Barriers to evidence-based nursing: a focus group study

Karin Hannes, Jo Vandersmissen, Liesbeth De Blaeser, Gert Peeters, Jo Goedhuys & Bert Aertgeerts

Accepted for publication 15 June 2007

Correspondence to K. Hannes:

e-mail: Karin.hannes@med.kuleuven.be

K. Hannes MSc

Research Fellow

Belgian Centre for Evidence-Based Medicine,

Belgian Branch of the Cochrane

Collaboration, Leuven, Belgium

J. Vandersmissen MSc RN

Staff Member, Nursing Unit

University Hospital Leuven, Leuven, Belgium

L. De Blaeser MSc RN

Staff Member, Nursing Unit

University Hospital Leuven, Leuven, Belgium

G. Peeters MSc RN

Program Coordinator

Belgian Health Care Knowledge Centre,

Brussels, Belgium

J. Goedhuys PhD

Professor

Catholic University Leuven-Academic Centre

for General Practice, Leuven, Belgium

B. Aertgeerts PhD MD

Professor

Belgian Centre for Evidence-Based Medicine,

Belgian Branch of the Cochrane

Collaboration, Leuven, Belgium and Catholic

University Leuven-Academic Centre for

General Practice, Leuven, Belgium

HANNES KHANNES K., VANDERSMISSEN JVANDERSMISSEN J., DEDE BLAESER LBLAESER L., PEETERS GPEETERS G., GOEDHUYS J.GOEDHUYS J.

&& AERTGEERTS B. (2007)AERTGEERTS B. (2007) Barriers to evidence-based nursing: a focus group

study. Journal of Advanced Nursing 60(2), 162–171

doi: 10.1111/j.1365-2648.2007.04389.x

AbstractTitle. Barriers to evidence-based nursing: a focus group study

Aim. This paper reports a study to explore the barriers to evidence-based nursing

among Flemish (Belgian) nurses.

Background. Barriers obstructing the call for an increase in evidence-based nursing

have been explored in many countries, mostly through quantitative study designs.

Authors report on lack of time, resources, evidence, authority, support, motivation

and resistance to change. Relationships between barriers are seldom presented.

Methods. We used a grounded theory approach, and five focus groups were

organized between September 2004 and April 2005 in Belgium. We used purposeful

sampling to recruit 53 nurses working in different settings. A problem tree was

developed to establish links between codes that emerged from the data.

Findings. The majority of the barriers were consistent with previous findings.

Flemish (Belgian) nurses added a potential lack of responsibility in the uptake of

evidence-based nursing, their ‘guest’ position in a patient’s environment leading to a

culture of adaptation, and a future ‘two tier’ nursing practice, which refers to the

different education levels of nurses. The problem tree developed serves as (1) a basic

model for other researchers who want to explore barriers within their own

healthcare system and (2) a useful tool for orienting change management processes.

Conclusion. Despite the fact that the problem tree presented is context-specific for

Flanders (Belgium), it gives an opportunity to develop clear objectives and targeted

strategies for tackling obstacles to evidence-based nursing.

Keywords: barriers, empirical research report, evidence-based nursing, focus

groups, qualitative research

Background

Over the past few years, concerns have been growing about

the use of evidence-based nursing (EBN) in health care.

Nurses at all levels are increasingly expected to use evidence

in a conscientious, explicit and judicious way. In Flanders

(Belgium), many barriers obstruct the calls for an increase in

EBN. We searched The Cochrane Database of Systematic

Reviews, ACP Journal Club, DARE, Medline, Sociological

Abstracts and CINAHL from 1998 up until spring 2006 to

gain insight into the reasons why nurses are not using

evidence in daily practice.

We found more than 25 quantitative studies that had used

the BARRIERS scale, developed and tested by Funk et al.

ORIGINAL RESEARCHJAN

162 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

(1991a, 1991b, 1995a, 1995b). French (2005) has summar-

ized most of these contributions. There is a high degree of

consistency in reporting ‘setting’ or ‘environment’ as an

important barrier. Setting includes inadequacy of facilities or

available equipment, lack of resources and time, lack of

support or cooperation from doctors and supervisors and

lack of authority to handle clinical problems. Problems such

as a lack of relevant evidence, conflicting results in literature,

information overload, lack of computer skills, difficulties in

interpreting statistical data, difficulties in generalizing re-

search results and applying them to daily practice are also

frequently mentioned. Similar outcomes are reported by other

authors using the BARRIERS scale or other quantitative

techniques (Walsh 1997, Sitzia 2001, McCleary 2003, Olade

2003, Sommer 2003, Kirshbaum et al. 2004, McKnight

2004, Mazurek Melnyk et al. 2004, Micevski et al. 2004,

Kenny 2005, Paramonczic 2005, Pravikoff et al. 2005).

Additional barriers reported include limited funding for

nursing research and a lack of incentives for evidence-based

action (Tsai 2000, Olade 2003, Pravikoff et al. 2005). Some

barriers relate to nurses themselves: attitudes, unwillingness

to participate in the EBN process, an anti-research culture or

anti-teamwork spirit, lack of motivation and fear of change

(Retsas 2000, Andrew & Kinn 2001, Sitzia 2001, Bryar et al.

2003, Carrion et al. 2004, Kirshbaum et al. 2004, Mazurek

Melnyk et al. 2004).

We found a limited number of qualitative studies addres-

sing barriers to EBN. The majority of the findings were

consistent with the results from quantitative studies (Adams

2001, McCaughan et al. 2002, Adamsen et al. 2003) . Some

additional barriers were mentioned, such as the influence of

pharmaceutical companies (French 2005), the time-delay

between publication of research results and their implemen-

tation in practice (Thompson 2003), a culture that favours

‘acting’ over ‘thinking’, a strong hierarchical structure,

difficulties in managing innovation and an inadequate system

for personal and professional development (Newman et al.

1998), patients’ experience as the driving force for nurses

(Rycroft-Malone et al. 2004), resistance to change and lack

of motivation (Ring et al. 2005). Few qualitative studies have

discussed relationships between the different barriers inven-

toried. Opportunities to develop targeted strategies to tackle

the obstacles experienced by nurses are therefore limited.

The study

Aim

The aim of this study was to explore the barriers to EBN

among Flemish (Belgian) nurses. The research objectives

were: (1) to make sense of the meaning, expectations,

attitudes and suggestions Flemish (Belgian) nurses bring to

EBN; (2) to explore whether the results of the study matched

previous insights from international research; (3) to develop a

problem tree linking all barriers so as to contribute to the

discussion about which obstacles can be tackled before nurses

will be able to integrate EBN in daily practice.

Methodology

The methodology was guided by a ‘grounded theory

approach’ (Strauss & Corbin 1997). Rather than beginning

with a particular theory on the implementation of EBN, we

started by examining problems in daily nursing practice,

using focus groups, and developed a conceptual framework

consistent with what we were observing. Data collection and

data analysis were concurrent. Data were collected and

analysed between October 2004 and October 2005.

Participants

Purposive sampling was used to recruit a total of 53 nurses,

based on four criteria: (1) variability of interest in EBN, (2)

variability of expertise in EBN, (3) geographical variability

and (4) variability in ‘setting’. We recruited between six and

12 participants for each focus group. Group I consisted of

seven academics who were chosen for their reputation as

good informants on EBN. Group II consisted of eight nurses

working in a hospital setting. Group III consisted of 12 nurses

providing home care. In Group IV, nine nurses who were

enrolled in an educational programme in pain management

participated, and for group V seven nurses working with

older patients participated.

Data collection

Five focus groups were conducted. An independent moder-

ator was hired to facilitate the discussions, using a semi-

structured interview guide. Two researchers took notes on the

non-verbal behaviour of participants. These notes are pre-

sented alongside the citations used in the findings section

below. Two major topics were discussed: (1) Applicability of

EBN and (2) Specific barriers to implement EBN. The focus

group discussions lasted between 1Æ5 and 2 hours.

Validity and reliability

Reliability was assured by recording and transcribing the

interview excerpts, using independent researchers from dif-

ferent disciplines to code data. Inter-rater agreement between

JAN: ORIGINAL RESEARCH Barriers to evidence-based practice

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 163

researchers ranged from 87% to 92%. Validity was assured

by describing the sample, the process of data collection and

analysis in detail. We used an independent moderator to

ensure that no influences from the research team occurred

during the focus group interviews. The results were validated

through a process of triangulation with existing literature.

Ethical considerations

All nurses in the sample had given their consent to participate

in the focus group. The research team presented a written

statement, in which they guaranteed that all data were to be

analysed anonymously and explained that individual talks

with members of the research team were possible, after the

focus group had finished.

Data analysis

We used the software program ATLAS-ti (5Æ0) (The ATLAS-ti

Center, Berlin, Germany) to analyse the data. A thematic

analysis was conducted (Benner 1985, Leininger 1985) and

refined by an inductive process of open and axial coding. We

developed a problem tree (Figure 1) linking the codes that

emerged from the data and grouping them under the major

themes identified. This technique was borrowed from the

‘logical framework approach’ used in objective-oriented

Project Design [Norwegian Agency for Development Cooper-

ation (NORAD) 1996].

Findings

Demographic characteristics of participants

Demographic details about the participants are described in

Table 1. The majority of participants were females. About

half of the participants worked part-time. We recruited

novice as well as experienced nurses, from different parts of

the country. About one in four participants was affiliated to a

university or scientific organization.

Major themes on barriers to evidence-based nursing

Five major themes emerged from the data: characteristics of

(1) doctors; (2) patients and family; (3) management/super-

visors; (4) nurses/nursing and (5) evidence. The findings are

supported by a selection of citations (a full report of the study

is available from the authors on request). Numbers preceding

the citations refer to their place in the software package used

Lack of time

Characteristicsof doctors

Characteristics ofpatients & family

Characteristics ofnurses / nursing

Characteristicsof evidence

Characteristics ofmanagement/supervisors

Do not acceptchange

Patient beliefs medical

Act againstevidence

Lack of know-ledge /skills

Influenced bymedia

High expectations

No academiccredit for local journals

No articles inmother tongue

No understanding ofscientific language

No motivationto read

Expensivejournals

Only supervisorshave access

Broadspectrum ofcomplexpatients

Noincentives,victimized

Nurses’opinion isa threat

Do not noticepatient relatedaspects

Do nottakenurses’advice

Patient indanger

Stick tohierarchicposition

Difficult to keep up-to-date

ConflictingEvidence

Lack ofevidence

Guest in patient’shouse

Adapt tofamily’swishes

No tools/medicationat home

Experience isimportant

Lack reflexto search

Depend onthe doctor

Negativeimage ofnursing

Reducednumberof nurses

Lack of respect for nurses

Heavyworkload

Negativecommentswhensearchingthe net

Lack ofmanpower

Noqualitytime forpatients

No (time/stimulifor) education

No notionof EBN

Lack ofskillsNAs take

over tasks

Two-tier-policy

Different compe-tences NA & RN

High costof care

Nurse isconsidereda cost

No instruc-tions onimple-mentingguidelines

Priority islower thecost, notquality ofcare

Information issponsored

Objecti-vity info?

Priority is medical/pharma themes

Creation of NA degree

RNs takeovermedicaltasks

lowpayment

Doer ratherthen thinker

MotivationEBP low

Lowqualitycontrol

Conflictingopinions

Centralfigure healthcare is doctor

Cure >Care

High tech

Therapeuticfreedom

Figure 1 Problem tree linking barriers to the implementation of evidence-based nursing.

K. Hannes et al.

164 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

and include (1) the focus group, (2) the statement made and

(3) the ID of the participant. Abbreviations used in the

citations refer to codes used by the observers: I is agreement,

O is denial and G is type of behaviour, followed by the ID-

number of a participant.

Characteristics of doctors

In general, nurses work under the supervision of doctors,

leading to a very dependent position with limited space for

autonomous decisions. Contradicting doctors’ opinions is ex-

tremely difficult, particularly for the older generation of nurses:

2:62:3: A number of doctors would consider it strange if you as a

nurse were to say ‘Yes but doctor, it is the rule here to keep patients

in bed for 12 hours after a heart catheterization’…If we take a look

in the literature…6 hours are sufficient. And then comes the reaction;

yes but where do you suddenly get that from…I am the one who…

Nurses doubt the ability of doctors to remain up-to-date on

important issues of daily practice. Additionally, doctors do

not always notice important patient-related aspects. It could

lead to a potentially dangerous situation for the patient as

well as the care provider:

10:105:3: I see things in the file that the physician has simply

disregarded and then I think about allergies or a previous operation and

hepatitis for the protection of the nurse…things that just do not interest

them or they have just passed over in the electronic dossier…(G: I: 2).

Proposals for the development of clinical pathways and

nurses’ opinions are sometimes experienced as a threat.

Doctors may deliberately decide to do the opposite in order

to reaffirm their dominant position, even in domains where

nurses have gained specific expertise:

5:17:2: On the subject of wound care, among other things…we are

actually regularly overruled. Would you believe it? We often find that

we have more insight into wound care than they do, but they do not

acknowledge that and would like to enforce their own way of

thinking.

From the nurses’ perspective, doctors are more willing to take

or ask advice from physiotherapists or dieticians. While

doctors tend to focus on cure, nurses give more attention to

comfort and care. According to some participants this

contributes to the incongruity of opinions. In response to

their position on the hierarchical ladder, nurses admit lacking

the reflex to search for solutions themselves and automatic-

ally delegate responsibility to the doctor. It places them in a

dependent position:

2:37:3: If they get round to serious discussions, then they will very

often refer the problem to another care provider; hence, ‘We need a

doctor for this problem’ not always the reflex of ‘What added value

can I offer as a nurse?’

Nurses also address the gap between the younger generation

of doctors and the rigid older generation, a problem that

should solve itself in the long term.

Characteristics of patients and family

Relations with patients differ between different types of

nurses. Nurses providing home-based care seem more likely

to compromise on ‘evidence’ because they considered them-

selves ‘guests’ in the private world of the patients:

5:53:10: In a hospital patients enter into your world, but you enter

their world and I think that however you try and get round it (G: I:

4), you will always have to make some concessions, you have to learn

to accept a bit; you can explain something, you can be occupied for

weeks or months with something, but you are dealing with human

nature…Yes, somehow introduce ‘respect’. These people are not little

children.

Sometimes, the patients do not have the right equipment,

tools or medicine at home, which is another obstacle to

providing the best possible care. Nurses often adapt to

patients’ wishes and expectations, even though the solution a

nurse proposes makes more sense. Some patients act entirely

against the advice that is given, or the patient’s family has

insisted on different treatment. In the case of a significant

change in scientific knowledge regarding certain treatments,

it seems particularly hard to convince patients and those

around them to accept it:

Table 1 Participant demographics (n = 53)

Sex

Male (%) 7 16Æ7Female (%) 35 83Æ3

Average age (min/max) 35 21/49

Average year of graduation (SDSD) 1991 8Æ708

Province

Antwerp (%) 3 7Æ1Brabant (%) 13 31

Limburg (%) 5 11Æ9East Flanders (%) 16 38Æ1West Flanders (%) 5 11Æ9

Average years of practice (SDSD) 12Æ39 8Æ203

% Present in practice*

Full-time (%) 18 42Æ9Part-time (%) 15 45Æ5

Affiliated with university or

scientific organization�

Yes (%) 11 26Æ2No (%) 29 69

*Nine missing values, mostly from academics working for univer-

sities; �Two missing values.

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� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 165

6:27:2: Once again it is the grandparent or the family who also from

their experience have other ideas, the general public’s view. Also,

when science has changed you really have to slog away to convince

people to get them to be with you on this point. (G: I: 5, 6).

Keeping up-to-date with scientific literature is extremely

difficult. Nurses work with patients with multiple patholo-

gies, especially those in home-based care settings or geriatric

units. Several nurses mention the lack of respect for their

work, from doctors as well as patients and their families.

Patients value doctors’ advice more than nurses’ opinions:

11:213:7: The more I look, the more I see nurses being treated as

fools (G: smiles: 6, 02) by many people and that really grieves me. I

notice that my people have a real need for appreciation, to feel they

are a full partner in the dialogue, to be respected and that on all sides

they are no longer accorded that respect, neither by the patients, not

in the least by the visitors but also not always by the doctors, and yet

we still go on trying to bring about that joint ownership with doctors.

Patients are also heavily influenced by less objective infor-

mation presented through the media. These messages result in

high expectations that cannot be fulfilled:

2:48:3: I think that many patients do generate an area of tension for

nurses. They can come up with a solution that they have seen in

[popular magazine] or on the internet or in a journal. ‘I have seen

there that such-and-such offers a solution; can you help me with

this?’ (G: smile: 6, 7). Actually, it is really an additional obstacle to

delivering evidence-based (EB) health care because you are confron-

ted with expectations of your patient and their family that do not

directly match with what you are doing…

Characteristics of management/supervisors

Management priorities differ from those of nurses. Managers

are mainly interested in how to control the costs of health

care. Nurses seem to be more concerned with the quality of

care. When targets in a certain unit of a hospital or institute

are not reached, it is the nursing staff that decreases, while the

medical staff remains the same. Nurses state that they are too

easily reduced to a cost:

11:131:6: And now I am just going to speak for hospitals. If we do

not achieve the targets that we have been set, then we get fewer

people, but the staff of physicians remains the same. In the end they

determine what the targets are (G: I: 4)…everything revolves around

the physician, this is exactly our feeling; who is here and now still

central, the patient or the physician? (G: I: 2).

Many managers and supervisors are proponents of imposing

guidelines. However, there are no clear instructions on how

to integrate them into daily care. Even if the guidelines are

feasible in practice there are no penalties for those who act

otherwise. According to some nurses, doctors still use their

therapeutic freedom as an excuse to neglect guidelines:

11:225:02: Would it not help doctors and other health workers if

they begin to appreciate that everything that appears in the literature

in guidelines, for example, regarding pain and so forth, is really a

restriction of their therapeutic freedom? If that is good practice, then

you as a doctor can surely not permit yourself to say ‘and now I am

going to do it differently’. If I did it differently, I would be

committing a professional error.

Characteristics of nurses/nursing

The general culture of practice. There is a strong resistance

and low interest within the group of nurses to adapt to

evidence-based treatments. According to a supervising nurse,

the resistance is greater for routine treatments than for

recently developed treatments:

11:184:3: The nearer it (evidence) comes to what you routinely

undertake, the more resistance you experience to changing things.

Washing, for example every day everyone must be washed, that is

something that you cannot discuss with nurses, because we have been

doing that for years. Every day we wash everyone from top to toe and

so this practice continues unchanged…On the other hand, things

such as analgesia, palliative care, things that were added on later, are

much easier to discuss (G: I: 1, 2, 4/laughter: 5).

Nurses who are motivated to invest in an evidence-based

approach fear the negative comments of others, for example,

when searching the web, because it creates a bigger work-

load. A reference nurse providing home-based care, as well as

several nurses working in a geriatric setting, state that they

mostly rely on experience. They tend to look back at the

process they have gone through with former patients to solve

a problem, instead of taking into account results from

theoretical studies:

11:180:5: What I also see is that some decisions are taken informally

in a rest home (G: I: 4)…nurses see a particular problem and then

they are going to link that back to residents that they have known:

‘What problem have we had there, what was important at that time,

what did not go well in order to start?’ They use this information to

handle the problem with which they are dealing today. They do not

keep a record of it, but they are certainly going to reach back to their

experience. I think that it differs from hospitals, because you see the

patients for such a short time. (G: I: 1, 2, 3, 4).

Changing the attitude of nurses to a more scientifically based

approach seems to be difficult, as most of them value ‘acting’

above ‘reading and interpreting research’. The lack of time is

one of the major obstacles of a general uptake of EBN. Some

nurses blame their own unwilling attitude in the ongoing

K. Hannes et al.

166 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

debate on the implementation of EBN, where time is often

used as an excuse:

6:35:5: The aspect ‘time’…nurses do have a full programme indeed,

but at the same time we cannot deny that nurses take it for granted: ‘I

am a nurse, so I do not have time’. That it becomes a synonym,

something to hide behind (G: I: 2).

Education. In recent years, there has been a decrease in the

number of registered nurses (RNs) and nursing students. The

acute need for more nurses forced the government into the

decision (1) to stimulate physiotherapists (too many in

Belgium) and health care practitioners from other disciplines

to re-educate themselves to become nurses and (2) to allow

nursing assistants (NAs) to fulfill some nursing tasks in

hospitals and other institutes. The position of NAs has been

legalized. The lack of RNs is considered a facilitating factor

in the development of guidelines in daily care, to be used by

NAs under supervision, especially in geriatric institutions

where NAs seem to be well integrated in daily care. It

contributes to the discussion about which tasks can be taken

on by NAs and which tasks can only be performed by RNs,

because of the specific expertise needed:

11:185:6: I have thrown my weight behind the introduction of

carers (NAs) in an acute setting. We were 100% behind this step.

Nevertheless, we have found that delegating tasks to NAs is a

difficult step. You must go about introducing this system almost in

terms of a directive; in this case you do such-and-such and in that

case you do so-and-so…it is not easy…At that time we used a

formula: ‘If the patient’s skin is touched in any way whatsoever,

this must be discussed. So washing: yes, taking a tablet: no’. (G:

private discussion 1, 2/seeks confirmation with 01 and 6: 7).

There is a difference in knowledge between RNs with a

master’s degree and bedside RNs (bachelor’s degree). Differ-

ences between the groups become most clear in the response

to the introductory question: ‘What is EBN?’ While the

concept is well known to the group of nurses working on an

academic level, RNs in at least one of the five focus groups

have no notion of the concept. Nurses working in an

institutional setting seem to be more aware of the content

than those working independently. Nurses not only address

their own lack of knowledge and skills, but also the limited

capacities of their fellow care providers, supervisors or

teachers:

2:22:4: If I think about college then I think about the level of the

lecturers in the first place. If you have a body of lecturers fewer than

half of whom have a master’s degree. I believe that they cannot pass

EBN on to the students.

Differences between the scientific capabilities of nurses are

the subject of mixed feelings. Some nurses feel there is no

problem having two groups with different skills, while

others doubt there will be any progress in the implemen-

tation of EBN in bedside nursing if the staff performing the

latter is not scientifically trained. Older nurses seem to be

aware of some changes in the curriculum. Expectations

regarding nursing students changed from ‘having gained the

right skills’ under the supervision of experienced colleagues

to ‘having the skills to find out how to handle’ a specific

problem in practice:

10:249:9: Training is now a bit minimalist as regards techniques (G:

I: 3, 4, 6). Consequently, the assumption is probably higher that

students should take a look themselves at ‘How are we going to do

that?’…Perhaps they have indeed learned the way in which they must

find things out, but their baggage is definitely smaller and perhaps the

need to find things out is greater.

Payment. Nurses state that there is no compensation or

support of any kind for their efforts to carry out evidence-

based practice. Another aspect that bothers them is the

incongruity in the payment between doctors and nurses.

Nurses acting under the doctors’ supervision are not allowed

to earn a payment for the clinical act. On the other hand,

doctors performing clinical services that can be provided by

nurses let the patient pay for this consultation, which leads to

financial malpractice that should be avoided in an evidence-

based culture:

10:161:5: If you now just look at injections that people have to have;

some of the doctors pass them on spontaneously and say, that is a

nursing job, but other doctors invite the patient to come to their surgery

every day and actually charge for a consultation. Where are we?

Characteristics of evidence

Several nurses lack the necessary knowledge and skills to

be able to implement EBN in daily practice. They are not

encouraged to gain computer skills, access keys to scientific

information are preserved for supervisors only, quality lit-

erature in Dutch language is scarce, statistical language is

difficult, subscriptions to important journals are often too

expensive and the motivation to read is generally low.

Nurses who do read are discouraged owing to conflicting

opinions or vague answers. They also complain about a

lack of evidence for both their clinical and ethical ques-

tions:

11:188:7: We have quite a few problems with people who are sent to

us with nutritional problems…Then you say, ok, we would like to do

JAN: ORIGINAL RESEARCH Barriers to evidence-based practice

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 167

something. What are the guidelines about doing a gastrostomy? You

find damn all about it in the literature, but pragmatically speaking the

one thing that is clear is ‘We must give preventive antibiotics

prophylactically’. But which antibiotics do they have to take…and

then I have not looked at everything else associated with this topic,

such as ethical issues…Do we have to or continue to treat those with

terminal dementia? To what extent do we have to go along with the

family? It has not yet been discussed. (G: I: 1, 3, 4/dreaming: 3, 4).

Several nurses doubt the objectivity and quality of the

scientific studies produced within their domains of interest.

Commercial firms sponsor many of the studies:

6:25:6: Just take the whole item about the breast-feeding story; in

society, enormous interest groups jump on the bandwagon. I just

want to say that if Nestle did a study you can indeed ask yourself

about the distortion or what those results really mean. You, as an

independent individual and professional, are perhaps more likely to

come to other conclusions.

What also bothers nurses is the impression that existing

evidence seems to give priority to popular medical themes,

mostly related to pharmaceutical products.

The problem tree

In the problem tree presented in Figure 1, relationships

between the barriers mentioned by the study population and

the context in which they are working are explored. The tree

is presented as a web of ideas, in which the codes within each

major theme are linked, grounded in the data. Links that

conflict with findings from previous studies are discussed in

the paragraph below. The tree adds value to the thematic

analysis by revealing relationships that cross the borders of

the major themes and thus presents a more nuanced picture

of the data. This illustrates the complexity of implementing

EBN and creates an opportunity to translate problems into

specific targets on which to focus.

Discussion

Methodological aspects

We decided to complete our focus group-based research

project before searching the literature, so as to be able to look

at the data with an open mind, free from the boundaries of

perspectives from other researchers. Some of our participants

had little or no notion of EBN. This finding is consistent with

previous studies (Sams & Gannon 2000, Micevski et al.

2004, Bahtsevani et al. 2005, Mott et al. 2005). The lack of

awareness of the EBN concept in some focus groups

contributed to the complexity of the moderator’s task.

Valuable time was spent on clarifying basic principles. The

focus group methodology was considered appropriate for

identifying barriers. However, in some groups, the education

level of nurses differed, leading to dominant voices from, for

example, expert nurses or nurses working on an academic

level. We cannot guarantee that all voices were sufficiently

heard.

The 53 nurses who participated formed a small sample of

Flemish (Belgian) nurses. The sample was neither random nor

representative. Instead, we chose to engage nurses working in

different settings, such as hospitals, home care and elder care.

As most settings were represented in only one or two focus

groups, comparisons between nurses working in different

settings is problematic. Future research could focus on an in-

depth study of barriers within each setting.

Finally, we would like to draw attention to some meth-

odological issues that developed on the problem tree. It

differs from the original concept in the logical framework

approach to Project Design. Although the focus group

participants identified all barriers and provided the ingredi-

ents, researchers have developed the final tree. Furthermore,

the tree does not aim to determine cause and effect relation-

ships, as is the case in the logical framework approach.

Instead, it reveals potential relationships that can be tested in

future research projects.

Contributions to EBN

The major findings of our study seem to be consistent with

findings from previous studies. Findings report a lack of time,

a difficult access to resources, a hierarchical structure, a lack

of support from doctors or management, a lack of relevant

studies for nursing, a lack of computer and other skills, little

motivation to carry out evidence-based practice, a reluctance

to change practice, the impact of pharmaceutical companies

on evidence, a culture promoting ‘acting’ instead of ‘research-

ing’ and the experience of patients as an important outcome

measure for evaluating clinical practice. However, Flemish

(Belgian) nurses added some topics that were not fully

addressed in previous research.

Some participants seemed to argue that nurses themselves

have a big responsibility to claim autonomy and authority for

decisions regarding patients. The hierarchical structure of

clinical professions, in which nurses’ position appears to be

close to the bottom, is reflected in differences in status,

power, authority and salary. Elements of ‘power’ also play a

part in Flemish (Belgian) nurses’ relationship with patients.

Nurses in home-based care are especially sensitive to the

K. Hannes et al.

168 � 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd

demands of patients, as they consider themselves to be

‘guests’ in the environment of the patient. The lack of respect

experienced by Flemish (Belgian) nurses from, for example,

allied health care practitioners and the fact that doctors do

not recognize the importance of nursing interventions have

been reported in a previous study (Siebens et al. 2006).

However, 91% of the nurses in Siebens’ study (Belgium)

stated that they were seen as an equal partner across

disciplines. In addition, managers tend to treat nurses simply

as a cost in the process of health care instead of a valuable

partner. Newman et al. (1998) also reported that nurses were

blamed or punished when patients complained, even when

the primary cause of an incident may have been an underlying

organizational procedure.

Evidence-based nursing has the potential to empower

nurses in their decision-making processes (Zeitz & McCutch-

eon 2003). However, the majority of Flemish (Belgian) nurses

do not achieve a sufficient level of mastery in applying EBN.

The peer pressure felt, for example, when searching for

information on the internet during working hours is consis-

tent with McKnight’s (2006) finding that taking time to read

on duty is difficult and, in some cases, felt as ethically wrong.

The lack of time to invest in the evidence-based movement

might be related to a lack of staff. Difficulties in recruiting

and retaining nurses have been mentioned by other authors

(Newman et al. 1998, Tsai 2000, Kirshbaum et al. 2004,

Pravikoff et al. 2005, Milissen et al. 2006). In Flanders

(Belgium), NAs have filled in the gap. Currently, they seem to

be more active in elder care institutions than in hospitals.

RNs in the focus groups still have their doubts about the

quality of the work NAs deliver. However, previous research

found that 43% of Belgian RNs considered the impact of

NAs positive. Only 15% reported a worsening of the quality

of care (Milissen et al. 2006). Some Flemish (Belgian) nurses

fear the whole situation will lead to a ‘two-tier’ education

and practice policy for nurses, a discussion previously

initiated by White and Taylor (2002). At least some of the

nurses in our sample tend to support Castledine’s (1997)

opinion that maybe not all nurses need to become research-

ers, but there is no excuse for them not to develop a research-

minded mentality. Nevertheless, it will be difficult for some

groups of nurses to engage themselves in the evidence-based

movement, especially those working in rural areas with

limited access to medical information and stakeholders, such

as librarians, methodological experts and well-trained expert

nurses.

Conclusion

In this study, we describe the barriers mentioned by Flemish

(Belgian) nurses. To our knowledge, no other study in the

field of nursing has proposed a problem tree, in which

barriers are linked and can easily be located. The tree has the

potential to be transformed into a tree of objectives, which

will be the focus of a subsequent research project. It will

enable us to identify clusters of strategies to tackle the

problems. We feel the tree is of relevance to the international

community of nurses and those who promote EBN. It could

function as a useful tool to orient change management

processes and serve as a model for other researchers who

explore barriers within their own healthcare system. How-

ever, one should bear in mind that the tree is context-specific

for Flanders (Belgium).

Acknowledgements

We wish to acknowledge the time and enthusiasm of the

nurses who took part in the focus groups and Prof. Dr. E.

Vermeire for his advice on the analysis of data.

Author contributions

KH was responsible for the study conception and design and

the drafting of the manuscript. KH, JV and GP performed the

data collection and KH, LD, JG and BA performed the data

What is already known about this topic

• Known external barriers to the use of evidence-based

nursing include a lack of time, resources, evidence,

authority and support.

• Known internal barriers include a lack of motivation

and resistance to change.

What this paper adds

• Nurses acknowledge a lack of responsibility in the

uptake of evidence-based nursing.

• Elements of power are visible in nurses’ relationships

with doctors, managers and patients, the latter being

more outspoken with nurses providing home-based

care who consider themselves ‘guests’ in the patient’s

environment.

• Different education levels might lead to ‘two-tier’

nursing practice.

• Relationships between barriers to evidence-based nur-

sing are presented in a problem tree, which facilitates

the development of clear objectives and targeted

strategies.

JAN: ORIGINAL RESEARCH Barriers to evidence-based practice

� 2007 The Authors. Journal compilation � 2007 Blackwell Publishing Ltd 169

analysis. BA obtained funding and provided administrative

support. JV, JG and BA made critical revisions to the paper.

JG and BA supervised the study.

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