STRENGTHS AND LIMITATIONS OF THIS STUDY

Utilisation of a descriptive cross-sectional design allows for a snapshot of predictors of stay intent among Jordanian registered nurses.

Inclusion of data on knowledge, attitude, practice and barriers of evidence-based practice provides a comprehensive understanding of factors influencing stay intent.

Surveyed a representative sample of nurses across five hospitals in Jordan enhances the generalisability of the study findings.

Self-reported data on knowledge, attitude and practice might be prone to bias.

Controlled for participant and workplace characteristics, minimising confounding factors.

Introduction

Nurses are an essential part of the healthcare workforce, playing a critical role in providing high-quality patient care. However, in light of the issues that healthcare systems confront around the world, the retention of experienced nurses has arisen as a major challenge.1 The shortage of nurses has been attributed to several issues including burn-out, work dissatisfaction and intention to leave the field.1 In recent years, there has been rising recognition of the significance of evidence-based practice (EBP) in nursing as a means of improving patient outcomes and the quality of care.2 3 The scoping review indicates a clear association between EBP implementation and positive patient outcomes across diverse healthcare contexts. Specifically, EBP interventions were found to lead to improvements in clinical outcomes, patient satisfaction and quality of care delivery.4 EBP is defined as the integration of the best available evidence with clinical expertise and patient values to inform decision-making in healthcare.3 Adopting EBP can have a significant impact on patients’ outcomes and patient safety. Despite this known fact, clinical practice is repeatedly not based on current research findings, and there is a gap between research findings (nursing knowledge) and nursing practice.5 The most significant barriers to EBP were the lack of knowledge and skill to use EBP, time mismanagement for reading and searching, the lack of motivation, the lack of resources and training.6–8

The utilisation of EBP significantly influences stay intent within professional contexts.9 By emphasising the integration of the best available research evidence with clinical expertise and patient values, EBP enhances job satisfaction and promotes professional growth.4 The study by Melnyk et al investigated the relationships between a culture of EBP, mentorship, EBP implementation, nurse job satisfaction and intent to stay.9 The study found that a strong EBP culture and mentorship were significant predictors of nurses implementing EBP in their practice. Additionally, nurses who implemented EBP reported greater job satisfaction and a higher intention to stay in their positions.9

The pilot study conducted by Arslan Yurumezoglu and Kocaman indicated significant improvements in job satisfaction and organisational commitment among nurses following the implementation of evidence-based nursing management practices.10 Additionally, there was a notable decrease in the intent to leave among participating nurses. These results suggest that evidence-based nursing management strategies have the potential to positively impact nurse satisfaction, commitment and retention rates in the Turkish healthcare context.10 In addition, through a comparison study, the authors examined the association between EBP implementation and nurse outcomes such as job satisfaction, burn-out and intent to leave across the different hospital settings. The findings of the study revealed that nurses in Magnet-conforming hospitals reported higher levels of EBP implementation compared with those in non-Magnet hospitals. Furthermore, nurses in Magnet-aspiring and Magnet-conforming hospitals reported lower levels of burnout and intent to leave compared with those in non-Magnet hospitals.11 The estimated cost of nursing turnover in 2015 was US$38 000–US$59 000 for each registered nurse (RNs), with a hospital cost of US$5M–US$8M.9 Jordan’s healthcare sectors have many challenges regarding the continuous nursing shortage. EBP implementation could increase job satisfaction and nurses’ desire to stay.9 The Jordanian Nursing Council (JNC) framework developed national standards and core competencies for RNs. It highlighted the importance of EBP in primary, secondary and tertiary healthcare settings.12 In addition, the JNC road map to 2025 recommended more integration of evidence-based clinical practice to improve the quality of nursing care.12

In Jordan, several studies have been conducted to assess the status of EBP implementation among healthcare professionals and students. Abuhammad et al and Al Khalaileh et al conducted their studies among Jordanian nurses to identify barriers and predictors of research utilisation in clinical settings.13 14 The study highlighted various barriers such as lack of time, resources and skills, along with organisational and environmental factors hindering research utilisation. The study identified various barriers, including lack of time, skills and organisational support, hindering research utilisation among nurses in Jordan. Additionally, Abuejheisheh et al and Salah and Abu-Moghli delved into predictors of intensive care unit (ICU) nurses’ adherence to EBP guidelines, particularly in critical care settings.15 16 These two studies identified factors such as knowledge, self-efficacy and organisational support as significant predictors of EBP implementation among ICU nurses. Lastly, AbuRuz et al examined the knowledge, attitudes and practices regarding EBP among healthcare professionals in Jordan, revealed moderate levels of knowledge and positive attitudes towards EBP but highlighted gaps in actual practice implementation.2 The challenge of EBP utilisation is apparent among nurse students, with research indicating moderate competency levels. Attitudes towards EBP typically outweigh actual practice.17 Abu-Baker et al found variations in beliefs and practices among undergraduate nursing students, highlighting the need for enhanced educational programmes to promote EBP.18 Despite its recognised significance, there remains a gap in understanding how EBP knowledge, attitudes, practices and barriers influence the intent of nurses to stay in their current positions. While previous studies have explored factors contributing to nurse turnover, few have specifically examined the role of EBP in this context.4 9 11 To address this knowledge gap, the current study identified factors influencing stay intent among Jordanian RNs, with a specific focus on the role of EBP knowledge, attitudes, practices and barriers

MethodologyStudy design and setting

A cross-sectional-correlational study assessed the role of EBP attitudes, practices, knowledge and barriers in predicting stay intent among nurses. Participants were recruited from five hospitals. The recruitment took place between January 2022 and June 2022 representing different sectors in the middle region of Jordan; two public hospitals, two private hospitals and one university-affiliated teaching hospital. One of the public hospital in Jordan’s capital, Amman, is with 189 RNs and 461 beds, the number of admissions reaches 26 570 cases and receives 160 877 emergency cases in the ER. It is a catchment area that includes the Greater Amman Municipality and nearby areas, serving a large population. The second public hospital located in East Amman is Jordan’s largest public hospital. It has 1305 RNs, a larger capacity of around 1210 beds and serves a larger number of patients each day, with the number of admissions reaches 104 006 cases and receives 726 550 emergency cases in the ER. The hospital’s catchment area likely covers parts of Amman and possibly nearby towns and suburbs.

The first private hospital is located in Amman, with 240 beds and over 450 qualified nurses, it is one of the leading hospitals in the country. The hospital caters to a diverse range of patients, both domestically and internationally. The second private hospital is the only specialised cancer centre in the Middle East treating both adult and paediatric patients. It is located in Amman, Jordan and has 360 beds and over 1200 qualified nurses. The centre receives approximately 7000 new patients annually, and the number of admissions reaches 14 000 cases, with an estimated 250 000 outpatient clinics visits annually. Both hospitals are strategically positioned in Amman, the capital city of Jordan, making them easily accessible to patients from various parts of the country.

The last hospital is a prestigious university-affiliated teaching hospital located in Amman, Jordan. It is situated in the heart of Amman, making it easily accessible to patients from across the city as well as surrounding areas. With 625 beds and over 800 nurses, it annually serves more than (500 000) patients in the outpatients clinics, carries out (25 000) surgical operations and receives (94 000) emergency cases in the ER.

The number of participants from each sector was determined according to the total number of nurses in each sector to be representative sample and to generalise our results to entire population.

Sampling and sample size

A convenience sampling method was used. Inclusion criteria included RNs who work full time and provide bedside patient care in all nursing units and wards, have more than 1 year of clinical experience and are not in leadership positions. The sample size was determined by using G* power V.3.1.7 software. For regression analysis, the power was 0.95, alpha was 0.05 two tailed and the minimum required sample size was 166. To compensate for the attrition and incomplete questionnaires, and to adequately represent the five hospitals, the sample size was increased to 311 participants.

Patient and public involvement

None.

Data collection procedure

After obtaining ethical approval from the Institutional Review Board of Zarqa University and the Scientific Research Committees of selected hospital, the researcher contacted the nurses physically at each hospital to give a brief description of the study, the data collection method and the required time to answer the questionnaires and ask her/him for participation. After obtaining the consent form from all eligible nurses to participate, the study package, which included the cover letter and the four self-administered questionnaires, was given to them for completion. The completed questionnaires were coded for analysis and kept in an envelope. A total of 311 packages were distributed, and the response rate was 100%.

Instruments

This study used a demographic questionnaire that assessed the characteristics of RNs and the workplace characteristics in addition to three instruments: The EBP questionnaire, the EBP barriers scale andMcCain’s Intent to Stay Scale. All of these three tools were widely used in previous research conducted in Jordan and other places worldwide and were suitable for the research context.

The demographic data questionnaire

The demographic data questionnaire was developed by the researchers of this study and guided by the reviewed studies. It included the participant’s age, gender, marital status and nursing education level. Further information was collected about organisational factors such as the type of hospital, methods used to update their EBP knowledge, the presence of a library in the hospital. These variables were assessed as possible confounders of the relationship between stay intent and EBP attitudes, practices and knowledge.

Upton and Upton developed the EBP questionnaire

Upton and Upton developed the EBP questionnaire to measure knowledge, practice and attitudes towards EBP.19 It consists of 24 items rated on a 7-point Likert scale and includes 3 subscales: EBP knowledge and skills (14 items), EBP practice (6 items) and EBP attitudes (4 items). Higher scores indicate more positive attitudes and more excellent knowledge regarding EBP. Cronbach’s alpha=0.87 for the whole questionnaire, 0.91 for the knowledge/skill subscale, 0.85 for the practice subscale and 0.79 for the attitude towards EBP subscale. Construct validity was established using an independent EBP measure yielding a moderately positive relationship between scales.19

EBP barriers scale

EBP barriers scale deals with nurses’ perceptions of research utilisation barriers and facilitators in clinical practice. It consists of four subscales: characteristics of the adopter; characteristics of the organisation; characteristics of the innovation; and characteristics of the communication.20 It includes 29 items rated on a 5-point Likert scale (1=to no extent, 2=to a little extent, 3=to a moderate extent, 4=to a great extent); respondents can also choose a no opinion alternative. The higher score for the BARRIERS scales denotes a greater perceived barrier.

The internal consistency reliability of the tool is 0.91 for the entire tool, with Cronbach’s alpha of 0.80, 0.80, 0.72 and 0.65 for each subscale, respectively.20 Content validity was established using the second measure of research utilisation and feedback from experts in the field.

McCain’s Intent to Stay scale

McCain’s Intent to Stay scale measures an employee’s intention to stay in his or her current position and contains five items arranged on a 5-point Likert type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores are summed and divided by the number of items to attain a mean. A higher score indicated higher intent to stay. Content validity of the Arabic version of McCain’s Intent to Stay scale was established by experts in nursing. The Intent to Stay scale was used by AbuAlRub,21 who also studied Jordanian nurses and reported the internal consistency of the scale to be 0.74. The Arabic version was used in the current study. The scale has excellent reliability (alpha=0.86) and validity.22

Data analysis

The IMB SPSS V.24 software was used for data analysis. Descriptive statistics were used to identify the characteristics of RNs. Independent t-test, one-way analysis of variance (ANOVA), Pearson correlation and multiple regression analysis were used to identify the association between knowledge, attitude, practice and barriers towards EBP and staying intent, controlling for the demographics of study participants. The normality of distributions and linearity of the study variables were examined before conducting the parametric tests by visually inspecting histograms and plots and interpreting the descriptive statistics of the main study variables. The homogeneity of variances’ assumption of one-way ANOVA was examined using Levine’s test. Various assumptions of multiple linear regression were also assessed (ie, independence, linearity and no multicollinearity). With a significance level of 5%, two-tailed tests were chosen.

ResultsSample characteristics

A sample of 311 RNs completed the study, including 137 (44.1%) males and 174 (55.9%) females (table 1). The mean age of the participants was 30 years (SD=5.77). More than half of the participants were married (n=162, 52.1%). Most participants have a bachelor’s degree in nursing (n=280, 90.0%). A total of 148 participants (47.6%) were from governmental hospitals. Most participants graduated from governmental universities (n=228, 73.3%). About 75.9% of the participants (n=236) reported that their institution has a library. However, only 20.1% said they frequently visit the library located in their institution. Only 21 participants (6.8%) believe that evidence-based nursing practice comes from experimental rather than descriptive research. Participants reported various methods used to update their EBP knowledge, including textbooks (n=156, 50.2%), internet (n=242, 77.8%), media such as television or radio (n=65, 20.9%), smartphone apps (n=117, 37.6%) and attending conferences (n=72, 23.2%). 56 participants (18.0%) said they do not visit online databases, 38 (12.2%) visit CINAHL, 69 (22.2%) visit PubMed, 41 (13.2%) visit EBSCO, 15 (4.8%) visit Ovid, 12 (3.9%) visit Cochrane library and 173 (55.6%) visit Google Scholar which is not a data based.

Table 1

Sample characteristics

Factors associated with a stay intent

The results of Pearson correlation analysis have shown that stay intent was positively correlated with EBP knowledge, r=0.177, p<0.05, EBP practices, r=0.160, p<0.01, EBP attitudes, r=0.255, p<0.01 and EBP adopter barriers, r=0.152, p<0.01. However, EBP organisation barriers (r=−0.085, p=0.130), EBP innovation barriers (r=−0.086, p=0.130), EBP communication barriers (r=−0.086, p=0.130), age (r=−0.048, p=0.400) and experience (r=−0.019, p=0.745) were not significantly associated with stay intent (online supplemental table 1).

Table 2 compares the levels of stay intent among the study participants based on their categorical demographic variables. An independent t-test was used to examine the mean differences in stay intent according to position, gender, social status, education, university and having a library at the workplace. The results of the independent t-test exposed that those participants who had a library at their workplace had higher stay intent mean scores than participants whose workplace had no library (t=4.331, p<0.05). The outcomes of one-way ANOVA have similarly shown a significant difference in stay intent among the study participants based on the hospital type (F=19.177, p<0.000). Post hoc analysis showed that participants in private hospital have more stay intent than those in governmental and teaching hospitals. In addition, those in teaching hospitals have higher stay intent than those in governmental hospitals.

Table 2

Categorical variables associated with a stay intent

Predicting participants’ stay intent

Table 3 displays the regression analysis results conducted to predict stay intent by participants’ EBP attitudes, practices, knowledge and barriers, controlling for the hospital type and having a library in the healthcare institution. The hospital type and having a library in the healthcare institution were entered in the first model of the regression analysis. In this model, both private hospitals (t=−4.842, Β=−0.298, p<0.001) and having a library in the healthcare institution (t=−2.170, Β=−0.127, p=0.031) were significantly correlated with stay intent. The first model described 11.6% of the variance in participants’ stay intent (F (3, 307)=14.51, p<0.01). After controlling for the hospital type and having a library in the healthcare institution, the second step of regression analysis indicated that the model examining the relationship between EBP attitudes and stay intent was significant (F (4, 306)=14.150, p<0.01). However, in this step, both private hospital (t=−4.367, Β=−0.267, p<0.001) and EBP attitudes (t=3.402, Β=0.185, p=0.001) were significantly correlated with stay intent. EBP attitudes contributed 3.2% of the variance above and beyond the variance explained by the first step.

Table 3

Predicting stay intent

EBP practices described 1.5% added variance and the 11.6% described by the first model. In this model, a private hospital (t=−4.615, Β=−0.283, p<0.001), having a library in the healthcare institution (t=−2.175, Β=−0.126, p<0.001) and EBP practices (t=2.313, Β=0.124, p=0.02) were significantly associated with stay intent. When the EBP practices entered the second model, it was significantly predicted to stay intent, controlling for the hospital type and having a library in the healthcare institution.

In addition, the regression analysis has also shown that participants’ EBP knowledge was significantly associated with stay intent, controlling for other variables. When participants’ EBP knowledge was entered into the model, having a library in the healthcare institution became insignificant (t=−1.833, Β=0.185, p=0.068). EBP knowledge accounted for 1.1% added variance and the 11.6% described by the first model. Finally, the regression analysis has shown that participants’ EBP adopter barriers were significantly associated with stay intent, controlling for other variables (F (4, 306)=11.92, p<0.01). After controlling for the private hospital type and having a library in the healthcare institution, EBP adopter barriers accounted for 1% added variance and the 11.6% described by the first model. In this model, private hospital (t=−4.681, Β=−0.287, p<0.001), having a library in the healthcare institution (t=−2.018, Β=−0.118, p<0.001) and EBP adopter barriers (t=−1.940, Β=−0.105, p=0.05) were significantly associated with stay intent.

Discussion

This study assessed the role of knowledge, attitude, practice and barriers of EBP in stay intent among Jordanian nurses. In the current study, stay intent was positively correlated with EBP knowledge, EBP practices, EBP attitudes and adopter barriers. This result aligns with previous studies that showed the role of EBP utilisation in nurses’ intent to stay in the workplace.9 This might be explained by the fact that nurses had commitment to their job and having good knowledge but according to the advancement in technology and updated interventions, they seek to be always up to date in their field to provide efficient care for their patients. However, EBP organisation barriers, EBP innovation barriers and EBP Communication barriers were not significantly associated with stay intent. These results were incongruent with the results of Jordanian studies.15 16 Nurses might have developed resilience and adaptive strategies to navigate through EBP-related challenges within their workplace, despite organisational and communication barriers. This adaptability could buffer the negative effects of these barriers on their stay intent. Additionally, the specific sample characteristics of the study population could also influence the results. Since the mean age of the sampled nurses was 30 years old, at that age, they may have relatively high levels of commitment to their organisation since they are still very early in their careers and are already inclined towards staying despite barriers. Hence, the impact of EBP organisational, innovation and communication barriers on stay intent may be attenuated. Also, the tools used to assess EBP barriers and stay intent may not fully capture the nuanced relationship between these variables. There could be unmeasured factors or measurement biases that obscure the true association between these barriers and stay intent. Furthermore, nurses who are well versed in EBP and are able to apply it in their practice may feel more competent and satisfied with their work. Additionally, engaging in EBP requires ongoing learning and professional development. Nurses who actively participate in EBP activities may perceive greater opportunities for growth and advancement. These nurses may feel a stronger sense of fulfilment knowing they are delivering the best possible care, which can positively impact their intent to remain in their current job. Nurses using evidence in their practice may potentially feel less burnout associated with uncertainty or ineffective practices, which may improve their intent to stay. The current study revealed that age and experience were not significantly associated with stay intent. This is inconsistent with the findings of previous studies, which found that nurses’ age and experience are positively correlated with stay intent among nurses.23–26

This could be explained by the fact that their professional commitment and socioeconomic factors could play a very important role in stay intent of nurses regardless of their age and experience. Nurses who have more professional commitment work hard to develop their skills and achieve occupational goals through and within the current working organisations as a result, more opportunities are opened for them in their organisations and professional commitment facilitates nurses feel more satisfied with their jobs, making their decision to leave the work is difficult. Additionally, when nurses work they will increase their family income and improve their quality of life. These factors were more important to nurses than their age and experience. The results of this study also revealed that participants who had a library at their workplace had higher stay intent than participants whose workplaces had no library. This finding agrees with the previous research, indicating that nurses’ intent to stay is high in sufficiently resourced environments.6 27 28 Having a library, however, is a part of a larger organisational environment that plays a role in stay intent such as education, career advancement and job satisfaction.29–31 Stay intent in this study was highest in private hospital, followed by teaching hospitals and lastly in government hospitals. These findings are consistent with a previous study.32 However, many studies were incongruent with these findings.21 23 33 34 The incongruences among studies may be related to various work-related variables in different healthcare settings. Working in private hospitals, having a library in the healthcare institutions and EBP practices were significantly associated with stay intent. This might be explained by the fact that private hospitals encourage using EBP more than governmental hospitals in response to accreditation certificate requirements. Additionally, the availability of a library in the hospital might help nurses to access recent research. Furthermore, nurses who feel their knowledge is updated could be able to provide nursing care supported by evidence and feel more competent, confident and satisfied, which might lead to more stay intent.

Strengths and limitations of the study

This study investigates EBP-related factors influencing stay intent among Jordanian nurses, addressing an important nursing topic. The findings are generalisable due to the large sample size of 311 nurses from 5 institutions. A comprehensive assessment of numerous EBP characteristics, such as knowledge, attitudes, practices and impediments, leads to a full understanding. Statistical analysis that controls for participant and workplace factors improves the results’ validity.

The study has limitations that may obstruct generalisability. A cross-sectional design could reveal relationships between variables but could not determine causality. A convenience sample of motivated participants could present bias. Furthermore, self-reported data collection could introduce biases like social desirability. Another limitation of this study is the lack of adjustment for confounding variables beyond the reported demographics and organisational factors in the main analysis.

Implications for practice

The findings of the current study reflected several barriers facing nurses that prevent their stay intent in their job especially nurses in governmental hospitals due to high workload and because the implementation of policies in governmental hospitals differs from that in private hospitals. The workload and high number of patients in governmental hospitals prevent nurses from going to library to search for EBP. Therefore, nurse managers and leaders should prioritise the development of EBP knowledge, skills and attitudes among their staff through continuing education, training programmes, mentorship and provide nurses with enough time to go to the library and search for best practices. Healthcare organisations and nurse leaders should work to create a supportive environment for nurses to stay in the profession such as providing additional staffing support and implementing policies to reduce non-essential tasks and increase time for EBP activities because nurses are also responsible for their families after finishing their shifts and need to go to their homes with little stress or tiredness. Addressing these factors makes nurses more likely to remain in their current positions, leading to increased job satisfaction and reduced turnover rates. In conclusion, improving knowledge, attitude, and practice and addressing barriers to EBP can have significant nursing implications for improving nurses stay intent.

Conclusion

Our findings show that EBP influences Jordanian nurses’ intent to stay. It highlights the importance of addressing EBP barriers, especially in private hospitals as well as library access issues, in enhancing nurse retention and healthcare outcomes in Jordan.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

The approval was obtained from the Institutional Review Board of Zarqa University (approval no: 36/2018). The questionnaires distributed in each selected hospital included a consent form involving information about the purpose of the study and assurance of anonymity and confidentiality. One of the researchers contacted the participants at selected hospitals and explained the study’s purpose, allowing them to take out from the study at any time. ID number was given for each hospital and each participant to ensure the anonymity of the participants. All participants signed the informed consent.

Acknowledgments

We acknowledge and thank the registered nurses who completed the questionnaires.