Nurse Managers’ Perspective towards Evidence Based –Nursing Management

Background: Evidence-based nursing management is the systematic manner of the best available evidence to management decision-making, with the goal of enhancing the performance of healthcare organizations. Aim: This study aimed to assess the nurse managers’ perspective towards evidence-based nursing management. Method: Setting: This study was conducted at four hospitals; including the International Teaching Tanta Hospital, and Kafr El-Shiekh University Hospital, which are affiliated to Ministry of Higher Education and Scientific Research, as well as Al-Minshawi General Hospital and Kafr El-Shiekh General Hospital, which are affiliated to Ministry of Health and Population. Subjects: This study involved all nurse managers (n=159) in four hospitals. Tools: Two tools were used: nurse managers’ evidence-based nursing management knowledge questionnaire and nurse managers’ opinions about evidence-based nursing management questionnaire. Results: 60.4% of nurse managers had a moderate level of knowledge about evidence-based nursing management. 74.8% of nurse managers had moderate utilize of evidence’s sources. The majority of nurse managers identified that the teamwork factor was the most common frequent barrier and facilitator at the same time. Conclusions: The nurse manager had moderate knowledge about evidence-based nursing management. There was the significance positive correlation between levels of nurse managers’ knowledge of evidence based-nursing management and their levels of nurse manager utilization of evidence sources in Ministry of Health and Population hospitals. Recommendations: Developing programs to enhance knowledge of evidence based-nursing management and utilization of evidence sources in decision-making process.


Introduction
Nursing plays a vital role in the health care industry because it concentration lies in patient care.Nurses work in various specialties to recuperate patient's health and prevent injuries and illness.As the largest health-care professionals, nurses when involved in the different parts of the healthcare process (management and nursing care), achieved better result; communication is enhanced, along with collaboration between the different professional groups, innovation, organizational commitment; and staff retention González Garcia, Pinto-Carral, Sanz Villorejo &Marques-Manchez, 2020).
Nurse managers are leaders who serve as guides for nurses, provide them with higher-level leadership, and coordinate activities within the nursing departments (Alharbi, Rasmussen &Magarey, 2022).To ensure the quality and safety of healthcare delivered, as well as cost efficiency and effectiveness, nurse managers must make decisions using an evidence-based nursing management approach (Alsubaie & Bugis, 2021).
Nurse managers at all management levels are fundamental for the nursing work process to focus on the scientific basis at the institutional and practical politics interface, as well as organize, stimulate, and make it possible for the nursing team to develop themselves in this context (Krah et al., 2023).The nurse manager handles an immense amount of responsibility, such as the hiring and firing of staff, judging the competency of staff, assuming budgetary responsibility, and taking overall responsibility for the delivery of safe, high-quality patient care (Shafaghat, Bastani, Imani Nasab, &Rahimizarchi , 2022).Therefore, nursing managers are forced to use evidence-based healthcare management to be effective (Hasanpoor, Siraneh  Nurse managers support EBP and their leadership activities to enhance its implementation, which are influenced by their organizations' , characteristics and environment (Bowles, Batcheller, Adams, Zimmermann &Pappas ,2019).
Many decisions are still being made primarily based on experience without reliance on any other sources of data.While health organizational environments continue to change vastly and rapidly, management practices are not evolving as fast as the increasingly data-driven environment.Within this context, evidence-based nursing management has been proposed as an approach to encourage greater reliance on data in decision-making (Hasanpoor et al., 2019).The adoption of evidence-based nursing management in this context is being seen as a timely strategic step that could enable nurse managers to better cope with the complexity of healthcare organizations by relying on the best available evidence to improve their decisionmaking, and consequently achieve better organizational outcomes (Shafaghat, et al., 2022).In the rapidly evolving healthcare field, it is vital to regularly assess the attitudes, skills, and knowledge of healthcare professionals, including nurse managers, regarding evidencebased nursing management approaches.This ongoing evaluation helps to identify obstacles and challenges that enable appropriate actions to be taken (Youssef,Saleeb, Gebreal &Ghazy, 2023

Study significance:
The shifting healthcare perspective over the last two decades has the complicated nursing management field.Nursing management as a skill and specialty has become an important and fundamental issue due to its nature and complexity (Hasanpoor et al., 2019 Evidence-informed decision-making is one of the core competencies for nurse managers.While developing managers' abilities is necessary for their adoption of evidence-based management, it is not sufficient alone since there are also individual, organizational, and institutional-level factors that influence resources utilization in decision-making.(Daouk-Öyry,Sahakian &Van de Vijer ,2021) The adoption of evidence-based management is predicated on a fit between the personal characteristics of the decision-maker and the demands of the context.So not only do the managers need to possess evidence-based management competencies, but they also need to be provided with the opportunity to practice evidence-based management in their organization Thus, to enhance the uptake of evidence-based nursing management, it is important to explore the nurse managers' perspectives towards evidence-based nursing management.

Aim of the Study
The aim of the study was to assess the nurse mangers' perspectives towards evidence-based nursing management.

Research questions:
- It consisted of 20 questions about evidencebased nursing management including items of concepts, importance, sources, barriers, facilitators, and process.The questions were in the form of true and false included (10 questions), multiple choices included (4 questions) and -cross matching included (6 questions).

Scoring system:
Each question was allotted score of one for correct answer and zero for wrong answer.The total score was calculated by summing scores of all categories and divided according to statistical cutoff points as follow: -High level of evidence-based nursing management knowledge > 85%.
-Poor level of evidence-based nursing management knowledge < 60%.Part 3: Utilization of evidence's sources questionnaire.This part is a self-administrated questionnaire to assess the nurse managers' utilization of information sources for making decisions.It included 20 items divided to six domains according to the following: -Scientific and research evidence included 3 items.
-Facts and information about the hospital included 4 items.
-Political-social development plans included 5 items.
-Ethical-moral evidence and values included 2 items.
-Values and expectations of all stakeholders included 3 items.

Scoring System:
The nurse managers' responses were measured using the five-point Likert Scale which ranged from 5=often, 4=always, 3=sometimes, 2= rarely, and 1=never.A sum of scores for each respondent was calculated to determine the most frequent utilization of evidence's sources according to the maximum percentage.The total score was calculated by summing scores of all categories and divided according to statistical cutoff points as follow: -High level of evidence utilization information sources > 75%.
-Low level of evidence utilization information sources ≤ 50%.-Decision-making environmental factors included 6 items 2 items as a barrier and 4 items as a facilitator.
-Training and research systems included 5 items 3 items as a barrier and 2 items as a facilitator.
-Organizational factors included 6 items 3 items as a barrier and 3 items as a facilitator.
-Team work factors included 6 items 3 items as a barrier and 3 items as a facilitator.

Scoring System:
The nurse manager opinions were measured by the 5-point Likert Scale, which ranged from 5= strongly agree to 1= strongly disagree.A sum of scores for each respondent was calculated to determine the most frequent barriers or most frequent facilitators of evidence-based nursing management.Method 1. Official permission to carry out the study was obtained from the Dean of Faculty of Nursing and was sent to the authoritative personnel of the previously mentioned settings.2. Ethical considerations: a) An approval of the Ethical and Scientific Research Committee at Faculty of Nursing was obtained, Cod No (62/5/2022).b) All participants were informed about the purpose of the study.c) An informed consent will be taken from each participant in the study including the right to withdraw at any time.d) Nature of the study was not causing any harm for the entire shamble harm for the entire sample.e) Confidentiality and privacy were taken into consideration regarding data collection.3. Tools of data collection were developed and translated into Arabic by the researcher based on recent literature review.4. The study, s questionnaire was translated into Arabic and presented to a jury of five experts in the area of specialty to check the face validity.Necessary modifications were made including clarification, simplifying certain words, excluding certain items and adding other 5.The face and content validity of tool (I) part (3) that entitled utilization of evidence's sources was 89.3%, while the face and content validity of tool II that named nurse managers' opinions about evidence-based nursing management questionnaire was 87.1%.6. Suitable statistics test was used to test the tools for its reliability of tools were tested using Cronbach's Alpha test.The reliability of Tool (I) part (3) that entitled utilization of evidence's sources was 0.892 and 0.873 for tool II that named nurse managers' opinions about evidence-based nursing management questionnaire.7. A pilot study was carried out by the researcher on (10%) of nurse managers (n=16).According to feedback from pilot study, the tools were modified by the researcher.The estimated time needed to complete the questionnaire items from nurse manger 15-20 minutes.8. Data collection phase: the data was collected from nurse managers by researcher.Who met them in different areas under the study during working hours to distribute the questionnaire.The nurse manager recorded their answers in the presence of a researcher to ascertain that all questions were answered.The data was collected over period six months starting from the beginning of January2023 until the end of June 2023.

Statistical analysis of the data
Data was fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp) Qualitative data were described using number and presenting.The Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation, median and.Significance of the obtained results was judged at the 5% level.The used tests were Chi-square test for categorical variables, to compare between different groups, Monte Carlo correction, correction for chisquare when more than 20% of the cells have expected count less than 5 ,Student t-test for normally distributed quantitative variables, to compare between two studied groups and Mann Whitney test for abnormally distributed quantitative variables, to compare between two studied groups.

Results
Table ( (3): Shows comparison between the nurse managers according to their level of utilization of evidence's sources dimensions.The majority (66.0%) of nurse managers had moderate levels of utilization to facts and information of hospital as an evidence's sources followed by 57.9% and 55.3%, for politicalsocial development plans and ethical-moral evidence value as an evidence's sources respectively.The lowest percentage (31.4%) of them had moderate level of utilization for scientific and research evidence.There was significant difference between El Minshawi General hospital & Kafr El-Shiekh General hospital in all dimensions of utilization except political-social development plans as a evidence's sources.The highest significant was for managers' professional expertise at El Minshawi General hospital, which nurse managers had high levels (65.0%) of utilization of evidence's sources, while at Kafr El-Shiekh hospital nurse managers had low level (48.5%) of utilization of evidence's sources.The lowest significant was for scientific and research evidence at El Minshawi General hospital who the majority (72.5%) of nurse managers had low level of utilization of evidence's sources, while at Kafr El-Shiekh General hospital (42.4%) of nurse manager had moderate level to utilization of evidence's sources.Teamwork factors was first ranking in all hospitals followed by organizational factors was second ranking at all hospitals except International Teaching hospital it was third ranking.While decisionmaking, environmental and training and research systems were third ranking in the total of dimensions of evidence-based nursing management barriers.Also, decision-making environmental was third ranking in all hospitals except International Teaching hospital it was fourth ranking and training, and research systems was fourth ranking in all hospitals except International Teaching hospital it was second ranking.The nurse managers' characteristics were fifth ranking at all hospitals.Table ( 5): Shows comparison between the nurse managers opinions in different hospitals according to mean of evidence based -nursing management facilitator dimensions.In total nurse managers the highest mean 78.51 ± 16.86 of their opinion was for teamwork factors as a facilitator of evidence based -nursing management followed by 73.58 ± 19.59 and 73.01 ± 18.24 for training and research systems and organizational factors respectively.While the lowest mean 64.86 ± 16.64 of nurse managers opinion was for nurse managers' characteristics as a facilitator of evidence based -nursing management.The table clear that there were significant differences at p1= 4.787 also in training and research systems at p1 = 2.176.The total teamwork factors was first ranking in all hospitals except Kafr El-Shiekh University hospital was third ranking followed by training and research systems was second ranking in all hospitals except El Minshawi General hospital was third ranking.While decision-making environment was fourth ranking and nurse managers' characteristics was fifth ranking in total and all hospitals.

Table (6):
Represented relation between level of nurse manager utilization of evidence sources and their knowledge of evidence based-nursing management in total University hospitals and total Ministry of Health hospitals.The table reveal that significant different relation between nurse manager's utilization of evidence sources and their knowledge of evidence based-nursing management in total Ministry of Health hospitals r = 0.351*.While no significant different relation between nurse manager's utilization of evidence sources and their knowledge of evidence basednursing management in total University hospitals r =0.020*.

Discussion
Concerning levels of the nurse managers' knowledge regard to evidence-based nursing management, the present study results revealed that the majority of the overall nurse managers had moderate level of knowledge regarding evidence-based nursing management.This result may be due to the highest percent of nurse managers had postgraduate studies in nursing which supported their knowledge regarding evidence-based research process.These results were agreed with Çelikkanat and Güngörmüş (2023) who indicated that nurse managers had moderate mean scores regarding knowledge about evidence-based management.Also, the current finding is consistent with Djukic, Jun and Fletcher (2021) who reported that most nurse managers had moderate level of knowledge about evidence-based management.In addition, the present results agreed with Jun ,Kovner , Dickson, Stimpfel andRosenfeld (2020) who found that nurse managers had moderate level of knowledge regarding evidence-based nursing management.However, the current results were not consistent with, Ahmed,Abdelwahab and Mohamed (2020) who revealed that nurse managers' knowledge level was lower due to lack of training on evidence-based management, which effect negatively on their practice of evidence-based decision-making.These results were disagreed with Ellboudy, Eid and Rashad (2018); Rockette (2021) they reported that the highest mean of nurse managers had low knowledge level about evidence-based management.Also, the result of Mohamed , Alhujaily ,Ahmed,Nouh and Almowafy (2024) study stated that nurse managers had limited awareness of evidencebased decision making due to the lack of educational programs on evidence-based management for nurse managers.The current study results elaborated that the highest percent of the nurse managers had moderate utilize of evidence's sources.This result may be due to the interest of nursing managers in searching for policies and regulations resources because of its positive effect on managerial decision-making related to their work.These findings were confirmed by Couwenberg (2021) who suggested that role of nurse managers as a policy maker considered as an important factor for evidence sources utilization.Also, Dereje ,Hailu and Beharu (2019); Lamesa,Seifu, Abdella and Ezo (2023 asserted that the role of the nurse managers in the hospital was associated with the utilization of evidence resources and most of nurse managers were more likely to utilize evidence resources compared to staff nurses and this related to having opportunities for nurse mangers to take workshops and training about evidences sources utilization.The current findings showed that the highest percentage of evidence sources utilization was among the nurse managers at Kafr El-Shiekh General hospital.This result may be due to the highest percentage of the nurse managers at Kafr El-Shiekh General hospital were have years of  2020) who found that there was positive relation between nurse managers educational qualification and their perception regarding evidence-based nursing management barriers.Moreover, nurse managers tend to have high perception if they had higher education level and on-job education.Concerning nurse managers' opinions in evidence based -nursing management barriers dimensions, the current study results revealed that the highest mean was regarding the teamwork factor.These results may be due to resistance of the teamwork to use of evidence sources, and lake of support from professional colleagues in nursing scientific research.This finding agreed with Naghibi, Mohammadzadeh and Azami-Aghdash (2021) found that nurse managers identified that teamwork support was the most barrier of evidence-based management.Also, the current findings consistent with Khoi ,Quan and Liamputtong (2023) they reported that a major repetitive barrier to evidence-based management was the lack of support which can come from colleagues, supervisors, managers, and at higher levels, from policymakers.The present study revealed that most nurse manager had high mean score regarding opinions about evidence-based nursing management facilitators.The current study results revealed that the highest mean score of nurse manager opinion about evidence-based nursing management facilitator was the majority of the nurse managers in Ministry of Health and Population hospitals.This may be due to the highest percentage of them attending the in-service educational programs about the role of nurse managers in Ministry of Health and Population hospitals.These results were supported by Aslan and Gürdap (2021) who reported that the highest percentage of the nurse managers had satisfactory perception regarding evidencebased management facilitator posteducational training.Also, the present results agreed with Kiliç and Celen (2024) who found that the educational training related to evidence-based management had positive effect on nurse managers opinions regarding evidence-based management facilitators.In addition, the current findings consistent with Ceylan and Demir (2022) they revealed that nurse managers cannot follow evidence-based management recommendations due to lack of educational training programs, lack of access to guidelines and the literature.All this reasons, ensuring that nurse managers with sufficient knowledge and knowing how to access information may facilitate their access and tendency to use evidence-based nursing management.The present results revealed that there was significant positive correlation between overall knowledge of evidence-based nursing management and overall utilization of evidence sources in Ministry of Health and Population hospitals.This result indicated the importance of developing and increasing the nurse managers' knowledge about evidence based-nursing management process to motivate them for utilization of evidence sources.Theis results agreed with Ellboudy et al., (2018) who reported that the nurse managers' knowledge had positive effect on their using of evidence sources.Also, the present findings in the same line with Välimäki et al., (2021) who concluded that there is a primary need for improving the knowledge level of all nurse managers regarding the evidence-based management process and utilization to increase the use of sources of evidence.Also, the current results agreed with Ruzafa-Martínez Fernandez-Salazar, Leal-Costa and Ramos-Morcillo (2024) who clarified that mangers knowledge effect utilization of evidence-based management sources and process.In addition, the present results consistent with Hasanpoor, Hallajzadeh, Siraneh, Hasanzadeh and Haghoshayie (2020) who found that there was strong significant relation between nurse managers knowledge regarding evidence-based management and their utilization of resources in decision making process.Moreover, Aynalem et al., (2021) concluded that having good knowledge about evidence-based nursing management was two times more likely to have good evidence sources utilization compared to having poor knowledge about evidence-based nursing management.In addition, the possible explanation for this could be knowledge about evidence-based nursing management may increase their appraisal skills and give more confidence in utilizing evidence sources.

Conclusion
Based on the findings of the present study, it was concluded that the majority of nurse managers had a moderate level of overall knowledge about evidence-based nursing management, and had a moderate utilization level of evidence sources.The majority of nurse managers identified that the teamwork factor was the most common frequent barrier and facilitator at the same time.Also, there was a significance positive correlation between levels of nurse manager's knowledge of evidence based-nursing management, and their level of utilization of evidence sources at Ministry of Health and Population Hospitals.

Recommendations
included 31 items divided into five domains according to the following: -Nurse managers' characteristics factors included 8 items 4 items as a barrier and 4 items as a facilitator.

Table ( 4
): Shows comparison between the nurse manager opinions in different hospitals according to mean of evidence based -nursing management barriers dimensions.In total the highest mean score of nurse managers 76.73 ± 19.96 for teamwork factors as barriers of evidence based -nursing management followed by 71.28 ± 19.30 and 68.45 ± 22.08 for organizational factors and training and research systems as barriers of evidence based -nursing management.While the lowest mean score of nurse managers 57.51 ± 22.31 for nurse managers' characteristics as a barrier of evidence based -nursing management.The table clear that there were significant differences at International Teaching hospital and Kafr El-Shiekh University hospital in all dimensions.