Determinants of Evidence Implementation by Nurses: #Evidencer Model for the Use of Evidence-Based Practice (#EvidencerMUSEBP)—A Structural Equation Model

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Introduction
Te competency of health professionals in evidence-based practice (EBP) plays a fundamental role in adopting and implementing EBP in clinical settings [1].Recent research has shown, in general terms, a lack of EBP competency in nurses in many countries and practice settings [2][3][4].EBP competency comprises four dimensions: attitudes, knowledge, skills, and use of EBP, which can reach diferent levels of progress in professionals [5].Te literature on the subject shows that health professionals, including nurses, have positive attitudes and beliefs about the importance and value of EBP for improving the care of patients and moderate levels of their EBP knowledge and skills.However, an adequate level in these dimensions does not necessarily result in changes in behavior, as the use of EBP in daily practice is generally low in all disciplines [6].
Nurses' EBP competency is intricately linked to individual characteristics, the work environment, and implementation strategies.Examining this relationship provides a more comprehensive understanding of how various factors infuence the adoption and application of EBP.
First, professional characteristics, such as age and educational level, are positively associated with EBP competence.Research suggests that younger nurses and those with higher education levels exhibit stronger competence in EBP [3,7].More specifcally, a Master's degree is associated with enhanced EBP knowledge and use [8].In addition, specifc EBP training has been associated with positive beliefs about EBP [8], and having experience in research has been associated with EBP knowledge and skills [9].Te clinical competency and professional values of nurses, as well as their role as mentors for nursing students, are key drivers of competence in this area [10,11].
Second, the work context plays a crucial role.Organizational factors, such as the availability of resources and institutional support, have been shown to infuence EBP competence [9].Specifcally, active participation in the center's afairs and leadership roles has signifcantly infuenced EBP competence [12].Furthermore, access to resources such as the Internet [13] and bibliographical databases [8] contributes to competence in this area.Tere are factors such as working in a magnet hospital that show contrary results depending on the country.A study conducted in Saudi Arabia led to an association with attitude towards EBP [14].In contrast, a study conducted in the USA showed a lack of diferences in the competencies of nurses, regardless of whether they worked in a magnet hospital or not [3].
Tird, implementation strategies play a crucial role in EBP competence.Specifc EBP training and the presence of specialized mentors have been associated with positive beliefs and increased knowledge of EBP [8].Moreover, research has demonstrated that mentorship and an organizational culture supportive of EBP positively impact professionals' competence in EBP [10,11].
As highlighted, research should test models to determine which variables have the most infuence on EBP [3].Existing studies have identifed specifc factors that could infuence some of the dimensions of EBP competence.However, the underlying mechanisms of these relationships and how these factors interact between them still need to be clarifed.Up to the present, two studies have been conducted with nursing professionals who tried to develop an explanatory model about the factors associated with competence and implementation of EBP.Te frst of these was conducted in the USA and was based on the ARCC© Model.Te results showed that EBP culture and mentorships were key variables that directly afected the knowledge, beliefs, competence, implementation, work satisfaction, and retention of nurses [15].On the other hand, the second study, conducted in Saudi Arabia, used a conceptual framework developed from published background works [16].Te skills and beliefs about EBP were the main factors related to their use and were also mediated by factors such as the EBP training of the nurses.Te facilitators and barriers also had a signifcant impact on the application of the EBP [16].However, these results have a limited generalization to other cultural settings.Cultural factors infuence EBP adoption in healthcare professionals by shaping attitudes toward authority, communication styles, beliefs about health, and the emphasis on collectivism or individualism.Addressing cultural nuances is crucial for tailoring efective implementation strategies.Besides, there are variables that were not found in either model that could be interesting to consider.
Among the theories and conceptual frameworks developed to explain factors that infuence the implementation of EBP, the Determinant Frameworks [17] present elements that are adequate for the establishment of an initial conceptual framework that allows testing the infuence of certain factors on the competency and use of EBP by nurses.In general terms, these frameworks include fve types of determinants: implementation object, characteristics of the professionals, end users, context, and strategy for facilitating the implementation and recognize, based on a systemic approach, the existence of relationships within and between the diferent levels, although the relationships between these determinants still need to be clarifed [18].
In 2020, we conducted a national study in Spain with nurses, in which many variables that monitored three of the determinants mentioned in that model were measured.Specifcally, these were the characteristics of the professionals, the context, and the strategy for facilitating the implementation [4].Beginning with the initial conceptual framework proposed [17], the starting hypothesis to be tested was the existence of a positive relationship between the characteristics of the professionals, the context, and the strategy for facilitating the implementation with EBP competence and, at the same time, with the dimensions that shape it (Figure 1).Te great heterogeneity between the studies investigating the factors and determinants of the competence and use of EBP does not allow us to be more specifc a priori.Terefore, the purpose of the present study was to develop and test a model supported by the Determinant Frameworks that could explain the relationships and the direct pathways between the nurses' characteristics, the context, and the strategies of implementation, with the dimensions of the EBP competence, attitude, knowledge, skills, and use of EBP.

Design.
Te EBP competence of nurses was evaluated with the data from an observational, cross-sectional, and national study conducted in Spain between January and February 2020 [4].Tis timeframe ofers a unique insight into the EBP competence of nurses in a prepandemic context.At the same time, this study design allows for the simultaneous collection of data at a single point in time, ofering a snapshot of the relationships and variables of interest in a same country.

Participants and Setting.
Te study included nurses who worked at public health centers from the National Health System in all the autonomous communities in Spain.Te following were the selection criteria: nurses currently employed at public health centers afliated with the NHS, 2 Journal of Nursing Management with at least one year of work experience, and working either at a hospital or primary care center with any type of contract.Data were collected through an online survey using a collaborative national campaign named #Evidencer.Te sampling was nonprobabilistic, with voluntary participation among professionals who chose to engage after receiving the invitation.Te campaign extended invitations to nurses nationwide via social media, professional associations, trade unions, and scientifc organizations to enhance representation.

Variables and Instruments.
Te online survey included questions about the characteristics of the nurses, context, strategy for facilitating the implementation, and EBP competence.

Characteristics of the Nurses.
Te sociodemographic and professional variables of the nurses included were age, sex, time since completing the Nursing degree, professional experience, level of education that includes bachelor, specialist nurse (refers to formal and ofcially recognized training that equips professionals with specifc clinical competencies in various areas such as obstetrics, community health, and pediatrics), master's degree, and doctorate degree, training on EBP, number of articles read in the last month, nursing students' mentor, and use of the Internet and other digital tools to access scientifc information.

Context.
To analyze the organizational context of clinical practice, the Spain-validated version of the questionnaire Practice Environment Scale of the Nursing Work Index (PES-NWI) was utilized to measure the context of nursing practice in health organizations.Tis instrument has been validated in Spanish in the hospital and primary care contexts [19,20].Both versions are similar with the same number of items and the original fve-factor model.Te Spanish versions of the questionnaire demonstrate robust psychometric properties, including validity and reliability.As outlined in these articles, the validation process underscores the instrument's capacity to efectively measure the nursing work environment in the Spanish context of community and hospital.In order to ensure accuracy, we used a neutral version of the items or employed two terms where necessary, to accommodate nurses from both contexts.Te questionnaire contained 31 items organized into fve factors: factor I includes nurse participation in the center's afairs (9 items); factor 2 includes nursing foundations of quality of care (10 items); factor 3 includes nurse manager ability, leadership, and support (5 items); factor 4 includes stafng and resource adequacy (4 items); and factor 5 includes nurse-physician relations (3 items).Te items were scored with a Likert scale with four response options (from "strongly disagree" to "strongly agree").
In addition to the PES-NWI, we looked at other factors related to the work environment, such as employment status, type of contract, work location, context of care (hospital or primary care), and access to the Internet while at work.

Strategy for
Facilitating the Implementation.Tis determinant was evaluated by asking the nurses if they worked at a center that was part of the "Best Practice Spotlight Organization (BPSO ® ) implementation program."Tese are healthcare centers that participate in the international Registered Nurse' Association of Ontario (RNAO) program for the implementation of Clinical Practice Guidelines (CPGs).Tis program has been implemented in Spain since 2012, and centers are selected through a competitive process; the centers present the proposals for implementing and evaluating the RNAO CPG in 3 years.Te implementation methodology followed in all centers is an adaptation of the knowledge to action model, which includes the following phases: (a) identify the problem and select the available knowledge; in this case, those provided by the CPG; (b) adapt the recommendations to the local setting; (c) assess the obstacles and the facilitators of the use of knowledge; (d) plan and execute the application; (e) supervise the use of knowledge; (f ) evaluate the results to determine the success of the application; and (g) develop sustainability strategies [21].

Outcomes
2.8.Analysis of Data.Data analysis was performed using the SPSS statistical package version 22.0 and AMOS version 20 (IBM Inc., 2013, NYC).Descriptive statistics were calculated to describe the participants' background characteristics (e.g., basic demographic variables and work-related variables) and key study variables (i.e., EBP competence, context, and strategies for facilitating the implementation of PBE programs).We further examined if any background characteristics were associated with key study variables using oneway ANOVA (for the EBP competence).Pearson's correlation coefcients were also calculated to examine the associations between key study variables.
A structural equation model (SEM) was constructed to test the hypothesized relationships among key study variables as depicted in the conceptual framework (Figure 1).Te variables showed adequate normality for the maximum likelihood estimation (MLE) method, i.e., skewness >2-3 and kurtosis >7-10 [22].Te signifcance of the regression coefcients was evaluated after estimating the parameters.Te efects with p ≤ 0.05 were considered signifcant.Te ft of the model was evaluated using χ 2 /df <5, the root mean square error of approximation (RMSEA) values ≤0.08, and the comparative ft (CFI), goodness of ft (GFI), and Tucker-Lewis index (TLI) values ≥0.90 indicate a good ft [23].

Ethical Considerations.
Te study was approved by the Ethics Committee of the University of Murcia (ID: 2540/ 2019).Te nurses were invited to participate voluntarily through an online survey.Tey were informed about the study's objectives, making it clear that their participation was completely anonymous and that they provided their consent to participate by sending it.

Results
Te nurses who completed the survey (n � 2370) had a mean age of 41.3 (SD � 9.8), a high percentage were women (79.80%), slightly more than half had a Master's degree (55.6%), and about 30% worked in an organization that was implementing the BPSO ® program.Te remaining socio- demographic variables are shown in Table 1.
With respect to the bivariate results, the categorical variables that were observed to have a statistically signifcant relationship with the dimensions from EBP competence are shown in Table 2. Relationships were observed between almost all dimensions from the EBP-COQ Prof ©    and working in a BPSO ® center were associated with the utilization dimension and total competency.Signifcant correlations were also observed between the quantitative sociodemographic variables, the dimensions from the PES-NWI, and the dimensions from the EBP-COQ Prof© questionnaire (Table 3).Age, the time since completing the nursing degree, and work experience showed signifcant and inverse bivariate correlations with attitude, knowledge, total EBP competence, and the dimension from the PES-NWI collegial nurse/physician relation, while positive correlations were obtained with nurse participation in the center's afairs and nursing foundations for quality of care.Te dimensions from the PES-NWI showed correlations with the dimensions from the EBP-COQ that oscillated between 0.020 and 0.094 with attitude, between 0.055 and 0.151 with knowledge, and between 0.134 and 0.217 with skills.Te dimension use of EBP showed the strongest correlations, with all the dimensions from the PES-NWI obtaining values between 0.306 and 0.535.
Te knowledge dimension of EBP competence was signifcantly infuenced by level of education (Doctorate) (β � 0.13, p < 0.001), EBP training >150 hours (β � 0.11, p < 0.001), and read >3 articles (β � 0.11, p < 0.001).In addition, the abovementioned variables, work in a BPSO ® center and the work context, had an indirect efect on the knowledge dimension of EBP competence.In total, the factors explained 61% of the variance on knowledge dimension.
Finally, the utilization dimension of EBP competence was signifcantly infuenced by Nurse Participation in the center's afairs (β � 0.10, p < 0.001), Nursing Foundations for Quality of Care (β � 0.26, p < 0.001), Nurse Manager Ability Leadership and Support of Nurses (β � 0.10, p < 0.001), and work in a PBSO ® Center (β � 0.10, p < 0.001).Furthermore, work in a BPSO ® center, work context, level of education (Doctorate), EBP training >150 hours, and reading> 3 articles had an indirect efect on the utilization dimension of EBP competence.Te factors explained 59% of the variance in the knowledge dimension (Table 4).

Discussion
Following the Determinant Framework [17], our study presents the frst empirical model that tested the relationship of certain variables associated with the characteristics of the professionals, the context, and the implementation strategies with EBP competence and utilization of a national sample of nurses in Spain whose sociodemographic and professional characteristics aligned with those of Spanish nurses employed in public health centers [24].Te fnal ft shows a model mainly linked to the utilization of EBP by clinical nurses.Tis model will be referred to as the #Evidencer model for the use of EBP (#EvidencerMUSEBP).
Te #EvidencerMUSEBP model consists of two main components.Te frst component is related to the utilization of evidence-based practice (EBP), which includes determinants associated with the context and implementation strategy.Te second component is related to the characteristics of professionals, such as their training and reading of articles.Tis component is directly linked to EBP competence, knowledge, and skills.Te #EvidencerMUSEBP model suggests that although professionals may possess sufcient knowledge and skills in EBP, it may translate into something other than an equivalent use of EBP.Tis is consistent with fndings from many studies [6].It can also explain why interventions that solely focus on training professionals only improve their knowledge and skills without signifcantly impacting the use of EBP [25,26].Without a doubt, the model is complex and requires a systematic strategy that can synchronously and cohesively infuence diferent factors to improve the use of EBP.Tis conclusion aligns with the fndings of a recent review on the implementation of change in nursing practice [27].
In our study, we found that the determinants "context" and "implementation strategy" accounted for 59% of the variation in the utilization of evidence-based practice (EBP).Tis indicates a considerable efect size.We use the Practice Environment Scale of the Nursing Work Index (PES-NWI) to evaluate the clinical environment, a reliable tool widely used to assess nursing practice environments across multiple countries [28].Also, this instrument includes the most common dimensions of the context described in the determinant frameworks widely used in evidence science; the majority of the frameworks outlined contextual determinants that could be ascribed to organizational support, fnancial resources, and social relations and support, as well as leadership, organizational culture, and climate [29].Our fndings showed that the overall score in the practice environment was directly related to EBP competence, which aligns with previous studies [12].In addition, we discovered 6 Journal of Nursing Management   Journal of Nursing Management institutions having a nursing philosophy directly infuence the use of EBP in clinical practice.Our fndings are consistent with other recent studies [30][31][32][33].
Regarding the dimensions evaluated in the context, it is surprising that the dimension of stafng and resource adequacy, commonly viewed as a barrier against the use of research in clinical practice [34,35], did not infuence the use of EBP.Tis fnding is consistent with previous studies [36].Experts have pointed out that resource and personnel availability may be favorable for applying EBP, but they must be accompanied by leadership, promotion opportunities, and participation in the institution for EBP use to be effective [29].Tis idea emphasizes the fact that we are dealing with a complex model, and a systemic strategy that can infuence the diferent factors in a synchronous and coordinated manner is needed to address it.
Concerning the determinant of "strategy for facilitating implementation," which is defned as the methods or techniques utilized to improve the adoption, application, and sustainability of a program or clinical practice [37], it has been assessed through the implementation program of clinical practice guidelines named BPSO ® of the RNAO.Te model showed a positive and direct relation between participation in this program and the use of EBP.Tis strategy involves the institution in both the implementation and development of Clinical Practice Guidelines (CPGs).It requires the support of executive directors and nurse managers at healthcare centers, promoting teamwork and a culture of change.Tese aspects are deemed fundamental for successfully implementing evidence-based practices [38].In line with our results, applying the BPSO ® program has shown favorable results in using EBP in clinical practice in health centers in Spain [39,40] and other countries [41,42].Tese fndings, consistent with previous studies, provide new empirical evidence supporting the link between organizational support for innovation and the adoption of innovative practices [43].
Te #EvidencerMUSEBP model also suggests that the implementation strategy indirectly afects EBP competence and knowledge, mediated by the practice environment, suggesting that the strategy to facilitate the implementation of evidence also positively infuences these two aspects at a secondary level.Empirical evidence has demonstrated that training professionals on aspects related to the culture of change and EBP knowledge included in the BPSO ® program leads to improvements in EBP competence and knowledge [44].Tese results confrm that the successful application of the EBP strategy tends to require a process of active change directed towards the use of the intervention by individuals and the organization [45] to achieve a change in the practice environment that, at the same time, infuences the competence of professionals.
Concerning the determinant characteristics of the nursing professionals related to the training and direct contact with scientifc updating and the overall score of the PES-NWI (context), the determinants showed a direct relationship with EBP competence, explaining 25% of the variance.In addition, the variables related to the characteristics of the professional (having a doctorate, having more than 150 hours of EBP training, and reading more than three articles per month), together with the overall score of the PES-NWI mediated by its efect on the general EBP competence, explained 61% of the variance, while having a doctorate also infuenced EBP skills, although the relationship was weak.Tese fndings are signifcant, as negative feelings or a lack of interest in research by nursing professionals have been described [46], so activities that promote the association between research and nursing practice should be promoted starting at the initial levels of nurse training.Also, the fnal model did not retain variables associated with the sociodemographic characteristics of the professionals, such as gender, age, or years of work experience, which are signifcant in previous studies [47].Tis omission suggests that in the ftting of the fnal model, these variables did not play a determinant role.Scientifcally, these variables may exert limited infuence on evidence-based practice (EBP) competence and utilization compared to factors more directly linked to the profession, environment, and implementation strategies.Moreover, their exclusion may contribute to a more parsimonious and specifc model, mitigating issues related to multicollinearity and emphasizing determinants more pertinent to the efective adoption of EBP in clinical settings.
Te results contribute towards prioritizing the determinants on which health organizations should propose interventions to improve EBP use and competence.Te #EvidencerMUSEBP and the associations established between the determinants studied show that it is vital to consider the characteristics of the professionals, the context, and the implementation strategies in a manner that is integrated and nonfragmented, as the successful application of EBP depends on the combinations of diferent determinants.Adopting an excessively reductionist approach, in which an intervention is conducted in a single variable, will not have the ability to infuence the improvement of the use of EBP.Two or more determinants can be combined to create effcient efects and with an amplifed efect that acts on nurses' use, knowledge, skills, and EBP competence.
Te study's fndings have notable implications for nurse managers, emphasizing the need for leadership development to promote evidence-based practices.Nurse managers can play a pivotal role in shaping organizational culture, fostering participation, and strategically engaging in programs like BPSO ® for successful EBP implementation.Customized implementation strategies, continuous professional development, and a focus on creating supportive environments are key considerations for nurse managers aiming to enhance EBP competence among their teams.

Limitations
It is important to acknowledge certain study limitations that can afect the interpretation of its results.First, the selection of participants relied solely on nurses' willingness, and data collection was done through online surveys.Tese two factors may have introduced bias in the selection process as the characteristics of the nurses who participated may difer from those who chose not to participate or those who do not 10 Journal of Nursing Management have access to the internet.We could not identify whether the nurses' master's degree was professionalizing or research based.Tis diference could afect the number of research hours and, consequently, infuence the results.Second, conducting a more detailed examination of the potential limitations associated with the positive correlation between participation in the BPSO ® program and the use of Evidence-Based Practice (EBP) would be helpful.Future research should focus on exploring contextual factors that may infuence the efectiveness of the program, such as diferences in organizational structure, nursing contexts like hospital and primary care, varying levels of engagement among participants, or potential challenges in implementing the program.Tis deeper analysis will provide a more balanced perspective and facilitate a better understanding of the program's real-world applicability and potential areas for improvement.Furthermore, while the study evaluated multiple variables related to the organizational context, it is essential to note that these variables were based on the perceptions of the participants as proposed by the questionnaire utilized, and this may not have comprehensively captured all the relevant aspects of the work environment that could have infuenced EBP competence.For future research, it is recommended to test the #EvidencerMUSEBP separately in hospital and primary care contexts and compare results across diferent regions.In addition, including additional determinants of the model that were not analyzed in this study, such as the type of evidence and the end users, and to evaluate the impact of these factors in the #EvidencerMUSEBP would provide further insights.

Conclusions
Te #EvidencerMUSEBP model incorporates characteristics of professionals, context, and implementation strategies, demonstrating a solid ft.Tis model provides empirical evidence that directly associates the characteristics of the nursing professionals, such as a high level of education, reading articles, and EBP training, with EBP knowledge and skills, thereby indirectly impacting the use of evidence.
On the other hand, the context conceived as the practice environment, which includes a nursing perspective, and is backed by institutional leaders and organizations that promote the feeling of belonging of the professionals, together with strategies such as the implementation of the CPG BPSO ® program, exerts a direct infuence on EBP adoption.Tese factors, at the same time, exert an indirect efect on EBP competence and knowledge.
Te study emphasizes the vital role of leadership for nurse managers in promoting evidence-based practices, highlighting the need for customized strategies and continuous professional development to enhance competence within healthcare teams.A key aspect is that healthcare services managers and providers must internalize the need to jointly address these elements, recognizing that improvement in EBP requires comprehensive, synchronous, and coordinated actions on all fronts.

Figure 1 :
Figure 1: Conceptual model.Te relationship between types of determinants and EBP competence.

Table 1 :
Sociodemographic and professional variables of the sample (N � 2370).

Table 2 :
Comparison of the sociodemographic and professional variables with the dimensions and total EBP-COQ-Prof©.
SD: standard deviation; 1,2,3,4,5 the category of nurses with which it has statistically signifcant diferences (p < 0.000) in the pairwise analysis of the Games-Howell post hoc comparison test.Journal of Nursing Management questionnaire with level of education, EBP training, reading scientifc articles, and being a nursing student mentor.Also, sex, use of social networks, having internet access at work, SN: specialist nurse; M: mean;
that the dimensions of nurse participation in the center's afairs, nursing foundations for quality of care, and nurse manager ability leadership and support of nurses have a positive, direct efect, more specifcally on the utilization of EBP.Tis means that promoting the participation of nurses in the institution's internal governing body, political and committee decisions, providing them with promotion opportunities, having good nursing managers and leaders, and

Table 4 :
Summary of the total, direct, and indirect efects of variables in the model.