Attitudes towards, and knowledge of, clinical effectiveness in nurses, midwives, practice nurses and health visitors

Attitudes towards, and knowledgeof, clinical effectiveness in nurses, midwives,practice nurses and health visitors

Dominic Upton BSc MSc PhD AFBPsS and C. Psychol

Senior Lecturer in Psychology, University of Wales Institute, Cardiff,

Faculty of Community Health Sciences, Llandaff, Cardiff, CF5 6YB, UK

Accepted for publication 1 May 1995

UPTONUPTON D.D. (1999)(1999) Journal of Advanced Nursing 29(4), 885±893

Attitudes towards, and knowledge of, clinical effectiveness in nurses,

midwives, practice nurses and health visitors

The dual concepts of evidence-based practice and clinical effectiveness have

become ever more important for nurses, midwives and health visitors in recent

years. In order that suitable initiatives can be derived and future policy shaped

and evaluated it is important that the current level of knowledge and attitudes

towards these concepts are recorded. The current study set out to examine these

variables in a large, representative sample (n � 370, response rate � 74%) of

nurses, midwives and health visitors. Results indicated that although a positive

attitude towards evidence-based practice exists, individuals consider

themselves to be lacking in certain key skills. Speci®cally, these appeared to be

related to research-based skills. However, despite this, respondents indicated a

large take up of evidence-based practice, although this may have been greater

were it not for the considerable clinical workload. The necessity for greater

dissemination of key research principles to nurses, midwives and health visitors

by members of their own profession is emphasized.

Keywords: attitudes, clinical effectiveness, evidence-based practice, nursing,

midwifery

INTRODUCTION

It is often assumed that decisions with potential social,

personal or medical implications are taken on the basis of

the best available evidence, rather than on the basis of

irrelevant evidence, or no evidence at all. However, this is

often not the case (Smith 1996). This realization has led to

the concepts of clinical effectiveness and evidence-based

practice becoming increasingly important in health care.

Indeed, in the recent White Paper on the future of the

National Health Service (NHS) within the United King-

dom the importance of clinical effectiveness was stressed

and a new National Institute for Clinical Excellence

(NICE) charged with evaluating the clinical and cost

effectiveness of new medical procedures proposed (Wal-

she 1998). The assumption is that the move towards

evidence-based practice could have a profound impact on

clinical activities in the health services and result in many

patients receiving better care and enjoying better health as

a consequence and, it has to be acknowledged, reduce the

substantial sums spent on ineffective or unproven diag-

nosis and treatment (Appleby et al. 1995).

Although the major focus of interest has been in the

medical ®eld (e.g. Sackett et al. 1997), this situation is

altering and the terms clinical effectiveness and evidence-

based practice are becoming ever more familiar within

both the professions allied to medicine (Kitchen 1997) and

the nursing profession (Kitson 1997a, Newell 1997).

However, this is not to say that the concept has become

fully integrated into the nursing profession. Indeed, some

have argued that the simple translation of evidence-based

medicine to evidence-based nursing or evidence-based

Journal of Advanced Nursing, 1999, 29(4), 885±893 Issues and innovations in nursing practice

Ó 1999 Blackwell Science Ltd 885

practice may be inappropriate without an alteration to

some elements of the underlying conceptual framework

(Kitson 1997a).

The concept of research-based practice is not new. The

Briggs Committee on Nursing (DHSS 1972) recommended

that nursing develop into a research-based profession. The

evidence on whether this has happened is, to date,

equivocal (McSherry 1997). There are barriers to the

implementation of research evidence into clinical practice

and these include such factors as the relative late uptake

of nursing research (Kitson 1997a); recurrent methodolog-

ical dif®culties in nursing research (Thomas & Bond

1995); lack of autonomy in nursing and the inaccessibility

of some research ®ndings (Walsh 1997); lack of both

research knowledge and the con®dence to implement

these ®ndings (Meah et al. 1996); and possibly lack of time

and funding opportunities (Marsh & Brown 1992). How-

ever, it is uncertain whether these same barriers exist to

impede the implementation of evidence-based practice

and whether recent initiatives have resulted in breaking

down some of these barriers.

There have been a number of developments supporting

the impetus of evidence-based practice: there are now a

number of journals (e.g. Clinical Effectiveness in Nursing),

books (e.g. Sackett et al. 1997), information sources (e.g.

Cochrane Collaboration) and policy-based initiatives in

both Scotland and Wales (Appleby et al. 1995) dedicated

to the subject. For example, one particular policy-led, and

proactive, development is the Welsh Of®ce Clinical Effec-

tiveness Initiative and a series of brie®ng papers have been

published to support implementation of this Initiative

(Welsh Of®ce 1995a, b, 1996a, b, c).

The success of some of these developments, and the

more general culture change required in order to produce

an evidence-based practice ethos throughout the health

service, requires a number of issues to be addressed

(Appleby et al. 1995). This does not necessarily refer

simply to strategic or organization developments but also

the practice, behaviour and attitudes of individual clini-

cians needs to be addressed. As Newell (1997) states:

`Many of the NHS strategies to promote change in imple-

menting clinical effectiveness operate primarily at the

institutional level, but the attitudes and behaviours of

individual clinicians also needs to be affected'.

The aim of many of the initiatives discussed is an

attempt at altering the attitudes and behaviours of clini-

cians. A sine qua non of this approach is a baseline level

of knowledge, attitude and practice to determine both the

success of any future interventions and to both frame and

direct these future interventions. The aim of the survey

reported here is to document and record the level of

knowledge of clinical effectiveness and evidence-based

practice and examine the attitudes towards these concepts

by a representative sample of nurses, midwives and health

visitors. Furthermore, it was intended to identify any

possible barriers to the implementation of evidence-based

practice and any possible solutions to overcome these

barriers.

THE STUDY

Method

In order to obtain the data a two-stage process was

adopted. Initially, a postal survey of a large, representative

sample of nurses, midwives and health visitors and

secondly, more in-depth interviews of a smaller number

of the sample. The focus of this report is on the postal

survey data; an analysis of the interview data will be

provided in a separate report.

SampleThe sample consisted of 500 subjects drawn from the

Welsh population of nurses, midwives, health visitors and

practice nurses. In order to obtain a sample representative

of the Welsh population of these professions a strati®ca-

tion of the sample was undertaken based upon the

population ®gures provided by the Welsh Of®ce (1996d).

Table 1 indicates the number in each professional group

within Wales and the corresponding strata for the sample.

The number of respondents, and consequently the re-

sponse rate, is also presented. Table 1 indicates that the

largest professional group were the nurses, which ac-

counted for 83% of the sample. In contrast, the midwives

Table 1 Strati®cation of sample and response rate

Professional group Number in Wales

Number of subjects

included in sample

Number of questionnaires

received Response rate (%)

Nurse 13880 415 295 71

Midwives 1851 55 50 90

Health visitors 334 10 9 90

Practice nurses 611 20 17 85

Total 16676 500 370 74

D. Upton

886 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 885±893

only accounted for 11%, the health visitors 2% and the

practice nurses 4%.

The study questionnaireInitially a questionnaire/attitude scale was designed to

address the aims of the study (see Upton & Lewis 1997 for

the development of the questionnaire). The questionnaire

sought to explore the following areas of interest.

Knowledge of clinical effectiveness and evidence-based practice

Items requested an individual to rate their perceived level

of knowledge of clinical effectiveness and evidence-based

practice at a general level on a visual analogue scale from 1

(Ì know a great deal about clinical effectiveness and

evidence-based practice') to 5 (Ì know very little about

clinical effectiveness and evidence-based practice'). An-

other subsection dealt with perceived knowledge of the

individual component skills of evidence-based practice

(e.g. research skills, awareness of major information types

and sources) with the individual respondent rating their

own ability from 1 (poor) to 7 (the best).

Practice of individual components of clinical effectiveness and

evidence-based practice

Individual respondents were requested to rate the fre-

quency of completing certain component key steps of

evidence-based practice (Sackett et al. 1997). For example,

how frequently (from Never to Frequently) had the indi-

vidual component ìdenti®ed a gap in my knowledge

which I need to ®ll'.

Attitudes towards clinical effectiveness and evidence-based

practice

Statements took one of two forms: a set of semantic

differentials required the individual to indicate at which

end of the spectrum of two opposing statements (e.g.

èvidence-based practice is a waste of time' to èvidence-

based practice is fundamental to professional practice')

they would place themselves; and a set of attitude state-

ments requiring the individual to indicate to what extent

they agreed or disagreed with each (e.g. `the evidence on

my practice is not worth the time involved in ®nding it').

Barriers and solutions

Individuals were requested to rate their level of agreement

as to the extent they perceived whether a list of possible

barriers were, indeed, barriers to their implementation of

evidence-based practice. A similar method was adopted

for the possible solutions to increasing the uptake of

clinical effectiveness and evidence-based practice.

Demographic details

An individual's age, sex, profession and grade were

requested.

ProcedureIn order to obtain the sample, a random sampling proce-

dure was adopted. In this way, an individual hospital/unit

from all those within Wales was selected using a random

number technique. A total of 21 hospital/units covering

the whole of Wales were approached for subjects from the

nursing profession and ®ve units for the midwifery sample

(no unit refused to participate). Subsequently, an individ-

ual ward/department was identi®ed within each hospital/

unit, again by random selection. The head of this ward/

department was then approached and their assistance

requested in the completion of the study. If they agreed to

participate (and none refused) then the number of indi-

viduals within the particular ward/department was

obtained. Subsequently, a number of questionnaires

suf®cient for the total number of quali®ed staff, with

explanatory letters and postage-paid return envelopes,

was sent to the head of the ward/department with a

request for them to distribute the questionnaires and

instruction letters to all members of quali®ed staff. This

was, consequently, a form of cluster sampling. It was not

possible to contact members of the nursing and midwifery

professions on an individual basis due to the unavailabil-

ity of a complete sampling frame.

In contrast, practice nurses and health visitors were

individually identi®ed, again using a random technique,

and each sent an individual questionnaire requesting their

assistance. The information was obtained by randomly

selecting individual practices from areas within which

health visitors and practice nurses operate. Consequently,

for example, all GP surgeries, health centres and associ-

ated units formed the sampling frame. From this total

population, 10 individual health visitors and 20 practice

nurses were randomly selected from individual units. No

individual refused to participate at this stage, although in

four cases individual health visitors were unable to be

contacted and another practice was therefore selected.

The survey commenced in April 1997 and was com-

pleted some 4 months later. It was felt essential to

complete the survey in as short a time as possible in

order to place the results within the stability of a speci®ed

time period.

Once received, all returned questionnaires were coded

and analysed on SPSS for Windows, version 7á5.

Results

1 The sampleOf the 370 responses some 92% (n � 341) were female. In

terms of grading, the majority (31%, n � 114) were at

grade E, while » 6% could be described as managers

(either grade I, or describing themselves as a `Manager',

n � 23). Most were under the age of 39 years (n � 207,

Issues and innovations in nursing practice Clinical effectiveness

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 885±893 887

56%), while only seven were above the age of 60 years.

Not surprisingly, therefore, this was re¯ected in the year

of quali®cation. The majority of the group had quali®ed

during the 1980s and 1990s (n � 246, 68%). The sample

was broadly representative of the population under con-

sideration.

2 Level of knowledge of clinical effectivenessand evidence-based practiceIn order to improve the presentation of this data a

subdivision into either a `high level' of knowledge (rated

4 or 5), a low perceived level of knowledge (rated 1 or 2) or

the mid-point (3) was performed. Using this categorization

the results indicated that many of the sample suggested

their level of knowledge to be low with only a small

number rating it to be high (see Figure 1). Overall some

160 subjects (43%) rated their knowledge as low, com-

pared to 83 (22%) rating it as high with 126 (34%) rating

the mid-point. This is supported by the fact that the modal

response for all groups was 1, low level of knowledge.

Figure 1 suggests some difference between the groups in

terms of rated perceived knowledge of clinical effective-

ness. Furthermore, when these data were analysed a

signi®cant association between profession and rated level

of knowledge was revealed (v2 � 17á01, d.f. � 6;

P � 0á009).

A further set of questions referred to individual com-

ponents of evidence-based practice. Thus a series of

questions requested the individuals to rate their level of

skill on a seven-point scale from 1 (`Poor') to 7 (`Best'). The

results of this investigation (see Table 2) revealed the

group scores to range from a low performance on IT skills

(mean � 3á26; SDSD � 1á50) to high perceived skill in

sharing of ideas and information with colleagues (mean-

� 5á42; SDSD � 1á11).

An interesting observation apparent in these ®gures is

that broadly the division is one of technical skills (such as

information technology, computer literature searches and

research skills) being rated the lowest, whereas those

personal or interpersonal skills were rated the highest (e.g.

dissemination of ideas about care to colleagues and

sharing of ideas and information with colleagues).

3 Attitudes towards evidence-based practiceand clinical effectivenessInitially the statements concerning attitudes towards spe-

ci®c elements of clinical effectiveness and evidence-based

practice were examined. For the purposes of presentation

the results have been compressed so that those rating 1 or

2 are collapsed and classi®ed as those that consider

`clinical effectiveness to be a key issue for the NHS'. Those

rating 3 are classi®ed as a mid-point, and those rating 4 or

5 are classi®ed as responding `clinical effectiveness is a

fad'. Figure 2 demonstrates the sample overall, considered

clinical effectiveness to be a key issue for the NHS.

In terms of differences between the professional groups

there appears a more positive attitude for the nurses and

midwifes than for the health visitors and practice nurses,

although this relationship was not statistically signi®cant.

The result of the comparison of the pair of statements

Èvidence-based practice is a waste of time' and Èvi-

dence-based practice is fundamental to my professional

practice' is presented in Figure 3. From the ®gure it is

apparent that the majority of individuals questioned

considered evidence-based practice to be fundamental to

their practice (n � 288, 78%), although there was a

minority (n � 23, 6%) that considered it a waste of time.

There was no signi®cant association between professional

group and rating on this particular statement.

Respondents generally displayed positive attitudes to-

wards evidence-based practice and its key elements.

However, as is to be expected, a number of professionals

considered clinical effectiveness to be a `fad' although it

Figure 1 Level of knowledge of

clinical effectiveness by pro-

fessional group. j � low; h �mid-point; � high.

D. Upton


should be noted that this view was in the minority and the

majority considered it to be a worthwhile and fundamen-

tal practice.

4 The application of evidence-based practiceRespondents were requested to rate how often (from Never

to Frequently) they had practised elements of evidence-

based practice in the past year in relation in an individual

patient's care (see Figure 4). Overall, the majority of

respondents stated that they either sometimes or frequently

completed the individual components of evidence-based

practice. The most frequently undertaken element of

evidence-based practice was involving patients fully in

their care. In contrast, the component of critical appraisal

of the literature was less frequently completed.

There was no association between any of these individ-

ual components and professional group.

Another component felt worthy of further investigation

was the extent to which professionals would alter their

practice dependent on where the evidence was derived. In

order to asses this particular issue respondents were asked

to rate the extent to which they would alter their practice,

dependent on a variety of sources of evidence (see

Figure 5).

The majority agreed that they would act on the opinions

of a colleague from the same profession (n � 286, 78%),

or evidence from their own practice (n � 331, 91%).

However, there was less certainty about acting on infor-

mation from the Internet with only 99 (27%) saying that

they would alter practice on the basis of evidence from

this source. It is also of interest to note the few numbers of

individuals that would alter their practice with evidence

presented from colleagues from a different profession

(n � 168, 46%).

Finally, an examination was undertaken to explore how

important the evidence-based practice was in the working

day and any possible barriers that may exist. There was an

overwhelming sense of a workforce which does not have

enough time to ®nd the evidence, that evidence is not

available in some areas and that the demands of the

service and the patients take priority. The responses to

two statement pairs, are presented in Table 3.

Practitioners generally view evidence-based practice as

fundamental to their practice. For example, 80%

(n � 285) considered this to be the case. However, there

is not enough time within the working day for profession-

als to keep up to date with the evidence. For example,

Table 2 Ratings of performance of component skills of evidence-

based practice

Individual component skill Mean SD

IT skills 3á26 1á50

Ability to undertake computer literature

searches

3á83 1á89

Converting your information needs into a

research question

3á48 1á39

Research skills 3á86 1á35

Ability to critically analyse evidence against

set standards

4á16 1á40

Ability to determine how valid the material is 4á20 1á24

Monitoring and reviewing of practice skills 4á29 1á25

Awareness of major information types and

sources

4á40 1á28

Ability to determine how useful the material is 4á46 1á25

Knowledge of how to retrieve evidence 4á57 1á28

Ability to apply information to individual cases 4á83 1á12

Ability to identify gaps in your professional

practice

4á97 1á15

Ability to review your own practice 5á11 1á10

Dissemination of new ideas about care to

colleagues

5á18 1á13

Sharing of ideas and information with

colleagues

5á42 1á11

Figure 2 Attitudes towards

clinical effectiveness by group.

j � CE is a key issue; h �mid-point; � CE is a fad.



only 30% (n � 110) considered themselves to have

enough time within the day to keep up with the evidence.

When participants were requested to document their

agreement to potential methods for increasing the uptake

of evidence-based practice, one of the major factors was

that of time (see Figure 6). It is interesting to note the rank

order of these factors. Most respondents considered better

dissemination, more time and library resources to be the

key issues with access to the Internet and greater avail-

ability of information technology (IT) resources being the

least required.

Discussion

This study aimed to survey and describe the knowledge

and attitudes of nurses, midwives and health visitors

towards evidence-based practice and clinical effective-

ness. To summarize, the study has indicated that in a

broadly representative sample a positive attitude towards

the concept of evidence-based practice and clinical effec-

tiveness exists. However, the self-rated level of knowledge

of clinical effectiveness was low, as was knowledge of

some of the components of evidence-based practice and

this was most apparent in the technical skills associated

with the concept. Furthermore, most individuals felt that

although they were frequently applying evidence-based

practice principles, a greater take-up of these was being

hampered by an excessive workload.

In terms of the sample, the response rate was extremely

good given the pressures that confront the groups being

asked to participate in the survey, and compare extremely

favourably to other reports. For example a response rate of

only 29% was reported by Marsh & Brown (1992) and 36%

by McSherry (1997). It is, of course, important to note that

the survey was completed in Wales which has had a

Clinical Effectiveness Initiative since 1994/5 and therefore

generalization to the rest of the United Kingdom needs to

be explored further.

The ®rst issue to highlight is the relatively low level of

perceived knowledge of the concept of clinical effective-

Figure 3 Respondent's value of

evidence-based practice. j �EBP is fundamental; h � mid-

point; � EBP is a waste of

time.

Figure 4 Practice of individual components of EBP. j � never; h � rarely; � sometimes; � frequently.

D. Upton


ness across the sample. On one hand this may be viewed

as rather dispiriting, especially given the Initiative in

Wales. However, this should not be viewed in isolation;

rather, the results concerning the actual application of

evidence-based practice should also be considered. These

indicated that the application of evidence-based practice

was relatively high. It may be that individuals are indeed

applying evidence-based practice principles, but are not

actually calling it this, either because they do not know

the term or because the information has become second

nature and part of normal everyday practice. Taken

overall, the results are indicative of a positive uptake of

evidence-based practice although there are certainly areas

of de®ciency that need to be addressed.

Primarily, the majority of these shortcomings could be

classi®ed as the technical, research-based skills. From the

information presented it would appear that nurses, mid-

wives and health visitors consider themselves to be adept

at the interpersonal skills but consider themselves lacking

in other more technical areas. Although no more than

speculation on the basis of the current results it would

appear that the move towards a research-minded profes-

sion still has some way to go as far as nurses, midwives

and health visitors are concerned. Certainly, this sugges-

tion would be supported by the results of other, more

speci®c, investigations and reports (e.g. Meah et al. 1996,

Kitson 1997a, McSherry 1997, Walsh 1997). The accessi-

bility (both in terms of physical location and user friend-

liness) of the research may be an area that warrants further

study, although there appears to have been little progress

since the initial highlighting of this as an issue (Hicks

1992, 1993, Meah et al. 1996).

The sample appeared to have a positive attitude towards

evidence-based practice. The majority considered it a key

issue for the NHS. This is obviously heartening and

suggest that the will of the clinical practitioners is behind

clinical effectiveness. Appleby et al. (1995) argued that

there is a need for a fundamental shift in the attitudes and

thinking of clinicians in order to introduce a clinical

effectiveness ethos within the NHS. From the results

presented here it would appear as if this culture shift has,

indeed, started. Consequently it may be concluded that, at

least from a nursing perspective, the attitude of profes-

sionals is not a barrier to successful implementation of a

clinical effectiveness culture. These barriers may be more

likely to be related to the infrastructure or organization in

which nurses, midwives and health visitors work Ð

again, issues highlighted recently (Kitson 1997b).

Although there is a positive attitude towards clinical

effectiveness there still remains a major barrier Ð that of a

lack of time. This barrier identi®ed by the respondents is not

altogether surprising in that other researchers have certain-

ly commented that `. . . today's NHS is complex, dynamic

and very busy. New demands, methods and services are

emerging all the time and views changing on when and for

whom a particular procedure should be used. Professional

Figure 5 Willingness to act on evidence from variety of sources. j � would act; h � uncertain; � would not act.

Table 3 Number of responses to statements concerning whether evidence-based practice is fundamental and whether it is a priority in

the working day

Midpoint

Evidence-based practice is fundamental to

professional practice

285

(80%)

52

(14%)

23

(6%)

Evidence-based practice is a waste of time

New evidence is so important that I make

the time in my work schedule

110

(31%)

102

(28%)

148

(41%)

My workload is too great for me to keep up to

date with all the new evidence



staff are under pressure to keep up with innovations and

with the workload' (Welsh Of®ce 1996b p. 3).

On the basis of the results presented here there are two

possible rami®cations. First, the introduction of evidence-

based practice may prove problematic because of the

heavy workload. A reduction in workload, and less

emphasis on throughput, may result in both the ethos,

and application of evidence-based practice becoming

more of a reality. The likelihood of a reduction in

workload (and its concomitant increase in the necessary

resources) occurring within the near future is remote. It

would, obviously, be of concern if a practice aimed at

improving patient care (which ultimately could result in

the reduction in workload due to the removal of ineffec-

tive or detrimental practices) is unable to be implemented

because of the current workload pressures. Therefore, a

review of methods that could result in a greater uptake of

an evidence-based culture without an excessive increase

in workload needs to be undertaken.

For example, the better and quicker dissemination of

proven improvements in practice, although ensuring that

this does not include questionable material (Appleby

et al. 1995, Naylor 1995). Whether this be via the new

technologies (given the results presented on views on

evidence from the Internet this may not be totally appro-

priate) or the more traditional manner of word of mouth or

expert demonstration is a matter of debate. Furthermore,

since the evidence presented suggests practice is more

likely to alter on the basis of evidence from a colleague

from the same profession rather than one from a different

profession then there is a need for more focused nursing/

midwifery evidence being presented to nurses, midwives

and health visitors by members of their own profession,

although the evidence that midwives undervalue research

they believe to have been undertaken by a member of their

own profession (Hicks 1992) needs to be taken into

account.

Another issue is the extent of the information currently

available for utilization by nurses, midwives and health

visitors. Estimates suggest that there is still an emphasis

on the medical profession with only 15% of clinical

effectiveness information relating to nursing, compared to

79% for medicine (Appelby et al. 1995). The dual prob-

lems of lack of information and the dif®culty in accessing

that which is available makes the challenges facing

professionals charged with implementation of evidence-

based practice considerable. It has to be recognized that

individual nurses, midwives and health visitors may ®nd

it problematic to undertake all the elements outlined as

essential for evidence-based practice (e.g. Sackett et al.

1997). Certainly, given the lack of perceived research

skills, the over-work and the low level of research-based

practice, then it may be that greater dissemination of key

principles needs to be considered. The results presented

reinforce the notion that better dissemination would assist

the implementation of evidence-based practice.

Study limitationsThis study is no different from any other research in

having its methodological de®cits. First, the questionnaire

designed was particularly lengthy and this probably ran to

excess which may have led to a lower response rate than

possible. Furthermore, some of the respondents may have

adopted a socially desirable position. Consequently, there

is a need for further studies that can take a more in-depth

and investigative approach to some of the queries. The

de®ciencies inherent in postal surveys should be also

noted. For example, the questionnaires may not have been

completed by the speci®ed recipient. Furthermore, the

questionnaire dealt with perceptions of knowledge and

practice. There is an obvious need for studies of actual

practice and knowledge. Finally, the sampling technique

could have led to bias in that some of the selected units

could have had a particular focus on evidence-based

Figure 6 Level of agreement with statement that Èvidence-based practice would increase if the following were in place'. j � agree;

h � uncertain; � disagree.

D. Upton


practice. However, it was hoped with a random selection

that any bias would be minimized and the sample be

representative of the total population in terms of their

experience and education concerning evidence-based

practice Ð it was felt that this was, indeed, the case.

CONCLUSION

With the above caveats in mind the study has presented a

broad picture of the current levels of knowledge and

opinions on clinical effectiveness and evidence-based

medicine. While not all the aspects considered can be

reported as being in a positive state and there are certainly

challenges ahead, it is apparent that the overwhelming

majority of nurses, midwives and health visitors have a

favourable attitude towards clinical effectiveness and

evidence-based practice and despite their heavy workload

are attempting to implement such practices for the good of

their patients and clients.

Acknowledgements

This research was completed with funding provided by

the Welsh Of®ce, under the guidance of the Clinical

Effectiveness Group/Outcomes Group and Clinical Effec-

tiveness Support Unit (Wales). Thanks must be extended

to members of the Research Steering Group for their

considerable contribution to the successful completion of

the study: Ms Noreen Edwards (Vice Chair of the Council

for Professions Supplementary to Medicine), Dr Ruth Hall

(Director of Public Health, North Wales), Professor Thelma

Parry (Dean of Academic Affairs, University of Wales

Institute, Cardiff), Mrs Yvonne Peters (Director of Nursing

and Quality, Llandough NHS Hospital Trust), Dr Simon

Smail (Sub-dean of Post-Graduate Medicine, University of

Wales College of Medicine), Professor Nigel Stott (Head of

Department of General Practice, University of Wales

College of Medicine), Professor Morton Warner (Director

of Welsh Institute of Health and Social Care) and Mr

Sandy Yule (Head of Radiography. University Hospital of

Wales, NHS Trust). The assistance of Mrs Penney Upton

and Miss Brynda Lewis with the completion of the study

must be acknowledged.

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Documents

Attitudes towards, and knowledge of, clinical effectiveness in nurses, midwives, practice nurses and health visitors