Evidence-based patient-centered needs assessment
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Scenario
The purpose of a needs assessment is to identify priorities of a community or patient population. The findings of a needs assessment can be an extremely useful tool to help organize and plan care decisions for a specific patient or group. By conducting a needs assessment, a nurse can then use the best evidence to guide the interventions selected to meet the identified needs and improve patient engagement.
Full instructions in attachment “Assessment 1 Instructions_Evidence-Based Patient-Centered”
Assessment 1 Instructions: Evidence-Based Patient-Centered Needs Assessment
For this assessment, you will complete an evidence-based patient-centered needs assessment of prospective health care technology that will improve patient engagement. You will
write a 4-5 page paper explaining the process and considerations that went into completing the patient needs assessment.
Introduction
Evidence-based practice is a key skill in the toolkit of the master’s-prepared nurse. Its goal is that health care practitioners use the best available evidence to improve population
health outcomes and make the best clinical decisions (Gallagher et al., 2020). In essence, evidence-based practice is all about ensuring quality care.
For this assessment will begin to apply some of the evidence-based practice strategies you have learned to ensure quality care for an individual patient. The primary strategy that you
will utilize to accomplish this is an evidence-based patient-centered needs assessment. A patient-centered needs assessment can help you organize the relationships between ideas,
challenges, or terms to utilize the best evidence to plan interventions. The overall goal of the resources and this assessment is to allow you the opportunity to apply evidence-
based practice and personalized care concepts in order to improve the health of a single patient.
Reference
Gallagher, F. L., Koshy Thomas, B., Connor, L., Sinnott, L. T., & Melnyk, B. M. (2020). The effects of an intensive evidence‐based practice educational and skills building program on
EBP competency and attributes. Worldviews on Evidence-Based Nursing, 17(1), 71–81.
Professional Context
Patient-centered needs assessment is a critical element in nursing care. The findings from the needs assessment can be effective tools for organizing a plan of action, prioritizing
patient care strategies, and developing personalized care approaches that improve patient engagement. In addition to organizing care, they can aid in ensuring that
the patient’s care is individualized to not only their health conditions, but also their familial, cultural, and environmental situations.
Scenario
The purpose of a needs assessment is to identify priorities of a community or patient population. The findings of a needs assessment can be an extremely useful tool to help organize
and plan care decisions for a specific patient or group. By conducting a needs assessment, a nurse can then use the best evidence to guide the interventions selected to meet the
identified needs and improve patient engagement.
Instructions
Develop a 4–5 page patient-centered needs assessment to demonstrate how to leverage health care technology to improve patient engagement and outcomes for a specific patient
population. This could focus on a disease or a disorder based on the best available evidence that has been individualized to treat your patient’s health, economic, and cultural needs.
The bullet points below correspond to the grading criteria in the rubric. Be sure that your paper address all of the bullets below, at minimum. If you are having a difficult time
choosing a topic, review the Healthy People 2030 topics and try and find a topic that is interesting an relevant to you.
Identify the importance of addressing patient engagement in the management of a patient’s specific health, economic, and cultural needs based on the best available
evidence.
Why is patient engagement necessary to ensure that patients are better able to manage their specific health conditions?
What evidence in the current literature(within the last 5 years) supports the benefit of patient engagement?
Explain the potential use and impact of information and communication technology tools needed to improve consumer health literacy for a specific patient population.
Consider what type of health care technology modalities are useful to improve consumer health literacy
Are there mobile applications, telehealth features, or other technology that can facilitate improving patient care?
Evaluate the value and relevance of the technology modalities that may be used to address the needs identified in the patient population assessment.
How does each proposed technology modality encourage patient engagement in an ethical, culturally sensitive, and inclusive way?
Ensure that your strategies:
Promote honest communications.
Facilitate sharing only the information you are required and permitted to share.
Enable you to make complex medical terms and concepts understandable to your patient and their family regardless of language, abilities, or educational level.
Consider how health information exchange and interoperability of technology modalities contribute to their value.
Identify innovative strategies for leveraging technology to support quality, ethical, and efficient patient care that is culturally and linguistically appropriate for the identified
patient population.
Consider how the selected technology impacts the patient in the most efficient way.
Is the selected technology culturally and linguistically appropriate?
Explain how the proposed strategies will mitigate the risk of adverse outcomes due to inequity in access to patient personal health data and technology modalities.
What are potential risks that could lead to adverse outcomes for certain members of the population?
How will those risks be mitigated?
How have your proposed strategies been used previously to address iniquities and risks?
Convey purpose of the assessment narrative in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and
scholarly communication standards.
Integrate relevant sources to support assertions, correctly formatting citations and references using APA style.
Submission Requirements
Length of narrative: 4–5 double-spaced, typed pages. Your narrative should be succinct yet substantive.
Course Navigation
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Number of references: Cite a minimum of 3–5 sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current
source materials defined as no older than five years unless it is a seminal work. Be sure you are citing evidence to support that your information is evidence-based.
APA formatting: Resources and citations are formatted according to current APA style.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:
Competency 1: Apply evidence-based practice to plan patient-centered care.
Identify the importance of addressing patient engagement in the management of a patient’s specific health, economic, and cultural needs based on the best available
evidence.
Competency 3: Evaluate the value, relevance, and ethics of available evidence upon which clinical decisions are made.
Evaluate the value and relevance of the technology modalities that may be used to address the needs identified in the patient population assessment.
Competency 4: Integrate evidence based practice, technology tools, and scholarly research to address patient and population needs.
Explain the potential use and impact of information and communication technology tools needed to improve consumer health literacy for a specific patient population.
Identify innovative strategies for leveraging technology to support quality, ethical, and efficient patient care that is culturally and linguistically appropriate for the
identified patient population.
Explain how the proposed strategies will mitigate the risk of adverse outcomes due to inequity in access to patient personal health data and technology modalities.
Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with organizational, professional, and scholarly standards.
Convey purpose of the assessment narrative in an appropriate tone and style, incorporating supporting evidence, and adhering to organizational, professional, and
scholarly communication standards.
Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.
SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.
VIEW SCORING GUIDE
RESEARCH ARTICLE
A guiding framework for needs assessment
evaluations to embed digital platforms in
partnership with Indigenous communities
Jasmin BhawraID
1, M. Claire Buchan2, Brenda Green3, Kelly SkinnerID
2, Tarun
Reddy KatapallyID
4,5,6*
1 School of Occupational and Public Health, Toronto Metropolitan University, Toronto, ON, Canada,
2 School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada, 3 Île-à-la-Crosse School
Division, The Northern Village of Île-à-la-Crosse, Île-à-la-Crosse, SK, Canada, 4 DEPtH Lab, Faculty of
Health Sciences, Western University, London, ON, Canada, 5 Department of Epidemiology and Biostatistics,
Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, 6 Lawson Health
Research Institute, London, Ontario, Canada
Abstract
Introduction
In community-based research projects, needs assessments are one of the first steps to
identify community priorities. Access-related issues often pose significant barriers to partici-
pation in research and evaluation for rural and remote communities, particularly Indigenous
communities, which also have a complex relationship with academia due to a history of
exploitation. To bridge this gap, work with Indigenous communities requires consistent and
meaningful engagement. The prominence of digital devices (i.e., smartphones) offers an
unparalleled opportunity for ethical and equitable engagement between researchers and
communities across jurisdictions, particularly in remote communities.
Methods
This paper presents a framework to guide needs assessments which embed digital plat-
forms in partnership with Indigenous communities. Guided by this framework, a qualitative
needs assessment was conducted with a subarctic Métis community in Saskatchewan,
Canada. This project is governed by an Advisory Council comprised of Knowledge Keepers,
Elders, and youth in the community. An environmental scan of relevant programs, three key
informant interviews, and two focus groups (n = 4 in each) were conducted to systematically
identify community priorities.
Results
Through discussions with the community, four priorities were identified: (1) the Coronavirus
pandemic, (2) climate change impacts on the environment, (3) mental health and wellbeing,
and (4) food security and sovereignty. Given the timing of the needs assessment, the com-
munity identified the Coronavirus pandemic as a key priority requiring digital initiatives.
PLOS ONE
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OPEN ACCESS
Citation: Bhawra J, Buchan MC, Green B, Skinner
K, Katapally TR (2022) A guiding framework for
needs assessment evaluations to embed digital
platforms in partnership with Indigenous
communities. PLoS ONE 17(12): e0279282.
https://doi.org/10.1371/journal.pone.0279282
Editor: Stephane Shepherd, Swinburne University
of Technology, AUSTRALIA
Received: June 1, 2022
Accepted: December 2, 2022
Published: December 22, 2022
Copyright: © 2022 Bhawra et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Data are co-owned
by the community and all data requests should be
approved by the Citizen Scientist Advisory Council
and the University of Regina Research Office.
Citizen Scientist Advisory Council Contact: Mr.
Duane Favel, Mayor of Ile-a-lacrosse, email:
[email protected]; [email protected]
University of Regina Research Office contact: Ara
Steininger, Research Compliance Officer; E-mail:
[email protected]. Those interested can
access the data in the same manner as the authors.
Conclusion
Recommendations for community-based needs assessments to conceptualize and imple-
ment digital infrastructure are put forward, with an emphasis on self-governance and data
sovereignty.
Introduction
Community engagement has been the cornerstone of participatory action research in a range
of disciplines. Every community has a unique culture and identity, hence community mem-
bers are the experts regarding their diverse histories, priorities, and growth [1–3]. As a result,
the successful uptake, implementation, and longevity of community-based research initiatives
largely depends on meaningful community engagement [4–9]. There is a considerable body of
evidence establishing the need for ethical community-research partnerships which empower
citizens and ensure relevant and sustainable solutions [1–3, 10]. For groups that have been
marginalized or disadvantaged, community-engaged research that prioritizes citizens’ control
in the research process can provide a platform to amplify citizens’ voices and ensure necessary
representation in decision-making [11]. Such initiatives must be developed in alignment with
a community’s cultural framework, expectations, and vision [12] to support continuous and
meaningful engagement throughout the project. In particular, when partnering with Indige-
nous communities, a Two-Eyed Seeing approach can provide valuable perspective to combine
the strengths of Indigenous and Western Knowledges, including culturally relevant methods,
technologies, and tools [13–15].
Many communities have a complicated relationship with research as a result of colonialism,
and the trauma of exploitation and discrimination has continued to limit the participation of
some communities in academic partnerships [16]. Indigenous Peoples in Canada experience a
disproportionate number of health, economic, and social inequalities compared to non-Indig-
enous Canadians [17]. Many of these health (e.g., elevated risk of chronic and communicable
diseases) [18–21]), socioeconomic (e.g., elevated levels of unemployment and poverty) [19,
22–24], and social (e.g., racism and discrimination) [19, 22–24]) inequities can be traced back
to the long-term impacts of assimilation, colonization, residential schools, and a lack of access
to healthcare [19, 20, 22–24]. To bridge this gap, and more importantly, to work towards
Truth and Reconciliation [25], work with Indigenous Peoples must be community-driven, and
community-academia relationship building is essential before exploring co-conceptualization
of initiatives [26].
One of the first steps in building a relationship is to learn more about community priorities
by conducting a needs assessment [27, 28]. A needs assessment is a research and evaluation
method for identifying areas for improvement or gaps in current policies, programs, and ser-
vices [29]. When conducted in partnership with a specific community, needs assessments can
identify priorities and be used to develop innovative solutions, while leveraging the existing
knowledge and systems that communities have in place [30]. Needs assessments pave the path
for understanding the value and applicability of research for community members, incorporat-
ing key perspectives, and building authentic partnerships with communities to support effec-
tive translation of research into practice.
For rural, remote, and northern communities within Canada, issues related to access (e.g.,
geographic location, transportation, methods of communication, etc.) pose significant barriers
to participation in research and related initiatives [31]. Digital devices, and in particular, the
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Funding: TRK received funding from the Canadian
Institutes of Health Research (CIHR) and the
Canada Research Chairs Program to conduct this
research. The funding organization had no role to
play in any part of the study implementation of
manuscript generation.
Competing interests: The authors have declared
that no competing interests exist.
extensive usage of smartphones [32] offers a new opportunity to ethically and equitably engage
citizens [33]. Digital platforms (also referred to as digital tools) are applications and software
programs accessible through digital devices. Digital platforms can be used for a variety of pur-
poses, ranging from project management, to healthcare delivery or mass communication [34].
Digital infrastructure–the larger systems which support access and use of these digital plat-
forms, including internet, satellites, cellular networks, and data storage centres [34]. The Coro-
navirus (COVID-19) pandemic has catalyzed the expansion of digital technology,
infrastructure and the use of digital devices in delivering essential services (e.g., healthcare)
and programs to communities [35, 36].
While digital platforms have been used in Indigenous communities for numerous initia-
tives, including environmental mapping initiatives (e.g., research and monitoring, land use
planning, and wildlife and harvest studies) [37, 38] and telehealth [39], there has largely been
isolated app development without a corresponding investment in digital infrastructure. This
approach limits the sustainability of digital initiatives, and importantly does not acknowledge
an Indigenous world view of holistic solutions [39].
Thus given the increasing prominence of digital devices [39, 40], it is critical to evaluate the
conceptualization, implementation, and knowledge dissemination of digital platforms. To
date, there is little guidance on how to evaluate digital platforms, particularly in partnership
with rural and remote communities [41]. A review of recent literature on community-based
needs assessments uncovered numerous resources for conducting evaluations of digital plat-
forms, however, a key gap is the lack of practical guidance for conducting needs assessments in
close collaboration with communities in ways that acknowledge existing needs, resources, sup-
ports and infrastructure that also incorporates the potential role of digital platforms in address-
ing community priorities.
This paper aims to provide researchers and evaluators with a framework (step-by-step
guide) to conduct needs assessments for digital platforms in collaboration with Indigenous
communities. To achieve this goal, a novel needs assessment framework was developed using a
Two-Eyed Seeing approach [13–15] to enable the identification of community priorities, barri-
ers and supports, as well as existing digital infrastructure to successfully implement digital
solutions. To demonstrate the application of this framework, a community-engaged needs
assessment conducted with a subarctic Indigenous community in Canada is described and dis-
cussed in detail.
Framework design and development
This project commenced with the design and development of a new framework to guide com-
munity-based needs assessments in the digital age.
Needs assessments
Needs assessments are a type of formative evaluation and are often considered a form of strate-
gic or program planning, even more than they are considered a type of evaluation. Needs
assessments can occur both before and during an evaluation or program implementation;
however, needs assessments are most effective when they are conducted before a new initiative
begins or before a decision is made about what to do (e.g., how to make program changes)
[29]. Typically, a needs assessment includes: 1) collecting information about a community; 2)
determining what needs are already being met; and 3) determining what needs are not being
met and what resources are available to meet those needs [42].
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Framework development
Based on existing literature, community consultation, and drawing expertise from our team of
evaluation experts who have over a decade of experience working with Indigenous communi-
ties on a range of research and evaluation projects, a novel framework was developed to guide
community-based needs assessments focused on the application of digital platforms.
This framework (see Fig 1) is driven by core questions necessary to identify community pri-
orities that can be addressed by developing and implementing digital platforms. Through team
discussion and community consultation, five key topic areas for the assessment of community
needs were identified: i) current supports; ii) desired supports; iii) barriers; iv) community
engagement; and v) digital access and connectivity. A series of general questions across the five
needs assessment topic areas were developed. Thereafter, a set of sub-questions were embed-
ded in each key topic area.
The Guiding Framework outlines an approach for conducting community needs assess-
ments which can be adapted across communities and jurisdictions. This framework offers a
flexible template that can be used iteratively and applied to various community-engaged needs
assessments in a range of areas, including but not limited to community health and wellness
projects. The questions assigned to each topic area can be used to guide needs assessments of
Fig 1. A guiding framework for community-based needs assessments to embed digital platforms.
https://doi.org/10.1371/journal.pone.0279282.g001
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any priority identified by community stakeholders as suitable for addressing with digital
platforms.
Needs assessment methods
The Guiding Framework was implemented in collaboration with a subarctic Indigenous com-
munity in Canada, and was used to identify key community priorities, barriers, supports, and
existing digital infrastructure which could inform the design and implementation of tailored
digital platforms.
Design
Using an environmental scan of relevant documents and qualitative focus groups and inter-
views, a needs assessment was conducted with the Northern Village of Île-à-la-Crosse, Sas-
katchewan, Canada between February and May 2020.
This project is governed by a Citizen Scientist Advisory Council which included research-
ers, Knowledge Keepers, Elders, and youth from Île-à-la-Crosse. The study PI (TRK) and Co-
Investigator (JB) developed a relationship with key decision-makers in Île-à-la-Crosse in 2020.
Through their guidance and several community visits, the decision-makers introduced the
research team to Elders, youth, and other community members to gain a better understanding
of current priorities and needs in Île-à-la-Crosse. The research team developed relationships
with these community members and invited them to join the Council to formally capture feed-
back and plan ongoing projects to promote health and wellbeing in the community. The
Council represents the needs and interests of the community, and guides the project develop-
ment, implementation, and evaluation. Council members were provided with Can $150 (US
$119.30) as honoraria for each meeting to respect their time, knowledge, and contributions.
Written consent was obtained from all focus group participants and verbal consent was
obtained from all key informants participating in interviews. This study received ethics clear-
ance from the research ethics boards of the University of Regina and the University of Sas-
katchewan through a synchronized review protocol (REB# 2017–29).
Setting
Established in 1776, Île-à-la-Crosse is a northern subarctic community with road access in
northwest Saskatchewan. Sakitawak, the Cree name for Île-à-la-Crosse, means “where the riv-
ers meet,” hence the community was an historically important meeting point for the fur trade
in the 1800s [43, 44] The community lies on a peninsula on the Churchill River, near the inter-
sections with the Beaver River and Canoe River systems. Île-à-la-Crosse has a rich history dat-
ing back to the fur trade. Due to its strategic location, Montreal-based fur traders established
the first trading point in Île-à-la-Crosse in 1776, making the community Saskatchewan’s oldest
continually inhabited community next to Cumberland House [45]. In 1821, Île-à-la-Crosse
became the headquarters for the Hudson’s Bay Company’s operations in the territory. In 1860,
the first convent was established bringing Western culture, medical services, and education to
the community.
Île-à-la-Crosse has a population of roughly 1,300 people [19]. Consistent with Indigenous
populations across Canada, the average age of the community is 32.7 years, roughly 10 years
younger than the Canadian non-Indigenous average [19]. Census data report that just under
half (44%) of the community’s population is under the age of 25, 46.3% are aged 25–64, and
9.3% aged 65 and over [19]. Members of the community predominantly identify as Métis
(77%), with some identifying as First Nations (18%), multiple Indigenous responses (1.2%),
and non-Indigenous (2.7%) [19]. Many community members are employed in a traditional
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manner utilizing resources of the land (e.g., hunting, fishing, trapping), others in a less tradi-
tional manner (e.g., lumbering, tourism, wild rice harvesting), and some are employed through
the hospital and schools. The community currently has one elementary school with approxi-
mately 200 students from preschool to Grade 6, and one high school serving Grades 7–12 with
adult educational programming. Île-à-la-Crosse has a regional hospital with Emergency Ser-
vices, which includes a health services centre with a total of 29 beds. Other infrastructure of
the community includes a Royal Canadian Mounted Police (RCMP) station, a village office,
volunteer fire brigade, and a catholic church [46].
Needs assessment approach
Île-à-la-Crosse shared their vision of integrating digital technology and infrastructure as part
of its growth, thus the needs assessment was identified as an appropriate method to provide
the formative information necessary to understand what the needs are, including who (i.e.,
players, partners), and what (i.e., information sources) would need to be involved, what oppor-
tunities exist to address the needs, and setting priorities for action with key community stake-
holders [47]. As a starting point and rationale for this needs assessment, the community of Île-
à-la-Crosse values the potential of technology for improving health communication, informa-
tion reach, access to resources, and care, and was interested in identifying priorities to begin
building digital infrastructure. Given the timing of the COVID-19 pandemic, being responsive
to community health needs were key priorities that they wanted to start addressing using a dig-
ital platform. This needs assessment facilitated and enabled new conversations around key pri-
orities and next steps.
The evaluation approach was culturally-responsive and included empowerment principles
[48–50]. Empowerment evaluation intends to foster self-determination. The empowerment
approach [50] involved community members–represented through the Citizen Scientist Advi-
sory Council–engaging in co-production of the evaluation design and implementation by
establishing key objectives for the evaluation, informing evaluation questions, building rele-
vant and culturally responsive indicators, developing focus group guides, leading recruitment
and data collection, and interpreting results [51]. In this way, the approach incorporated local
community and Indigenous Knowledges as well as Western knowledge, in a similar approach
to Two-Eyed Seeing [13–15]. Using these needs assessment evaluation results, the community
will identify emerging needs and potential application issues, and work with the researchers to
continue shaping project development and implementation.
Two-Eyed Seeing to embed digital platforms
Two-Eyed Seeing as described by Elder Albert Marshall [13, 14], refers to learning to see with
the strengths of Indigenous and Western Knowledges. Our engagement and overall approach
to working with the community of Île-à-la-Crosse takes a Two-Eyed Seeing lens, from co-
conceptualization of solutions, which starts with understanding the needs of the community.
All needs are a result of direct Indigenous Knowledge that was provided by the Advisory
Council. Indigenous Knowledge is not limited to the knowledge of Elders and Traditional
Knowledge Keepers; however, they play a critical role in guiding that knowledge through by
providing historical, geographic, and cultural context. Moreover, the Knowledge Keepers can
be key decision-makers in the community, and in our case, they were key informants who par-
ticipated in this needs assessment. Every aspect of needs assessment was dependent on the
Advisory Council and Key informants providing the Indigenous Knowledge that the research
team needed to tailor digital solutions. As a result, Two-Eyed Seeing approach informed all
aspects of the research process.
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As we are working to develop, and bring digital platforms and technologies (i.e., Western
methods) to address key community priorities, Indigenous Knowledge is central to the overall
project. Indigenous Elders, decision-makers, and Advisory Council members are bringing
both their historical and lived experience to inform project goals, key priority areas, target
groups, and methods. Île-à-la-Crosse is a predominantly Metis community, which differs in
culture from other Indigenous communities in Canada—First Nations and Inuit communities.
Ceremony is not a key part of community functioning; thus, specific cultural ceremonies were
not conducted upon advice of the Advisory Council. Instead, the knowledge of historical
issues, challenges, and success stories in the community is considered Indigenous Knowledge
for this needs assessment, and more importantly, this Indigenous Knowledge informed the
focus areas and next steps for this project. Overall, the spirit of collaboration and co-creation
which combined Western research methods/technology with Indigenous Knowledge and
expertise is considered Two-Eyed Seeing in this project. This lens was taken at all phases, from
the engagement stage to Advisory Council meetings, to planning and executing the needs
assessment and next steps.
Data collection
In order to obtain an in-depth understanding of the key priorities and supports within the
community of Île-à-la-Crosse, this needs assessment used a qualitative approach. An environ-
mental scan was conducted in February 2020 of current school and community policies and
programs. Published reports, meeting memos, community social media accounts, and the Île-
à-la-Crosse website were reviewed for existing policies and programs. The Citizen Scientist
Advisory Council identified appropriate data sources for the document review and corrobo-
rated which programs and initiatives were currently active in the community.
Qualitative data were collected from key decision-makers and other members within the
community. A purposeful convenience sampling approach was employed to identify members
of the community who could serve on the Council and participate in focus group discussions.
Key decision makers and existing Council members recommended other community mem-
bers who could join the focus group discussions to provide detailed and relevant information
on community priorities, digital infrastructure, supports, and challenges. Two focus groups
were conducted by members of the research team in Île-à-la-Crosse with the Council in May
2020. Focus group participants were asked to describe community priorities, supports, and
barriers, as well as experience and comfort with digital platforms. Each focus group had four
participants, were two-hours in length, and followed an unstructured approach. Three key
informant interviews were conducted in Île-à-la-Crosse between February and April 2020.
One-hour interviews were conducted one-on-one and followed a semi-structured interview
format. The focus groups and key informant interviews were led by the study PI, TRK, and
Co-Investigator, JB, who have extensive training and experience with qualitative research
methods, particularly in partnership with Indigenous communities. Focus groups and key
informant interviews were conducted virtually using Zoom [52]. The key informant interviews
and focus groups were audio-recorded and transcribed. All data were aggregated, anonymized,
and securely stored in a cloud server. Data are owned by the community. Both the Council
and the research team have equal access to the data.
Data analysis
All documents identified through the environmental scan were reviewed for key themes. A list
of existing school and community programs was compiled and organized by theme (i.e.,
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education-focused, nutrition-focused, health-focused, etc.). Follow-up conversations with key
informants verified the continued planning and provision of these programs.
Following the 6-step method by Braun and Clarke (2006), a thematic analysis was con-
ducted to systematically identify key topic areas and patterns across discussions [53]. A short-
list of themes was created for the key informant interviews and focus groups, respectively. A
manual open coding process was conducted by two reviewers who reached consensus on the
final coding manual and themes. Separate analyses were conducted for key informant inter-
views and focus group discussions; however, findings were synthesized to identify key themes
and sub-themes in key priorities for the community, community supports and barriers, as well
as digital connectivity and infrastructure needs.
Needs assessment findings
The needs assessment guiding framework informed specific discussions of key issues in the
community of Île-à-la-Crosse. Key informant interviews and focus group discussions com-
menced by asking about priorities–“what are the key areas of focus for the community?” In all
conversations–including a document review of initiatives in Île-à-la-Crosse–health was
highlighted as a current priority; hence, questions in the guiding framework were tailored to
fit a needs assessment focused on community health. The following five overarching evalua-
tion questions were used to guide the evaluation: i) What are the prominent health issues fac-
ing residents of Île-à-la-Crosse?; ii) What supports are currently available to help residents
address prominent health issues in the community?; iii) What types of barriers do community
members face to accessing services to manage their health?; iv) How is health-related informa-
tion currently shared in the community?; and v) To what extent are health services and infor-
mation currently managed digitally/electronically? The evaluation questions were kept broad
to capture a range of perspectives. An evaluation matrix linking the proposed evaluation ques-
tions to their respective sub-questions, indicators, and data collection tools is outlined in
Table 1.
Feedback on each needs assessment topic area is summarized in the sections below. Sample
quotes supporting each of the key topic areas is provided in Table 2.
Table 1. Evaluation matrix of a needs assessment focused on community and digital health.
Original framework question for each topic
area
Questions & Sub-questions Indicators Data Sources
Priorities
1. What are the key areas of focus for the
community?
• What are the prominent health issues facing
residents of Île-à-la-Crosse?
�What are the key health issues among children
and youth in the community?
Qualitative feedback from
key informant interviews
and focus groups
Key informant interviews with the
decision makers of the school
division and community
Unstructured focus groups with
the Citizen Scientist Advisory
Council
Current supports
2. What supports are currently in place to
address this area?
2.1. How well do the supports currently
address this area?
2.2. Are there ways that these supports could
be improved?
• What supports are currently available to help
residents address prominent health issues in the
community?
�What types of supports are available at the i)
school, and ii) community level?
�What factors influence the use of these
supports?
�What are ways these supports could be
adapted to better suit your community’s needs?
Qualitative feedback from
key informant interviews
and focus groups
School programs, school
policies, school budget
Community Research
Conference Executive
Summary Document
Key informant interviews with the
decision makers of the school
division and community
Unstructured focus groups with
the Citizen Scientist Advisory
Council
Document review
(Continued)
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Key priorities
Four priorities were identified through the focus groups, key informant interviews, and docu-
ment review (Fig 2). Given the timing of the discussion, the primary issue of concern was the
COVID-19 pandemic. Many community members were worried about contracting the virus,
and the risk it posed to Elders in the community. Of greater concern, however, was how
COVID-19 exacerbated many existing health concerns including diabetes and hypertension in
Table 1. (Continued)
Original framework question for each topic
area
Questions & Sub-questions Indicators Data Sources
Desired supports
3. What supports do you need for this area?
3.1. What types of tools or resources could
help support this area (e.g., funding,
personnel, technology, tailored tools)?
3.2. In what ways could we maximize the
reach of new supports (e.g., remote digital
engagement)?
• What supports do you wish were available to
help residents address prominent health issues in
the community?
�What type of supports would they be? (e.g.,
resources, infrastructure, programming, policies)
� In what ways could we enable more people to
access the new supports (e.g., remote digital
engagement)?
Qualitative feedback from
key informant interviews
and focus groups
School programs, school
policies, school budget
Community Research
Conference Executive
Summary Document
Community health
infrastructure
Key informant interviews with the
decision makers of the school
division and community
Unstructured focus groups with
the Citizen Scientist Advisory
Council
Document review
Barriers
4. Are there any barriers to addressing this
priority?
5. What could help overcome this barrier
(e.g., funding, personnel, technology, tailored
tools)?
5.1. Are there any community members that
are disproportionately impacted by this
barrier (e.g., youth, Elders)?
• What types of barriers do community members
face to accessing services to manage their health?
� Are there ways to support the community to
help them overcome these barriers?
� Are there specific barriers for children and
youth in particular?
Qualitative feedback from
key informant interviews
and focus groups
Community Research
Conference Executive
Summary Document
Key informant interviews with the
decision makers of the school
division and community
Unstructured focus groups with
the Citizen Scientist Advisory
Council
Document review
Community engagement
6. What are the existing modes of
communication in the community (i.e., social
media, radio, word-of-mouth)?
6.1. Who is typically part of the conversation
on this topic area (i.e., which members of the
community)?
6.2. How often do community members
connect on this topic or area of interest?
• How is health-related information currently
shared in the community?
�How did you find out (for community
members) /communicate (for decision-makers)
health information during the COVID-19
pandemic?
Qualitative feedback from
key informant interviews
and focus groups
Key informant interviews with the
decision makers of the school
division and community
Unstructured focus groups with
the Citizen Scientist Advisory
Council
Digital infrastructure and connectivity
7. How accessible is i) data, or ii) WiFi in the
community?
8. Are there any digital tools currently being
used to help address this area?
8.1. If yes, what is the reach of these digital
tools (e.g., user groups)?
8.2. If yes, how comfortable are community
members with these digital tools (i.e., digital
literacy)?
8.3. If not, where or how could a digital
platform/tool help with this area?
9. What factors enable/discourage use of
digital tools?
10. What are some barriers preventing
community members from using digital tools
in this area?
10.1. What could facilitate access or use of
digital tools in this area?
• All questions from column 1.
• To what extent are health services and
information currently managed digitally/
electronically?
� Do you see any benefit of increasing the
digital infrastructure for health services in the
community?
�What are some challenges applying digital
tools to healthcare in the community?
Qualitative feedback from
key informant interviews
and focus groups
Smartphone use and access
in the community
WiFi/data connectivity and
access
Key informant interviews with the
decision makers of the school
division and community.
Unstructured focus groups with
the Citizen Scientist Advisory
Council
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Table 2. Sample quotes supporting needs assessment topic areas.
Key Topic Area Sample Quotes
Priorities “[There are] pre-existing risks [and] issues like diabetes, blood pressure, and other diseases that the community has dealt with it in the
past.” (KI 1)
“Floods can also be an issue for the community and [. . .] if this data could be implemented on the app that would be great.” (KI 1)
“. . .the municipality is taking care of the most vulnerable people, mainly their food and medicine. Food security [is] one of the major
issues for the community.” (KI 1)
“[is] it was possible to access data about [community members’] food needs and to get information on what these needs are?” (KI 2)
“Mental health issues with the youth is a concern [in the community] during this time.” (K1 2)
“[Climate change] actually is starting to worry me a lot more now. Comparing last year’s weather to this year, it’s a huge difference [. . .]
both in terms of temperature and how it looks outside. Last year we were already getting snow in mid-October and this year we did get
our first snowfall around that time, but the snow didn’t stay. It melted away and only really started to stay about hallway through
November.” (FGR1 R1)
“I know some of my family talked [about] it. Because based last year during December versus this year early December where this year
there wasn’t that deep snow, meanwhile last year we already had snow going up to our knees at the time. I think when I do think about
[climate change], then it’s definitely stresses me out. (FG1 R2)
“[Climate change] does stress me out. Especially, last year, I saw a bear out that was not supposed to be out.It was way too early and there
was still snow and it looked confused and I was like this is actually happening. . .this is climate change. Especially with this year, the kind
of messed up weather we were having was warm and all of a sudden, it got extremely cold. It’s just kind of all over the place” (FG2 R1)
“I feel like the biggest concern with all that is our main road. We have only one road out of here in summer. Like there is one road in, and
one road out. So that would be the main concern of how do we get out, how do people come in, like. . .. and that’s probably the biggest
concern.” (FG2 R2)
Current supports “. . .wellness can mean different things to different people [. . .] For example, for some individuals, wellness means spirituality, which is
associated with language and culture, while for others it means being physically, mentally, emotionally and spiritually healthy.”
(KI 2)
“Through extensive discussions regarding wellness and what wellness meant to each individual, the following themes emerged as
components to be included in the wellness model: 1. Healthy parenting; 2. Healthy youth; 3. Healthy communities; 4. Elders; 5. Healing
towards wellness; 6. Food sovereignty” (Northern Village of Île-à-la-Crosse–Community Research Conference Executive Summary
Document)
“A significant portion of the gathering was dedicated to the importance of Elders, who are seen as Knowledge Holders who are best
positioned to revive and reinvigorate the sorely missing spiritual and cultural aspects of the community. Elders have both enormous
responsibility and immense capacity to share traditional knowledge and teachings. Therefore, the Elders’ Lodge being part of and at the
core of the initiative will provide many opportunities for community and intergenerational knowledge transmission.” (Northern Village
of Île-à-la-Crosse–Community Research Conference Executive Summary Document)
“The community prioritizes food sovereignty and initiatives such as the greenhouses for growing vegetables and fruits. There are after-
school programs (traditional food education: preparing and cooking bannock, duck, fish and other traditional foods), and community
land-based activities (e.g., berry picking led by Elders), which heighten awareness of food security and sovereignty, and encourage Youth-
Elder bonding and intergenerational knowledge transmission.” (Northern Village of Île-à-la-Crosse–Community Research Conference
Executive Summary Document)
“I had a class that was heavily focussed around the greenhouse last year, but besides that I haven’t really gone to the greenhouse much this
school year.” (FG1 R1)
“We were helping around in the greenhouse a lot. Planting new crops, harvesting them. We also had our own little side crops that we did
for a class project where we each planted our own crops and grew them and wrote down the different growth stages on it. [. . .] Yeah, I
enjoyed it.” (FG1 R2)
“[The greenhouse program] is still ongoing and it’s beautiful in there, and there is a lot of plants. And we have planted a lot of those
plants and we harvests a lot of those plants as well. And we do that to take home a lot of the food that we grow and collect from the green
house so that we could take it home to. . . you know, cut it up for supper and stuff like that, and sometimes our projects are to take
pictures and show what we’ve made out of the stuff that we have taken home. So, it’s still pretty good program being ran by the school.”
(FG2 R1)
Desired supports “Looking to the future, the overall improvement of family wellness, and indirectly community wellness, will be viewed through the
holistic lens of healthy parenting, with interventions focused on mental wellness and addressing substance misuse.” (Northern Village of
Île-à-la-Crosse–Community Research Conference Executive Summary Document)
“With various existing programs focusing on youth wellness in the community, nuanced changes were needed, especially by
incorporating Elders and the Elders’ Lodge. The consensus was that Île-à-la-Crosse needed well-nourished youth who are educated in
land-based activities and enjoy rich Elder-Youth bonding.” (Northern Village of Île-à-la-Crosse–Community Research Conference
Executive Summary Document)
“Traditional language revitalization by and through youth and young adults was prioritized as an urgent need and viewed as the essence
of the wellness model. Additionally, the community expressed a commitment to a respectful relationship with and stewardship of the
environment through programs that re-develop traditional family activities. Furthermore, addressing the root causes of trauma (e.g.,
colonialism, oppression, stigma) through mental wellness and addiction programming that promote a supportive and inclusive
community.” (Northern Village of Île-à-la-Crosse–Community Research Conference Executive Summary Document)
(Continued)
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the community. For example, routine procedures were postponed and community members
with other health conditions were not receiving routine healthcare during the height of the
pandemic. The St. Joseph’s Hospital and Health Centre services Île-à-la-Crosse and bordering
communities, hence maintaining capacity for COVID-19 patients was a priority. COVID-19
exposed existing barriers in the healthcare system which are described in greater detail in the
barriers to community health section.
Another priority discussed by many community members was climate change and the envi-
ronment. Community members noted that changes in wildlife patterns, land use, and early
winter ice road thaw were areas of concern, particularly due to the impact these factors have
on traditional food acquisition practices (i.e., hunting) and food access. For instance, the geo-
graphic location of Île-à-la-Crosse is surrounded by a lake, and the main highway which con-
nects the community to the land has experienced increased flooding in the past few years.
In addition to posing immediate danger to community members, food security and sover-
eignty are also closely linked to road access. While the community produces some of its own
food through the local fishery and greenhouses, Île-à-la-Crosse is still dependent on a food
supply from the south (i.e., Saskatoon). During COVID-19, food access was further restricted
due to limited transport and delivery of food products, which increased the risk of food
Table 2. (Continued)
Key Topic Area Sample Quotes
Barriers “I was turned down when I went to get glasses because I’m from the northwest” (FG1 R4)
“The community has to fight against different types of racism. Young people are invaluable in this process.” (KI 2)
“[For COVID] we need to address household risk, especially because of overcrowding.” (FG1 R3)
“Some of the community members from various healthcare and educational backgrounds pointed out the potential for illness and
addiction in the community. They noted that there continues to be stigma associated with community programs addressing these issues,
which inhibit participation and healing. Going back to the root causes of dysfunction and understanding the history of the community
and the oppression and colonialism it has experienced will help individuals and the community to embark on healing journeys towards
achieving wellness.” (Northern Village of Île-à-la-Crosse–Community Research Conference Executive Summary Document)
Community engagement “. . .mainly we use radio and social media–like Facebook–to share information in the community” (KI 3)
“I feel like this app is going to be very positive [. . .] and it’s also [the Internet is] just full of lies, this app will really connect you to
reality. . .” (FG2 R3)
“Every so often I do [listen to the radio], but not that often. Only whenever it’s on and I’m too lazy to change it. . . I would say [we get
news from] a mixture of people spreading it around and radio station I would say. A mixture of that.” (FG1 R1)
“I think Facebook is definitely a way people can check [for COVID information]. . . I think the radio is great for sharing information but
I think that there is not a lot of people that. . .like there aren’t many teens listening to the radio” (FG1 R3)
Digital access and
connectivity
“I look forward to the project because [we] need to embrace technology moving forward. There have been some technological
advancements being used at the nursing program here, and technology will help with the issues that our Northern communities face.”
(KI 3)
“We need to have assistance for the Elders when it comes to explaining how to use the applications.” (FG1 R1)
“I don’t check my email often I do I do for work, but that’s like three times a week. I don’t
use it that often. I think through the app directly and notifications, I’ll be the best.” (FG2 R2)
“[Internet speed] is good. It depends what provider you are using and where you live in town.” (FG1 R2)
“Where you live where you come into town, that area is where it cuts off every so often and it’s more slow around that area. But when you
get more towards town and near the ICSI building and you use the actual ICSI internet provider, that’s where it tends to be a lot
smoother.” (FG2 R1)
“. . .But with Sasktel its mostly a smooth performance all around town here.” (FG2 R2)
“[For sharing information], I would say just texting each other honestly. . .because even on snapchat, that’s another way a lot of, I know
my peers connect with each other. I stay in touch with a lot of people outside of this community and with friends in Saskatoon, and other
places.” (FG1 R1)
“I think the main way the kids and teenagers these days are connecting is through texting and snapchat. Even though I don’t have
snapchat, I think that a lot of people, like 90% of people in the school, the main way of connecting is probably through snapchat.” (FG1
R2)
“We have good cell service in the village. . .we know all of them use [smartphones] and we need to educate them about data safety. This is
important for building apps for [community] problems.” (KI 2)
FG–Focus Group; R–Respondent; KI–Key Informant
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insecurity for community members. Food insecurity was believed to be of bigger concern for
Elders in the community compared to younger members. Younger community members
expressed having the ability to source their own food in a variety of capacities (e.g., fishing in
the lake), whereas Elders rely more heavily on community resources and support (e.g., grocery
stores, friends, and family).
Community members also discussed issues surrounding mental health and wellbeing. This
topic was of particular concern for youth and Elders in the community. Community members
discussed the importance of identifying covert racism (vs. discrimination) that exists within
health services that exacerbated mental health issues and care, as well as developing coping
strategies, resilience, and supports to prevent mental health crises. Key informants emphasized
the need to minimize the stigma around mental health and focus on holistic wellbeing as they
work to develop strategies to improve community wellness.
Community health supports
Île-à-la-Crosse has been working on developing supports to improve community health
through various initiatives. A document review identified a community-specific wellness
model which has informed program development and planning over the past few years. The
key components of the Île-à-la-Crosse wellness model are: i) healthy parenting; ii) healthy
Fig 2. Summary of key health priorities.
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youth; iii) healthy communities; iv) Elders; v) healing towards wellness; and vi) food sover-
eignty. The Elders Lodge in the community provides support for holistic wellbeing by promot-
ing intergenerational knowledge transmission, guidance to youth and community members,
as well as land-based activities which improve bonding, cultural awareness, and mental and
spiritual well-being among community members. The Elders Lodge hosts both drop-in and
organized events.
Several initiatives have been developed to support food sovereignty in the community,
including a greenhouse program where fruits and vegetables are grown and shared locally.
This program is run in partnership with the school to increase food knowledge and skills
among youth. In addition, after-school programs including traditional food education (i.e.,
cooking classes) and land-based activities (i.e., berry picking) led by Elders support the goals of
the wellness model. The community is currently working on developing additional programs
dedicated to improving mental wellness among adults, youth, and Elders.
Barriers to community health
When key informants were asked to identify barriers to community health, they described
delays in access to timely health information. For example, daily COVID-19 tests conducted at
the regional health centre in Île-à-la-Crosse were relayed to the provincial health authority;
however, information about the total number of COVID-19 cases could take up to one week
to be sent back to the community. This time lag restricted community decision-makers’ ability
to enact timely policy (i.e., contact tracing) and rapidly respond to managing cases.
A second barrier that was raised by community members was a delay in access to timely
healthcare. The Île-à-la-Crosse hospital is a regional health service centre serving the commu-
nity as well as surrounding areas. Community members noted that the load often exceeded the
capacity of the single hospital, and some patients and procedures were relocated to hospitals
and clinics in the larger city of Saskatoon, Saskatchewan. This was reported to be challenging
for many community members as it was associated with longer wait times, long commutes,
and sometimes required time off work. Many of these challenges were exacerbated during the
COVID-19 pandemic. As a result of the pandemic, many medical centres and hospitals post-
poned routine and elective medical procedures in an attempt to accommodate the overwhelm-
ing influx of patients who contracted COVID-19. In addition, community members were
advised to avoid spending time in health centres to limit risk of exposure to the virus. These
COVID-related changes further delayed access to timely healthcare for many community
members of Île-à-la-Crosse.
Several community members reported experiencing institutional racism in healthcare and
social service settings outside of Île-à-la-Crosse. This was particularly exacerbated during the
COVID-19 movement restrictions, where community members faced significant difficulties in
accessing services and care in larger urban centres, and experienced further discrimination
due to the stigma of COVID-19-related rumours about communities in the north.
Lastly, community members discussed a lack of awareness about some health topics,
including where and how to access reliable health information. Some community members
attributed this lack of awareness to a general distrust in government health information due to
a history of colonialism and exploitation in Canada, which likely contributed to increased mis-
information about COVID-19 risk and spread.
Health communication
The primary modes of communication within Île-à-la-Crosse are radio and social media.
These platforms were used throughout the pandemic to communicate health information
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about COVID-19 case counts and trends. Community members also reported obtaining health
information from healthcare practitioners (i.e., for those already visiting a healthcare pro-
vider), Elders, and the internet. Key informants indicated an interest in improving digital
infrastructure to enable sharing of timely and accurate health information with community
members and minimize misinformation. Key informants also reported room for improvement
in the community’s digital health infrastructure, particularly in improving timely communica-
tion with community members, and to inform decision-making in crisis situations.
Digital infrastructure and connectivity
Île-à-la-Crosse has its own cell tower which offers reliable access to cellular data. The commu-
nity also has access to internet via the provincial internet provider–SaskTel, as well as a local
internet provider—Île-à-la-Crosse Communications Society Inc. Key informants and commu-
nity members confirmed that most individuals above 13 years of age have access to smart-
phones, and that these mobile devices are the primary mode of internet access. However, it
was unclear whether everyone who owns smartphones also has consistent data plans or home
internet connections. Key informants described the great potential of digital devices like
smartphones to increase the speed and accuracy of information sharing. Discussions with both
key informants and community members suggested the need for a community-specific app or
platform which could provide timely health information that was tailored to the community’s
needs.
Community members noted that expanding digital infrastructure had to be paired with
efforts to improve digital literacy–particularly as it relates to data security, privacy, and online
misinformation. A separate initiative was discussed which could work to improve digital liter-
acy among youth and Elders, as this would improve both the uptake of digital health platforms,
as well as their usefulness and application. Key informants discussed the importance of build-
ing digital infrastructure that would enable data sovereignty, self-governance, and determina-
tion. The key informants, who are also primary decision-makers in the community, described
opportunities for ethical development of digital platforms that would ensure that data is
owned by the community.
Discussion
Needs assessments are commonly the first step in understanding specific community needs,
[27, 28]; however, few evaluation frameworks provide practical guidance on how to engage
communities in needs assessments [41]. This paper provides a step-by-step guide for conduct-
ing needs assessments in collaboration with communities in the digital age. Using the series of
questions outlined in the Guiding Framework, researchers and evaluators can gain an in-
depth understanding of a community’s priorities, needs, existing capacity, and relevant
solutions.
The Guiding Framework was critical to establishing a partnership with the community
of Île-à-la-Crosse, as it enabled the research team to obtain detailed insight into their priori-
ties–in this case, community health–as well as community capacity. Taking a Two-Eyed
Seeing approach [15], conversations with the community highlighted strengths of Western
digital technology and the diversity of Indigenous Knowledges for addressing priorities
[13]. This approach was also important to establishing trust and respect for the variety of
perspectives that could be used to address community priorities. The resulting partnership
also enabled the conceptualization of tangible action items that were aligned with current
and future priorities–a key factor in the sustainability and feasibility of community-based
initiatives [4–8, 54].
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Challenges and opportunities for using digital platforms for priorities
identified by needs assessment
Many rural and remote communities face similar challenges and share common priorities
with Île-à-la-Crosse. For example, resource and service access, including food and other essen-
tial supplies, healthcare, and internet connectivity are issues faced by many rural and remote
communities across Canada [55–60]. Key informants and community members from our
partner community corroborated these access issues, particularly in relation to public health.
Given the potential for digital technology to bridge access gaps, it has become pertinent to
invest in digital infrastructure and platform development.
Research has shown that in many rural and remote communities, smartphone ownership is
not the limiting factor–it is internet inequity, which is defined as differential internet access
based on wealth, location (urban, rural, or remote), gender, age, or ethnicity [61]. The United
Nations has declared internet access a human right [10], which makes it imperative to develop
digital infrastructure such as internet connectivity to improve digital accessibility. Île-à-la-
Crosse has its own cell tower which offers reliable access to cellular data. The community of
Île-à-la-Crosse also has access to consistent and dedicated internet service through a provincial
internet provider and local internet provider. The needs assessment showed that the universal-
ity of smartphone ownership combined with good internet connectivity lays the foundation
for the development of tailored, culturally appropriate digital health platforms in communities
like Île-à-la-Crosse.
In particular, the needs assessment revealed that smartphone apps, which most citizens are
well-versed with, can be used to provide local services and access to resources. For example, a
locally developed app can connect the Mayor’s office with community members in real-time
to provide updates on COVID-19 outbreaks. Apps also have the potential to connect commu-
nities to resources within and outside of the community [35, 57]. For example, advanced artifi-
cial intelligence algorithms can be used to anticipate community needs prior to urgent crises
like COVID-19, environmental disasters, or food crises [35, 62–65]. To date, the issue has not
been the lack of technology or ability to bridge this gap for rural and remote communities.
Instead, larger systemic inequities have limited our ability to co-create local solutions for global
problems by decentralizing technology that is widely available [35, 66], which highlights
upstream inequities in developing digital platforms.
Recommendations for inclusive digital needs assessments
Given the widespread adoption of digital technology, digital platforms can provide rich data to
identify and address community crises [2, 3, 35]. Importantly, co-created digital platforms can
be used to share knowledge in real-time with community members and other stakeholders to
enable remote engagement, which is especially important during crisis situations such as a
pandemic [2, 3, 35]. As we implement creative digital platforms in varied programs or research
projects, we must also integrate this digital perspective into the evaluation process. Research
and evaluation literature has well established approaches to needs assessment evaluations [29,
42, 67]; however, in the 21st century, we need to account for the use and application of digital
platforms in community-focused initiatives. To identify how and where digital platforms can
play a role in addressing community priorities, we propose several recommendations for
inclusive community-based needs assessments.
First, at the crux of all community-based needs assessments is relationships. A relationship
built on respect, reciprocity, mutual understanding, and prioritizing the needs and vision of
communities is essential for sustainable impact. The First Nations OCAP1 principles [68]
informed conversations between the research team and community about data ownership and
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control. These principles include ownership of knowledge and data, control over all aspects of
research, access to information about one’s own community, and possession or control of data
[68]. The OCAP1 principles ensure First Nations and other Indigenous Peoples the right to
their own information, and also reflect commitments to use and share information in a way
that maximizes the benefit to a community, while minimizing harm. Some communities may
choose to lead a project, or work closely in collaboration with experts for specific projects. Irre-
spective of the project dynamics, needs assessments rely on detailed information and context
about a community for a project to succeed.
Second, it is important for researchers and evaluators to gain an understanding of the cur-
rent digital infrastructure and connectivity in the community. The needs assessment frame-
work (Fig 1) includes relevant questions for identifying data and WIFI access in a community,
penetration of digital devices, and existing digital infrastructure. Even for community-based
initiatives that are not focused on a digital platforms, digital technologies will inevitably be a
part of the solution, a barrier, or both. Hence the digital landscape has become part of the con-
text that we must capture and understand in a needs assessment to better design and develop
programming, policies, and other initiatives.
Third, it is important to ask the question of where and how a digital tool or platform could
help. Are there gaps that digital platforms can help address or fill? In rural and remote commu-
nities, in particular, digital platforms can provide access to real-time information and services
not otherwise available. For example, Telehealth [69, 70] in the Canadian north offers citizens
access to essential healthcare services, including video appointments with medical specialists.
Prior to Telehealth, many residents would need to fly into bigger cities in the nearest province
to access health care [55].
Lastly, an understanding of the broader context which affects a community’s ability to
adopt digital platforms is critical to the success of digital initiatives. This includes, but is not
limited to, capturing data on socioeconomic status and the accessibility of internet-connected
digital devices. Digital platforms should help to bridge the divide in resource, service, and
information access–not widen the gap. For some communities, this may require working on
building digital infrastructure and obtaining dedicated funds to expand access prior to imple-
menting digital initiatives. In addition, digital literacy cannot be taken for granted. Digital lit-
eracy refers to individuals’ ability to not only use digital devices, but according to Eshet-
Alkalai [71], “includes a large variety of complex cognitive, motor, sociological, and emotional
skills, which users need in order to function effectively in digital environments.” In its simplest
form, digital literacy may include the ability to navigate digital platforms, download apps, and
communicate electronically. Other more specific skills include ability to read and understand
instructions, terms and services, as well as data privacy and security statements [72–74] As
part of a needs assessment, identifying digital literacy within a community is an important step
to safe, ethical, and relevant digital tool development.
Considering the challenges, immense potential, and learnings from applying the Guiding
Framework, a tailored digital platform was conceptualized called Sakitawak Health.
Development of Sakitawak Health
Sakitawak Health is a culturally-responsive digital epidemiological platform to monitor, miti-
gate, and manage COVID-19 outbreaks. The needs assessment concluded that digital plat-
forms can be used for emerging or other existing population health crises within Île-à-la-
Crosse and potentially other Indigenous communities. Moreover, to co-create digital plat-
forms, the Île-à-la-Crosse Citizen Scientist Advisory Council identified key features to embed
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PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 16 / 22
in CO-Away, including free virtual care for citizens via a smartphone app at the frontend, and
access to anonymized community data on the backend for decision-makers.
The app will provide three key precision medicine services that are specific to each citizen:
1) continuous risk assessment of COVID-19 infection; 2) evidence-based public health com-
munication; and 3) citizen reporting of food availability, access to public services, and
COVID-19 symptoms and test results. These culturally-responsive features have been co-cre-
ated with Métis decision-makers in Île-à-la-Crosse based on imminent community needs and
preferences. CO-Away will enable real-time data collection through continuous citizen
engagement to inform municipal jurisdictional policies.
There are three guiding principles for developing Sakitawak Health: I) Citizen empower-
ment and data ownership: Active engagement is enabled through app features such as visualiz-
ing community risk. More importantly, the community owns the data to ensure data
sovereignty; II) Privacy: Utilizing a cutting-edge methodology called federated machine learn-
ing, we will develop artificial intelligence algorithms that stores sensitive data such as partici-
pant location on mobile devices itself (i.e., sensitive data are not stored in external servers); III)
Security and scalability: The backend server will be located in Cloud in Canada, which allows
for horizontal and vertical scalability (i.e., the potential for developing multiple frontend apps
and decision-making dashboards).
Recognizing the importance of data sovereignty and Indigenous self-
governance
Data sovereignty and social justice are important aspects of community-based work, particu-
larly for communities that have experienced discrimination or systemic inequities [2, 75]. Data
sovereignty refers to meaningful control and ownership of one’s data [76]. For Indigenous
communities in Canada, self-determination and self-governance are of paramount importance
given the colonial history of oppression, trauma, and disenfranchisement [77], and data sover-
eignty and ownership of digital platforms can promote that independence. In conducting digi-
tal community-based needs assessments, the application of a Two-Eyed Seeing lens enables us
to leverage strengths of both Indigenous and Western Ways of Knowing to help focus on key
priorities and develop solutions.
The engagement and overall approach to working with the community of Île-à-la-Crosse
applied a Two-Eyed Seeing lens. In the needs assessment with Île-à-la-Crosse, Two-Eyed See-
ing involved incorporation of Métis Knowledge during team engagements, which ensured that
any digital platforms developed would incorporate Indigenous Knowledge to promote data
sovereignty. All priorities identified within this manuscript are a result of direct Indigenous
Knowledge that was provided by the Council. Indigenous Knowledge is not limited to the
knowledge of Elders and Traditional Knowledge Keepers; however, they play a critical role in
guiding that knowledge through by providing historical, geographic, and cultural context. Dis-
cussions with Île-à-la-Crosse about data sovereignty centered around citizen ownership of
data, community access, and ensuring data privacy and security. The ultimate goal of this
approach to data sovereignty is to facilitate decreased dependence on external systems and use
digital solutions for Indigenous self-determination and self-governance.
Next steps
The needs assessment represents the first phase of a larger evaluation strategy to develop and
implement culturally appropriate digital platforms for community health. Phase 1 involved
identifying core health priorities and desired supports in the community of Île-à-la-Crosse.
Based on the needs assessment findings, Phase 2 of this project will involve the development of
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PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 17 / 22
tailored digital health platforms and programming to support digital literacy. As part of Phase
2, digital literacy programs and tailored digital health platforms will be pilot tested and adapted
prior to their implementation. In Phase 3, a process evaluation will be conducted to assess the
reach, uptake, and use of digital health platforms and digital literacy programming. Integrated
knowledge translation will be conducted during all phases to ensure continuous feedback,
communication, and knowledge sharing with all relevant stakeholder groups.
Conclusions
Needs assessments can facilitate important conversations in community-based research and
evaluation to learn about key priorities, challenges, and opportunities for growth. The Guiding
Framework for Community-Based Needs Assessments to Embed Digital Platforms details a
step-by-step approach to begin a conversation with communities to better understand their
needs, and to tailor research and evaluation projects focused on embedding digital platforms.
In Île-à-la-Crosse, the needs assessment framework has propelled the launch of a timely, com-
munity-engaged digital initiative to address key priorities, starting with COVID-19. Overall,
tailored platforms can help bridge existing gaps in resource, program, and service access in
Indigenous communities, irrespective of their location across the world.
Supporting information
S1 File.
(DOCX)
Acknowledgments
The authors would like to acknowledge the contributions of community members of Île-à-la-
Crosse. The Elders, youth, and key decision-makers who are part of the Île-à-la-Crosse Citizen
Scientist Advisory Council have been invaluable in providing support, guidance, and cultural
training to the research team. The authors also acknowledge the support of the Canadian
Internet Registration Authority in advancing the uptake of digital health applications.
Author Contributions
Conceptualization: Jasmin Bhawra, Brenda Green, Kelly Skinner, Tarun Reddy Katapally.
Data curation: Jasmin Bhawra, M. Claire Buchan.
Formal analysis: Jasmin Bhawra, M. Claire Buchan.
Funding acquisition: Tarun Reddy Katapally.
Investigation: Jasmin Bhawra, M. Claire Buchan, Brenda Green, Kelly Skinner, Tarun Reddy
Katapally.
Methodology: Jasmin Bhawra, Tarun Reddy Katapally.
Project administration: Jasmin Bhawra, Brenda Green, Tarun Reddy Katapally.
Resources: Brenda Green, Kelly Skinner, Tarun Reddy Katapally.
Software: M. Claire Buchan.
Supervision: Jasmin Bhawra, Brenda Green, Kelly Skinner, Tarun Reddy Katapally.
Visualization: M. Claire Buchan.
Writing – original draft: Jasmin Bhawra, M. Claire Buchan.
PLOS ONE Embedding digital tools with Indigenous communities
PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 18 / 22
Writing – review & editing: Brenda Green, Tarun Reddy Katapally.
References
1. Wallerstein N, Duran B, Oetzel JG, Minkler M. Community-Based Participatory Research for Health:
Advancing Social and Health Equity. 2017.
2. Smith LT. Decolonizing Methodologies: Research and Indigenous Peoples. London; New York; Dune-
din: Zed Books Ltd; University of Otago Press; Distributed in the USA exclusively by St Martin’s Press;
2021. https://doi.org/10.4324/9781315597843-10.
3. Datta R. Decolonizing both researcher and research and its effectiveness in Indigenous research. Res
Ethics 2018; 14:1–24. https://doi.org/10.1177/1747016117733296.
4. Carr-Hill R, Street AD. Economic Analysis of Cost-Effectiveness of Community Engagement to Improve
Health 2008.
5. Mason AR, Carr Hill R, Myers LA, Street AD. Establishing the economics of engaging communities in
health promotion: What is desirable, what is feasible? Crit Public Health 2008; 18:285–97. https://doi.
org/10.1080/09581590802277366
6. Popay J, Attree P, Hornby D, Milton B, Whitehead M, French B, et al. Community engagement to
address the wider social determinants of health: A review of evidence on impact, experience & process
2007.
7. Narayan D. Empowerment and Poverty Reduction: A Sourcebook. Washington, D.C.; The World
Bank; 2002.
8. Cairncross L, Morrell C, Drake J, Brownhill S. Tenants Managing: An Evaluation of Tenant Management
Organisations in England. London: Office of the Deputy Prime Minister; 2002.
9. Pratchett L, Durose C, Lowndes V, Smith G, Stoker G, Wales C. Empowering communities to influence
local decision making: systematic review of the evidence. London: 2009.
10. La Rue F. Report of the Special Rapporteur on the Promotion and Protection of the Right to Freedom of
Opinion and Expression, Frank La Rue: addendum. 2011.
11. Cyril S, Smith BJ, Possamai-Inesedy A, Renzaho AMN. Exploring the role of community engagement in
improving the health of disadvantaged populations: A systematic review. Glob Health Action 2015; 8.
https://doi.org/10.3402/gha.v8.29842 PMID: 26689460
12. Wehipeihana N, Davidson EJ, Mckegg K. What Does it Take to do Evaluation in Communities and Cul-
tural Contexts Other Than Our Own? J Multidiscip Eval 2010; 6:182–92.
13. Bartlett C, Marshall M, Marshall A. Two-Eyed Seeing and other lessons learned within a co-learning
journey of bringing together indigenous and mainstream knowledges and ways of knowing. J Environ
Stud Sci 2012; 2:331–40. https://doi.org/10.1007/s13412-012-0086-8.
14. Iwama M, Marshall M, Marshall A, Bartlett C. Two-Eyed Seeing and the Language of Healing in Com-
munity-Based Research. Can J Nat Educ 2009; 32:3–23.
15. Martin DH. Two-eyed seeing: a framework for Indigenous approaches to Indigenous health research.
Can J Nurs Res 2012; 44:20–42.
16. Sylvestre P, Castleden H, Martin D, McNally M. “Thank you very much. . . You can leave our community
now.”: Geographies of responsibility, relational ethics, acts of refusal, and the conflicting requirements
of academic localities in indigenous research. Acme 2018; 17:750–79.
17. Frohlich KL, Ross N, Richmond C. Health disparities in Canada today: Some evidence and a theoretical
framework. Health Policy (New York) 2006; 79:132–43. https://doi.org/10.1016/j.healthpol.2005.12.010
PMID: 16519957
18. Public Health Agency of Canada. Key Health Inequalities in Canada: A National Portrait. 2018.
19. Statistics Canada. Île-à-la-Crosse, NV [Census subdivision], Saskatchewan and Saskatchewan [Prov-
ince] (table). Ottawa: 2017. https://doi.org/Statistics Canada Catalogue no. 98-316-X2016001.
20. Waldram JB, Herring A, Young TK. Aboriginal Health in Canada: Historical, Cultural, and Epidemiologi-
cal Perspectives. 2nd editio. Toronto: University of Toronto Press; n.d.
21. Marrone S. Understanding barriers to health care: a review of disparities in health care services among
indigenous populations. Int J Circumpolar Health 2007; 66:188–98. https://doi.org/10.3402/ijch.v66i3.
18254 PMID: 17655060
22. Central Urban Métis Federation Inc., Kinistin Saulteaux Nation, Saskatoon Health Region. Strengthen-
ing the Circle: Partnering for Improved Health for Aboriginal People. Saskatoon, SK: 2010.
PLOS ONE Embedding digital tools with Indigenous communities
PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 19 / 22
23. King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. Lancet
2009; 374:76–85. https://doi.org/10.1016/S0140-6736(09)60827-8 PMID: 19577696
24. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet 2009; 374:65–
75. https://doi.org/10.1016/S0140-6736(09)60914-4 PMID: 19577695
25. Marsh TN, Coholic D, Cote-Meek S, Najavits LM. Honouring the Truth, Reconciling for the Future Hon-
ouring the Truth, Reconciling for the Future Summary of the. vol. 12. 2015.
26. Levac L, Parizeau K, Varghese J, Morton M, Jackson E, Hawkins L. Towards a framework for building
community-university resilience research agendas. Soc Sci 2018; 7. https://doi.org/10.3390/
socsci7120260.
27. Smith LU. Community engagement framework for community assessment and improvement planning.
J Public Heal Manag Pract 2017; 23:S22–8. https://doi.org/10.1097/PHH.0000000000000600 PMID:
28542060
28. Pavlish CP, Pharris MD. Community-based collaborative action research : a nursing approach. Sud-
bury, MA: Jones & Bartlett Learning; 2012.
29. Watkins R, Meiers MW, Visser YL. Section 1 –Needs Assessment:Frequently Asked Questions. 2012.
https://doi.org/10.1596/9780821388686_ch02.
30. Skinner K, Burnett K, Pratley E, Parker B, Dovick B. Case Study 2: Engaging Youth in a Needs Assess-
ment for Programming and Evaluation, 2021, p. 97–100. https://doi.org/10.1007/978-3-030-34390-3_
13.
31. Pelletier CA, Pousette A, Ward K, Fox G. Exploring the perspectives of community members as
research partners in rural and remote areas. Res Involv Engagem 2020; 6:1–10. https://doi.org/10.
1186/s40900-020-0179-6.
32. O’Dea S. Number of smartphone users from 2016 to 2021 2021. https://www.statista.com/statistics/
330695/number-of-smartphone-users-worldwide/.
33. Katapally TR. Global Digital Citizen Science Policy for Pandemics. J Med Internet Res 2020; 22:
e19357. https://doi.org/10.2196/preprints.19357.
34. Kenney M, Zysman J. The next phase in the digital revolution. Commun ACM 2018; 61:54–63.
35. Katapally TR. A global digital citizen science policy to tackle pandemics like COVID-19. J Med Internet
Res 2020; 22:1–7. https://doi.org/10.2196/19357 PMID: 32408267
36. Whitelaw S, Mamas MA, Topol E, Van Spall HGC. Applications of digital technology in COVID-19 pan-
demic planning and response. Lancet Digit Heal 2020; 2:e435–40. https://doi.org/10.1016/S2589-7500
(20)30142-4 PMID: 32835201
37. Gearheard S, Aipellee G, O’Keefe K. The Igliniit Project: Combining Inuit Knowledge and Geomatics
Engineering to Develop a New Observation Tool for Hunters. SIKU Knowing Our Ice Doc. Inuit Sea Ice
Knowl. Use, 2010, p. 181–202. https://doi.org/10.1007/978-90-481-8587-0.
38. Bennett TD, Lantz TC. Participatory photomapping: a method for documenting, contextualizing, and
sharing indigenous observations of environmental conditions. Polar Geogr 2014; 37:28–47. https://doi.
org/10.1080/1088937X.2013.873089.
39. O’Donnell S, Beaton B, McMahon R, Hudson HE, Williams D, Whiteduck T. Digital technology adoption
in remote and Northern Indigenous communities in Canada. Can Sociol Assoc 2016 Annu Conf
2016:1–44.
40. Katapally T, Kannan P, Kwabia E. Citizen Science and COVID : Identifying the Needs of Rural and
Remote Education COVID-19 SERIES : FROM CRISIS TO RECOVERY. 2021.
41. Centers for Disease Control and Prevention (CDC). Community Needs Assessment: Participant Work-
book. Particip Workb 2013:1–77.
42. Stufflebeam DL, Shinkfield AJ. Evaluation theory, models, and applications. 1st ed. San Francisco,
CA: Jossey-Bass; 2007.
43. McLennan D. Sakitawak Development’s Facebook Page n.d.
44. Cameco Corp. Patuanak—English River First Nation—Community Profiles—Community. Cameco
North Saskatchewan 2020.
45. McLennan D. The Encyclopedia of Saskatchewan: Île-à-la-Crosse n.d. https://esask.uregina.ca/entry/
ile-a-la-crosse.jsp.
46. Favel D, Roy G. Northern Village of Ile a la Crosse. 2013.
47. Health Quality Ontario. Needs Assessment Resource Guide for Family Health Teams. J Contin Educ
Nurs 2009; 37:148–9. https://doi.org/10.3928/00220124-20060701-02.
PLOS ONE Embedding digital tools with Indigenous communities
PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 20 / 22
48. Askew K, Beverly MG, Jay ML. Aligning collaborative and culturally responsive evaluation approaches.
Eval Program Plann 2012; 35:552–7. https://doi.org/10.1016/j.evalprogplan.2011.12.011 PMID:
22284941
49. Chouinard JA, Cram F. Culturally Responsive Approaches to Evaluation: Empirical Implications for The-
ory and Practice 2020. https://doi.org/https%3A//10.4135/9781506368559
50. Fetterman DM. Empowerment Evaluation. Int Encycl Soc Behav Sci Second Ed 2015:577–83. https://
doi.org/10.1016/B978-0-08-097086-8.10572-0.
51. Voegeli C. Evaluation Advisory Groups: Considerations for Design and Management. Can J Progr Eval
2021. https://doi.org/10.3138/cjpe.69949.
52. Zoom Video Communications Inc. Security guide 2016.
53. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3:77–101. https://
doi.org/10.1191/1478088706qp063oa.
54. Pratchett L, Lowndes V, Smith G, Stoker G, Wales C, Durose C. Empowering communities to influence
local decision making. 2009.
55. Oosterveer TM, Young TK. Primary health care accessibility challenges in remote indigenous communi-
ties in Canada’s North. Int J Circumpolar Health 2015; 74:1–7. https://doi.org/10.3402/ijch.v74.29576
PMID: 26507717
56. Skinner K, Burnett K, Williams P, Martin D, Stothart C, LeBlanc J, et al. Challenges in assessing food
environments in northern and remote communities in Canada. Can J Public Heal 2016; 107:eS60–3.
https://doi.org/10.17269/cjph.107.5324 PMID: 27281518
57. Goodridge D, Marciniuk D. Rural and remote care. Chron Respir Dis 2016; 13:192–203. https://doi.org/
10.1177/1479972316633414.
58. Forbes D, Edge D. Canadian home care policy and practice in rural and remote settings: Challenges
and solutions. J Agromedicine 2009; 14:119–24. https://doi.org/10.1080/10599240902724135 PMID:
19437267
59. McNally MB, Rathi D, Joseph K, Evaniew J, Adkisson A. Ongoing policy, regulatory, and competitive
challenges facing Canada’s small internet service providers. J Inf Policy 2018; 8:167–98. https://doi.
org/10.5325/jinfopoli.8.2018.0167.
60. Haight M, Quan-Haase A, Corbett BA. Revisiting the digital divide in Canada: The impact of demo-
graphic factors on access to the internet, level of online activity, and social networking site usage. Inf
Commun Soc 2014; 17:503–19. https://doi.org/10.1080/1369118X.2014.891633.
61. Katapally TR. The SMART framework: Integration of citizen science, community-based participatory
research, and systems science for population health science in the digital age. JMIR MHealth UHealth
2019; 7:1–12. https://doi.org/10.2196/14056 PMID: 31471963
62. Gray DM, Joseph JJ, Olayiwola JN. Strategies for Digital Care of Vulnerable Patients in a COVID-19
World—Keeping in Touch. JAMA Heal Forum 2020; 1:e200734. https://doi.org/10.1001/
jamahealthforum.2020.0734.
63. Meechang K, Leelawat N, Tang J, Kodaka A, Chintanapakdee C. The acceptance of using information
technology for disaster risk management: A systematic review. Eng J 2020; 24:111–32. https://doi.org/
10.4186/ej.2020.24.4.111.
64. Castro D, New J. The Promise of Artificial Intelligence. Tex Med 2016; 115:32–5. https://doi.org/10.
7551/mitpress/12385.001.0001.
65. Zhou L, Zhang C, Liu F, Qiu Z, He Y. Application of Deep Learning in Food: A Review. Compr Rev Food
Sci Food Saf 2019; 18:1793–811. https://doi.org/10.1111/1541-4337.12492 PMID: 33336958
66. Katapally TR. Are democratic nations ready to democratize technology?: Tarun Katapally for Inside Pol-
icy. Macdonald-Laurier Inst 2020. https://macdonaldlaurier.ca/democratic-nations-democratize-
technology/.
67. Saunders RP, Evans MH, Joshi P. Developing a Process-Evaluation Plan for Assessing Health Promo-
tion Program Implementation: A How-To Guide. Health Promot Pract 2005; 6:134–47. https://doi.org/
10.1177/1524839904273387 PMID: 15855283
68. The First Nations Information Governance Centre. The First Nations Principles of OCAPTM Training
Course 2021:1–6. https://fnigc.ca/ocap-training.
69. Telehealth 2021. North Heal 2021. https://www.northernhealth.ca/services/digital-health/telehealth.
70. Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Patients and families experiences with
video telehealth in rural/remote communities in northern Canada. J Clin Nurs 2009; 18:2573–9. https://
doi.org/10.1111/j.1365-2702.2008.02427.x PMID: 19694885
71. Eshet-Alkalai Y. Digital Literacy: A Conceptual Framework for Survival Skills in the Digital era. J Educ
Multimed Hypermedia 2004; 13:93–106.
PLOS ONE Embedding digital tools with Indigenous communities
PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 21 / 22
72. Tomczyk Ł. Skills in the area of digital safety as a key component of digital literacy among teachers.
Educ Inf Technol 2020; 25:471–86. https://doi.org/10.1007/s10639-019-09980-6.
73. Oh SS, Kim KA, Kim M, Oh J, Chu SH, Choi JY. Measurement of digital literacy among older adults:
Systematic review. J Med Internet Res 2021; 23:1–15. https://doi.org/10.2196/26145.
74. Nouri SS, Avila-Garcia P, Cemballi AG, Sarkar U, Aguilera A, Lyles CR. Assessing mobile phone digital
literacy and engagement in user-centered design in a diverse, safety-net population: Mixed methods
study. JMIR MHealth UHealth 2019; 7:1–11. https://doi.org/10.2196/14250 PMID: 31469083
75. Kukutai T, Taylor J, editors. Indigenous Data Sovereignty: Toward an Agenda. The Australian National
University Press; 2016. https://doi.org/10.1109/IPDPSW.2014.214.
76. Hummel P, Braun M, Tretter M, Dabrock P. Data sovereignty: A review. Big Data Soc 2021; 8. https://
doi.org/10.1177/2053951720982012.
77. Allan B, Smylie J. First Peoples, Second Class Treatment. First Peoples, Second Cl Treat Role Racism
Heal Well-Being Indig Peoples Canada 2015:1–65.
PLOS ONE Embedding digital tools with Indigenous communities
PLOS ONE | https://doi.org/10.1371/journal.pone.0279282 December 22, 2022 22 / 22
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AORN Journal 1
PRESIDENT’S MESSAGE
The Challenges of Ethical Decision
Making in Nursing
Vangie Dennis, MSN, RN, CNOR, CMLSO
The profession of nursing is rife with decisions
that can be difficult and challenging. Nurses have
a responsibility to patients, health care team
members, and our profession to ensure ethical decisions
are upheld in the organization and in practice. Our mor-
al and ethical value systems are frequently challenged.
As a result, nurses often struggle with making correct
decisions.
Nurses’ unspoken pledge to duty is an integrated and
fundamental part of nursing practice that holds nurs-
es accountable for the well- being of patients and their
families, ensuring interventions are appropriate to
optimize care. Another essential principle that under-
lies nursing practice is respect for the intrinsic dignity,
value, and rights of all individuals.1 Nurses are hard-
wired and committed to providing optimal care to their
patients while respecting the rights and decisions of
individuals; however, sometimes care requirements
can interfere with what we believe are the correct
decisions. Thus, it is essential for nurses to understand
and demonstrate competency in providing ethical
care. According to AORN’s Perioperative Explications for
the ANA Code of Ethics for Nurses With Interpretive
Statements, “Ethical practice is … a critical aspect of
nursing care, and the development of ethical com-
petency is paramount for present and future nursing
practice.”2(p2)
ETHICAL DILEMMAS
At times in nursing, our personal morals cannot determine
the course of action and can conflict with decisions. In
such situations, called ethical dilemmas,
the nurse is expected to choose between
different options. The nurse is conflicted
because each of the opposing choices is eth-
ically supported while at the same time each
of the opposing choices is also considered
ethically problematic.3(p1517)
Nurses find themselves confronted with ethical dilemmas
daily that may occur during patient care or other work-
place activities; many of these can be categorized as world-
imposed dilemmas or moral uncertainties.
World- imposed ethical dilemmas are when decisions
are being determined by an outside force and there is
no option to make an independent decision. In such
instances, the nurse is bound to follow outside instruc-
tion based on the current situation. Nurses are faced
with decisions that may be forced upon them because of
policies, administrative decisions, or management direc-
tion. For example, the current nursing shortage has led
to inadequate staffing that has affected care decisions.
In my organization and many others, the coronavirus
disease 2019 (COVID- 19) pandemic affected how we
staffed perioperative areas, such as the postanesthe-
sia care unit, with less- than- optimal nurse- to- patient
ratios. Nurses felt overworked and questioned whether
care was being compromised, but they submitted to the
staffing model even though it conflicted with what they
believed optimal care should be. In addition, there was
a rush to fast- track personnel into specialty areas with-
out adequate training because of staffing needs. Nurses
were sometimes deployed to specialty areas without
having the skills and competencies needed to care for
the specific patient population.
http://doi.org/10.1002/aorn.13733
© AORN, Inc, 2022.
2 AORN Journal
July 2022, Vol. 116, No. 1Dennis
Moral uncertainty can be thought of as what a virtuous
person would do, or what is right to do, despite individuals’
own personal beliefs about the situation. The conclusion
does not guarantee that they are correct. Many times, an
individual can become morally biased because of vested
interests, peer influence, culture, religion, upbringing, or
influence from the status quo.4 Nurses often find them-
selves doubting their own beliefs and decisions. Moral
uncertainty impacted health care during the pandemic. For
example, as part of providing appropriate care, nurses try
to ensure that patients and their families have adequate
emotional support. However, the COVID- 19 pandemic
limited the ability for families to be with their loved ones;
at times, patients died without their loved ones by their
side. My last place of employment realized the importance
of family member presence during the end- of- life stage
and implemented a practice called “No One Dies Alone”
so loved ones could be with their family member during
their passing.
Moral uncertainty also can arise in situations in which patients
refuse care or certain care approaches. For example—as
nurses, although we know the various treatments for breast
cancer, there are patients who do not want to proceed with
radical treatment. A nurse could become judgmental and
assume this is what the patient should do for themselves and
their family. However, nurses should not impose their own
views on patients.5
Cultural Considerations
The focus on cultural competency is how the caregiv-
er responds to the value systems of our diverse pop-
ulation. The multigenerational workforce of today can
influence the quality of care and staff member interac-
tion. Generational differences among employees can be
beneficial to an organization because diversity nurtures
inventiveness and a differentiated approach to problem-
solving. When nurses do not understand cultural compe-
tency, the results can affect our care and create ethical
dilemmas. An individual’s value systems— whether the
individuals are nurses or patients— can influence the
decisions we make. The importance of not generalizing
individuals and instead attempting to understand, relate
to, and appreciate the behaviors of members from all
generations is instrumental in understanding genera-
tional differences and maintaining effective and satisfy-
ing relationships at work.6 It is critical for us to acquaint
ourselves with the patient’s culture to fully understand
their behavior within the cultural context.7
CONCLUSION
Perioperative nursing presents its own unique challenges,
and there have been unprecedented levels of transforma-
tion over the last decade that have affected our ethical
decisions regarding patient care. Nurses are among the
most critical stakeholders in all of this change. Together,
we must develop opportunities while collaboratively pro-
moting processes that involve team members as part of
the decision- making process. It is important that nurses
comprehend the impact of the ethical decisions we make;
although ethical decisions may not always be clear, they
should always be made with the patient’s best interests
in mind.
REFERENCES
1. Nursing: Scope and Standards of Practice. 3rd ed. Silver
Spring, MD: American Nurses Association; 2015.
2. AORN’s Perioperative Explications for the ANA Code of Eth-
ics for Nurses With Interpretive Statements. Denver, CO:
AORN, Inc; 2017. https://aorn.org/guide lines/ clini cal-resou
rces/code-of-ethics. Accessed May 24, 2022.
3. DeKeyser Ganz F, Berkovitz K. Surgical nurses’ perceptions
of ethical dilemmas, moral distress and quality of care. J Adv
Nurs. 2012;68(7):1516- 1525.
4. MacAskill W, Bykvist K, Ord T. Moral Uncertainty. Oxford,
UK: Oxford University Press; 2020.
5. Brink H. The science of nursing: current issues and dilem-
mas. Curationis. 1992;15(2):12- 18.
6. Stokowski LA. The 4- generation gap in nursing. Medscape.
http://www.medsc ape.com/viewa rticl e/781752_2. Published
April 11, 2013. Accessed April 25, 2022.
7. Diller JV. Cultural Diversity: A Primer for the Human Services.
5th ed. Stamford, CT: Cengage Learning; 2015.
Vangie Dennis, MSN, RN, CNOR, CMLSO, is the AORN
President and an assistant vice president of Perioperative
Services, AnMed Health, Anderson, SC. Ms Dennis has no
declared affiliation that could be perceived as posing a poten-
tial conflict of interest in the publication of this article.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
J Clin Nurs. 2021;30:3385–3397. wileyonlinelibrary.com/journal/jocn | 3385© 2021 John Wiley & Sons Ltd
Received: 12 February 2021 | Revised: 22 April 2021 | Accepted: 1 May 2021
DOI: 10.1111/jocn.15861
R E V I E W
Nurse bias and nursing care disparities related to patient
characteristics: A scoping review of the quantitative and
qualitative evidence
Patricia S. Groves PhD RN, Assistant Professor1 |
Jacinda L. Bunch PhD RN, Assistant Professor1 |
Janice A. Sabin PhD MSW, Research Associate Professor2
1University of Iowa College of Nursing,
Iowa City, IA, USA
2School of Medicine, University of
Washington, Seattle, WA, USA
Correspondence
Patricia S. Groves, University of Iowa
College of Nursing, 50 Newton Rd, Iowa
City, IA, 52242 – 1121, USA.
Email: [email protected]
Abstract
Introduction: Investigations of healthcare workers’ implicit attitudes about patient char-
acteristics and differences in delivery of healthcare due to bias are increasingly common.
However, there is a gap in our understanding of nurse- specific bias and care disparities.
Aims: To identify (a) the types of available evidence, (b) key factors and relationships
identified in the evidence and (c) knowledge gaps related to nurse bias (nurse atti-
tudes or beliefs towards a patient characteristic) and nursing care disparities (health-
care disparities related specifically to nursing care).
Methods: Authors completed a scoping review using the Joanne Briggs Institute
method and PRISMA- SCR checklist. Five databases were searched. After screening,
215 research reports were included and examined. Data were extracted from research
reports and assessed for thematic patterns and trends across multiple characteristics.
Results: Nurse bias and/or care disparity investigations have become increasingly
common over the 38- year span of included reports. Multiple patient characteristics
have been investigated, with the most common being race and/or ethnicity, gender
and age. Twenty- nine of 215 studies identified a potential relationship between nurse
bias regarding a characteristic and nursing care of individuals with that characteristic.
Of these studies, 27 suggested the bias was associated with a negative disparate im-
pact on nursing care. Only 12 reports included evaluating an intervention designed to
reduce nurse bias or nursing care- related healthcare disparities.
Conclusions: Despite increasing research focus on individual bias and disparities in
healthcare, the accumulated knowledge regarding nurses has not significantly advanced
past a descriptive, exploratory level. Nor has there been a consistent focus on the role of
nurses, who represent the largest component of the professional healthcare workforce.
Relevance to clinical practice: National and international codes of ethics for nurses
require provision of care according to individual, unique patient need, disregarding
bias and incorporating patient characteristics into their plan of care.
K E Y W O R D S
healthcare disparities, implicit bias, nurse attitudes, nurses, patient characteristics, review
3386 | GROVES Et al.
1 | INTRODUC TION
In June of 2020, tragic events, including the disproportionate
COVID- 19 deaths among Black, Indigenous, and People of Color
(BIPOC) and racist violence towards Black Americans and others,
have served to bring long- standing issues of racism and other types
of bias to international attention (Horowitz et al., 2020; Pappas,
2020). Protests for social justice and equity continue to grow around
the world. Healthcare is not immune to problems such as systemic
racism and individual bias towards healthcare recipients based upon
social characteristics (Artiga et al., 2020). The IOM report Unequal
treatment: Confronting racial and ethnic disparities in health care in
2003 brought the issue of healthcare disparities to global attention
(Institute of Medicine, 2003). In fact, there is an increasingly large
body of research that examines individual provider’s attitudes to-
wards patient characteristics and differences in the quality of care
those persons receive; this research examines healthcare disparities
as well as provider bias.
Healthcare disparities refer to differences among groups “in
health insurance coverage, access to and use of care, and quality of
care… that cannot be explained by variations in healthcare needs,
patient preferences, or treatment recommendations” (Artiga et al.,
2020). For example, differences in quality- of- pain treatment associ-
ated with race or ethnicity would be a healthcare disparity. Note this
differs from a health disparity, which indicate difference in health
states or outcomes— “a higher burden of illness, injury, disability,
or mortality experienced by one group relative to another” (Artiga
et al., 2020). In this review, we are particularly interested in nurs-
ing care disparities, which we define as healthcare disparities related
specifically to nursing care.
Disparities in quality measures have been noted by patient
race and ethnicity, socioeconomic status (SES), age, sexual orienta-
tion and gender (Agency for Healthcare Research & Quality, 2020;
CMS Office of Minority Health & RAND Corporation, 2017; Kates
et al., 2018; U.S. Department of Health & Human Services Office
of Minority Health, 2011). Healthcare disparities have sometimes
been used in conjunction or interchangeably with discrimination, or
“differences in care that result from biases, prejudices, stereotyp-
ing, and uncertainty in clinical communication and decision- making”
(Institute of Medicine, 2003, p. 4). In response to these trends in
quality measure disparities, Kilbourne and colleagues have created a
useful three- phase framework for advancing disparity research, be-
ginning with detection and ending with interventions aimed and re-
ducing and eliminating health and healthcare disparities (Kilbourne
et al., 2006).
Implicit bias is a contributing factor to healthcare disparities.
Implicit bias refers to attitudes and beliefs about patient charac-
teristics that exist outside of conscious awareness, influencing be-
haviour without acknowledgement, control or volition (Hall et al.,
2015; Ranganath & Nosek, 2007). Implicit bias is more readily ac-
tivated under conditions of high cognitive load such as fatigue,
high workload or distraction, and time pressure (Byrne & Tanesini,
2015; Greenwald & Banaji, 1995; Hall et al., 2015), which are
common conditions for direct- care nurses (Agency for Healthcare
Research & Quality, 2019; Teng et al., 2010). Explicit bias, by con-
trast, results from conscious thoughts and beliefs that individu-
als deliberately think about and report (Hall et al., 2015). Related
broad terms seen in the literature include prejudice, stereotyping
and stigma, while terms specific to characteristics include those
such as racism, homophobia and sexism. Because terminology
varies over time, and only recently has bias been categorised as
implicit versus explicit, we will use the term bias to encompass any
attitude or belief towards a patient characteristic, whether it be
explicit or implicit.
Bias towards patient characteristics is as real and as prevalent in
healthcare providers as it is in the general population. Early studies
and more recent systematic reviews revealed healthcare profession-
als have low- to- moderate implicit bias scores in relation to race and
ethnicity, similar to the general population (FitzGerald & Hurst, 2017;
Hall et al., 2015; Sabin et al., 2008, 2009), as measured by methods
such as the Implicit Association Test (Greenwald et al., 1998). Implicit
biases can impact quality of care for already vulnerable individu-
als, such as those belonging to health disparity populations (Hart
& Mareno, 2014). Implicit bias is thought to be particularly salient
during one- on- one interactions with healthcare recipients, lessening
communication quality and effectiveness in subtle ways, contribut-
ing to healthcare disparities (Cooper et al., 2012; Hall et al., 2015;
Sabin & Greenwald, 2012; Wyatt et al., 2016).
Despite the vast and varied amount of interaction that occurs
between nurses and recipients of care, there is a critical gap in our
understanding of bias in nurses and healthcare disparities related to
the delivery of nursing care. Understanding the types of bias held by
nurses (nurse bias) and the potential impacts on healthcare dispar-
ities will enable pursuit of strategies to mitigate bias and enhance
nursing education. Understanding the science related to nurse bias
and nursing care disparities is also critical to ethical nursing prac-
tice as indicated by nursing codes of ethics (e.g. American Nurses
Association [ANA], 2015; International Council of Nurses [ICN],
What does this paper contribute to the wider
global clinical community?
• This scoping review presents the international state of
the science regarding nurse attitudes or beliefs towards
a patient characteristic (nurse bias) and healthcare dis-
parities related specifically to nursing care (nursing care
disparity).
• The findings indicate that individual nurse bias and nurs-
ing care disparities in healthcare are not uncommon and
are reported in multiple countries and clinical settings.
• The findings support the need to advance accumulated
knowledge around nurse bias and nursing care dispari-
ties past a descriptive, exploratory level; a research
agenda is offered.
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2012; Nursing & Midwifery Council [NMC], 2018). In this paper, our
purpose is to comprehensively review published research related to
nurse bias and nursing care disparities.
2 | AIMS
The aims of this systematic scoping review were to identify (a) the
types of available evidence, (b) key factors and relationships identi-
fied in the evidence and (c) knowledge gaps related to nurse bias
(nurse attitudes or beliefs towards a patient characteristic) and
nursing care disparities (healthcare disparities related specifically to
nursing care). Specifically, our questions were as follows:
• What forms of nurse bias and nursing care disparities have been
investigated?
• What potential relationships between nurse bias and nursing care
have been identified or examined?
• What strategies have been implemented and evaluated to address
issues related to nurse bias and nursing care disparities?
3 | METHODS
3.1 | Design
Because of the potential breadth and diversity of research related to
bias and healthcare disparities in nursing care, we chose to complete
a scoping review. The general purposes of scoping reviews in a given
field, according to Munn are to: identify types of evidence available,
clarify key concepts, examine the research methods, identify key
related factors or characteristics, identify knowledge gaps, analyse
knowledge gaps and provide the foundation for a traditional system-
atic review (Munn et al., 2018). Thus, the scoping review approach
was very well- suited to our review questions. We followed the
Preferred Reporting Items for Systematic reviews and Meta- Analyses
extension for Scoping Reviews (PRISMA- ScR) Checklist (File S1).
We used the Joanne Briggs Institute method (Peters et al., 2015)
in order to provide systematic rigour to our scoping review, which
included, in addition to the aim and review questions above, the el-
ements of concept, context and inclusion criteria. The scoping re-
view protocol was developed and approved by the review team prior
to searching the literature. The principal focus that delineates the
scope and breadth of the review, or key concept, was the scope and
impact of nurse bias and nursing care disparities. The context was
identified as wherever nursing care is delivered by registered nurses.
Therefore, we identified three types of inclusion criteria: types of
participants, the phenomena/interventions of interest and types of
studies. Types of outcomes were unknown so were not limited in
any way. Study participants could either be (1) registered nurses (or
international equivalent) in any setting who deliver care, excluding
providers such as nurse practitioners or midwives or (2) recipients
of nursing care (excluding from nursing providers) providing data
regarding care received from nurses. The phenomena of interest
were any implicit or explicit bias and/or any type of healthcare
disparity associated with nursing care, including interventions ad-
dressing these phenomena, as defined above. All quantitative and
qualitative research design reports were included, excluding articles
that did not report primary research. Because it was not relevant
to the review questions or required for scoping reviews, a quality
assessment of the research reports was not conducted (Peters et al.,
2015; Tricco et al., 2018). Screening questions were developed to
reflect these inclusion/exclusion criteria.
3.2 | Search strategy
In consultation with a health sciences librarian experienced in sys-
tematic review searching, search strategies were devised for the
following databases: CINAHL (EBSCO), PubMed, Business Source
Complete (EBSCO), Scopus (Elsevier) and Dissertations and Theses
(ProQuest). Identifying search terms began in December 2018
and were finalised in late February 2019. Developing the database
searches required extensive review of relevant records for term
gathering, as well as extensive testing and revision of strategies. A
sensitive approach, comprised of both subject terms and keyword
terms, was used for all the platforms with subject searching capabil-
ity. The English language filter was applied, as translation of stud-
ies was not an option. Although pre- set search filters were mostly
avoided, the large yield required some narrowing, including a cus-
tomised filter for identifying studies. The full search strategy for
CINAHL that follows (conducted 14 February 2019) was adapted for
use in all the mentioned databases. All search strategies are available
from the corresponding author upon one’s request.
#1. MH “Healthcare Disparities” OR MH “Race Factors” OR MH
“Sex Factors” OR MH “Prejudice” OR MH “Skin Pigmentation”
OR MH “Stereotyping” OR MH “Stigma” OR MH “Individuality”
OR MH “Racism” OR MH “Homophobia” OR MM “Cultural Bias”
OR MM “Ethnic Groups+” OR TI (disparit* OR bias OR racism
OR racial OR “race factor*” OR prejudice OR stereotyp*)
#2. MH “Nurses+” OR MH “Nurse Attitudes” OR MH “Nursing
Interventions” OR MH “Nursing Manpower+” OR MH “Nursing
Care+” TI (nurs* OR RN* OR BSN OR ADN) OR AB (nurs* OR RN*
OR BSN OR ADN) OR MW nurs*
#3. MM “Patient Safety+” OR MH “Quality of Health Care+” OR MM
“Patient Centered Care” OR MH “Health Services Accessibility+”
OR MM “Accidental Falls” OR MH “Patient Safety+” OR MM
“Decision Making+” OR MM “Pain+” OR MH “Patient Care+” OR
MM “Outcomes (Health Care)+” OR TI (“patient satisfaction” OR
“medical error*” OR “treatment error*” OR equit* OR “nursing
care” OR quality N3 care OR access* N3 care OR “pain treat-
ment” OR “missed care”) OR AB (“patient satisfaction” OR “medi-
cal error*” OR “treatment error*” OR equit* OR “nursing care”
OR quality N3 care OR access* N3 care OR “pain treatment” OR
“missed care”)
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#4. MH “Study Design+” OR TI (study OR studies OR trial* OR quan-
titative OR qualitative OR empirical OR intervention* OR experi-
ment*) OR AB (study OR studies OR trial* OR quantitative OR
qualitative OR empirical OR intervention* OR experiment*)
#5. MH “Education, Nursing+” OR MH “Students, Nursing+” OR MH
“Caregivers+” OR MH “Nurse Practitioners+” OR MH “Advanced
Practice Nursing+”
(#1 AND #2 AND #3 AND #4) NOT #5, limited to English
language = 3872.
3.3 | Study selection process
Duplicates were removed from the combined searches and the titles
and abstracts were copied into an Excel spreadsheet. One report
identified during the process of search development but not cap-
tured via the search strategies was added. Two reviewers screened
the remaining 4,635 titles and abstracts for possible inclusion. The
reviewers completed two test runs of over 150 abstracts to refine
the screening criteria wording and to compare and discuss differ-
ing screening decisions. Once the reviewers felt confident that the
screening criteria were useful and usable and that the criteria were
being used similarly by both reviewers, all titles and abstracts were
screened by each reviewer. Reviewers screened each item indepen-
dently, selecting either (a) “maybe” or (b) “no” with an exclusion rea-
son. Screening decisions of the two reviewers were then compared
within a single Excel spreadsheet, and each disagreement was dis-
cussed and a consensus decision made. Final screening criteria for
exclusion included:
• Not in English
• Not a research report
• Does not involve (1) licensed RNs as participants OR (2) licensed
RN care as part of findings (i.e. we excluded nursing students and
APRNs)
• Does not include either (1) implicit/explicit bias in nurses towards
a patient characteristic OR (2) healthcare disparities related to
nursing care
• Study duplicate
The two reviewers then each independently screened each of
the remaining 371 items with “maybe” decisions, this time using
the full text. An Excel spreadsheet was again used to compare
F I G U R E 1 PRISMA diagram:
Identification and selection of studies
[Colour figure can be viewed at
wileyonlinelibrary.com]
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screening decisions of (a) “yes” or (b) “no” with an exclusion reason.
Disagreements were again resolved by consensus, resulting in 215
included articles for the review (see Table S1 and Appendix S1 for
all included reports). The Preferred Reporting Items for Systematic
Reviews and Meta- Analyses (PRISMA) diagram illustrating the
screening process can be found in Figure 1.
3.4 | Data charting and analysis
Data were extracted from the research reports using a charting
tool. The charting tool was initially created prior to article screening,
based on the review questions. Following screening, the two review-
ers revised the tool based on characteristics of the articles they had
observed during full- text screening. With the assistance of a data
manager, the charting tool was built in REDCap, a secure online data
collection tool (University of Iowa, 2018). The two reviewers worked
together to chart the first five included research reports, using the
REDCap charting tool. Based on discussions during data extraction,
the charting tool was revised for clarity and to offer more categori-
cal selections for some questions (e.g. geographical location of study).
Fields included items describing the publication (e.g. author, publica-
tion year), the study (e.g. purpose, setting, sample, design), findings
(e.g. outcome measurement, results) and review- specific elements (e.g.
area of bias/disparity, intervention). The two reviewers then charted
the same next ten research reports independently and then compared
and discussed their results, and revised the charting tool again (final
charting tool can be seen in the Figure S1). The remaining research
reports were then divided between the reviewers for charting.
When charting was completed, the data were exported from
REDCap into an Excel worksheet, where it was checked for miss-
ing values and other errors. Once these were resolved, free- text
fields such as the setting and the type of bias or healthcare dispar-
ity were examined and those items were further categorised for
consistency. For example, setting entries such as “primary care”
and “clinic” were categorised as “outpatient,” and bias entries such
as “homelessness,” “unemployed” and “class” were categorised as
“socioeconomic.” At this point, the research reports could be sorted
and analysed according to multiple characteristics. Using the Excel
spreadsheet functions, multiple data visuals were created to use in
conjunction with the tabular data to assess for thematic patterns
and trends.
4 | RESULTS
4.1 | Studies included
Ultimately, 215 studies were included and used to address our re-
view questions. Publication dates ranged from 1981– 2018, with
one report captured from the beginning of 2019 when we ended
literature searches (see Table S1 and Appendix S1 for all included
reports). A plurality of studies took place in the USA (n = 100; 47%)
followed by Europe (n = 49; 23%), with the majority in a hospital set-
ting (n = 123; 57%). Most studies used a quantitative design (n = 127;
59%) and examined some type of nurse bias (n = 202; 94%), with
considerably fewer examining some type of healthcare disparity re-
sulting from nursing care (instead of or in addition to bias; n = 36;
17%). Twenty- three categories of bias and fifteen categories of nurs-
ing care- related disparities were identified in the included reports,
as discussed below. Of the 215 studies, 166 studies (77%) obtained
data relevant to the review from clinicians including nurses, 38 stud-
ies (18%) obtained relevant data from healthcare recipients, medi-
cal records or community members, and 11 studies (5%) obtained
data from both nurses and healthcare recipients, medical records or
community members. Of the 215 included reports, 64 (30%) did not
report results separately as they related to nurses and instead re-
ported results as a group for multiple clinicians that included nurses.
F I G U R E 2 Publication dates of included studies [Colour figure can be viewed at wileyonlinelibrary.com]
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4.2 | Narrative description
What forms of nurse bias and nursing care disparities have been
investigated? Over nearly 40 years, researchers have investigated
the presence of nurse bias regarding many patient characteristics
as well as the presence of healthcare disparities as a result of dis-
parate (possibly biased) nursing care. These studies have become
increasingly frequent over time, as can be seen in Figure 2. Table 1
shows the wide variety of categorised patient characteristics that
were investigated as a potential trigger for nurse bias or related
to a healthcare disparity resulting from nursing care. Several cat-
egories of nurse bias targeting patient characteristics were un-
common, seen in five or less reports over the 38 included years:
personality (e.g. emotionality of caregivers, niceness of patients
in pain), religion, disability, immigrant status, victim of domestic
violence, physical attractiveness, do not resuscitate status, fam-
ily structure, health literacy or education and accusation of child
abuse or neglect. Five categories of nurse bias were more com-
mon, represented in ten to nineteen reports: gender identity or
sexual orientation, medical diagnosis (e.g. Hansen’s disease, tu-
berculosis), socioeconomic (e.g. homelessness, impoverishment),
overweight and obesity, and substance misuse.
The most common targets for bias were race and/or ethnicity,
present in 61 of the 215 studies, gender (n = 43) and age (n = 41).
The fourth and fifth most common patient characteristics were the
stigmatising conditions of a diagnosis of human immunodeficiency
virus (HIV) or acquired immunodeficiency syndrome (AIDS) and a
psychiatric diagnosis or behaviour, respectively. The trend of these
“top five” in publications over time can be seen in Figure S2. Nurse
bias categories for each article are indicated in the Table S1.
The nursing care- related healthcare disparities explored were
nearly as diverse, with fifteen categories identified. The most com-
monly investigated areas of nursing care disparities were seen in nine
reports each: caring and respectful communication and behaviour,
interaction time and pain management. Disparities in general quality
of care provided by nurses were investigated in five reports. Less
commonly investigated areas of nursing care disparities were seen
in two reports each: clinical interventions, documentation of key
assessments, patient- centred care and triage management. Finally,
each of the following areas was investigated in one report each: de-
pression screening, diagnosis, dignity management, documentation
of symptom distress, fertility counselling, patient education and vio-
lent incident management. Nursing care disparity categories by arti-
cle are indicated in the Table S1. Frequency of nursing care disparity
categories is also indicated in Table 1.
What potential relationships between nurse bias and nursing
care have been identified or examined? We identified research re-
ports in the final sample that collected data on both (1) nurse bias
(or attitudes) regarding one or more patient characteristics, and (2)
quality of nursing care related to that bias. These data were broadly
characterised. Nurse bias data could have been collected in a study-
specific survey instrument, an established instrument or through a
narrative qualitative response to a question. Quality of nursing care
could be measured via observation, medical record or administrative
data, nurse- reported intent for care, nurse self- report of actual care
or narrative qualitative response to a question.
Out of the 215 included reports, 29 (13%) examined or identified
a potential relationship between one or more nurse biases and nurs-
ing care provided to individuals with the characteristic(s) in question
(see Table 2). For example, in the western region of Ghana, Dodor
and Kelly (2010) found tuberculosis (TB) stigma was associated with
TA B L E 1 Frequency of nurse bias and nursing care disparity
categories
Nurse bias categories Frequency
Race/ethnicity 61
Gender 43
Age (older, younger or unspecified) 41
Diagnosis of human immunodeficiency virus or
acquired immunodeficiency syndrome (HIV/AIDS)
34
Psychiatric diagnosis or behaviour 24
Gender identity or sexual orientation 19
Medical diagnosis 18
Socioeconomic 17
Overweight and obesity 11
Substance misuse 10
Personality 5
Religion 4
Disability 3
Immigrant status 3
Victim of domestic violence 2
Physical attractiveness 2
Do not resuscitate status 1
Family structure 1
Health literacy or education 1
Accusation of child abuse or neglect 1
Nursing care disparity categories Frequency
Caring and respectful communication and behaviour 9
Interaction time 9
Pain management 9
General quality of care 5
Clinical interventions 2
Documentation of key assessment 2
Patient- centred care 2
Triage management 2
Depression Screening 1
Diagnosis 1
Dignity management 1
Documentation of symptom distress 1
Fertility counselling 1
Patient education 1
Violent incident management 1
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behaviours such as maltreatment and shunning of patients with TB.
Of these 29 reports, 22 offered results specific to nurses alone, and
all collected data only from clinicians. Approximately half of the re-
ports (n = 15) were from studies based in the USA. The majority of
nursing care settings were in the hospital (n = 17), though the spe-
cific hospital setting varied. Most studies used quantitative designs
(n = 17), with eight studies using qualitative designs and four studies
using mixed methods. Only one of the studies, a laboratory experi-
ment, employed an intervention (an empathy- inducing, perspective-
taking simulation; Drwecki et al., 2011).
The 29 studies examining a relationship between a nurse bias
and a nursing care disparity addressed 13 categories of bias or nurs-
ing care disparity, with the most frequent being bias towards persons
living with human immunodeficiency virus or acquired immunodefi-
ciency syndrome (n = 7) or another medical diagnosis (n = 5). These
studies were heterogeneous in terms of not only design and nurse
bias target of interest, but also care setting (e.g. hospital, long- term
care, community), methodology (e.g. cross- sectional descriptive,
phenomenology, factorial vignette), outcomes measured for indica-
tions of disparity (e.g. intention to provide culturally congruent care,
planned interventions to promote mothering role, pain management
decisions, clinical decision- making) and instrumentation (e.g. semi-
structured interviews, new or established scales and questionnaires,
observations). However, with two exceptions (Early, 1998; Haider
et al., 2015), study results suggested an association between a nurse
bias and a negative impact on nursing care, resulting in disparity.
What strategies have been implemented and evaluated in care
settings to address issues related to nurse bias and nursing care
disparities? Of the 215 reports included in the review, 12 (6%) re-
ported evaluation of an intervention to address issues related to bias
and/or nursing care disparities. For example, Gallop and colleagues
(1992) used educational videos, medical experts, group discussion
and the video or presence of a person living with AIDS in an attempt
to impact AIDS- related knowledge, attitude, concerns and empathic
behaviours. (See Table 3 for full list of reports with intervention
evaluations; note that additional interventions and outcomes within
the studies unrelated to the review question are not included). Of
these 12 reports, 6 provided results specific to nurses alone, and all
collected data from clinicians alone. Slightly more than half of the
reports (n = 7) were from studies based in the USA. Most nursing
care settings were again in the hospital (n = 8). Two studies used
mixed- methods designs, one study used a qualitative design, and
the majority used quantitative designs (n = 10). Once again, these
studies are quite heterogeneous, with eight categories of bias/dis-
parities addressed. A plurality of studies addressed the issue of bias
towards or healthcare disparities of persons living with HIV/AIDS
(n = 5). Interventions and intervention bundles varied widely, ranging
from wearing an obesity suit to programmes developed on an inter-
national scale (see Table 3), though most used some type of knowl-
edge or skills- based training (n = 8). Four studies used contact with
the target patient population as part of the intervention.
Of the 12 studies reporting an intervention to address issues re-
lated to bias and/or nursing care disparities, eight studies reported
some degree of success with the intervention(s), with two multi-
programme interventions reporting mixed success. Success for
the purposes of this review was designed as a measurable, but not
necessarily statistically significant, improvement in the targeted
outcome. However, due to the wide variation in setting, samples,
interventions, implementation, time frames, instrumentation and
outcomes, it is not possible to draw conclusions about the relative
success of interventions.
5 | DISCUSSION
Investigations of nurse bias or nursing care disparities have become
increasingly common. In the 38 complete years spanning the located
reports, 20 reports were published in the first 13 years (1981– 1993),
58 reports in the second 13 years (1994– 2006) and 136 reports in
the final 12 years (2007– 2018). A wide variety of patient character-
istics has been investigated as they relate to nurse bias or nursing
care disparities. The most common of these has been race and/or
ethnicity, gender and age, which together accounted for nearly half
the incidences of bias/disparity categories examined in the included
research reports. It is particularly interesting that 54 reports were
published prior to the IOM report Unequal treatment: Confronting ra-
cial and ethnic disparities in health care in 2003, which brought global
attention to healthcare disparities (Institute of Medicine, 2003).
Relatively, few investigators examined or identified a potential
relationship between nurse bias (explicit or implicit) regarding a par-
ticular social characteristic and nursing care of individuals with that
characteristic. Only 29 studies reported data for both (1) nurse bias
regarding one or more patient characteristics and (2) quality of nurs-
ing care related to that bias. Nearly half of this set of heterogeneous
studies were focused on persons living with HIV/AIDS or another
medical diagnosis. However, 27 of the 29 studies suggested an asso-
ciation between a nurse bias and a negative impact on nursing care
resulting in disparity, such as the relationship between race/ethnic-
ity bias and level of pain treatment (Drwecki et al., 2011).
Even fewer investigators reported evaluating an intervention de-
signed to reduce nurse bias or nursing care disparities; these were
published mainly within the past ten years. This was a quite varied
set of 12 studies, of which only six studies provided results specific
to nurses alone. This made it difficult to identify trends or common-
alities in the interventions. The studies located for this review drew
upon interventions from other fields, such as intergroup contact in-
terventions from psychology (personal interaction between group
members; Pettigrew & Tropp, 2006), but inconsistent use and re-
porting makes it difficult to draw conclusions about the success of
individual interventions.
5.1 | Implications
The first study to apply the nascent social psychology science of
implicit bias to healthcare for any health profession was reported
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onditions (https://onlinelibrary.w
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13652702, 2021, 23-24, D
ow
nloaded from
https://onlinelibrary.w
iley.com
/doi/10.1111/jocn.15861 by C
apella U
niversity, W
iley O
nline L
ibrary on [06/09/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
| 3393GROVES Et al.
by Green & colleagues in, 2007, who examined implicit bias regard-
ing race among physicians using case vignettes (Green et al., 2007).
Investigators have increasingly recognised that nurses are also prone
to the biases that impact other providers and the general popula-
tion (FitzGerald & Hurst, 2017; Hall et al., 2015; Maina et al., 2018).
This may be reflected in the upward trend of published studies over
time. The remarkable number of patient characteristics examined in
terms of nurse bias reflects the diverse populations for whom nurses
care. Likewise, nurses provide care within diverse settings and cul-
tures. The sheer number and variety of research reports located for
this scoping review preclude a systematic review of similar scope.
However, specifically nurse- focused integrative or systematic re-
views may be warranted for research reports of the most frequently
explored categories of patient characteristics, such as race and/or
ethnicity, gender, age, diagnosis of HIV or AIDS, or psychiatric diag-
nosis or behaviour. Though systematic reviews have already been
conducted in many of these areas, often nursing has not been a
focus (e.g. Dehon et al., 2017; Failla & Connelly, 2017; Hall et al.,
2015; Mather et al., 2014), though there have been recent excep-
tions (Rush et al., 2017).
What is less clear is the everyday practical impact of nurse bias
or the actual source of nursing care disparities. The field of implicit
bias in healthcare care is in its early stages of development, with
the vast majority of studies in this review still being descriptive, fo-
cusing either on identifying, examining and/or measuring a bias, or
identifying, examining and/or measuring a healthcare disparity re-
lated to nursing care. Kilbourne and colleagues (2006), who devel-
oped the previous referenced framework for research in health and
healthcare disparities, refer to these studies as being in phase one,
or “detection.” Most studies did not attempt to link a nurse bias to
an impact on the quality of nursing care. Studies of this type would
belong to phase two, or “understanding,” in the Kilbourne research
framework. The limited number of studies in this second research
phase makes it difficult to determine if nurses practice equitably
even when they are biased against or have negative attitudes about
a patient characteristic. Likewise, it is difficult to determine what
role nurse bias may play in nursing care disparities versus factors
such as health care policy, access to care, organisational characteris-
tics, inadequate education, cultural competence or clinical evidence.
It is difficult to intervene in the suggested nurse bias →nursing care
disparity →poorer patient outcome sequence (Institute of Medicine,
2003) when these relationships are poorly understood. Further de-
velopment of the theoretical model of nurse bias and healthcare dis-
parities is needed.
Finally, despite the breadth of nurse bias and nursing care dis-
parity research in the past 38 years, there is a lack of intervention
and implementation research. This is perhaps a natural conse-
quence of the limited research exploring the why and how of the
proposed relationship between bias and healthcare disparity (phase
two; Kilbourne et al., 2006). Kilbourne and colleagues (2006) refer
to the research phase including studies that involve development,
implementation and evaluation of interventions as phase three, or
“reduction or elimination” of health and healthcare disparities. These A
ut
ho
r(s
)
Ye
ar
St
ud
y
lo
ca
tio
n
Se
tt
in
g
Po
pu
la
tio
n
St
ud
y
de
si
gn
Bi
as
c
at
eg
or
y
N
ur
se
– o
nl
y
re
su
lts
Bi
as
im
pa
ct
o
n
nu
rs
in
g
ca
re
D
ia
s
de
S
ilv
a,
&
A
ra
új
o
Pa
z
20
17
So
ut
h
A
m
er
ic
a
O
ut
pa
tie
nt
C
lin
ic
ia
ns
Q
ua
lit
at
iv
e
M
ed
ic
al
d
ia
gn
os
is
Ye
s
Ye
s
Li
, e
t a
l.
20
17
A
si
a
O
ut
pa
tie
nt
C
lin
ic
ia
ns
Q
ua
nt
ita
tiv
e
Su
bs
ta
nc
e
m
is
us
e
Ye
s
Ye
s
O
rd
an
e
t a
l.
20
18
A
si
a
H
os
pi
ta
l—
m
at
er
ni
ty
C
lin
ic
ia
ns
M
ix
ed
m
et
ho
ds
Ps
yc
hi
at
ric
d
ia
gn
os
is
o
r b
eh
av
io
ur
Ye
s
Ye
s
Se
ym
ou
r e
t a
l.
20
18
U
S
H
os
pi
ta
l—
ge
ne
ra
l
C
lin
ic
ia
ns
M
ix
ed
m
et
ho
ds
O
ve
rw
ei
gh
t a
nd
o
be
si
ty
N
o
Ye
s
N
ot
e:
D
ia
gn
os
is
o
f h
um
an
im
m
un
od
ef
ic
ie
nc
y
vi
ru
s
or
a
cq
ui
re
d
im
m
un
od
ef
ic
ie
nc
y
sy
nd
ro
m
e
is
in
di
ca
te
d
by
th
e
ab
br
ev
ia
tio
n
H
IV
/A
ID
S
di
ag
no
si
s.
U
ni
te
d
St
at
es
is
in
di
ca
te
d
by
th
e
ab
br
ev
ia
tio
n
U
.S
.
TA
B
LE
2
(C
on
tin
ue
d)
13652702, 2021, 23-24, D
ow
nloaded from
https://onlinelibrary.w
iley.com
/doi/10.1111/jocn.15861 by C
apella U
niversity, W
iley O
nline L
ibrary on [06/09/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
3394 | GROVES Et al.
research topics are in the earliest stages of development, perhaps
also reflecting how implicit bias in healthcare is a relatively new spe-
cific field of study. Certainly, the ultimate aim of this body of re-
search should be to improve the care and outcomes of healthcare
recipients and the community.
In summary, it is promising that a wide range of potential nurse
biases and nursing care disparities have been investigated. However,
there is not a clear trend towards locating relationships among these
factors and testing interventions to improve care and patient out-
comes. As this field of research matures, not only is it important to
move the field towards intervention, but it is important to collect
outcome data from the healthcare recipients and community them-
selves, not only the clinicians as seen in this review (Kilbourne et al.,
2006).
5.2 | Strengths and limitations
Reducing the influence of bias on healthcare and outcomes and elim-
inating healthcare disparities is a priority for many organisations, in-
cluding the U.S. National Institute on Minority Health and Health
Disparities (2020), U.S. Department of Health and Human Services
(2020), Agency for Healthcare Research and Quality (2020), Institute
for Healthcare Improvement (2020), Centers for Medicare and
Medicaid Services (2020), ANA (2020) and the American Hospital
Association (2020). This scoping review thus addresses a critical
issue in nursing, health and society. The review was strengthened by
a systematic and transparent review process. We have presented a
broad overview of published research related to bias and healthcare
disparities in nursing care, providing the reader with a starting guide
to the literature and identifying both progress and gaps in the field.
Despite the comprehensive search strategy and broad defini-
tions of terms, it is still possible that eligible studies were missed.
Indeed, the use of multiple bias- and disparity- related terms such
as healthcare disparities, race factors, sex factors, prejudice, skin
pigmentation, stereotyping, stigma, individuality, racism, homopho-
bia, cultural bias and ethnic groups made it difficult at times to de-
termine eligibility. Including only studies published in English may
have resulted in omitting international studies. Reports unavailable
in full text were also not incorporated into the review. We did not
examine reference lists due to the high number of publications al-
ready captured by the electronic search methods. The nature and
size of a scoping review also preclude providing details about each
included study while making synthesis challenging. While the recent
TA B L E 3 Research reports evaluating interventions to address issues related to bias and healthcare disparities in nursing care
Author(s) Year Study location Setting Population Study design
Nurse- only
results Intervention type Bias category Outcome target
Outcome
improvement
Gallop et al. 1992 Canada Hospital Clinicians Quantitative No Educational video, question period with an AIDS
medical expert, 1- hr group discussion, video or
presence of person living with AIDS
HIV/AIDS diagnosis AIDS- related knowledge, attitude, concerns
and empathic behaviours
Yes
Kemppainen et al. 1996 U.S. Hospital Clinicians Quantitative Yes Basic HIV training, peer group discussions,
individual patient contact training
HIV/AIDS diagnosis Prejudice and attitudes towards caring for
persons with AIDS
No
Uys et al. 2009 Africa National Clinicians Quantitative Yes 5 unique programmes all including information,
skill building and contact interventions
HIV/AIDS diagnosis Nurse HIV/AIDS stigmatising behaviours No
Drwecki et al. 2011 U.S. Simulation
Laboratory
Clinicians Quantitative Yes Simulated perspective- taking Race/ethnicity
Socioeconomic
Pain treatment bias Yes
Falker & Sledge 2011 U.S. Hospital Clinicians Quantitative No Educational self- learning module Overweight and
obesity
Weight stigmatisation Yes
Blair Irvine et al. 2012 U.S. Long- term care Clinicians Quantitative No Internet video- based behavioural skills and
knowledge training
Psychiatric diagnosis or
behaviour
Attitudes and stigmatisation Yes
Lohiniva et al. 2016 Africa Hospital Clinicians Quantitative Yes Interactive training modules (discussion, practice,
contact intervention)
HIV/AIDS diagnosis HIV stigma Yes
Edwards et al. 2016 Africa, Caribbean Hospital Clinicians Quantitative Yes 4 multi- stakeholder leadership hub programmes HIV/AIDS diagnosis
Socioeconomic
Nurse HIV/AIDS stigmatising behaviours Mixed
Pelts & Galambos 2017 U.S. Long- term care Clinicians Mixed methods No Intergroup contact via storytelling video Gender identity or
sexual orientation
Attitudes related to serving lesbian and gay
older adults
Yes
Traister 2018 U.S. Hospital Clinicians Mixed methods Yes 1- hr unspecified educational intervention Gender identity or
sexual orientation
Nursing attitudes about LQBTQ community Yes
Weech- Maldonado
et al.
2018 U.S. Hospital Clinicians Quantitative No 2 hospital programmes including infrastructure
development, executive coaching, training and
individual- level action plans
Race/ethnicity
Age
Gender
Diversity attitudes, implicit bias, and racial/
ethnic identity status
Mixed
Hales et al. 2018 New Zealand Hospital Clinicians Qualitative No Simulated obesity suit Overweight and
obesity
Attitudes towards people with extreme obesity Yes
Note: Diagnosis of human immunodeficiency virus or acquired immunodeficiency syndrome is indicated by the abbreviation HIV/AIDS diagnosis.
United States is indicated by the abbreviation U.S.
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| 3395GROVES Et al.
coronavirus pandemic has brought the problem of health and health-
care disparities to international attention (Pappas, 2020) and Black
Lives Matter protests have done the same for societal racism and
bias, these current events are not included in our review because
they are not yet reflected in a substantial body of literature. Finally,
we did not appraise the quality of research due to the heterogeneity
of the methods, which is considered acceptable for scoping reviews
(Arksey & O’Malley, 2005; Munn et al., 2018; Peters et al., 2015).
6 | CONCLUSIONS
Individual provider bias and disparities in healthcare are not uncom-
mon. Despite an increasing research focus in this field of research,
the accumulated knowledge has not significantly advanced past a
descriptive, exploratory level. Nor has there been a consistent focus
on the role of nurses, who represent the largest component of the
professional healthcare workforce. This review also reveals the
wide variety of patient characteristics examined in relation to nurse
bias and nursing care disparities. This heterogeneous, primarily de-
scriptive work not only provides a number of avenues for further
investigation but reveals limited lines of research progressing from
detection to understanding and ultimately reduction or elimination
of disparities. We thus recommend the following research agenda:
(1) explore the content and frequency of implicit and explicit bias
among nurses, (2) examine implicit and explicit bias among nurses,
specifically in the context of the 2020 coronavirus pandemic and
societal racism and bias, (3) identify mechanisms by which these bi-
ases may or may not impact quality of nursing care (nursing care
disparities), (4) identify areas where implicit and explicit biases im-
pact health outcomes (health disparities) and (5) further develop and
evaluate educational interventions and curriculum to mitigate the
impact of bias among nurses on patient care and health.
7 | RELE VANCE TO CLINIC AL PR AC TICE
The ICN’s international Code of Ethics for Nurses argues “nursing care
is respectful of and unrestricted by considerations of age, colour,
creed, culture, disability or illness, gender, sexual orientation, nation-
ality, politics, race, or social status” (2012, p. 1). The first provision
of the US’s ANA Code of Ethics for Nurses concurs, instructing nurse
to provide care according to individual, unique patient need, disre-
garding bias and incorporating patient characteristics into their plan
TA B L E 3 Research reports evaluating interventions to address issues related to bias and healthcare disparities in nursing care
Author(s) Year Study location Setting Population Study design
Nurse- only
results Intervention type Bias category Outcome target
Outcome
improvement
Gallop et al. 1992 Canada Hospital Clinicians Quantitative No Educational video, question period with an AIDS
medical expert, 1- hr group discussion, video or
presence of person living with AIDS
HIV/AIDS diagnosis AIDS- related knowledge, attitude, concerns
and empathic behaviours
Yes
Kemppainen et al. 1996 U.S. Hospital Clinicians Quantitative Yes Basic HIV training, peer group discussions,
individual patient contact training
HIV/AIDS diagnosis Prejudice and attitudes towards caring for
persons with AIDS
No
Uys et al. 2009 Africa National Clinicians Quantitative Yes 5 unique programmes all including information,
skill building and contact interventions
HIV/AIDS diagnosis Nurse HIV/AIDS stigmatising behaviours No
Drwecki et al. 2011 U.S. Simulation
Laboratory
Clinicians Quantitative Yes Simulated perspective- taking Race/ethnicity
Socioeconomic
Pain treatment bias Yes
Falker & Sledge 2011 U.S. Hospital Clinicians Quantitative No Educational self- learning module Overweight and
obesity
Weight stigmatisation Yes
Blair Irvine et al. 2012 U.S. Long- term care Clinicians Quantitative No Internet video- based behavioural skills and
knowledge training
Psychiatric diagnosis or
behaviour
Attitudes and stigmatisation Yes
Lohiniva et al. 2016 Africa Hospital Clinicians Quantitative Yes Interactive training modules (discussion, practice,
contact intervention)
HIV/AIDS diagnosis HIV stigma Yes
Edwards et al. 2016 Africa, Caribbean Hospital Clinicians Quantitative Yes 4 multi- stakeholder leadership hub programmes HIV/AIDS diagnosis
Socioeconomic
Nurse HIV/AIDS stigmatising behaviours Mixed
Pelts & Galambos 2017 U.S. Long- term care Clinicians Mixed methods No Intergroup contact via storytelling video Gender identity or
sexual orientation
Attitudes related to serving lesbian and gay
older adults
Yes
Traister 2018 U.S. Hospital Clinicians Mixed methods Yes 1- hr unspecified educational intervention Gender identity or
sexual orientation
Nursing attitudes about LQBTQ community Yes
Weech- Maldonado
et al.
2018 U.S. Hospital Clinicians Quantitative No 2 hospital programmes including infrastructure
development, executive coaching, training and
individual- level action plans
Race/ethnicity
Age
Gender
Diversity attitudes, implicit bias, and racial/
ethnic identity status
Mixed
Hales et al. 2018 New Zealand Hospital Clinicians Qualitative No Simulated obesity suit Overweight and
obesity
Attitudes towards people with extreme obesity Yes
Note: Diagnosis of human immunodeficiency virus or acquired immunodeficiency syndrome is indicated by the abbreviation HIV/AIDS diagnosis.
United States is indicated by the abbreviation U.S.
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3396 | GROVES Et al.
of care (ANA, 2015). The professional standards of the NMC in the
UK supports these ideas as well, charging nurses to prioritise peo-
ple and “avoid making assumptions and recognise diversity and indi-
vidual choice” (2018, p. 6). Thus, understanding the science related
to nurse bias and nursing care disparities is critical to ethical nurs-
ing practice. Due to the inequitable impact of the coronavirus pan-
demic and the widespread global embrace of the Black Lives Matter
movement, society, including the research enterprise, may be ready
to quickly move forward towards healthcare equity. Deliberative ef-
forts to advance the study of nurse bias and nursing care disparities
with the goal of increasing equitable care are critical to this cause.
ACKNOWLEDG MENT
We would like to thank our health sciences librarian, Jennifer
DeBerg, MLIS for her assistance with search strategies and conduct
of the search; our data manager, Maria Hein, for her assistance with
the REDCap coding tool; and Janet K. Williams, PhD, RN, FAAN, for
her editorial assistance.
DATA AVAIL ABILIT Y S TATEMENT
Data sharing not applicable – no new data generated.
ORCID
Patricia S. Groves https://orcid.org/0000-0002-2312-0676
R E FE R E N C E S
Agency for Healthcare Research and Quality (2019). Nursing and patient
safety. https://psnet.ahrq.gov/prime rs/prime r/22/nursi ng- and-
patie nt- safety.
Agency for Healthcare Research and Quality (2020). 2019 National
healthcare quality and disparities report. https://www.ahrq.gov/
resea rch/findi ngs/nhqrd r/nhqdr 19/index.html.
American Hospital Association (2020). Resources on health equity and
value. https://ifdhe.aha.org/resou rces- healt h- equit y- and- value.
American Nurses Association (2015). Code of ethics for nurses with inter-
pretive statements. https://www.nursi ngwor ld.org/pract ice- polic y/
nursi ng- excel lence/ ethic s/code- of- ethic s- for- nurse s/.
American Nurses Association (2020). The nurse’s role in addressing discrim-
ination: Protecting and promoting inclusive strategies in practice set-
tings, policy, and advocacy. https://www.nursi ngwor ld.org/~4ab20
7/globa lasse ts/pract icean dpoli cy/nursi ng- excel lence/ ana- posit
ion- state ments/ socia l- cause s- and- healt h- care/the- nurse s- role- in-
addre ssing – discr imina tion.pdf.
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a meth-
odological framework. International Journal of Social Research
Methodology, 8(1), 19– 32. https://doi.org/10.1080/13645 57032
00011 9616.
Artiga, S., Orgera, K., & Pham, O. (2020). Disparities in health and health
care: Five key questions and answers. https://www.kff.org/dispa ritie
s- polic y/issue – brief/ dispa ritie s- in- healt h- and- healt h- care- five-
key- quest ions- and- answe rs/
Byrne, A., & Tanesini, A. (2015). Instilling new habits: Addressing implicit
bias in healthcare professionals. Advances in Health Sciences Education,
20(5), 1255– 1262. https://doi.org/10.1007/s1045 9- 015- 9600- 6.
Centers for Medicare and Medicaid Services (2020). Equity initiatives.
https://www.cms.gov/About – CMS/Agenc y- Infor matio n/OMH/
equit y- initi atives.
CMS Office of Minority Health, & RAND Corporation. (2017). Ethnic dis-
parities by gender in health care in Medicare Advantage. https://www.
cms.gov/About – CMS/Agenc y- Infor matio n/OMH/Downl oads/
Healt h- Dispa ritie s- Racia l- and- Ethni c- Dispa ritie s- by- Gende r- Natio
nal- Report.pdf
Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A.,
Greenwald, A. G., & Inui, T. S. (2012). The associations of clini-
cians’ implicit attitudes about race with medical visit communi-
cation and patient ratings of interpersonal care. American Journal
of Public Health, 102(5), 979– 987. https://doi.org/10.2105/
ajph.2011.300558.
Dehon, E., Weiss, N., Jones, J., Faulconer, W., Hinton, E., Sterling, S., &
Choo, E. K. (2017). A systematic review of the impact of physician
implicit racial bias on clinical decision making. Academic Emergency
Medicine, 24(8), 895– 904. https://doi.org/10.1111/acem.13214.
Dodor, E. A., & Kelly, S. J. (2010). Manifestations of tuberculosis stigma
within the healthcare system: The case of Sekondi- Takoradi
Metropolitan district in Ghana. Health Policy, 98(2– 3), 195– 202.
https://doi.org/10.1016/j.healt hpol.2010.06.017.
Drwecki, B. B., Moore, C. F., Ward, S. E., & Prkachin, K. M. (2011).
Reducing racial disparities in pain treatment: the role of empa-
thy and perspective- taking. Pain, 152(5), 1001– 1006. https://doi.
org/10.1016/j.pain.2010.12.005.
Early, M. R. (1998). Influence of selected nurse attributes on proposed nurs-
ing care of battered women in the emergency department. [Doctoral
dissertation, University of Michigan]. Retrieved from ProQuest
Dissertations Publishing. (109877159).
Failla, K. R., & Connelly, C. D. (2017). Systematic review of gender dif-
ferences in sepsis management and outcomes. Journal of Nursing
Scholarship, 49(3), 312– 324. https://doi.org/10.1111/jnu.12295.
FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare profession-
als: a systematic review. BMC Medical Ethics, 18, 1– 18. https://doi.
org/10.1186/s1291 0- 017- 0179- 8.
Gallop, R. M., Taerk, G., Lancee, W. J., Coates, R. A., & Fanning, M. (1992).
A randomized trial of group interventions for hospital staff car-
ing for persons with AIDS. AIDS Care, 4(2), 177– 185. https://doi.
org/10.1080/09540 12920 8253089.
Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni,
L. I., & Banaji, M. R. (2007). Implicit bias among physicians and its
prediction of thrombolysis decisions for black and white patients.
Journal of General Internal Medicine, 22, 1231– 1238.
Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: atti-
tudes, self- esteem, and stereotypes. Psychological Review, 102(1),
4– 27.
Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring
individual differences in implicit cognition: the implicit association
test. Journal of Personality and Social Psychology, 74(6), 1464– 1480.
https://doi.org/10.1037//0022- 3514.74.6.1464.
Haider, A. H., Schneider, E. B., Sriram, N., Scott, V. K., Swoboda, S. M.,
Zogg, C. K., Dhiman, N., Haut, E. R., Efron, D. T., Pronovost, P. J.,
Freischlag, J. A., Lipsett, P. A., Cornwell, E. E. 3rd, MacKenzie,
E. J., & Cooper, L. A. (2015). Unconscious race and class biases
among registered nurses: Vignette- based study using implicit
association testing. Journal of the American College of Surgeons,
220(6), 1077– 1086.e1073. https://doi.org/10.1016/j.jamco
llsurg.2015.01.065.
Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W.,
Payne, B. K., Eng, E., Day, S. H., & Coyne- Beasley, T. (2015). Implicit
racial/ethnic bias among health care professionals and its influ-
ence on health care outcomes: A systematic review. American
Journal of Public Health, 105(12), e60– 76. https://doi.org/10.2105/
ajph.2015.302903.
Hart, P. L., & Mareno, N. (2014). Cultural challenges and barriers through
the voices of nurses. Journal of Clinical Nursing, 23(15– 16), 2223–
2233. https://doi.org/10.1111/jocn.12500.
Horowitz, J. M., Paker, K., Brown, A., & Cox, K. (2020). Amid national reck-
oning, Americans divided on whether increased focus on race will lead
to major policy change. https://www.pewre search.org/socia l- trend
13652702, 2021, 23-24, D
ow
nloaded from
https://onlinelibrary.w
iley.com
/doi/10.1111/jocn.15861 by C
apella U
niversity, W
iley O
nline L
ibrary on [06/09/2023]. See the T
erm
s and C
onditions (https://onlinelibrary.w
iley.com
/term
s-and-conditions) on W
iley O
nline L
ibrary for rules of use; O
A
articles are governed by the applicable C
reative C
om
m
ons L
icense
| 3397GROVES Et al.
s/2020/10/06/amid- natio nal- recko ning- ameri cans- divid ed- on-
wheth er- incre ased- focus – on- race- will- lead- to- major – polic y- chang e/
Institute for Healthcare Improvement (2020). Health equity. http://www.
ihi.org/Topic s/Healt h- Equit y/Pages/ defau lt.aspx.
Institute of Medicine (2003). Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care. The National Academies Press.
International Council of Nurses (2012). The ICN code of ethics for nurses.
https://www.icn.ch/sites/ defau lt/files/ inlin e- files/ 2012_ICN_
Codeo fethi csfor nurses_%20eng.pdf.
Kates, J., Ranji, U., Beamesderfer, A., Salganicoff, A., & Dawson, L. (2018).
Health and access to care and coverage for lesbian, gay, bisexual, and
transgender (LGBT) individuals in the U.S.. https://www.kff.org/dispa
ritie s- polic y/issue – brief/ healt h- and- acces s- to- care- and- cover age-
for- lesbi an- gay- bisex ual- and- trans gende r- indiv idual s- in- the- u- s/
Kilbourne, A. M., Switzer, G., Hyman, K., Crowley- Matoka, M., & Fine,
M. J. (2006). Advancing health disparities research within the
health care system: a conceptual framework. American Journal
of Public Health, 96(12), 2113– 2121. https://doi.org/10.2105/
ajph.2005.077628.
Maina, I. W., Belton, T. D., Ginzberg, S., Singh, A., & Johnson, T. J. (2018).
A decade of studying implicit racial/ethnic bias in healthcare provid-
ers using the implicit association test. Social Science and Medicine,
199, 219– 229. https://doi.org/10.1016/j.socsc imed.2017.05.009.
Mather, B., Roche, M., & Duffield, C. (2014). Disparities in treatment of
people With mental disorder in non- psychiatric hospitals: A re-
view of the literature. Archives of Psychiatric Nursing, 28(2), 80– 86.
https://doi.org/10.1016/j.apnu.2013.10.009.
Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., &
Aromataris, E. (2018). Systematic review or scoping review?
Guidance for authors when choosing between a systematic or
scoping review approach. BMC Medical Research Methodology,
18(1), 143. https://doi.org/10.1186/s1287 4- 018- 0611- x.
National Institute on Minority Health and Health Disparities (2020).
Overview. https://www.nimhd.nih.gov/about/ overv iew/.
Nursing and Midwifery Council (2018). The Code: Professional standards
of practice and behaviour for nurses, midwives and nursing associates.
https://www.nmc.org.uk/globa lasse ts/sited ocume nts/nmc- publi
catio ns/nmc- code.pdf.
Pappas, S. (2020). Fighting inequity in the face of COVID- 19. Monitor on
Psychology, 51(4). https://www.apa.org/monit or/2020/06/covid
– fight ing- inequity.
Peters, M. D. J., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., &
Soares, C. B. (2015). Guidance for conducting systematic scoping
reviews. International Journal of Evidence Based Healthcare, 13(3),
141– 146. https://doi.org/10.1097/XEB.00000 00000 000050.
Pettigrew, T. F., & Tropp, L. R. (2006). A meta- analytic test of intergroup
contact theory. Journal of Personality and Social Psychology, 90(5),
751– 783. https://doi.org/10.1037/0022- 3514.90.5.751.
Ranganath, K. A., & Nosek, B. A. (2007). Implicit attitudes. In R. F.
Baumeister, & K. D. Vohs (Eds.), Encyclopedia of social psychology
(pp. 465– 466). Sage.
Rush, K. L., Hickey, S., Epp, S., & Janke, R. (2017). Nurses’ attitudes
towards older people care: An integrative review. Journal of
Clinical Nursing, 26(23– 24), 4105– 4116. https://doi.org/10.1111/
jocn.13939.
Sabin, J., & Greenwald, A. (2012). The influence of implicit bias on
treatment recommendations for four common pediatric condi-
tions: Pain, urinary tract infection, ADHD, and asthma. American
Journal of Public Health, 102, 988– 995. https://doi.org/10.2105/
AJPH.2011.300621.
Sabin, J., Nosek, B. A., Greenwald, A., & Rivara, F. P. (2009). Physicians’
implicit and explicit attitudes about race by MD race, ethnicity, and
gender. Journal of Health Care for the Poor and Underserved, 20(3),
896– 913. https://doi.org/10.1353/hpu.0.0185.
Sabin, J., Rivara, F. P., & Greenwald, A. G. (2008). Physician implicit at-
titudes and stereotypes about race and quality of medical care.
Medical Care, 46(7), 678– 685. https://doi.org/10.1097/MLR.0b013
e3181 653d58.
Teng, C. I., Hsiao, F. J., & Chou, T. A. (2010). Nurse- perceived time pressure
and patient- perceived care quality. Journal of Nursing Management,
18(3), 275– 284. https://doi.org/10.1111/j.1365- 2834.2010.01073.x.
Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D.,
Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl,
E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft,
A., Wilson, M. G., Garritty, C., … Straus, S. E. (2018). PRISMA
Extension for Scoping Reviews (PRISMA- ScR): Checklist and
Explanation. Annals of Internal Medicine, 169(7), 467– 473. https://
doi.org/10.7326/M18- 0850.
U.S. Department of Health and Human Services (2020). Healthy People
2020 framework. https://www.healt hypeo ple.gov/sites/ defau lt/
files/ HP202 0Fram ework.pdf
U.S. Department of Health and Human Services Office of Minority
Health. (2011). HHS action plan to reduce racial and ethnic health dis-
parities: A nation free of disparities in health and health care. https://
minor ityhe alth.hhs.gov/asset s/pdf/hhs/HHS_Plan_compl ete.pdf
University of Iowa (2018). REDCap. https://redcap.icts.uiowa.edu/redca p/.
Wyatt, R., Laderman, M., Botwinick, L., Mate, K., & Whittington, J.
(2016). Achieving health equity: A guide for health care organizations.
http://www.ihi.org/resou rces/Pages/ IHIWh itePa pers/Achie ving-
Healt h- Equity.aspx
SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Groves PS, Bunch JL, Sabin JA.
Nurse bias and nursing care disparities related to patient
characteristics: A scoping review of the quantitative and
qualitative evidence. J Clin Nurs. 2021;30:3385–3397.
https://doi.org/10.1111/jocn.15861
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506 | Quality Improvement Showcase
REPORT
A Five-Step Evidence-Based Practice Primer for
Perioperative RNs
Christopher H. Stucky, PhD, RN, CNOR, CSSM, NEA-BC;
Marla J. De Jong, PhD, RN, CCNS, FAAN; Jose A. Rodriguez, DNP, RN, CCNS, CNOR
ABSTRACT
Perioperative nurses work in one of the most complex healthcare settings and must adapt to rapid advances in
technology, treatments, and scientific discoveries to maintain clinical competence and provide care that reflects
current evidence. Evidence-based practice (EBP) is a standard of professional nursing performance and an expec-
tation of professional nursing practice. Because EBP is foundational to health care quality and safety, periop-
erative nurses must understand the concepts of EBP and have the capacity to apply evidence to their clinical
practice. However, some perioperative nurses struggle with EBP concepts and find it difficult to access, appraise,
and apply evidence. In this article, we describe the five-step EBP process and provide valuable insights into EBP
for perioperative RNs.
Key words: evidence-based practice, health care quality, health care safety, EBP.
Perioperative nurses work in one of the most com-
plex health care settings and must adapt to rapid
advances in technology, treatments, and scientific
discoveries to maintain clinical competence and provide
clinical care that reflects current evidence.1 Evidence-
based practice (EBP) is the process by which perioperative
nurses plan and deliver care based on the best evidence,
expert clinical knowledge, and patient preferences and
values.2 Evidence-based practice is foundational to health
care quality and safety, and perioperative nurses must
understand the concepts of EBP and have the capacity to
apply evidence to their clinical practice. The fundamen-
tal premise of EBP is ensuring that health care is reliable,
safe, effective, affordable, and efficient.3 As health care
progresses toward a value-based system, where value is
a function of quality and cost,4 consumers, policymakers,
and payers are increasingly demanding EBP.5
Evidence-based practice is a standard of nursing profes-
sional performance,6 and all nurses have an ethical and
legal commitment to integrate evidence into practice.7
AORN considers research to be the foundation of periop-
erative nursing practice and regards EBP as fundamental
to quality patient care.8 However, some perioperative
nurses struggle with EBP concepts and find it difficult to
access, appraise, and apply evidence.9 Therefore, the pur-
pose of this article is to describe the five-step EBP process
and provide valuable insights into EBP for perioperative
RNs.
BACKGROUND
Evidence-based practice in nursing has a rich history,
beginning with Florence Nightingale in the 1800s.10
Although robust EBP frameworks are relatively contem-
porary, historically, nurses applied informal frameworks
to guide clinical practice through scientific discoveries.
In the 1980s, when the emphasis was to close the gap
between research and practice, nurses started using
a process known as research utilization (ie, applying
http://doi.org/10.1002/aorn.13220
© AORN, Inc, 2020
Quality Improvement Showcase | 507
November 2020, Vol. 112, No. 5 Report
findings from single studies to change nursing prac-
tice).11 In the 1990s, EBP supplanted research utilization,
given increased awareness regarding the importance of
using multiple sources of evidence to make practice
decisions.11
The impetus for evidence-based approaches was the con-
cern that it required years to translate scientific discover-
ies to clinical practice,12 and the aim to integrate current
evidence and individual clinician expertise. Sackett et al13
defined evidence-based medicine as:
the conscientious, explicit, and judicious use
of current best evidence in making decisions
about the care of individual patients. The
practice of evidence-based medicine means
integrating individual clinical expertise with
the best available external clinical evidence
from systematic research.13(p71)
Within nursing, science and art merge in a context of car-
ing that integrates research evidence.14 This context of
caring combines research evidence, clinical expertise, and
patient preferences and values to inform clinical decision
making and influence high-quality patient outcomes.14
In practice, nurses often employ a practical approach
to EBP, using the nursing process as a guide.15 Stannard
proposed a pragmatic definition of EBP for nursing: “EBP
for nursing is a way of entering the situation with curios-
ity and engagement that follows the nursing process by
responding to the issue or problem using the best avail-
able evidence.”15(p1080)
Benefits of an Evidence-Based Process
The benefits of EBP extend to patients, consumers of
health care, nurses, and health care organizations. Through
creating and sustaining EBP environments, health care
organizations, educators, and clinicians have advanced
the quality and safety of health care delivery and promot-
ed optimal patient outcomes.11 Evidence-based practice
provides nurses and organizations confidence that they
are optimizing health system performance and advanc-
ing each element of the Quadruple Aim (ie, improving the
patient experience of care, improving the health of popu-
lations, lowering the cost of care, and improving the work
experience of caregivers).16
Evidence-based practice empowers nurses by building
autonomy.17 As nurses develop a command of relevant
evidence through increased clinical knowledge, they
become empowered to practice to the fullest extent
of their capabilities.17 When nurses are empowered to
make informed, evidence-based clinical decisions tai-
lored to patients’ needs and values, their job satisfaction
improves and they are more likely to remain in the nurs-
ing profession.18
A health care organization’s financial health is related to
clinician performance.5 National pay-for-performance
initiatives and value-based purchasing have heavily influ-
enced leaders of health care organizations to implement
and standardize evidence-based practices to achieve
the best financial and clinical outcomes.5 Thus, by basing
their practice on evidence, nurses can impact the finan-
cial health of the entire health system and improve overall
patient health.
Barriers to EBP
Leaders in the health care industry have recognized
the importance of EBP for decades, and yet consistent
implementation of EBP remains a challenge.19 Barriers
to EBP implementation typically occur in two categories:
individual (ie, those inherent to the nurse) and organiza-
tional (ie, those related to leadership, resources, and cul-
ture).11 Common individual barriers are inadequate skills,
lack of knowledge, and lack of time.20 Some researchers
determined that although nurses could identify clinical
practice issues, they were unable to translate the issues
into well-constructed clinical questions.21 This finding is
consistent with previous studies, which found that nurs-
es lacked the confidence and skills to evaluate research
and implement EBP effectively.5,21,22 The major organiza-
tional barriers to EBP are workload (ie, time pressures),
As nurses develop a command
of relevant evidence through
increased clinical knowledge, they become
empowered to practice to the fullest
extent of their capabilities.
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Stucky et al November 2020, Vol. 112, No. 5
insufficient resources (eg, lack of access to online jour-
nals), ineffective interprofessional collaboration, lack of
authority to change practice, and a workplace culture
resistant to change.19
EBP Models
Nurses have developed several EBP models to help
demystify the translation of scientific evidence into
clinical practice.23 Many health care organizations have
adopted EBP models that align with their organizational
goals, fit their clinical context, and guide a systematic
approach to implement and sustain practice changes
collaboratively.24 The predominant EBP models are the
Iowa Model of Evidence-Based Practice to Promote
Quality Care, the Advancing Research and Clinical
Practice Through Close Collaboration Model, and
the Johns Hopkins Nursing Evidence-Based Practice
Model.23 Although EBP models have distinct differenc-
es that hinder their application within some settings,24
they share similar steps. Next, we discuss five intuitive
and pragmatic steps to EBP (Figure 1) that were first
described by Sackett.2
STEPS OF EBP
The best evidence available to clinicians is a fusion of
research evidence, their expert clinical knowledge, and
patient and family preferences. Evidence-based practice
is not simply applying science to nursing care. Rather, as
nurses think critically and integrate all knowledge, both
clinical and scientific, they will make the best patient care
decisions.25
Step 1: Identify the Problem
The first step is for nurses to identify a clinical practice
problem within the perioperative continuum and create
a clinical question. For EBP initiatives, nurses typically
structure clinical questions in the PICOT format:
• P (patient, population, or problem),
• I (intervention or issue),
• C (comparative or current treatment),
• O (outcomes), and
• T (time).14
A well-formulated clinical question is needed to produce
focused and timely literature searches that will yield appro-
priate evidence to answer the question.14 Sometimes,
questions exclude one or more PICOT elements, specifi-
cally the intervention or time component.
Step 2: Access the Best Evidence
The second step of EBP is to access the best evidence. The
PICOT question helps streamline the search process. The
search strategy depends on factors such as the context
of the question, available resources, and urgency of the
search. One approach is to access published guidelines in
which subject matter experts have already searched and
appraised the literature, and formed, rated, and published
practice recommendations. For example, perioperative
nurses commonly use AORN’s Guidelines for Perioperative
Practice8 to identify expeditiously broad evidence-based
recommendations for perioperative patient care. These
guidelines, which are published annually, contain a review
of research and non-research evidence and clinical prac-
tice recommendations rated according to their underlying
strength and quality of evidence.8 National agencies such
as the Agency for Healthcare Research and Quality and Figure 1. The five steps of evidence-based practice.
Quality Improvement Showcase | 509
November 2020, Vol. 112, No. 5 Report
the Centers for Disease Control and Prevention also offer
clinical guidelines.26,27
Searching medical and nursing literature can seem over-
whelming to some nurses.9 Nurses who are unfamiliar
with searching the literature can ask an advanced practice
RN, a nurse scientist, or a health science librarian within
their institution to help them comprehensively search the
literature.
Initially, perioperative nurses may search electron-
ic databases for systematic reviews about their top-
ic. Databases, such as the Cochrane Library,28 contain
systematic reviews and meta-analyses that experts
produced to summarize research results. Finding syn-
thesized evidence can save clinicians time, especially
if the review is recent. If no systematic review is avail-
able or the review is outdated, perioperative nurses can
search electronic databases (eg, Cumulative Index to
Nursing and Allied Health Literature [CINAHL], Embase,
PubMed, Google Scholar, Web of Science) for individual
peer-reviewed studies using keywords from the PICOT
question and considering contextual factors such as set-
ting and available resources. Although nurses can search
most electronic databases for free, the availability of
full-text articles depends on the subscription status of
an organization. Searching for literature is an iterative
process, and often yields many results. Nurses should
narrow the search results to relevant studies by carefully
reading manuscript titles and abstracts.
In the PICOT question example offered in Sidebar 1, expe-
rienced team members performed a systematic literature
search using electronic databases and key words relative
to surgical site infection (SSI) reduction and SSI bun-
dles. Ultimately, they found a combination of systematic
reviews, prospective clinical trials, non-experimental stud-
ies, case reports, and clinical practice guidelines that met
their criteria.
Step 3: Critically Appraise the Evidence
The third step in EBP is to critically appraise the evidence
from the literature review. Nurses must use the most cur-
rent, the most relevant, and the highest-quality evidence
to support changes in nursing practice.14 Although other
sources29 provide more extensive explanations, a powerful
Sidebar 1. Example of a Perioperative
PICOT Question
Perioperative leaders at a busy military medical
center were concerned about increased rates of
surgical site infections (SSIs) for patients having
elective surgeries (P), which were occurring at
levels higher than benchmarked national averages.
Nursing leaders formed an interprofessional team
to assess the problem and review current practic-
es. Team members were concerned by the lack
of standardized protocols, inconsistent patient
education, and bioburden on surgical instruments.
Team members recalled reading AORN Journal
articles about clinical strategies to reduce SSIs,1
including infection prevention bundles that involve
patient education, antibiotic protocols, surgical
site preparation, postoperative incision care, and
staff engagement;2 and innovative adjunctive
technologies to decrease bioburden.3 This led
team members to question whether implementing
a comprehensive infection prevention bundle (I)
in subsequent patients, as compared to previous
patients (C), would decrease SSI rates (O), when
analyzed over 12 months (T). The team decided
to compare quarterly SSI rates to track trends and
determine intervention efficacy. The team wrote
the question in a PICOT format: “In _____ (P), how
does _____ (I), as compared to _____ (C), predict or
influence _____ (O) over _____ (T)?” For example, “In
patients undergoing elective surgeries (P), how does
implementing an infection prevention bundle (I), as
compared to prior practices (C), predict or influence
SSI rates (O) over 12 months (T)?”
REFERENCES
1. Bashaw MA, Keister KJ. Perioperative strat-
egies for surgical site infection prevention.
AORN J. 2019;109(1):68-78.
2. Money L, Eyer M, Duncan K. Creating a sur-
gical site infection prevention bundle for
patients undergoing cesarean delivery. AORN
J. 2018;108(4):372-383.
3. Rodriguez JA, Hooper G. Adenosine triphos-
phate-bioluminescence technology as an
adjunct tool to validate cleanliness of surgical
instruments. AORN J. 2019;110(6):596-604.
510 | Quality Improvement Showcase
Stucky et al November 2020, Vol. 112, No. 5
skill for nurses to develop is a practical understanding of
the various categories of published research and non-re-
search (Table 1).
Standardized tools help nurses critically appraise the
strength and quality of scientific and other forms of evi-
dence. To better address perioperative clinical questions,
AORN adapted the Johns Hopkins Nursing Evidence-
Based Practice Model30 to form the AORN Evidence Rating
Model.31 At a glance, appraisal tools may appear intimidat-
ing. However, through education and practice, nurses can
develop proficiency in categorizing and appraising evidence.
As with previous steps, it may be helpful for perioperative
nurses to request assistance from an advanced practice RN
or a librarian the first time that they appraise the evidence.
Perioperative nurses can begin the appraisal process by
determining the evidence level or strength of the study
(Figure 2). The hierarchy of evidence ranges from I (stron-
gest) to III for research evidence and IV to V (weakest)
for non-research evidence.31 Nurses rate the evidence
strength based on the study design. Level I evidence, such
as randomized controlled trials and experimental studies, is
the strongest, most reliable, and best evidence to answer a
clinical question.32 Level V evidence, such as expert opinion
and case reports, is the weakest and least reliable evidence
but may be relevant if no stronger evidence is found.
Next, the perioperative nurse can use AORN’s Research
Evidence Appraisal Tools31 to determine the quality of
evidence: “A” for high quality, “B” for good quality, or “C”
for low quality or major flaws. To obtain an “A” rating, the
research should have consistent results, sufficient sample
size, adequate controls, definitive conclusions, and consis-
tent recommendations.29 Combined with the strength of
the evidence, research that receives a final score of I–A
Table 1. Categories of Literature Used to Inform Evidence-Based Practice Decisions1
Randomized controlled trial (RCT) A type of experimental study in which investigators randomly assign participants and manipulate
variables to find cause-and-effect relationships between experimental and control groups
Meta-analysis A rigorous, statistical approach for combining findings from multiple independent studies, if statis-
tically appropriate, in a quantitative systematic review
Quasi-experimental research Similar to experimental research, this type of research lacks either a random assignment of partici-
pants, manipulation of variables, or a control group
Non-experimental research
(eg, cross-sectional and retrospective
studies, case report, survey)
A type of research that differs from experimental research, in that investigators do not manipulate
independent variables or randomly assign participants
Quantitative research A type of research that investigates phenomena relying on data that is observed or measured
using statistical techniques
Qualitative research (eg, focus groups,
interviews, observation)
A type of research that aims to provide an improved understanding of behaviors and perceptions,
typically in naturalistic settings
Descriptive research A type of research that describes the characteristics of a phenomenon or population studied with-
out regard for explaining cause-and-effect relationships
Systematic review A type of secondary research that is an unbiased and high-level systematic analysis of all primary
evidence using precise search, selection, and appraisal methodology to answer a predefined
research question
Literature review A descriptive or narrative summary of evidence on a topic
Clinical practice guideline, consensus, posi-
tion statement, or white paper
A set of evidence-based recommendations by experts, and sometimes includes a multidisciplinary
panel of experts, intended to optimize patient care
Case report A detailed scientific report of a single clinical observation
Expert opinion (eg, column, letter to the
editor)
An opinion made by an expert that is often based on clinical expertise and observation, but may or
may not be evidence-based
Reference
1. Gliner JA, Morgan GA, Leech NL. Research Methods in Applied Settings: An Integrated Approach to Design and Analysis. 3rd ed. New York, NY:
Routledge; 2017.
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(ie, strongest evidence, highest quality) is better evidence
to implement as compared to research assessed as V–C
(ie, weakest evidence, lowest quality).29 Because appraiser
characteristics can potentially influence quality evidence
appraisal, some subjectivity exists within the process.29
Thus, it is helpful for a group of nurses to reach a con-
sensus regarding the score. In many organizations, small
groups of nurses (eg, hospital-, department-, or unit-based
EBP committees) work together to critically appraise the
evidence. Continuing the perioperative SSI bundle exam-
ple, interprofessional team members used the AORN
Research Evidence Appraisal Tools to determine the
strength and quality of the evidence. Using the best qual-
ity evidence, the interprofessional team identified an evi-
dence-based intervention (ie, a comprehensive SSI bundle)
to implement.
Step 4: Apply the Change to Practice
The fourth step is to apply the change to practice. In this step,
nurses integrate scientific evidence with their expert clinical
judgment while considering patients’ beliefs, preferences,
and values.14 Because nursing is a science and an art, nurses
rely heavily on their ability to apply evidence to their unique
care environment and individual patients. Sometimes, after
carefully reviewing the evidence and considering care con-
cerns, no change in current practice is warranted.
Research evidence is necessary for EBP but is insufficient
alone for making patient care decisions.33 The ability to con-
sider patient preferences in clinical decision-making requires
critical reflection and practical wisdom.34 For instance, nurs-
es employ critical thinking when evidence supporting patient
care decisions are conflicting or non-existent.35 The inter-
vention also may conflict with patient values, cultural norms,
or patient preferences. Expert clinical knowledge helps nurs-
es to consider care alternatives that meet the needs of their
patients or clinical settings after considering the context of
all critical elements, including merging evidence with patient
rights and preferences.13 The ability of nurses to individualize
care is what differentiates EBP from research use, and helps
to ensure a patient-centered approach.35
Applying changes to practice frequently involves making
an organizational change or adopting new policies and
practices. Practice changes may involve
• forming an interprofessional implementation team,
• revising standard orders,
• ordering new equipment or supplies,
• making changes to the electronic medical record,
• creating a timeline with scheduled checkpoints for the
practice change,
• educating clinicians,
• developing a clinical tool,
• piloting the change with a particular surgical specialty,
or
• using change champions to promote and operationalize
EBP changes.14
Nurses can use templates, flowcharts, spreadsheets, or
Gantt charts (ie, a chart that displays a project schedule) to
maintain project progression and enhance communication
Figure 2. An example hierarchy of evidence and
quality appraisal rating. AORN Hierarchy of Evidence
Model. Adapted with permission from AORN.org.
Copyright © 2015, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
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Stucky et al November 2020, Vol. 112, No. 5
among team members. Depending on the nature of the
surgical setting and proposed change, perioperative nurs-
es may need to obtain institutional review board approval
before changing clinical practice and collecting outcome
data.
Continuing the perioperative SSI bundle example, the
interprofessional team created a comprehensive plan for
an evidence-based SSI prevention bundle, project time-
lines, variables targeted for data collection and analysis,
proposed benchmarks, and dissemination strategies.
Next, EBP team leaders engaged senior medical center
leaders to obtain their support for the implementation.
The team invited all relevant stakeholders to solicit their
feedback regarding the plan. The institutional review
board determined that the work was not human subjects
research and therefore was offered exempt status. Team
members collected SSI data, trained clinicians through-
out the medical center on SSI bundle elements, provided
patient and family education preoperatively and post-
operatively, and invited change champions to join the
implementation team. Lastly, the interprofessional team
started small by slowly introducing the change across
the medical center, focusing on the implementation pro-
cess, and overcoming challenges that required attention
(eg, reinforcing change).
Step 5: Evaluate the Change
The final step of the EBP process is to evaluate the change
in practice. Evaluation is instrumental in determining the
effectiveness of the practice change and helping nurses
determine whether the translation of evidence into prac-
tice was successful. The nurse should evaluate:
• how effectively the team followed the first four steps of
the EBP process,
• the outcome of the intervention, and
• how the outcomes compared to those found in the
literature.35
Perioperative nurses can compare postimplementation
data to baseline data to determine the effectiveness
and impact of the intervention.36 Continuous monitoring
of both the EBP process and the outcome measures by
the perioperative nurse helps refine the change in prac-
tice to achieve similar outcomes as those identified in the
literature. However, interventions from controlled stud-
ies do not always guarantee similar clinical results when
implemented,37 partially because of differences in popu-
lations, settings, implementation strategies, and measure-
ment. When nurses identify unfavorable outcomes, it is
crucial to determine the cause. Nurses must analyze the
results, investigate potential errors in measurement, and
address any issues that could produce undesired results.
Through monitoring, nurses can support the positive
effects of the practice change and implement measures to
resolve negative effects.37
Extending the perioperative SSI bundle example, the
interprofessional team continuously monitored the prac-
tice change and reported results after three months. The
rate of SSIs decreased from 4.3% (n = 107) to 1.9% (n =
47), lowering their SSI rate to below the national average.
The initial results appeared promising, so team members
continued monitoring for trends and variations. After 12
months, the interprofessional team determined that the
SSI bundle implementation was a success, and the proj-
ect potentially improved quality and safety for surgical
patients.
Disseminate Results
While not a formal step, nurses should disseminate their
results locally and nationally through venues such as
hospital or surgery center grand rounds, conferences,
and publications. Although the results may lack gener-
alizability, dissemination enables perioperative nurses
to facilitate thoughtful discourse about lessons learned;
address potential transferability of the practice change
considering factors such as patient demographics, clini-
cal setting, and patient and family preferences; and rec-
ommend future research. Given a cyclical relationship
between research and clinical practice,38 perioperative
Evaluation is instrumental in
determining the effectiveness of
the practice change and helping nurses
determine whether the translation of
evidence into practice was successful.
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November 2020, Vol. 112, No. 5 Report
nurses are well-positioned to identify topics for research
and improvement.
To conclude the perioperative SSI bundle example, the
interprofessional team shared data regarding the effec-
tiveness of the comprehensive SSI bundle and its impact
on surgical patient outcomes with all stakeholders.
Additionally, perioperative nurse team members present-
ed the findings at local, regional, and national profession-
al meetings, and published their work in a perioperative
nursing journal.
CREATING SUPPORTIVE EBP
ENVIRONMENTS
To create a supportive EBP environment, hospital lead-
ers must develop and embrace a spirit of inquiry and sup-
portive culture that values and supports EBP and nursing
innovation.5 A spirit of inquiry empowers nurses and pro-
vides the ability for nurses to challenge current practices
and share innovative solutions.39 A supportive organiza-
tional culture allows the time and space for nurses to for-
mulate ideas, seek advice, receive mentorship, and share
their ideas with others.39
Executive leaders (both clinicians and administrators)
hold key positions that influence EBP in their facilities.
Nursing leaders can increase organizational EBP capac-
ity by obtaining support and buy-in from senior leaders
within the hospital system, integrating EBP in every
decision-making activity, transparently sharing data sys-
tem-wide, and launching initiatives to increase clinician
autotomy.19,40 To overcome individual barriers, health
care organizations can provide clinicians with time, edu-
cation, training, and mentorship to improve and maintain
their use of evidence and identify change champions to
lead organizational change toward the achievement of
an EBP culture.19,41
Nurses can increase EBP capacity in their hospitals by
learning, cultivating, and mentoring other staff members’
EBP competence.42 Evidence-based practice competence
is a valuable skill set that perioperative nurses can apply
and share with others during the entire span of their
career. Thus, it is important to recognize the critical indi-
vidual importance of nurses in progressing toward a sup-
portive environment and culture that embraces EBP.
CONCLUSION
Evidence-based practice is a powerful problem-solving
approach for clinical decision-making and is a standard
and expectation of professional nursing practice. In this
article, we described the five-step EBP process and pro-
vided valuable insights into EBP for perioperative RNs.
To improve health care quality and safety, perioperative
nurses must develop the capability to identify clinical
problems, access and appraise the best evidence, and
implement and evaluate best practices. Evidence-based
practice competence is a valuable skill set that periopera-
tive nurses can apply across the entire span of their career
and share with others.
Editor’s notes: CINAHL is a registered trademark of EBSCO
Industries, Inc, Birmingham, AL. Embase is a registered trade-
mark of Elsevier Limited, Oxford, UK. PubMed is a registered
trademark of the US Department of Health and Human
Services, Bethesda, MD. Google Scholar is a trademark of
Google, LLC, Mountain View, CA. Web of Science is a regis-
tered trademark of Camelot UK Bidco Limited, London, UK.
REFERENCES
1. Stucky CH, De Jong MJ, Kabo FW. Military surgical
team communication: implications for safety. Mil
Med. 2020;185(3–4):e448–e456.
2. Sackett DL. Evidence-based medicine. Semin Perinatol.
1997;21(1):3–5.
3. Stevens KR. The impact of evidence-based practice
in nursing and the next big ideas. Online J Issues Nurs.
2013;18(2):4.
4. Welton JM, Harper EM. Nursing care value-based
financial models. Nurs Econ. 2015;33(1):14–19, 25.
5. Warren JI, McLaughlin M, Bardsley J, et al. The strengths
and challenges of implementing EBP in healthcare
systems. Worldviews Evid Based Nurs. 2016;13(1):
15–24.
6. American Nurses Association. Nursing: Scope and
Standards of Practice. 3rd ed. Silver Spring, MD:
American Nurses Association; 2015.
7. American Nurses Association. Code of Ethics for
Nurses with Interpretive Statements. 2nd ed. Silver
Spring, MD: American Nurses Association; 2015.
8. AORN. Guidelines for Perioperative Practice. Denver,
CO: AORN, Inc; 2020.
514 | Quality Improvement Showcase
Stucky et al November 2020, Vol. 112, No. 5
9. Farokhzadian J, Khajouei R, Ahmadian L. Evaluating fac-
tors associated with implementing evidence-based prac-
tice in nursing. J Eval Clin Pract. 2015;21(6):1107–1113.
10. Mackey A, Bassendowski S. The history of evidence-
based practice in nursing education and practice.
J Prof Nurs. 2017;33(1):51–55.
11. Schmidt NA, Brown JM. Evidence-Based Practice for
Nurses: Appraisal and Application of Research. 4th ed.
Burlington, MA: Jones & Bartlett Learning; 2019.
12. Morris ZS, Wooding S, Grant J. The answer is 17 years,
what is the question: understanding time lags in trans-
lational research. J R Soc Med. 2011;104(12):510–520.
13. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,
Richardson WS. Evidence based medicine: what it is
and what it isn’t. BMJ. 1996;312:71–72.
14. Melnyk BM, Fineout-Overholt E. Evidence-Based
Practice in Nursing & Healthcare: A Guide to Best
Practice. 3rd ed. Philadelphia, PA: Wolters Kluwer
Health; 2015.
15. Stannard D. A practical definition of evidence-
based practice for nursing. J Perianesth Nurs. 2019;
34(5):1080–1084.
16. Bowles JR, Adams JM, Batcheller J, Zimmermann D,
Pappas S. The role of the nurse leader in advancing
the quadruple aim. Nurse Lead. 2018;16(4):244–248.
17. Wilson M, Sleutel M, Newcomb P, et al. Empowering
nurses with evidence-based practice environments:
surveying Magnet, Pathway to Excellence, and
non-Magnet facilities in one healthcare system.
Worldviews Evid Based Nurs. 2015;12(1):12–21.
18. Wallen GR, Mitchell SA, Melnyk B, et al. Implementing
evidence-based practice: effectiveness of a struc-
tured multifaceted mentorship programme. J Adv
Nurs. 2010;66(12):2761–2771.
19. Williams B, Perillo S, Brown T. What are the fac-
tors of organisational culture in health care settings
that act as barriers to the implementation of evi-
dence-based practice? A scoping review. Nurse Educ
Today. 2015;35(2):e34–e41.
20. Sadeghi-Bazargani H, Tabrizi JS, Azami-Aghdash S.
Barriers to evidence-based medicine: a systematic
review. J Eval Clin Pract. 2014;20(6):793–802.
21. Mohsen MM, Safaan NA, Okby OM. Nurses’ percep-
tions and barriers for adoption of evidence based
practice in primary care: bridging the gap. Am J Nurs
Res. 2016;4(2):25–33.
22. Melnyk BM, Fineout-Overholt E, Gallagher-Ford L,
Kaplan L. The state of evidence-based practice in
US nurses: critical implications for nurse leaders and
educators. J Nurs Adm. 2012;42(9):410–417.
23. Speroni KG, McLaughlin MK, Friesen MA. Use of evi-
dence-based practice models and research findings
in Magnet-designated hospitals across the United
States: national survey results. Worldviews Evid Based
Nurs. 2020;17(2):98–107.
24. Gawlinski A, Rutledge D. Selecting a model for evi-
dence-based practice changes: a practical approach.
AACN Adv Crit Care. 2008;19(3):291–300.
25. Canada AN. Probing the relationship between evi-
dence-based practice implementation models and
critical thinking in applied nursing practice. J Contin
Educ Nurs. 2016;47(4):161–168.
26. Clinical guidelines and recommendations. Agency for
Healthcare Research and Quality. https://www.ahrq.
gov/preve ntion/ guide lines/ index.html. Reviewed July
2018. Accessed July 12, 2020.
27. Publications. Centers for Disease Control and Preven-
tion. https://www.cdc.gov/publi catio ns/. Accessed July
12, 2020.
28. Cochrane Library. Cochrane reviews. https://www.
cochr aneli brary.com/cdsr/reviews. Updated 2020.
Accessed July 12, 2020.
29. Spruce L, Van Wicklin SA, Hicks RW, Conner R, Dunn
D. Introducing AORN’s new model for evidence rat-
ing. AORN J. 2014;99(2):243–255.
30. Dang D, Dearholt SL. Johns Hopkins Nursing
Evidence-Based Practice: Model and Guidelines. 3rd
ed. Indianapolis, IN: Sigma Theta Tau International;
2018.
31. Spruce L, Van Wicklin SA, Wood A. AORN’s revised
model for evidence appraisal and rating. AORN J.
2016;103(1):60–72.
32. Fineout-Overholt E, Melnyk BM, Stillwell SB,
Williamson KM. Evidence-based practice step by
step: critical appraisal of the evidence: part I. Am J
Nurs. 2010;110(7):47–52.
33. Siminoff LA. Incorporating patient and family pref-
erences into evidence-based medicine. BMC Med
Quality Improvement Showcase | 515
November 2020, Vol. 112, No. 5 Report
Inform Decis Mak. 2013;13(suppl 3):S6. https://doi.
org/10.1186/1472-6947-13-S3-S6.
34. Den Hertog R, Niessen T. The role of patient prefer-
ences in nursing decision-making in evidence-based
practice: excellent nurses’ communication tools. J
Adv Nurs. 2019;75(9):1987–1995.
35. Lin SH, Murphy SL, Robinson JC. Facilitating evi-
dence-based practice: process, strategies, and resourc-
es. Am J Occup Ther. 2010;64(1):164–171.
36. White S, Spruce L. Perioperative nursing leaders imple-
ment clinical practice guidelines using the Iowa Model
of evidence-based practice. AORN J. 2015;102(1):
50–59.
37. Melnyk BM, Fineout-Overholt E, Stillwell SB,
Williamson KM. Evidence-based practice: step by
step: the seven steps of evidence-based practice. Am
J Nurs. 2010;110(1):51–53.
38. Charles EJ, Kron IL. Bedside-to-bench and back
again: surgeon-initiated translational research. Ann
Thorac Surg. 2018;105(1):10–11.
39. Melnyk BM, Fineout-Overholt E, Stillwell SB,
Williamson KM. Evidence-based practice: step by step:
igniting a spirit of inquiry. Am J Nurs. 2009;109(11):
49–52.
40. Gallagher-Ford L. Implementing and sustaining EBP
in real world healthcare settings: a leader’s role in cre-
ating a strong context for EBP. Worldviews Evid Based
Nurs. 2014;11(1):72–74.
41. Cullen L, Hanrahan K, Farrington M, et al. Evidence-
based practice change champion program improves
quality care. J Nurs Adm. 2020;50(3):128–134.
42. Storey S, Wagnes L, LaMothe J, Pittman J, Cohee
A, Newhouse R. Building evidence-based nursing
practice capacity in a large statewide health system:
a multimodal approach. J Nurs Adm. 2019;49(4):
208–214.
Christopher H. Stucky, PhD, RN, CNOR, CSSM, NEA-
BC, is a nurse scientist and deputy chief of research at
the Center for Nursing Science and Clinical Inquiry at
Womack Army Medical Center, Fort Bragg, NC. Dr Stucky
has no declared affiliation that could be perceived as posing a
potential conflict of interest in the publication of this article.
Marla J. De Jong, PhD, RN, CCNS, FAAN, is the dean at
University of Utah College of Nursing, Salt Lake City. Dr De
Jong has no declared affiliation that could be perceived as posing
a potential conflict of interest in the publication of this article.
Jose A. Rodriguez, DNP, RN, CCNS, CNOR, is an
assistant professor and deputy director of the Adult-
Gerontology Clinical Nurse Specialist Program at the
Uniformed Services University of the Health Sciences,
Bethesda, MD. Dr Rodriguez has no declared affiliation that
could be perceived as posing a potential conflict of interest in
the publication of this article.
Editor’s note: The views expressed are solely those of the
authors and do not reflect the official policy or position of the
US Army, US Air Force, the Department of Defense, or the US
Government.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
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