Original Article

Effectiveness of a Computer-Based Educational

Program on Nurses’ Knowledge, Attitude, and
Skill Level Related to Evidence-Based Practice
Patricia Hart, RN, PhD, LeeAnna Eaton, RN, PhD, Marlette Buckner, RN, MN, CNS-BC, Beth N. Morrow, RN, MSN, APRN, BC, Darcy T. Barrett,
RN, MSN, CNRN, Danielle D. Fraser, RN, MS, CNS, BC, Dwayne Hooks, MN, APRN, BC, CNHA, CALA, CAS, Rebecca L. Sharrer, RN, CIC

ABSTRACT
Purpose: To conduct a baseline assessment of nurses’ perceptions of knowledge, attitude, and skill level
related to evidence-based practice (EBP) and research utilisation; determine the level of organisational
readiness for implementing EBP and research; and examine the effectiveness of a computer-based educa-
tional program on nurses’ perceptions of knowledge, attitude, and skill level related to EBP and research
utilisation.
Design: A descriptive, quasi-experimental design with a one-group, pre-intervention survey, interven-
tion, and post-intervention survey method was used. A convenience sample of 744 nurses working in an
integrated health care system was recruited. The study was conducted from May 2006 through November
2006.
Methods: Data collection instruments were a demographic data questionnaire and the Evidence-Based
Nursing Questionnaire. An education intervention on principles of EBP and research utilisation was
conducted via three computer-based learning modules.
Findings: Statistically significant differences in perceptions of knowledge, attitude, and skill level,
as well as beliefs about organisational readiness were found after nurses participated in the computer-
based education intervention. Although nurses indicated having positive attitudes about using research to
support best nursing practice, gaps in knowledge and skills in retrieving research publications, evaluating
the evidence, and incorporating the evidence into practice remain. Nurses rated their managers, senior
nursing administrators, and staff nurses on their unit higher than hospital managers in supporting changes
to practice based on research.
Conclusions: Nurses in clinical settings need to be able to use research findings and incorporate EBP into
their nursing practice to promote positive patient outcomes. Appropriate organisational infrastructures
are essential for promoting EBP and research utilisation in clinical settings. Diverse and effective methods
are essential in educating and engaging nurses in EBP and research utilisation. Computer-based education
is an effective approach that can be used by nursing leaders in health care organisations to educate and
engage nurses in EBP initiatives and research utilisation.
KEYWORDS evidence-based practice, research utilisation, nurse, knowledge, skill, attitude, education, com-
puters
Worldviews on Evidence-Based Nursing 2008; 5(2):75–84. Copyright © 2008 Sigma Theta Tau International

Patricia Hart, Manager, Clinical Onboarding, Organizational Learning, LeeAnna Eaton, Director, 7 Blue Cardiovascular Progressive Care Unit and 4 West Cardiac Telemetry,
WellStar Kennestone Hospital, Marietta, Georgia. Marlette Buckner, Clinical Nurse Specialist, Acute Care, Beth N. Morrow, Infection Control Coordinator and Core Measures
Specialist, WellStar Douglas Hospital, Douglasville, Georgia. Darcy T. Barrett, Clinical Nurse Specialist, Critical Care, Danielle D. Fraser, Clinical Nurse Specialist, Critical Care,
WellStar Kennestone Hospital, Marietta, Georgia. Dwayne Hooks, Executive Director, Patient Care Services, WellStar Windy Hill Hospital, Marietta, Georgia. Rebecca L. Sharrer,
Strategic Director, Infection Prevention/Employee Health, WellStar Health System, Atlanta, Georgia.
Address correspondence to Patricia Hart, Clinical Onboarding, Organizational Learning, WellStar Health System, 2000 South Park Place, Atlanta, GA 30339;
tricia.hart@wellstar.org
Accepted 4 January 2008
Copyright ©2008 Sigma Theta Tau International
1545-102X/08

Worldviews on Evidence-Based Nursing r Second Quarter 2008 75

Computer-Based Educational Program
Evidence-based practice (EBP) is the process of clinical
decision making by integrating the best research evidence
with clinical expertise and patient’s values (Sackett et al.
2000). EBP is continually evolving as new and relevant ev-
idence emerges and clinical practice decisions change to
promote optimal patient care. EBP is a framework for “an-
swering clinical questions” by evaluating and incorporating
the best clinical knowledge related to the patient’s state,
the clinical setting, and clinical circumstances (Haynes
et al. 2002).
Evidence-based nursing care is of high priority for
nursing leaders in health care organisations in developed
countries. Nurses in clinical settings should use EBP and
research to sharpen their assessment skills, develop and im-
plement policies and procedures, execute effective nursing
interventions, and develop plans of care to promote posi-
tive patient outcomes (Lewis et al. 1998). Educating and
engaging nurses in EBP initiatives and research utilisation
can be daunting and costly. The vast number of nurses
working in health care organisations presents unique chal-
lenges in communication and educational initiatives. Nurs-
ing leaders need to develop effective and cost-efficient
strategies to educate nurses about EBP initiatives and re-
search utilisation to facilitate a culture that promotes the
use of EBP in clinical settings.
BACKGROUND
Knowledge and Skills
Several reasons have been cited for why nurses do not rou-
tinely incorporate evidence into their practice. These in-
clude a lack of research awareness, lack of technical skills
in evaluating the quality of the research (Olade 2003; Ger-
rish & Clayton 2004), and lack of knowledge on how to
obtain relevant information (Mott et al. 2005; Pravikoff et
al. 2005). Disparities also exist between nurses’ perceptions
of their knowledge and skill level toward EBP. In some stud-
ies, nurses rated their level of knowledge and skill related
to EBP as low (Mullem et al. 1999; Melnyk et al. 2004)
while another study indicated that nurses reported higher
levels of EBP knowledge and skill (Upton & Upton 2005).
In addition, higher educational levels (Hatcher & Tranmer
1997; Olade 2003) and professional title (Mullem et al.
1999) were statistically significant in “predicting” higher
levels of knowledge and skill toward the implementation
of EBP.
Attitude
Researchers cite nurses’ attitudes as one of the most im-
portant factors in implementing EBP (Hicks 1998; Upton
1999; Hundley et al. 2000; Upton & Upton 2005; McSh-
erry et al. 2006). Some researchers suggest that nurses have
76 Second Quarter 2008 r Worldviews on Evidence-Based Nursing
a negative attitude toward EBP (Hicks 1998; Upton 1999)
while others suggest they have a positive attitude (Hatcher
& Tranmer 1997; Hundley et al. 2000; Upton & Upton
2005; McSherry et al. 2006). Some studies show nurses
with positive attitudes were more likely to use evidence-
based research in practice (Hatcher & Tranmer 1997;
Estabrooks et al. 2003; Melnyk et al. 2004). Other re-
searchers have shown that nurses who believe that EBP im-
proves patient outcomes provide higher levels of evidence-
based care (Melnyk et al. 2004).
Organisational Readiness
Inadequate organisational and leadership support and lack
of resources have been identified as barriers that prevent
implementing EBP (e.g., Melnyk et al. 2004; Bahtsevani
et al. 2005; McSherry et al. 2006). Research also shows
that nurses perceive a lack of organisational commitment
for EBP, which indicates that organisational infrastructures
do not yet have the requisite elements for facilitating the
implementation of research into practice. Nurses who per-
ceive they are supported by administrators and peers are
more likely to engage in research activities and translate
research findings into practice (Champion & Leach 1986,
1989). In contrast, lack of administrator support and re-
sources are barriers to implementation (Cooke & Grant
2002). Nurses also perceive more support from their peers
and managers for implementing research findings into
practice than from physicians and other health care pro-
fessionals (Hatcher & Tranmer 1997).
Computer-based education (CBE) may be an effective
and cost-efficient strategy to educate and engage nurses in
EBP and research utilisation. CBE is defined as an instruc-
tional type of program in which a computer is utilised in
the teaching process to enhance the education of a student
(Tripathi 1998). CBE has been used to supplement or re-
place conventional teaching methods and is an alternative
method to provide information in a uniform and reliable
manner. Investigators exploring the use of CBE report find-
ings such as reduction in travel costs and personnel time,
the capability to deliver the same consistent program, and
the flexibility to meet rapidly changing needs (Franck &
Langenkamp 2000; Welton et al. 2000; Janicki & Liegle
2001).
LITERATURE REVIEW
A search was performed in CINAHL, Medline, EBSCO
host, and Proquest databases for research conducted be-
tween 1990 and 2006 for studies that indicated the effects
of an educational program focused on nurses’ awareness
of research and implementation of research. Key search
terms were education, course, EBP, research utilisation, and

nursing. While numerous descriptive, exploratory stud-
ies have been conducted on nurses’ attitudes, beliefs, and
practices related to EBP (Rodgers 2000; Estabrooks et al.
2003; Melnyk et al. 2004; Upton & Upton 2005), only four
interventional nursing studies were identified (Hundley
et al. 2000; Nilsson et al. 2001; Tsai 2002; Ellis et al. 2005).
However, no research studies were identified that showed
the effectiveness of a CBE program on nurses’ perceptions
of knowledge, attitude, and skill level related to EBP and
research utilisation.
Ellis et al. (2005) examined the effects of a facilitator-
led educational program to assist nurses in developing pro-
tocols to address practice issues. Participants reported in-
creased understanding about EBP and were more confident
about their ability and skills to improve best practices after
participating in the facilitated workshops.
Hundley et al. (2000) evaluated the effectiveness of two
approaches to increase research awareness among mid-
wives and nurses. The control group was provided with
an education and training program only and the interven-
tional group was provided with the education and training
program as well as policy and practice interventions. Find-
ings showed that the interventional group was more likely
to engage in research utilisation and participate in reading
research journals.
Nilsson et al. (2001) conducted a 2-year educational
program to facilitate the dissemination and implementa-
tion of research findings in clinical practice at the unit
level. Four themes emerged from the qualitative portion
of the study including (1) organisational and leadership
issues, (2) acquiring a new role, (3) responses and reac-
tions of others, and (4) orientation to research. The re-
searchers concluded “research utilisation and the change
to research-based nursing practice are complex issues
which require both organisational and educational efforts”
(p. 679).
Tsai (2002) examined the effects of an 8-week research
utilisation course. Nurses in the experimental group had
a more positive attitude toward research, perceived greater
support from their institutions, and higher levels of par-
ticipation in research than did the nurses in the control
group.
Measurement of
Dependent Variables
Knowledge
Convenience Attitude
→ →
Sample Skill
Organisational Readiness
Figure 1. Research design: One-group, pre-intervention survey, intervention, and post-intervention survey.
Worldviews on Evidence-Based Nursing r Second Quarter 2008 77
Computer-Based Educational Program
PURPOSE
This research study was conducted because no reports of
studies were found that indicated the effectiveness of a CBE
program on nurses’ perceptions of knowledge, attitude, and
skill level related to EBP and research utilisation. The pur-
poses of the research study were to conduct a baseline as-
sessment of nurses’ perceptions of knowledge, attitude, and
skill level related to EBP and research utilisation; determine
the level of organisational readiness for creating a culture
that integrates EBP and research into daily practice; and
examine the effectiveness of a CBE program on nurses’
perceptions of knowledge, attitude, and skill level related
to EBP and research utilisation.
METHODS
Design
A descriptive, quasi-experimental design with a one-group,
pre-intervention survey method, and post-intervention
survey method was used (Figure 1). A quantitative method
was used to structure the data collection process to ob-
tain pre- and post-survey data to compare differences in
nurses’ perceptions of knowledge, attitude, and skill level
as well as beliefs about organisational readiness after par-
ticipating in the educational intervention in a large sample
size.
Sample & Setting
A convenience sample of registered nurses (RNs) and li-
censed practical nurses (LPNs) working in an integrated
health care system located in a southeastern state in the
United States was recruited. The potential recruitment pool
was estimated around 2,600 nurses. The integrated health
care system consisted of five hospitals, physician practice
groups, and outpatient services.
Study Instruments
Data collection instruments were a demographic data ques-
tionnaire and the Evidence-Based Nursing Questionnaire
(Nagy et al. 2001). Nurses were asked to complete the ques-
tionnaires before the CBE intervention and again 2 weeks
after completing the intervention.
Measurement of
Intervention
Dependent Variables
Knowledge
CBL Attitude
→
Education Program Skill
Organisational Readiness
Computer-Based Educational Program
Evidence-based nursing questionnaire. Permission was re-
ceived to use the Evidence-Based Nursing Questionnaire
developed by Nagy et al. (2001) to measure conditions
that “nurses believe support or hinder the development
of evidence-based nursing” (p. 314). Content and con-
struct validity were established by Nagy et al. The 32-item
questionnaire has six subscales: (1) organisational support
(readiness), (2) nurses’ beliefs and attitudes of research ev-
idence, (3) EBP skills, (4) clinical relevance of research, (5)
nurses’ knowledge of research language and statistics, and
(6) available time for EBP. The response format is a 5-point
Likert-scale from “strongly disagree” (1) to “strongly agree”
(5). Subscale scores ranging from 1 to 5 are achieved by
summing the items in each subscale and dividing by the
number of items in the subscale to obtain a mean value.
Initial Cronbach’s alpha coefficients for the subscales
were organisational support (readiness) 0.84, nurses’ be-
liefs and attitudes of research evidence 0.79, EBP skills
0.81, clinical relevance of research 0.59, nurses’ knowl-
edge of research language and statistics 0.73, and available
time for EBP 0.52. For this study, the following four sub-
scales (with corresponding Cronbach’s alpha coefficients)
were used (1) organisational support (readiness) 0.85, (2)
nurses’ beliefs and attitudes of research evidence 0.74, (3)
EBP skills 0.83, and (4) nurses’ knowledge of research lan-
guage and statistics 0.75. These four subscales were se-
lected because they were aligned with the study concepts
being measured. Comparison of the original Cronbach’s al-
phas and those of this study show that the integrity of the
internal consistency of reliability was maintained within
each subscale.
Intervention
Education on EBP and research utilisation was provided via
three computer-based learning (CBL) modules. Four clin-
ical nurse specialists within the health care system who
were knowledgeable in the principles of EBP and nursing
research developed the modules. The modules contained
educational content such as developing a clinical ques-
tion warranting further investigation, performing a liter-
ature review, reading and critiquing research articles, and
examples of implementing evidence into daily practice.
Table 1 shows the objectives for each of the CBL modules.
The three CBL modules were posted on the Intranet educa-
tion site 1 month apart to facilitate the content progression
of the series and allow adequate time for completion. Each
of the three modules took an estimated 15 to 20 minutes
for a participant to complete.
Data Collection
Data collection and completion of the CBLs were con-
ducted from May 2006 through November 2006. Informa-
78 Second Quarter 2008 r Worldviews on Evidence-Based Nursing
TABLE 1
Computer-based learning module objectives
CBL Module I
r Asking the burning clinical question
◦ Define EBP
◦ Identify a health care system initiative that is consistent
with EBP
◦ Define literature review
◦ Describe electronic and library resources for obtaining literature
◦ Define the steps in conducting a literature review
CBL Module II
r How to read and understand a research article
◦ Define EBP
◦ Define and compare quantitative and qualitative research
◦ Describe the purpose of the introduction, methods, results, and
discussion sections of a quantitative research article
◦ Review the content and highlight key statements in each section
of a quantitative research article
CBL Module III
r Utilizing research: putting evidence into nursing practice
◦ Provide examples of how EBP is applied in the clinical setting
to improve patient care outcomes
◦ Identify resources/groups that actively support EBP
and research
◦ Identify employees available to mentor nurses interested
in nursing research and EBP initiatives
tion about the study and a cover letter consent form were
added to the health care organisation’s computer-based In-
tranet education site. All nurses were invited to participate
in the study. If nurses agreed to participate, they selected the
Intranet web link, allowing them to access the study site.
Nurses who completed the pre-intervention survey ques-
tionnaires and all three educational CBL modules were in-
vited to participate in the post-intervention survey portion
of the study.
The pre-intervention survey was placed on the Web site
for 6 weeks and then removed before the posting of the
first CBL module. A new CBL module was placed on the
computer-based Intranet education site once a month until
all three modules in the series were posted (3 months to-
tal). The three CBL modules were then removed from the
website. The post-intervention survey was placed on the
website 2 weeks after the CBL module series was removed
and remained on the site for 6 weeks.
Ethical Consideration
The research study was approved by an institutional re-
view board and the participating agency’s nursing research
committee to ensure the protection of human subjects.
A cover letter indicated the ethical responsibilities of the
researchers and the rights of participants. Each nurse had a
 Computer-Based Educational Program

unique identifier to access the computer-based Intranet ed- TABLE 2

ucation site. Code numbers were assigned and substituted Sample characteristics N = 744
for participant’s unique identifiers by one of the principal RANGE M SD
investigators (PI) to ensure anonymity. The code listing
was only accessed by this PI and the listing was kept in the Age (years) 20–65 43.64 10.33
PI’s office in a locked file cabinet and destroyed once the Years of experience <1–47 16.71 11.45
pre- and post-survey data were matched. Completion of the N (%)
surveys by the participants was acknowledged as consent Gender
to participate in the study. Female 676 (90.9)
Male 42 (5.6)
Data missing 26 (3.5)
Data Analysis Race
Quantitative data were analysed using the Statistical Pack- White/Caucasian 546 (73.4)
age for the Social Sciences (SPSS) for Windows 12.0 Black/African American 106 (14.2)
(SPSS 2003). Descriptive statistics (percentages, frequen- Hispanic/Latino 5 (0.7)
cies, means, and standard deviations) and inferential statis- Native American 3 (0.4)
tics (dependent t tests) were used to describe demographic Asian/Pacific Islander 17 (2.3)
data and answer the research questions. A p value of ≤ .05 Arabic 1 (0.1)
Other 16 (2.2)
was considered statistically significant.
Data missing 50 (6.7)
Licensure
RN 654 (87.9)
RESULTS LPN 60 (8.1)
Sample Data missing 30 (4.0)
The pre-intervention survey was completed by 744 nurses Degrees
and the post-survey was completed by 314 nurses. The LPN 56 (7.5)
Diploma RN 74 (9.9)
majority was RNs (87.9%) with 8.1% indicating that they
Associate degree 240 (32.3)
were LPNs. Nearly all were female (90.9%; see Table 2). Baccalaureate degree 305 (41.0)
Age ranged from 20 to 65 years with a mean of Master’s degree 28 (3.8)
43.64 years (SD = 10.33). The majority was Cau- Post Master’s certificate 1 (0.1)
casian (73.4%) with the next largest group being African Doctorate 2 (0.3)
American (14.2%). Licensure ranged from less than Data missing 38 (5.1)
1 year to 47 years with a mean of 16.71 years (SD =
11.45). Almost half held baccalaureate degrees (41.0%)
and approximately one-third held associate degrees
ity of patient care (90.5%). Participants also believed
(32.3%).
that research helped nurses in decision-making processes
(75.8%).
Pre-intervention Survey Knowledge
Responses on the EBP surveys were recoded and condensed Pre-intervention Survey Skills
from “agree” and “strongly agree” to “agree,” from “dis- Over 58% were confident in their ability to retrieve and
agree” and “strongly disagree” to “disagree,” and from “nei- evaluate research reports (Table 3). However, 59.8% re-
ther agree nor disagree” to “uncommitted” in order to cal- ported needing more skills in evaluating research before
culate percentages for each category. Over half (55.8%) be- they could use it to change nursing practice. Over half
lieved they were confident in understanding the language (63.4%), were confident they had the necessary skills to
in research articles (Table 3). Nurses reported less confi- conduct a computerised literature search.
dence (46.5%) about their abilities in understanding the
statistics used in research articles. Pre-intervention Survey Organisational Readiness
Overall, 59.1% agreed the organisation provided sup-
Pre-intervention Survey Attitude port and encouraged evidence-based activities (Table 4).
An overwhelming 93.9% were supportive of research and Nursing managers (57.8%), senior nursing administrators
believed the importance of incorporating EBP into prac- (53.2%), and staff nurses (51.7%) were rated higher than
tice (Table 3). Further, nurses believed nursing research were hospital managers (15.1%) in supporting practice
and EBP activities were important in improving the qual- changes based on research. However, 45.8% agreed the

Worldviews on Evidence-Based Nursing r Second Quarter 2008 79

Computer-Based Educational Program

TABLE 3
Selected items from pre-intervention survey knowledge, attitude, and skill level N = 744
DISAGREE UNCOMMITTED AGREE MISSING
STATEMENT % (N) % (N) % (N) % (N)

Knowledge subscale 7.4 (55) 38.2 (284) 54.4 (405) 0.0 (0)
1. Understand research statistics in articles 17.7 (132) 35.5 (264) 46.5 (346) 0.3 (2)
2. Understand research language in articles 12.2 (91) 31.9 (237) 55.8 (415) 0.1 (1)
Attitude subscale 0.1 (1) 6.0 (45) 93.9 (698) 0.0 (0)
1. Nursing research is an important way of improving the quality of patient care 1.1 (9) 8.1 (60) 90.5 (673) 0.3 (2)
2. Research does help nurses in their decision-making 3.1 (23) 20.3 (151) 75.8 (564) 0.8 (6)
Skill subscale 5.1 (38) 36.7 (273) 58.2 (433) 0.0 (0)
1. Have the skills necessary to conduct a computerised literature search 13.9 (103) 22.6 (168) 63.4 (472) 0.1 (1)
2. Need more skills in evaluating research before I can use it to change practice 17.9 (133) 22.3 (166) 59.8 (445) 0.0 (0)

hospital had a climate that encouraged staff to pursue new DISCUSSION

ideas. Additionally, only 22.1% agreed nurses in the hospi-
tal were encouraged to carry out research.
Intervention Effect on Knowledge, Attitude, Skill
Level, and Organisation Readiness
Dependent t tests were conducted to examine the effect
that the CBE intervention had on nurses’ perceptions of
knowledge, attitude, and skill level related to EBP and re-
search utilisation and their perceptions of the organisation’s
readiness in supporting EBP activities (Table 5). Statisti-
cally significant differences were found in perceptions of
knowledge, t (0.05, 312) = –2.296, p = .022, attitude,
t (0.05, 313) = -–4.750, p < .001, and skill level, t (0.05,
313) = –4.322, p < .001, and beliefs about organisational
readiness, t (0.05, 313) = –8.601, p < .001, between pre-
survey and post-survey scores.
The findings show a significant improvement in nurses’
perceptions of knowledge, attitude, and skill level as well
as nurses’ perceptions of organisational readiness related to
EBP and research utilisation through a targeted CBE inter-
vention. Statistically significant differences in perceptions
of knowledge, attitude, and skill level as well as beliefs
about organisational readiness were found after nurses par-
ticipated in the CBE intervention.
Consistent with findings in the literature, nurses had a
positive attitude toward EBP (Hundley et al. 2000; Melnyk
et al. 2004; Upton & Upton 2005). A majority of nurses
reported feeling confident in understanding the language
used in research publications and less confident about their
abilities in understanding research statistics. In addition,
nurses had the necessary skills to conduct a computerised
literature review. However, as reported in other studies
(Newhouse et al. 2005; Pravikoff et al. 2005; Upton &

TABLE 4
Selected items from pre-intervention survey organisational readiness N = 744
DISAGREE UNCOMMITTED AGREE MISSING
STATEMENT % (N) % (N) % (N) % (N)

Organisational readiness subscale 2.7 (20) 38.2 (284) 59.1 (440) 0.0 (0)
1. This hospital has a climate which encourages staff to 24.6 (183) 29.5 (219) 45.8 (341) 0.1 (1)
pursue new ideas
2. The manager of my unit/department would be supportive 9.8 (73) 32.4 (241) 57.8 (430) 0.0 (0)
if I wanted to change practice on the basis of research
3. Hospital management would support practice based on 37.4 (278) 47.1 (351) 15.1 (112) 0.4 (3)
research even if it was not in keeping with hospital policy
4. RNs in this hospital are encouraged to carry out research 30.5 (227) 47.3 (352) 22.1 (164) 0.1 (1)
5. Nursing staff in my unit will change practice when there is 9.1 (68) 38.9 (289) 51.7 (385) 0.3 (2)
sufficient evidence to support it
6. Senior nurse administrators will support change in 8.6 (64) 38.1 (283) 53.2 (396) 0.1 (1)
practice when there is sufficient evidence to support it

80 Second Quarter 2008 r Worldviews on Evidence-Based Nursing

 Computer-Based Educational Program

TABLE 5 order to complete the study activities. However, the health-

Dependent t tests comparing means and standard deviations for care organisation utilises a CBL format for delivery of many
pre- and post-intervention survey scores of its educational initiatives so completion of the CBL mod-
PRE- POST- ules during work hours amidst patient care responsibilities
INTERVEN- INTERVEN- is a typical format for nurses within the organisation.
TION SURVEY TION SURVEY
N MEAN (SD) MEAN (SD) t p

Knowledge 313 3.42 (.74) 3.52 (0.78) −2.296 .022 IMPLICATIONS

Attitude 314 3.83 (.46) 3.95 (0.48) −4.750 .000
Skill 314 3.30 (.67) 3.43 (0.63) −4.322 .000
Organisational 314 3.18 (.56) 3.42 (0.59) −8.601 .000
readiness
Upton 2005), nurses need more skills in evaluating re-
search before they could use it to change their practice.
Melnyk et al. (2004) also found that nurses’ knowledge
and beliefs about EBP are related to the degree that nurses
engage in EBP initiatives. The high proportion of nurses
in this sample who have not been equipped with skills
in their training indicates the need for leaders to develop
education programs to increase both awareness and com-
petency in evaluating and integrating research into clinical
practice.
Similar to findings by Nagy et al. (2001), nurses believed
the organisation provided support and encouraged EBP ac-
tivities, although, only a small percentage believed hospital
managers encouraged nurses to carry out research (Melynk
et al. 2004; Fink et al. 2005). Consistent with previous re-
search findings, nurses perceived more support from their
peers and managers for implementation of research find-
ings into practice than from physicians and health care
administrators (Hatcher & Tranmer 1997).
LIMITATIONS
Nurses completed the pre-intervention surveys, three CBL
modules, and post-intervention surveys while working on
their nursing units. Interruptions may have occurred dur-
ing content review of the three CBL modules and comple-
tion of the surveys. This may have influenced the effective-
ness of the learning process as well as survey completion.
Additionally, nurses may have had interactions with other
nurses while completing pre- and post-surveys, which may
have influenced their responses.
Nurses may have been exposed to other EBP initiatives
within as well as outside the health care system. Because of
the fact that the study was conducted over 7 months, the
researchers could not control for nurses’ exposure to other
EBP initiatives.
An alternative method would have been to provide
nurses with time away from patient care responsibilities in
These findings have implications for nursing practice in
the areas of education, nursing accountability, and organi-
sational infrastructure. Nurses’ perceptions of knowledge,
attitude, and skill level in understanding and incorporat-
ing EBP into their nursing practice is crucial in ensuring
positive patient outcomes. Though nurses have positive at-
titudes about using research to support best nursing prac-
tice, there remains a substantial gap in knowledge and skill
level in retrieving research publications, evaluating the ev-
idence, and incorporating evidence into practice.
Education
The challenge of enhancing nurses’ confidence in under-
standing the language and statistics used in research can
be daunting. Directly related to knowledge is the skill to
conduct a computerised literature search and the ability to
retrieve and evaluate research reports. Traditionally, nurs-
ing leaders have left the responsibility of educating nurses
about EBP and research to formal nursing programs or at-
tempted to cover the topics quickly during staff develop-
ment programs. These methods fail to reach those already
in practice or limit the access to those participating in staff
development programs incorporating EBP and nursing re-
search topics.
Educating and engaging nurses in EBP and research ini-
tiatives in large health care organisations can be a tremen-
dous task. Removing nurses from the bedside caring for
patients is challenging considering today’s nursing short-
age. Educational programs should be developed to culti-
vate learning about EBP and foster skills, which promote
evidence-based nursing practice. CBE is an effective and
cost-efficient way to educate and engage large numbers of
nurses within a health care organisation. Benefits of CBE
include reduction in travel costs and personnel time, the
capability to deliver the same consistent program, and the
flexibility to meet rapidly changing needs (Kulik & Kulik
1991; Janicki & Liegle 2001). CBE programs should be fo-
cused on topics such as defining EBP, conducting literature
reviews, evaluating quantitative and qualitative research
articles, understanding the language and statistics used in
research, incorporating the best evidence into policies and
procedures, and identifying resources available within the
organisation.

Worldviews on Evidence-Based Nursing r Second Quarter 2008 81

Computer-Based Educational Program
Educational programs that incorporate examples of cur-
rent practice enhancements based on EBP are opportunities
for nurses to synthesise the process for basing nursing prac-
tice on the best evidence. By revealing the evidence behind
practice changes and highlighting the processes to incorpo-
rate and implement changes into clinical practice, nurses
are given the opportunity to understand and evaluate the
benefits of best practice initiatives.
Nursing Accountability
EBP requires that current nursing research is translated into
nursing practice and, ultimately, results in positive and im-
proved patient outcomes. The challenge is how to integrate
research and knowledge with nursing practice at the bed-
side. Nurses have a professional responsibility and account-
ability to stay abreast of current research (United Kingdom
Central Council for Nursing, 1992a, 1992b; American
Nurses Association 2004). Upton & Upton (2005) deter-
mined that most nurses do not view EBP as an intrusion;
rather, nurses consider it an important element of cur-
rent nursing practice. Professional responsibility implies
that individual nurses have an obligation to apply current
research findings to daily nursing practice. In addition,
nurses have the responsibility to conduct nursing research
that adds to the body of evidence (Hancock & Easen 2004).
However, even when acquisition of knowledge and expe-
rience with research exists, one cannot be ensured that
research will be translated into practice. A nurse’s decision
to incorporate evidence-based findings into practice is af-
fected by the nurse’s attitude, knowledge, and skill toward
nursing research (Upton & Upton 2005).
Organisational Infrastructure
Nurses need to be aware of the resources within the health
care organisation that support EBP and research. Knowl-
edge, attitude, and skills are critical but ineffective if nurses
do not perceive the organisation is ready to provide sup-
port for EBP initiatives and research. Therefore, appropri-
ate organisational structures and processes are essential in
promoting EBP and research utilisation in clinical settings.
In the United States, the Nursing Executive Center
(2005) recommends that health care leaders examine ex-
isting research and conduct original research with the aim
of EBP dissemination and compliance throughout the or-
ganisation. Models designed to assist in structuring EBP
initiatives to close the gap between research and practice
include: Advancing Research and Clinical Practice through
Close Collaboration (ARCC) Model, Stetler Model, and
Iowa Model (Stetler 2001; Melnyk & Fineout-Overholt
2002; Titler 2002).
Nurse leaders are challenged with implementation
strategies that support EBP across multiple nursing units
82 Second Quarter 2008 r Worldviews on Evidence-Based Nursing
in an organisation. Strategies to support EBP activities in-
clude using clinical nurse specialists and nurse educators
on nursing units, developing committees to ensure that
policies and practice are evidence based, having an experi-
enced research coordinator on site to consult with nurses
to initiate research activities to enhance EBP, and develop-
ing a collaborative relationship between health care organ-
isations and educational institutions (Melnyk et al. 2004;
Melnyk & Fineout-Overholt 2005). Additionally, incorpo-
rating elements into EBP educational programs that specif-
ically indicate and define the organisation’s readiness and
commitment to support EBP may increase nurses’ percep-
tions and awareness of the organisation’s readiness to en-
gage in EBP and research (Fink et al. 2005; Malloch &
Porter-O’Grady 2006).
IMPLICATIONS FOR FUTURE RESEARCH
Because this study was conducted in an integrated,
community-based health care setting using a convenience
sample, replicating it in a different health care environment
with a random sample of nurses would be worthwhile. Also,
it is recommended that the study be replicated in different
geographic regions or countries so that findings could be
more generalised.
Many nurses find electronic technology intimidating
and the data collection tool used for this study was com-
puter based. Replication using a paper data-collection tool
used alone or in conjunction with computers, would pro-
vide all nurses with a venue in which to participate.
A future replication study could include an experimen-
tal group who receives the CBE and a control group who
does not receive the CBE. This approach would allow for
comparisons of the two groups to determine the effective-
ness of the CBE intervention.
CONCLUSIONS
Building a culture in which research is valued and EBP
becomes the norm among nurses and nurse leaders is es-
sential to the progression of nursing practice. Diverse and
effective methods are essential in educating and engag-
ing nurses in EBP and research utilisation. Findings show
that nurses need more skills in evaluating research be-
fore they can incorporate best evidence into their nursing
practice. CBE provides a convenient and flexible medium
for educating nurses working in different departments
and varying shifts. CBE is an effective approach that can
be employed by nursing leaders to educate and engage
large numbers of nurses in EBP initiatives and research
utilisation.

References
American Nurses Association. (2004). Nursing: Scope and
standards of practice. Washington, DC: American Nurses
Association.
Bahtsevani C., Khalaf A. & Willman A. (2005). Evaluating
psychiatric nurses’ awareness of evidence-based nurs-
ing publications. Worldviews on Evidence-Based Nursing,
2(4), 196–207.
Champion V.L. & Leach A.S. (1986). The relationship of
support, availability, and attitude to research utilization.
Journal of Nursing Administration, 16(3), 19, 37.
Champion V.L. & Leach A.S. (1989). Variables related to
research utilization in nursing: An empirical investiga-
tion. Journal of Advanced Nursing, 14(9), 705–710.
Cooke L. & Grant M. (2002). Support for evidence-based
practice. Seminars in Oncology Nursing, 18(1), 71–78.
Ellis I., Howard P., Larson A. & Robertson J. (2005). From
workshop to work practice: An exploration of context
and facilitation in the development of evidence-based
practice. Worldviews on Evidence-Based Nursing, 2(2),
84–93.
Estabrooks C.A., Floyd J.A., Scott-Findlay S., O’Leary K.A.
& Gushta M. (2003). Individual determinants of re-
search utilization: A systematic review. Journal of Ad-
vanced Nursing, 43(5), 506–520.
Fink R., Thompson C. & Bonnes D. (2005). Overcoming
barriers and promoting the use of research in practice.
Journal of Nursing Administration, 35(3), 121–129.
Franck L.R. & Langenkamp M.L. (2000). Mandatory ed-
ucation via the computer: Cost-effective, convenient,
and creative. Journal of Nursing Staff Development, 16(4),
157–163.
Gerrish K. & Clayton J. (2004). Promoting evidence-based
practice: An organizational approach. Journal of Nursing
Management, 12, 114–123.
Hancock H. & Easen P. (2004). Evidence-based practice–
an incomplete model of the relationship between theory
and professional work. Journal of Evaluation in Clinical
Practice, 10(2), 187–196.
Hatcher S. & Tranmer J. (1997). A survey of variables re-
lated to research utilization in nursing practice in the
acute care setting. Canadian Journal of Nursing Adminis-
tration, 10, 31–35.
Haynes B., Devereaux P.J. & Guyatt G.H. (2002). Clini-
cal expertise in the era of evidence-based medicine and
patient choice. Evidence Based Medicine, 7, 36–38.
Hicks N. (1998). Evidence-based health care. Bandolier, 5,
8.
Hundley V., Milne J., Leighton-Beck L., Graham W. & Fitz-
maurice A. (2000). Raising research awareness among
midwives and nurses: Does it work? Journal of Advanced
Nursing, 31(1), 78–88.
Worldviews on Evidence-Based Nursing r Second Quarter 2008 83
Computer-Based Educational Program
Janicki T. & Liegle J. (2001). Development and evaluation
of a framework for creating web-based learning mod-
ules: A pedagogical and systems perspective. Journal of
Asynchronous Learning Networks, 5(1), 58–84.
Kulik C. & Kulik J. (1991). Effectiveness of computer-
based instruction: An updated analysis. Computers in
Human Behavior, 7, 75–94.
Lewis S.L., Prowant B.F., Cooper C.L. & Bonner P.N.
(1998). Nephrology nurses’ perceptions of barriers
and facilitators to using research in practice. American
Nephrology Nurses’ Association Journal, 25(4), 397–406.
Malloch K. & Porter-O’Grady T. (2006). Introduction to
evidence-based practice in nursing and health care. Boston,
MA: Jones and Bartlett.
McSherry R., Artley A. & Holloran J. (2006). Research
awareness: An important factor for evidence-based prac-
tice? Worldviews on Evidence-Based Nursing, 3(3), 103–
115.
Melnyk B.M. & Fineout-Overholt E. (2002). Putting re-
search into practice. Rochester ARCC. Reflections on
Nursing Leadership, 28(2), 22–25.
Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-
based practice in nursing & healthcare: A guide to best
practice. Philadelphia: Lippincott, Williams & Wilkins.
Melnyk B.M., Fineout-Overholt E., Feinstein N.F., Li H.,
Small L., Wilcox L. & Kraus R. (2004). Nurses’ per-
ceived knowledge, beliefs, skills, and needs regarding
evidence-based practice: Implications for accelerating
the paradigm shift. Worldviews on Evidence-Based Nurs-
ing, 1(3), 185–193.
Mott B., Nolan J., Zarb N., Arnison V., Chan R., Codner
T., Casey T., Jenkins B., Ulrych G., Blackburn C., Glan-
field L., Halcomb E. & Davidson P.M. (2005). Clinical
nurses’ knowledge of evidence-based practice. Contem-
porary Nursing, 19(1–2), 96–104.
Mullem C.V., Burke L.J., Dohmeyer K., Farrell M., Harvey
S., John L., Kraly C., Rowley F., Sebern M., Twite K.
& Zapp R. (1999). Strategic planning for research use
in nursing practice. Journal of Nursing Administration,
29(12), 38–44.
Nagy S., Lumby J., McKinley S. & Macfarlane C. (2001).
Nurses’ beliefs about the conditions that hinder or sup-
port evidence-based nursing. International Journal of
Nursing Practice, 7, 314–321.
Newhouse R., Dearholt S., Poe S., Pugh L. & White K.
(2005). Evidence-based practice: A practical approach
to implementation. Journal of Nursing Administration,
35(1), 35–40.
Nilsson Kajermo K., Nordstrom G., Krusebrant A. &
Lutzen K. (2001). Nurses’ experiences of research uti-
lization within the framework of an educational pro-
gramme. Journal of Clinical Nursing, 10, 671–681.
Computer-Based Educational Program
Nursing Executive Center. (2005). Evidence-based nursing
practice: Instilling rigor into clinical practice. Washington,
DC: The Advisory Board Company.
Olade R.A. (2003). Attitudes and factors affecting research
utilization. Nursing Forum, 38(4), 5–15.
Pravikoff D.S., Pierce S.T. & Tanner A. (2005a). Evidence-
based practice readiness study supported by academy
nursing informatics expert panel. Nursing Outlook,
53(1), 49–50.
Pravikoff D.S., Tanner A.B. & Pierce S.T. (2005b). Readi-
ness of U.S. nurses for evidence-based practice. The
American Journal of Nursing, 105(9), 40–51.
Rodgers S. (2000). A study of the utilization of research in
practice and the influence of education. Nurse Education
Today, 20, 279–287.
Sackett D.L., Straus S.E., Richardson W.S., Rosenberg W.
& Haynes R.B. (2000). Evidence-based medicine: How to
practice and teach EBM. London: Churchill Livingstone.
Statistical Package for the Social Sciences, Inc. (2003). SPSS
base 12.0 for windows user’s guide. Chicago, IL: Author.
Stetler C.B. (2001). Updating the Stetler model of research
utilization to facilitate evidence-based practice. Nursing
Outlook, 49, 272–278.
Titler M.G. (2002). Use of research in practice. In G. Lo-
Biondo & J. Haber (Eds.), Nursing research: Methods,
84 Second Quarter 2008 r Worldviews on Evidence-Based Nursing
critical appraisal and utilization (5th Ed.). St. Louis, MO:
Mosby.
Tripathi A.K. (1998). Glossary of distance education
and internet terminology. Retrieved April 16, 2008,
from http://www.cusd.claremont.edu/www/computing/
doc/intro/netterms glossary.html.
Tsai S. (2002). The effects of a research utilization in-
service program on nurses. International Journal of Nurs-
ing Studies, 40, 105–113.
United Kingdom Central Council for Nursing. (1992a).
Code of professional conduct for the nurse, midwife, and
health visitor. London: Author.
United Kingdom Central Council for Nursing. (1992b).
Scope of professional practice. London: Author.
Upton D. (1999). Attitudes towards, and knowledge
of, clinical effectiveness in nurses, midwives, practice
nurses and health visitors. Journal of Advanced Nursing,
29(4), 885–893.
Upton D. & Upton P. (2005). Nurses’ attitudes to evidence-
based practice: Impact of a national policy. British Journal
of Nursing, 14(5), 284–288.
Welton R., Nieves-Khouw F., Schreiber D.A. & McElreath
M. (2000). Developing computer-based training for age-
related competencies. Journal of Nursing Staff Develop-
ment, 16(5), 195–201.