Improve nursing in evidence-based practice: How Chinese nurses' read and comprehend scientific literature.

OBJECTIVES: To examine Chinese nurses' practice of reading and understanding scientific literature and elucidate the motivating and deterring factors.
METHODS: This is a cross-sectional study conducted between March and June 2015. A random sample of 853 full-time registered nurses from three tertiary and two secondary hospitals in China filled out a set of self-administered questionnaires, including literature habit questionnaire(41 items), the situational motivation scale and the socio-demographic and professional characteristics questionnaire(15 items).
RESULTS: Significant majority (89.2%) of the respondents reported perception of barriers to keeping up to date with literature. The language barrier was the most prominent, followed by poor presentation and readability of articles. Using simpler language when writing articles, improving ones' foreign language proficiency and getting education or training on nursing research were raised as the top facilitators. Additionally, reading and understanding literature was significantly associated with the nurses' educational background, motivation, genders and work settings.
CONCLUSIONS: The survey of the current status of literature education among Chinese nurses suggests that providing protected time, training for critical thinking, and incentive mechanisms will help improve nurses' engagement in literature and create a culture of academic inquiry.

Introduction

With increasing societal expectation for high quality and outcome driven medicine, nursing care is moving away from rituals and traditions toward evidence-based delivery models [1]. Nurses are expected to understand and apply research evidence into clinical practice. This process not only enhances the clinical effectiveness and improves patient outcomes, but also facilitates personal and professional growth for nurses [2], [3]. Nurses are also encouraged to partake in and initiate research and quality improvement activities in their institutions [4]. Unfortunately despite abundant clinical and health services research production, the translation of research findings into practice remains slow and haphazard [5], [6], [7], resulting in a so-called “research-practice gap”. As a profession dedicated to the front lines of healthcare, nurses are uniquely situated to close this gap by harnessing and contributing to knowledge in the scientific literature.

One of the major challenges in professional development for nurses is nurturing of the ability to understand and evaluate research articles for potential practical application [8]. The readability and comprehensibility of articles have been frequently reported to contribute to nurses' perceived barriers to research utilization [9], [10], [11]. For example, the amount of information presented can be overwhelming and the nurses do not know how to distinguish and retrieve the relevant pieces [6]. The statistical analyses can be mystifying; applicable research findings can be hidden and inaccessible; the content of the article can be obscure and unrelated to daily clinical practice; and the articles can be poorly written or presented [3], [12]. As most articles are published in English, language barrier can be a significant obstacle for nurses in China and other non-English speaking regions [3], [13].

Reading and understanding research articles is essential for nurses to acquire up-to-date knowledge and apply it to improve patient care [13]. Nurses may rarely read scientific articles due to a variety reasons, including lack of time or interest [4]. Some nurses may have the desire and intention to read, but are prevented from doing so by shortages in foundation knowledge and language barriers. To date, factors involved in nurses' engagement with literature have not been well explored and there is limited insights into how to improve nurses' capacity to effectively digest and use information found in the literature.

China has one of the largest cohort of nurses in the world [6]. It is imperative to bridge the gap between research and practice in China under the policy of ‘‘High Quality Nursing Care’’ [14]. The quantity and quality of research periodicals have rapidly grown, providing nurses with valuable resources. There are more than 20 Chinese nursing journals [15]. One study showed that 84% Chinese nurses read articles routinely; however the finding cannot be readily generalize as the sample size was limited [15]. In order to encourage research utilization, more research is needed to examine the reading motivations, habits, and barriers, and formulate facilitating strategies.

The aim of this study was to examine factors associated with reading and understanding literature among Chinese registered nurses working in the hospital setting. The specific objectives were to: 1) investigate the reading habits of nurses; 2) identify the barriers that hinder the reading and understanding of literature among nurses; 3) examine the level of motivation for nurses to read literature; 4) explore modifying factors for the barriers and facilitators of reading and understanding literature; and 5) suggest ways to promote familiarity with literature. This study may contribute to the design and delivery of targeted nursing education or intervention program to improve nurses' ability of reading and understanding literature.

Methods

Study design

This is a cross-sectional study conducted between March and June 2015.

Setting and sample

A cluster sample of registered nurses were recruited from three tertiary hospitals (500 beds each) and two secondary hospital (300–500 beds) in Changsha, Haikou and Harbin, China. A total of 900 full-time registered nurses were selected from the staff lists randomly (200 nurses recruited from each tertiary hospital and 150 nurses from each secondary hospital) and asked to complete a confidential self-administered questionnaire.

Ethical considerations

This study was approved by the Institutional Review Board of (Grant Number: 2015036). The front page of the on-line questionnaire included an explanation of the purpose of the study and a guarantee of anonymity and confidentiality of the information provided. The completion of the questionnaire was taken as consent to participation.

Data collection

Literature habit questionnaire

This questionnaire was developed based on literature review (e.g., [9]), semi-structure interview with 15 registered nurses and 10 experts. The questionnaire had good internal validity with Cronbach's α of 0.85 and content validity index of 0.81. In addition to the reading habits (including frequency, quantity, and goals of reading), participants were asked whether they thought each item constituted a barrier or facilitator for reading and understanding literature and provide reasons for not reading more. Participants were asked to rank items they considered as the top three barriers, reasons and facilitators. They were also invited to leave additional comments and insights.

The situational motivation scale (SIMS)

The Chinese version of the SIMS [16] was used to evaluate the motivation of reading literature among registered nurses. The SIMS contains 16 items covering four domains, including situational intrinsic motivation, identified regulation, external regulation, and motivation. A seven-point Likert-type scale (ranging from 1,‘‘not at all’’ to 7,‘‘exactly’’) is used to assess why someone currently engages in an activity. The published Cronbach's α of the SIMS was 0.76–0.83 [16]. In this study, Cronbach's α of the SIMS was 0.83.

The socio-demographic and professional characteristics questionnaire

Background information collected include age, gender, marital status, level of education, religion, position, professional title, years of experience working as a nurse, institution, hospital, ward, research and teaching experience, tutor and previous training on nursing research.

Data analysis

All statistical analyses were conducted using SPSS version 16.0. Frequency, mean and standard deviation were used to describe the socio-demographic characteristics of the nurse respondents and to summarize the questionnaire scores. Pearson correlation analysis was used to examine the relationship between the barriers/facilitators of reading literature and reading motivation. Independent t-test and one-way ANOVA were used to compare the scores for barriers and facilitators among different demographic groups. Multilinear stepwise regression was performed to assess factors associated with barriers or facilitators. The dependent variable was the total scores of barriers and facilitators. Independent variables were the socio-demographic and professional factors shown to have significance in the independent t-test or one-way ANOVA. Statistical significance was established at P < 0.05. As categorical variables, gender, level of education, years of experience working as a nurse, religion, institution, hospital, professional title, and ward were transformed into dummy variables in linear regression with male, master's degree or above, ≥21, no religious faith, secondary (level 2) hospital, non-teaching hospital, senior nurse, and assist ward as the reference group.

Results

Participant characteristics

A total of 900 questionnaires were distributed, and 860 were returned. Seven were incomplete and discarded, yielding 853 (666 from tertiary centers, 187 from secondary hospitals) for analysis (response rate 94.8%). The respondents' mean age was 28.82 ± 6.49 years. The vast majority (96.1%) was female, 78.1% was primary nurses, and 50.8% was married. Academic qualification ranged from certificates (technical school, (15.2%), diploma/associate's degree (30.1%), bachelor's degree (53.1%), to master's degree and above (0.8%). Only 10.7% endorsed religious faith. A small percentage (6.9%) was unit managers. On average, the respondents have been working as nurses for 8.15 ± 7.33 years. Slightly more than half (54.4%) have received training on research, but only 15.4% had research experiences (Table 1).

Table 1

Socio-demographic characteristics of Chinese nurses and associated univariate analyses (n = 853).

Characteristics		n(%)	BarriersZ/χ2 (P)	FacilitatorsZ/χ2 (P)
Age (years)	≤25	317(37.2)
	26–35	390(45.7)
	≥36	132(15.5)
	Missing	14(1.6)
Gender	Female	820(96.1)	−2.21(0.027)
	Male	33(3.9)
Marital status	Single	403(47.2)
	Married	433(50.8)
	Divorce	12(1.4)
	Widowed	1(0.1)
	Missing	4(0.5)
Level of education	Certificate (technical school)	130(15.2)	19.00(0.000)	11.73(0.008)
	Diploma (associate's degree)	256(30.1)
	Bachelor's degree	453(53.1)
	Master's degree or above	7(0.8)
	Missing	7(0.8)
Religion	Buddhist	66(7.7)
	Taoism	6(0.7)
	Christian	26(3.0)		10.37(0.016)
	No religious faith	723(84.8)
	Declined to answer	25(2.9)
	Missing	7(0.8)
Experience working as a nurse (years)	1–5	421(49.4)		14.34(0.002)
	6–10	206(24.2)
	11–20	143(16.8)
	≥21	80(9.4)
	Missing	3(0.2)
Institution a	Tertiary (level 3) hospital	666(78.1)		−2.11(0.035)
	Secondary (level 2) hospital	187(21.9)
Hospital	Teaching	750(87.9)	−3.11(0.002)	−4.21(0.000)
	Non-teaching	103(12.1)
Ward	Surgery	176(20.6)	24.89(0.002)	60.25(0.000)
	Internal medicine	282(33.1)
	Obstetrics and Gynecology	53(6.2)
	Pediatrics	36(4.2)
	Operating room	62(7.3)
	Intensive care unit	96(11.3)
	Emergency	86(10.1)
	Outpatient	25(2.9)
	Assist b	26(3.0)
	Missing	11(1.3)
Position	General nurse	794(93.1)
	Unit manager or above	59(6.9)
Professional title	Primary nurse	666(78.1)	20.07(0.000)
	Junior nurse	151(17.7)
	Senior nurse	31(3.6)
	Missing	5(0.6)
Nursing research experience	Yes	131(15.4)
	No	716(83.9)
	Missing	6(0.7)
Teaching experience	No	469(55.0)
	School teaching	24(2.8)
	Clinical teaching	354(41.5)
	Missing	6(0.7)
Tutor	No	846(99.2)
	Yes	7(0.8)
Training on nursing research	No	378(44.3)
	Systematic training	119(14.0)
	Short-term training	345(40.4)
	Missing	11(1.3)

Note.a The Chinese public hospitals are graded into three levels by size and technical complexity (MOH, 1989). Level 3 hospitals are the large, high-tech hospitals (500 + beds)and Level 2 hospitals are those with medium size and technology (300–500 beds). b Include the nuclear medicine department and outpatient chemotherapy infusion center.

Habits of reading literature

As summarized in Table 2, a small proportion of nurses read literature regularly on a daily (3.5%), weekly (9.8%) or monthly (9.3%) basis. Ten percent never read and the remaining 66.0% only read when needed. When asked about the type of literature read in the past three months, 64.4% only read Chinese articles, and 28.3% only read foreign language articles. The abstract was regarded as the first (61.1%) and major (40.4%) content to read. The main sources of articles were newspapers and magazines (39.2%), online searches (43.2%) and academic databases (17.5%). The majority of nurses (64.6%) read articles on empirical clinical research, with goals for publication (42.1%), clinical or teaching requirement (41.9%), and familiarizing with hot topics (31.3%).

Table 2

The status quo of reading literature among Chinese nurses(n = 853).

Variable		Yes opinion(%)
The frequency of reading literature	Never	92(10.8)
	Everyday	30(3.5)
	Every week	84(9.8)
	Every month	79(9.3)
	When necessary	568(66.6)
The number of literature published in foreign language you have read in the past 3 months	0	549(64.4)
	1–5	208(24.4)
	6–10	49(5.7)
	11–20	23(2.7)
	≥21	22(2.6)
	Missing	2(0.2)
The number of Chinese literature you have read in the past 3 months	0	241(28.3)
	1–5	430(50.4)
	6–10	95(11.3)
	11–20	43(5.0)
	≥21	37(4.2)
	Missing	7(0.8)
Part of the literature which is your major focus	Abstract	345(40.4)
	Introduction	41(4.8)
	Methods	138(16.2)
	Results	63(7.4)
	Discussion and conclusion	182(21.3)
	Don't know	79(9.3)
	Missing	5(0.6)
Part of the literature you read first	Abstract	521(61.1)
	Introduction	134(15.7)
	Methods	47(5.5)
	Results	41(4.8)
	Discussion and conclusion	59(10.7)
	Don't know	52(6.1)
	Missing	5(0.6)
The major sources of reading literature	Newspapers or magazines	335(39.2)
	Online search	369(43.2)
	academic databases	149(17.5)
The type of literature you read most frequently	Summaries of clinical experience	569(64.6)
	Reviews	194(20.5)
	Research monographs	90(8.4)
The main purpose of reading literature a	Publication	359(42.1)
	Project Application	74(8.7)
	Looking for research ideas	74(8.7)
	Being familiar with hot topics in nursing research	267(31.3)
	Necessary for clinical practice and teaching	357(41.9)
	Others b	43(5.0)
Barriers to reading literature	Yes	761(89.2)
	No	92(10.8)

Note.a Multiple response. b for self interest, knowledge supplement, self-study.

Perceptions of barriers to reading literature

The majority (89.2%) of nurses reported some barriers to reading literature (Table 3). All perceived barriers were substantiated by more than 50% of the respondents. “When reading literature, nurses feel strenuous because of the deficiency in foreign language” was the most frequently reported barrier, endorsed by 96.0% of the respondents, followed by “because of the deficiency in statistics knowledge, it is difficult to understand the research results” (85.4%), and “It is difficult to understand the scientific or academic terms in literature” (82.9%). Interestingly, what the nurses weighed as the top three greatest barriers did not complete match the barriers with the most number of supporters. While deficiency in foreign language (66.8%) and statistics (27.0%) were still the top two, “Too much literature on the same topic, don't know which one to choose” (15.1%) came in as the third most important barrier. No one reported any additional barrier.

Table 3

The barriers and facilitators of reading literature among Chinese nurses(n = 853).

Rank order	Barriers	Yes opinion(%)	Facilitators	Yes opinion(%)
1	When reading literature, nurses feel strenuous because of the deficiency in foreign language	819(96.0)	Use simple language in literature to improve the readability	768(90.0)
2	Because of the deficiency in statistics knowledge, it is difficult to understand the research results	728(85.4)	Improve self foreign language proficiency	751(88.1)
3	It is difficult to understand the scientific or academic terms in literature	707(82.9)	Get education or training on nursing research and literature retrieval	743(87.1)
4	Too much literature on the same topic, don't know which one to choose	676(79.3)	Organize seminars on reading nursing literature	736(86.3)
5	It is difficult to understand the research methods in literature	647(75.8)	Establish some incentive mechanisms to encourage readers and communicators	732(85.8)
6	Unable to scientifically evaluate the value and practicability of research results in literature	624(73.2)	Ask for help when having difficulties in reading literature	732(85.8)
7	Nurses don't know the key points needed to read, due to the overwhelming of information in the literature	572(67.1)	When reading literature published in foreign language, make use of dictionary or translation software	728(85.3)
8	Unable to make judgment for conflicting results reported in the literature	530(62.1)	Reading scientific papers as a part of nurses' career development.	726(85.1)
9	The research content is difficult to understand	529(62.0)	Subscribe journals in department	707(82.9)
10	The readability of the literature is poor or the literature is unclearly reported	476(55.8)	Provide or establish peer support networks or mechanisms	705(82.7)

Reasons for not reading literature

Nurses reported that they do not read because of “deficiency in foreign language for reading literature” (91.1%), “too busy with work, don't have time to read literature” (78.0%), “lack of education or training in nursing research and literature retrieval” (77.6%), “feeling that reading literature is not useful” (33.3%), among others (Table 4). The top three reasons ranked by nurses to have the greatest impact were lack of time (34.0%), deficiency in foreign language (26.2%), and lack of training (14.0%). Additional reasons raised include lack of access to research opportunities, and perceived irrelevance of articles to clinical practice.

Table 4

The reasons why less or no reading literature among Chinese nurses(n = 853).

Rank order	Reasons	Yes opinion(%)
1	Deficiency in foreign language for reading literature	777(91.1)
2	Too busy with work, don't have time to read literature	431(78.0)
3	Lack of education or training in nursing research and literature retrieval	662(77.6)
4	No awareness or habit of reading literature	618(72.5)
5	Insufficient resources of literature retrieval	577(67.7)
6	No awareness of nursing research	554(65.0)
7	Lack of confidence in nursing research	531(62.3)
8	Not convenient to get literature	501(58.7)
9	Don't know how to get literature	464(54.4)
10	Nor interested in literature on nursing research	457(53.6)
11	The prospect of being a nurse is not good, unwilling to make efforts for further study	317(37.2)
12	Feel that reading literature is not useful	284(33.3)

Note. Other reasons: no opportunity to contact nursing research, some literature lack of practicability and meaning.

Facilitators of reading literature

The facilitators received support from greater than 80.0% of the respondents. “Use simple language in literature to improve the readability” (90.0%) was by far the most common, followed by “improve one's foreign language proficiency” (88.1%), and “get education or training on nursing research and literature retrieval” (87.1%). These were also ranked as the three most influential facilitators. Notably, the facilitators presented a mirror image of the barriers and reasons for not reading. No additional facilitator was mentioned.

Relationship between barriers/facilitators and reading motivation

Negative correlation was noted between the total score of barriers and intrinsic motivation (r = −0.10, P = 0.003), and between the total score of facilitators and amotivation (r = −0.10, P = 0.001), respectively. Additionally, there was positive association between the total score of barriers and amotivation (r = 0.11, P = 0.001), between the total score of facilitators and intrinsic motivation (r = 0.08, P = 0.016) and identified regulation (r = 0.10, P = 0.006).

Factors influencing the barriers and facilitators of reading literature

Low educational level and lack of intrinsic motivation was associated with greater number of perceived barriers to reading literature. Female nurses and nurses working in non-teaching hospitals perceived more significant barriers. Nurses with religious faith or higher levels of education and reading motivation reported more facilitators for reading literature. These factors accounted for 4.3% and 6.1% of the total variance in perceptions of barriers and facilitators, respectively (Table 5).

Table 5

Independent predictors for the total scores of Barriers and Facilitators in Chinese nurses (n = 853).

	Adjust R2	F	Standardized beta	Standardized error	t	P
Predictors for total scores of Barriers	0.04	10.43a
Bachelor's degree			0.15	0.21	4.45	0.000
Intrinsic motivation			−0.09	0.44	−2.67	0.008
Female			0.08	0.61	2.30	0.022
Non-teaching hospital			0.07	0.40	2.06	0.040
Predictors for total scores of Facilitators	0.06	8.93a
No religious faith			−0.09	0.33	−2.60	0.010
Intrinsic motivation			0.11	0.26	3.23	0.001
Bachelor's degree			−0.10	0.53	−3.07	0.002
Identified regulation			0.09	0.23	2.51	0.012

Note. a P < 0.01.

Discussion

To the best our knowledge, this was the first study in Mainland China to examine registered nurses' perceived barriers to, reasons for and facilitators for reading literature in clinical practice. Our data showed that although more than half of nurses read literature out of necessity, only less than 10% read regularly. In comparison, 65% of Australia nurses read journals monthly or more frequently [17]. So did 84% of Chinese nurses reported by Zhou et al. [15]. We found that the majority of Chinese nurses (89.2%) felt significant barriers to reading literature, higher than Hong Kong (69%), and US and UK (65%). This may be related to the lack of research-related education or training (54.4%) and participation (15.4%) as reported by our respondents. As the current situation of literature reading is suboptimal in China, research utilization initiatives are likely to be more successful if the reading habits of nurses improve [17].

Since English is not their native language, Chinese nurses reported language as the greatest barrier to reading literature, similar to other non-English-speaking countries in Europe and Asia [18]. Because most research papers are published in English [6], [18], language insufficiency may prohibit the digestion and application of research findings. It would be important to improve the nurses' English comprehension, possibly through tools (e.g., dictionary, translation software) designed for academic reading.

Many nurses noted that the results or methods in research articles are difficult to understand because of academic jargons, contributing to the poor presentation and readability of literature. Some nurses did not know how to search and retrieve articles or choose the best evidence from the overwhelming collection of information. We found that inadequate foundation of research knowledge and educational background influence perceptions of both barriers and facilitators of reading literature. Despite the advancement in information technology and nursing education in China, the lack of training on research and evidence-based practice remains a concern. Often research curricula are only available for candidates of bachelor's or higher degrees, and not for diploma or associate programs that are the main producer of new nurses [6]. Nurses with a higher educational background tend to pursue higher academic achievement, want challenges, and possess positive attitude and interest toward research, a finding consistent with previous studies [6], [19]. These results highlight the importance of training in nursing research, either as part of the academic program or continuous nursing education. Hospital or department may organize seminars on reading articles, or subscribe to journals. On the other hand, improving the presentation and readability of literature by authors, editors, and publishers may also help.

The three top reasons for not reading were deficiency in foreign language, lack of time, and inadequate research training. The lack of time for reading literature while balancing daily clinical duties has been a common and recurrent problem reported both nationally and internationally [20]. Although the evidence-based health care policies has been stipulated by the Ministry of Health in Mainland China [3], the shortage of nurses, and their overwhelming workload [21], make it impossible to regularly read and keep up with the increasing numbers of publications [22]. We still have a long way to explore realistic and effective strategies to make the necessary changes to the work pattern of nurses.

Another interesting finding is that reading motivation was associated with both perceived barriers and facilitators. According to the self-determination theory [23], motivation depends on self-determination, intrinsic motivation, extrinsic motivation, identified regulation and amotivation. In this study, intrinsic motivation and identified regulation played more important roles in nurses' literature reading than extrinsic motivation. Intrinsic motivation refers to performing a behavior for their own sake, deriving pleasure and satisfaction in the process [24]. Identified regulation implies an option as it occurs when the behavior is considered important for the subject's goals [24]. Motivation generates consequences. Intrinsic motivation is mostly associated with positive outcomes (e.g., persistence) followed by identified regulation [25]. Nurses may read literature or engage in research for difference purposes. For example, Cheng et al. [26] reported that 52.9% nurses conduct research for job promotion, 37.2% for developing the field of nursing. Thus, motivation may become a catalyst for literature reading and further research utilization.

How can we stimulate intrinsic motivation and identified regulation to encourage nurses to read literature and even apply the findings to evidence-based clinical practice? We suggest that nurses must first acknowledge that research is essential for ensuring high quality patient care and optimize benefits to all parties in the health care system and take research as a career responsibility. Nurses in our sample recognized facilitating strategies, including establishing incentive mechanisms, incorporating reading to career development, and peer support. Additionally, nurses can ask for help when having difficulty reading literature, to reduce frustration.

The type of hospital was an important factor affecting barriers to reading literature. We speculate the following reasons. Compared with community hospitals, nurses in teaching hospitals are more likely to have higher educational background and more opportunities and avenues to access articles or updated research information. Organizational culture could also guide the attitude and behavior of individual members [6]. A culture that encourages nurses to get continuing education or training on research can empower nurses to study independently and to conduct research [3].

Limitations

This study was a cross-sectional survey, thus, we could not conclude any causal relationships. Self-administered questionnaires might not be robust enough to objectively present the values involved, such as the motivation for reading. Therefore, further studies using mixed-method approaches are needed.

Conclusions

This study evaluated the current situation of Chinese registered nurses' literature reading and understanding, and the underlying barriers, reasons, and facilitators. The nurses' educational background, reading motivation, gender, and work setting had significant association with their reported behavior and perceived barriers and facilitators. Therefore, we suggest that it is necessary to improve research education for nurses, establish incentive mechanisms or academic atmosphere for readers and communicators.

Implications and recommendation

This study provides an insight into the barriers to reading literature, and the reasons why nurses don't read. It also highlights factors perceived by nurses to facilitate reading. Language deficiency, lack of time, inadequate training, poor presentation and readability of literature, and low level of education and reading motivation, contributed to nurses' reading habits. We suggest that hospitals, medical institutions, and health professional managers should make a concerted effort to explore ways to provide protected time, create a research-friendly climate, and establish systems for nurses to read, communicate, evaluate and utilize research articles. Moreover, it is crucial to equip nurses with essential research knowledge and skills through training.

Conflict of interest

There is no potential conflict of interest.