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DOI: 10.2174/1874434602014010254, 2020, 14, 254-262

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DOI: 10.2174/1874434602014010254, 2020, 14, 254-262

The Open Nursing Journal
Content list available at: https://opennursingjournal.com


Evidence-Based Practice and its Relationship to Quality Improvement: A Cross-
Sectional Study among Egyptian Nurses

Ebtsam Aly Abou Hashish1,2,* and Sharifah Alsayed2

1Faculty of Nursing, Alexandria University, Egypt
2College of Nursing, King Saud bin Abdul-Aziz University for Health Sciences, Jeddah, Saudi Arabia



Implementing Evidence-Based Practice (EBP) and Quality Improvement (QI) were recognized as the core competencies that should be held by all
healthcare professionals, especially nurses, as front-line healthcare providers. Assessment of the current level of knowledge, skills, and attitude of
nurses, regarding EBP and QI, is important for the design of strategies that could enhance the competence of nurses in such practices and, in turn,
promote patient care quality.


This study aimed to assess the attitudes, knowledge, and skills of nurses in Evidence-Based Practice (EBP) and Quality Improvement (QI), in
addition, to studying the relationship between EBP and QI.


A cross-sectional study was conducted using a convenient sample of nurses (N=300) who work in three Egyptian hospitals in Alexandria city,
representing the university, governmental, and private health sectors. The EBP and QI questionnaires were used in addition to a demographic form
for the studied nurses. Statistical analysis was carried out using ANOVAs, student t-test, Pearson correlation, and Regression analysis (R2).


Nurses displayed positive attitudes toward both EBP and QI. However, they perceived themselves to be lacking sufficient EBP knowledge and
need to improve their QI skills. There was a strong positive correlation between EBP and QI with a predictive power of QI on EBP (r= 0.485, R2 =
0.273, p<0.001).


Nurses need educational support for enhancing their attitude, knowledge, and skills related to EBP and QI. To prepare for educational programs,
hospitals and nursing administrators should consider the characteristics of nurses, work schedules, and obstacles in the use of EBP. Hospital
managers should also implement effective strategies to resolve the barriers and boost facilitators to increase the use of EBP among Egyptian nurses
and promote QI.

Keywords: EBP, Cross-sectional study, Hospitals, Nurses, Quality improvement, ANOVA.

Article History Received: July 20, 2020 Revised: October 04, 2020 Accepted: October 07, 2020


A noteworthy focus has been placed on enhancing the
quality of healthcare services, patient safety outcomes, and cost

* Address correspondence to this author at King Abdulaziz Medical City,
National Guard Health Affairs Mail Code 6565 P.O.Box.9515 Jeddah, 21423
Kingdom of Saudi Arabia; Tel: 0966502214979;
E-mail: ebtsam_ss@hotmail.com; abouhashishe@ksau-hs.edu.sa

control in the healthcare system framework [1, 2]. Therefore, a
more prominent emphasis was placed on Evidence-Based
Practice (EBP), which was recognized as crucial for promoting
healthcare excellence [3,4]. EBP is defined as a systematic
method of evaluating the best available scientific evidence
from studies and clinical experience, including patient
interests, beliefs, expectations, and needs to make a clinical

EBP and Quality Improvement The Open Nursing Journal, 2020, Volume 14 255

decision that will affect patient care in particular circumstances
[5, 6]. EBP has become a suitable framework and the
predominant care model that has been recognized for
facilitating the transfer of research evidence to clinical practice
[7]. Likewise, as a key requirement within health care
organizations, there is a growing body of inquiries regarding
implementing Quality Improvement (QI) initiatives. Yet, the
determinants of QI success in hospitals are poorly understood.
Hospital possession and preservation of the adequate
knowledge and skills required for QI will boost the quality of
health care services [8].

1.1. EBP and QI

Implementing EBP and QI are recognized as crucial
competencies that should be held by all healthcare
professionals. Clinical research, EBP, and QI are separate but
interrelated areas of investigation [9, 10]. QI is described as
systematic, information-driven change-focused activities
designed to improve healthcare [3]. Although EBP was
considered the gold standard and a problem-solving approach
to deliver safe and high-quality patient care [5], QI was found
to be a vital contextual organizational factor for the adoption of
EBP and can be used to validate the introduction of EBPs [3]
while clinical research offers empirical evidence for EBP [10].
To significantly influence the improvement of quality in
healthcare, there is a need to apply evidence-based practice
(EBP). Without EBP, healthcare providers are at risk for
variances in care that could seriously affect patient outcomes
[11]. The inconsistent incorporation of research evidence into
clinical practice persists, amid guidance and market pressure,
and the gap between research evidence and EBP is frequently
reported [12]. Also, few empirical studies have investigated
EBP in relation to QI [4].

1.2. Context and Significance of the Study

Egyptian Hospital Accreditation Program complements
that quality is improved when the hospital ensures that care
follows “best practices” that are based on professional and
evidence-based literature, not on individual opinion or routine.
Consequently, the demand for quality improvement in hospitals
is growing [13]. Nurses play a critical role in improving
healthcare quality and their work has a significant effect on the
patients’ care and health since they are actively involved in
almost all aspects of hospital quality. Based on this
assumption, nurses are at the heart of the system and
considered the best people to work towards improving the
processes by which quality care is delivered in the healthcare
setting [14].

The World Health Organization, in particular, has
suggested that nursing in Egypt is one of the skilled professions
that has faced many challenges in past years. The key nursing
problems are focused on education, performance, and little
institutional recognition or support in the workplace.
Healthcare organizations are now challenged to improve
nurses’ skills and knowledge of emerging professional health
expertise through ongoing training and development [15].
Nurses have traditionally relied on the professional opinions of
experienced nurses in clinical decision-making [16]. But these
conventional methods are not only outdated but also unsafe.

Also, experienced-based knowledge can also be linked to
biased thinking, which leads to errors. Nowadays, as they are
interested in clinical decision-making, nurses are forced to
integrate scientific findings and make appropriate and
justifiable decisions in their practice [1, 2].

Implementation of evidence-based practice (EBP) in health
care organizations is recognized as a clinical practice
challenge. It requires a comprehensive collection of skills to
formulate questions that occur during the work and the ability
to perform analysis on it, objectively analyze information, and
implement outcomes in the patient care process [11, 17].
Despite the availability of innovative research-based know-
ledge and published papers with the potential to increase the
quality of nursing care and progress on EBP, nursing practice
is still not evidence-based [4, 16].

Other studies showed that nurses rarely integrate research
findings into their practice and may not be well trained for
EBP. They lack adequate knowledge of evidence-based
concepts and use them to a limited level [18 – 20]. Many nurses
reported that they do not know how to find the appropriate
research reports and have difficulty in identifying clinical
practice implications of the research findings [18]. Thus, they
tend to use knowledge from experience and social interactions
and only a small percentage of nurses consistently use EBP
[18 – 20]. Moreover, despite the benefits of EBP, there are
numerous barriers hampering the adoption and use of EBP and
research continues to find inconsistencies in its implementation
in the clinical work environment [1, 16]. Hence, it seems
imperative to overcome the obstacles and promote facilitators
in order to adopt the best evidence and improve care delivery
and patient outcomes [9].

1.3. Problem Statement

Notably, the majority of studies examine nurses’ and other
healthcare professionals’ views on EBP and barriers
encountered, yet when it comes to its relation to quality
improvement among Egyptian nurses, the evidence is
somewhat limited. In the Egyptian context, the culture in
healthcare agencies and schools of nursing did not encourage
the utilization of EBP and EBP literacy. Considering the
novelty of EBP’s ideas in nursing education, most Egyptian
nursing research focused on the understanding of nursing
educators’ evidence-based practice [21 – 24] with delimited
research targeting nurses in clinical settings [23]. It is believed
that the health care system does not have empowered nurses to
engage in research and EBP [23, 24]. This could impede the
translation of the research activities into a unified EBP
framework. Even with the growing focus on EBP, little is
known about current EBP’s knowledge, skills, and attitude and
its relationship to QI among nurses in Egyptian hospitals, and
the barriers that could be faced in EBP applications. To the best
of the researchers’ knowledge, there is a paucity of research in
the clinical sector, and there is no previous study targeting EBP
and its relationship to QI in different health sectors.

Hence, it is important and timely to explore the factors that
can help nurses and policymakers gain more insight into the
obstacles to adopt and implement EBP in nursing and how this
can apply to QI. Therefore, the present research was targeted to
contribute to this research gap.

256 The Open Nursing Journal, 2020, Volume 14 Abou Hashish and Alsayed

1.4. Aim of the Study

The main objectives of this research were to: assess nurses’
perception of knowledge, skills, and attitude in EBP and QI,
and investigate the relationship between EBP and QI.

Further objectives were to identify the barriers and
facilitators nurses perceived for EBP and to identify the
individual and work-related characteristics that might be
associated with the perception of EBP and QI.


2.1. Research Design and Setting

A cross-sectional descriptive research design was
conducted in inpatient care units at three Egyptian hospitals
associated with various health sectors in Alexandria City:
namely Hospital 1, which is a non-profit teaching hospital
associated with Alexandria University with a capacity of 300
beds; Hospital 2 is a government hospital affiliated with the
Ministry of Health, with a total of 130 beds; Hospital 3 is a for-
profit private health sector-related, with a capacity of 100 beds.
These hospitals play a major role in providing extensive and
multi-specialty healthcare services in many regions/ gover-
norates in Egypt, including medical, surgical, emergency, and
multi-specialty care.

2.2. Participants and Sampling

A convenience sample of staff nurses, working at the
aforementioned hospitals, was invited to take part in the study
(N=300). Convenience sampling (also known as availability
sampling) is a particular form of non-probability sampling
technique that relies on data collection from a population
willing to participate in the study. Inclusion criteria included all
nurses who have at least six months of experience in their
hospitals and willingness to participate, while nurses less than
six months of experience and interns were excluded. The
sample size was calculated using the “Epi info program version
7” based on a 5% variance, 95% confidence level, and 0.80
power, and the minimum sample size was 100 nurses from
each hospital.

2.3. Study Measurements Tools

2.3.1. EBP Questionnaire (EBPQ)

The EBPQ was developed by Upton and Upton [17] and
adapted to assess the perceptions of EBP among nurses. The
EBPQ comprises 24 items covering three subscales: knowledge
(14 items), use/skills (six items), and attitudes (four items). The
responses were calculated on a seven-point Likert scale,
ranging from 1 (strongly disagree) to 7 (strongly agreed). A
higher score shows a higher level of knowledge, use, and a
positive attitude towards EBP. Besides, the researchers have
introduced two open-ended questions to ask nurses about
perceived barriers and facilitators to implement EBP from their
point of view.

2.3.2. Quality Improvement Questionnaire (QIQ)

Hwang and Park [4] developed the QIQ questionnaire to
assess the perception of QI by nurses. QIQ includes 17 items

reflecting three subscales: knowledge (three items), skills (nine
items), and attitude (five items). Responses were graded on a
Likert scale of 5 points, where 1 corresponds to minimum or
strongly disagree and 5 corresponds to excellent or strongly
agree. A higher score shows a higher level of QI subscales.
Permission to use the study instruments was received. In
addition, the researcher developed a form of demographic and
work-related characteristic for studied nurses.

2.4. Validity and Reliability

The study tools were translated into Arabic to suit the
culture of the participants and tested for content validity along
with the fluidity of the translation in the field of study by a jury
of academic members. A minor modification was made in
rewording few statements according to the received feedback.
The study instruments were tested for internal reliability using
Cronbach’s alpha correlation coefficient. The findings proved
both EBPQ and QIQ as reliable tools, with correlation
coefficient α of 0.94 and 0.91, respectively. Moreover, a pilot
study was achieved with 30 nurses (10%) on 10 nurses from
each hospital who were excluded from the study subjects.

2.5. Data Collection

To collect the required data, official approval was obtained
from the administrators in the specified hospitals. Upon
receiving their approval, the questionnaires were hand-
delivered in a paper format by the first author with specific
guidance to nurses. According to their work shifts and break
time described by each unit nurse manager, the author
approached nurses. A final of 300 completed questionnaires
were collected over three months (May-July 2018).

2.6. Ethical Considerations

Approval was received from the Faculty of Nursing,
University of Alexandria. The researchers clarified to all
participants the purpose of the study. Data privacy and
confidentiality were maintained and ensured by obtaining
informed consent. Participants were granted anonymity and the
right to withdraw from the study at any time.

2.7. Data Analysis

Data were analyzed using IBM SPSS version 22. The
internal consistencies of the EBPQ and QI scales were
determined with Cronbach’s alpha coefficients. The normality
of the data was obtained through descriptive statistics of
means, standard deviations, and frequencies. Data on the
general features of nurses, EBP, and QI levels are summarized
using frequencies, percentages, mean, and standard deviations
(SDs). For each EBP and QI subscale, the mean scores were
added. Content analysis was used for the two open-ended
questions regarding perceived barriers and facilitators to the
implementation of EBP. In order to identify the single largest
barriers and facilitators, the frequencies and percentages of
respondents who reported each barrier and facilitator were
calculated, and items were ranked in order accordingly.

Analyses of variance (ANOVA) was used to analyze
variations in EBPQ and QI scores among hospitals and in
relation to participants’ individual and work-related charac-

EBP and Quality Improvement The Open Nursing Journal, 2020, Volume 14 257

teristics and Pearson’s correlation test was used to assess the
relationship between the EBP and QI. The Regression Analysis
(R2) has been used to test the independent variable (QI)
predictive power on the dependent variable (EBP). R2 change
was tested with the F-test. A significant F value for R2 meant
that the QI added a significant prediction of EBP. Based on the
univariate analysis, stepwise multiple regression analyses were
performed to determine factors associated with EBP and QI
levels, respectively. Nurses’ age, years of nursing experience,
and educational level were significantly correlated with the
scores for both EBPQ and QI scales; hence, we utilized the
overall scale scores in the analysis. The statistical significance
point has been set at p ≤0.05.


3.1. Nurses’ Demographic and Work-related Charac-

The general characteristics of the respondents are shown in
Table 1. The majority (75.7%) of the nurses surveyed were
female, and 42.3% were between the age of 30 and under 40
years old. Nurses were distributed between 23.0% and 26.7%
across different units of work. Approximately one-quarter of
nurses (26.7%) worked in ICUs and the same proportion
worked in miscellaneous (multi-specialty) units. The highest
percentage of nurses (43.3%) held a bachelor’s nursing degree,

while 39.0% had a high school diploma. In addition, 38.3% of
nurses had less than five years of experience, while 10.7% had
more than 20 years of nursing experience. Approximately two-
thirds (65.3%) of nurses were verified to have previous EBP
information, 81.63% of them referred to the previous study as
the main source of this information.

3.2. Nurses Perception of EBP and QI at Studied Hospitals

With regard to the perception of research variables, Table 2
indicates that the mean score and standard deviation of the
perception of overall EBP by nurses are moderate (3.57±0.70)
with the highest mean for attitudes towards EBP (4.80±1.18),
followed by the use of EBP (3.57±1.20) and EBP knowledge
(3.22±0.68). Additionally, Table 2 reveals no significant
difference among nurses’ groups at the three studied hospitals
regarding their perception of overall EBP (F =0.832, p= 0.436).
Only a significant difference was found among nurses’ groups
regarding their attitudes toward EBP (F=3.469, p= 0.032).
Nurses at hospital 3 (profit hospital) reported higher attitudes
towards EBP than nurses in hospitals 1 and 2 (university and
governmental hospitals). On the other hand, significant
differences were found among nurses’ groups regarding their
perception of overall QI (F =4.638, p= 0.010) and related
subscales (p<0.05). Nurses at hospital 3 reported higher QI
knowledge (F =3.200, p=0.042), attitudes towards QI (F
=5.206, p=0.006), and QI skills (F =0.5.464, p= 0.005) than
nurses in hospitals 1 and 2.

Table 1. Distribution of nurses’ groups according to demographic characteristics (N = 300).

Demographic characteristics

(N= 300)
No. %

Male 73 24.3

Female 227 75.7
Age (years)

<20 58 19.3
20 – <30 127 42.3
30 – <40 73 24.3
40 – <50 34 11.3

≥50 8 2.6

Medical 69 23.0
Surgical 71 23.6

ICU 80 26.7
Miscellaneous (Multi-specialty) 80 26.7

Bachelor’s degree of Nursing 130 43.3

Diploma of Technical Institute 53 17.7
Diploma of Secondary Nursing School 117 39.0

Years of experience
<5 115 38.3

5 – <10 71 23.7
10 – <15 48 16.0
15 – <20 34 11.3

≥20 32 10.7
Previous Information with EBP

258 The Open Nursing Journal, 2020, Volume 14 Abou Hashish and Alsayed

Demographic characteristics

(N= 300)
No. %

Yes 196 65.3
No 104 34.7

Source of this Information (n=196)
Previous study 160 81.63

workshop/ Training program 36 18.37

Table 2. Nurses’ perception of EBP and QI at the studied hospitals.

Variables of the study Overall
Mean ± SD.

Hospital 1
Mean ± SD.

Hospital 2
Mean ± SD.

Hospital 3
Mean ± SD.


Overall EBP¥ 3.57±0.70 3.58±0.85 3.62±0.63 3.50±0.59 0.832 0.436

Knowledge of EBP 3.22±0.68 3.23±0.76 3.29±0.59 3.12±0.67 1.673 0.189
Use (skills) of EBP 3.57±1.20 3.76±1.37 3.52±1.26 3.42±0.91 2.171 0.116

Attitudes Toward EBP 4.80±1.18 4.55±1.20 4.92±1.36 4.98±0.91 3.469 0.032*

Overall QI 3.90±0.58 3.78±0.73 3.88±0.49 4.03±0.47 4.638 0.010*
QI knowledge 4.36±0.66 4.42±0.63 4.23±0.71 4.43±0.61 3.200 0.042*

Skills of QI 3.49±0.76 3.29±0.93 3.57±0.59 3.61±0.69 5.464 0.005*
Attitudes towards QI 4.35±0.71 4.29±0.78 4.23±0.67 4.53±0.62 5.206 0.006*

SD: Standard Deviation F: F value for ANOVA test *: Statistically significant at p ≤ 0.05.
¥EBP on Seven-point Likert scale QI on Five-point Likert scale

3.3. Barriers and Facilitators to the implementation of EBP

In response to the two open-ended questions asking about
perceived barriers and facilitators to the implementation of
EBP, the number of nurses responded to these questions was
201(67.0%). Some nurses identified more than one barrier or
facilitator. The most widely identified obstacles to EBP were:
lack of time for reading and searching (100.0%), lack of
adequate staff knowledge and skills of EBP (93.75%),

inadequate training of nurses on EBP, especially diploma
degrees (64.38%), and inadequate resources and facilities
(56.25%). On the contrary, the most important facilitators that
could help nurses use EBP were periodic training programs on
EBP and updated nursing research (100.0%), supportive
hospital management (79.60%), and the presence of facilities
and role models for applying knowledge and skills of EBP
(44.78%). See Supplementary Table 1.

Table 3. Multivariate regression analysis between EBP and QI.

Variables B SE t p
95% CI

QI knowledge 0.164 0.051 3.206 0.001* 0.95-0.396
Attitudes towards QI 0.062 0.049 1.261 0.208 -0.239-0.052

Skills of QI 0.289 0.032 8.797 <0.001* 0.333-0.524
r= 0.485, R2 = 0.273, F = 36.973, p<0.001*

B: the coefficient estimates SE: standard error t: t-test value F: F-test
r: Pearson correlation coefficient R2: regression coefficient
CI: Confidence interval LL: Lower limit, UL: Upper Limit *Statistically significant at p≤ 0.5

Table 4. Stepwise regression results for factors associated with overall EBP and QI scores.

B SE t p

95% CI

B SE t p
95% CI

Evidence-based practice Quality improvement
Age -4.457 1.189 3.748 0.001* -0.408-0.127 -2.994 1.493 2.006 0.046* -0.237-0.002

Years of experience 3.564 0.902 3.951 0.001* 0.107-0.320 1.829 1.132 1.615 0.107 -0.016-0.162
Education level 2.065 0.772 2.676 0.005* -0.215-0.033 3.697 0.969 3.817 0.001* -0.224-0.072

B: the coefficient estimates SE: Standard Error t: Student t-test *: Statistically significant at p ≤ 0.05
CI: Confidence interval LL: Lower limit, UL: Upper Limit

������� 1

EBP and Quality Improvement The Open Nursing Journal, 2020, Volume 14 259

3.4. Correlation and Multivariate Regression Analysis
between EBP and QI

Table 3 indicates a strong positive, moderate correlation
between the EBP and QI, as perceived by nurses (r= 0.485,
p<0.001). The coefficient of regression between QI and its
related dimensions, as independent variables, and EBP, as a
dependent variable, was R2=0.273. This means that ap-
proximately 27.3% of the explained variance of EBP is
accounted for QI and associated subscales, particularly, QI
knowledge and skills that contribute important prediction of
EBP where the regression model is significant (F= 36.973,
p<0.001). For further correlation values, see Supplementary
Table 2.

3.5. Factors Associated with Nurses’ Perceptions of EBP
and QI

Table 4 showed the stepwise regression analysis, which
revealed that the overall EBP score was significantly associated
with nurses’ age, years of experience, and educational level.
Younger nurses had the lowest perceived EBP score
(β=-4.457,p<0.001), whereas nurses with more years of
experience and a bachelor’s education degree had higher EBP
scores (β=3.564, p<0.001; β=2.065, p=0.005), respectively. As
for QI, the result showed that age and educational level were
statistically important factors correlated with the QI ratings.
Specifically, younger nurses (β=-2,994, p= 0.046) had a lower
perceived QI rating, while bachelor’s nurses had a higher QI
rating (β=3,697, p<0.001).


The present study revealed that nurses have a moderate
perception of the overall attitude and use of EBP while they
have a low knowledge level of EBP. Nurses were optimistic
towards EBP but felt that they lacked the adequate knowledge
to fully understand the language of EBP and to carry out its
activities, particularly those who did not work on nursing
research and finding evidence. This finding goes in the same
line with many previous studies. For example, Egyptian studies
conducted by Mohsen et al. [25] found that nurses had a
positive attitude towards EBP, yet they lacked the knowledge
and basic skills of EBP for practical application. Nevertheless,
Mohamed and Mohamed [26] reportedly found that nurses had
unfavorable attitudes towards EBP and preferred using
traditional methods over changing to new approaches in care.
They perceived themselves to have a reasonable level of skills
to pursue various EBP activities. Other studies conducted by
Karki et al. [27], Ammouri et al. [28], and Foo et al. [29]
showed that nurses’ perceptions of EBP knowledge and skills
were variable and they lacked the competence and knowledge
to conduct it, but they had a positive and supportive attitude
towards EBP.

The current findings revealed that some barriers reported
by nurses might negatively affect their knowledge, attitude, and
skills and impede their smooth adoption of EBP. The most
commonly identified obstacles to EBP were lack of time, lack
of sufficient personnel expertise and EBP preparation, and
insufficient services and facilities. The current study confirmed
what has been shown in previous studies regarding common

barriers to the adoption of evidence-based practice among
Egyptian nurses, such as lack of evidence-based information,
difficulty in evaluating the validity of research articles and
reports, lack of resources and time to read research articles and
change their current practice, insufficient resources to
implement EBP, and limited Information Technology (IT)
skills [22, 25, 26]. Many nurses have not received any formal
training on the application of EBP [25, 26]. This is in line with
previous studies that documented similar results in addition to
insufficient organizational support and lack of research
awareness/use [19, 28].

On the contrary, nurses emphasized many facilitators that
could help them incorporate EBP as periodic training programs
on EBP …

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