autonomy in nurses (Kim et al., 2017; Melnyk et al., 2017). In addition, EBP presents a systematic approach to decision‐making that leads to the best practices and demonstrates the accountability of clinicians to the care provided. Because considering available, high‐quality evidence increases the probability of doing the right thing at the right time and for the right patient (Dang et al., 2022).

Confirming the participants' experience of this study, Irwin et al. have found that implementing an evidence‐based change helps nurses learn about their clinical practice and experience empowerment and authority. It also provides the basis for team activities, inter‐professional cooperation and partnership, and new interactions within the teams and between the stakeholders (Irwin et al., 2013). EBP is the pinnacle of nursing practice for providing high‐quality, safe, patient‐centred care. It enables nurses as clinical specialists to actively participate and play their role as a member of the inter‐professional team in clinical decision‐making (Disler et al., 2019).

The theme of facing obstructive challenges reflects the nurses' experience of perceived barriers in EBP implementation. These barriers were mainly related to the nature of the nursing profession, clinical environment, resources and facilities and the readiness of the organizational context. In line with these results, a review of the studies highlights the barriers to EBP at individual, professional and organizational levels, including lack of time and resources (Clarke et al., 2021; Moosavi et al., 2020), the high number of patients (Moosavi et al., 2020), increased workload (Jordan et al., 2016; Tobiano et al., 2017), resistance to change (Ecker et al., 2021; Theys et al., 2020), lack of commitment to change (Pericas‐Beltran et al., 2014), lack of self‐confidence and EBP‐related experiences (Tobiano et al., 2017) and complex environments (Ogden et al., 2016; Theys et al., 2020).

In this study, the age and work experience of nurses were also identified as one of the individual barriers. In a 2016 study, Jordan et al. found that nurses younger than 40 years of age have a greater understanding of EBP (Jordan et al., 2016). It has also been found that younger nurses have a greater willingness and a more positive attitude to use EBP (Dalheim et al., 2012; Warren, McLaughlin et al., 2016). Therefore, the presence of young staff with less work experience has been introduced as a factor facilitating the EBP in the organization (Baird & Miller, 2015; Li et al., 2019). This can be due to educating young nurses with curricula containing EBP and empowering them to systematically search and access current knowledge that enables them to implement EBP with increased capability and awareness (Jordan et al., 2016; Warren, Montgomery & Friedmann, 2016). According to the participant's experience, despite the appropriate and accepting organizational atmosphere in the study departments and the follow‐up and supervision of responsible people, including the head nurses, physicians and faculty members; The lower prioritization of managers at other levels such as clinical supervisors and their lack of information about EBP and the lack of regular monitoring have been the barrier to the implementing this process. Consistent with these findings, other studies have identified a lack of support for change (Dadich et al., 2015; Pericas‐Beltran et al., 2014) and a lack of knowledge and skills in the EBP (Augustino et al., 2020; Clarke et al., 2021) as barriers to the implementing EBP. The value and priority of EBP implementation in the organization and appropriate monitoring and feedback from managers lead to the creation of a supportive organizational climate for change (Baird & Miller, 2015; Melnyk et al., 2010; Whiteside et al., 2016). Therefore, it appears that improving the motivation, information and active participation of leaders and managers at all organizational levels play an important role in initiating, maintaining and sustaining an evidence‐based change.

5.1. Limitations and strengths

One of the strengths of this study is the reflection of the real nurses' experiences from the context of participation in the process of developing and implementing EBP. Also, the researchers have used integrated methods such as individual interviews, group sessions and observation for data collection. These results, as an experience in a developing country, can, along with other similar studies, create a more comprehensive view of the dimensions of evidence implementation in clinical practice and create the basis for developing programmes to expand, maintain and continue sustainable evidence‐based changes in the healthcare system. Provide health. Due to its qualitative nature, this study can only be generalized to similar employees and clinical environments.

6. CONCLUSION

According to the findings, it can be concluded that despite individual and organizational barriers, the stakeholders' participation in all stages of development, implementation and evaluation is the key to success in the process of creating evidence‐based changes in nursing practice. Hence, strategies such as promoting inter‐professional relationships, creating opportunities for all levels of care and treatment staff to participate, continuous interaction, constant evaluation of the practice, providing feedback in the real situation, employing internal and external organizational facilitators for removing the individual and organizational barriers, and motivation to accept and create change are recommended.

7. RELEVANCE TO CLINICAL PRACTICE

Since the findings indicate that nurses have enough enthusiasm and motivation for change and EBP; therefore, researchers and health managers can increase the probability of success in the change implementation and sustainability by involving the nurses in the development process and translating evidence to practice. In addition, it is recommended that before implementing EBP interventions, the context be analysed to identify barriers and foster the facilitators. Because it seems every organization needs to develop successful implementation and facilitation strategies based on the characteristics of its context. Designing evidence‐based intervention studies in the healthcare system context can help to identify more effective facilitating strategies to create sustainable changes.

AUTHOR CONTRIBUTIONS

Homeira Khoddam have made contributions to study design, acquisition of data, analysis, interpreting of data, drafting and revising the article. Mahnaz Modanloo have made contributions to study design, acquisition of data, analysis, interpreting of data, drafting and revising the article. Neda Mehrdad have made contributions to study design, interpreting of data, drafting and revising the article. Fatemeh Heydari have made contributions to study design, acquisition of data, drafting and revising the article. Razieh Talebi have made contributions to study design, acquisition of data, analysis and interpreting of data, drafting and revising the article. All authors read and approved the final article.

FUNDING INFORMATION

This work was supported by the Golestan University of Medical Sciences, School of nursing and midwifery.

CONFLICT OF INTEREST STATEMENT

The authors of this article declare that they have no conflict of interest.

ETHICS STATEMENT

This study has been approved and granted by the Golestan University of Research and Technology deputy and confirmed by national committee of ethics in research on 23rd May 2021 (Code: IR.GUMS.REC.1400.039).

Khoddam, H. , Modanloo, M. , Mehrdad, N. , Heydari, F. , & Talebi, R. (2023). Nurses' experience of integrating evidence‐based changes into their practice: A qualitative study. Nursing Open, 10, 6465–6478. 10.1002/nop2.1898

DATA AVAILABILITY STATEMENT

Data consist of the transcribes of interviews with participants that were conducted in Persian. Some of the items are translated and mentioned in the text of the article as quotations. The findings of this study are available on request from the corresponding author.