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