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Abstract

Introduction

Evidence-based practice (EBP) is essential in enhancing nursing care quality, patient outcomes, and clinical decision-making. However, nurses’ engagement with EBP often varies depending on educational background and institutional support. Bridging programs have been introduced to help diploma-prepared nurses advance their knowledge and competencies through academic progression.

Objective

This study aimed to compare the knowledge, attitudes, and implementation of EBP between diploma-prepared nurses and nurses who completed bridging programs in hospitals across Palestine.

Method

A descriptive-comparative design was employed using a convenience sample of 200 registered nurses (104 diploma and 96 bridging program graduates) from multiple hospitals in the West Bank. Data were collected using validated self-administered questionnaires measuring knowledge, attitudes, practice, and EBP implementation. Independent t-tests and logistic regression were used for analysis.

Results

Bridging nurses scored higher in all EBP domains, including knowledge (5.95 vs. 5.09), attitudes (5.80 vs. 5.06), practice (5.46 vs. 5.30), and implementation (5.42 vs. 4.91). Bridging nurses were significantly more likely to implement EBP. Gender, years of experience, and hospital setting were also significantly associated with higher EBP engagement.

Conclusion

Nurses with bridging education demonstrate stronger EBP competencies compared to diploma nurses. These findings emphasize the importance of academic progression and institutional support in promoting evidence-based nursing. Educational interventions and supportive work environments are recommended to enhance EBP engagement across all levels of nursing practice.

Keywords

evidence-based practice nursing education bridging nurses diploma nurses implementation

Introduction

Evidence-based practice (EBP) has become a fundamental element in modern healthcare, aiming to enhance patient outcomes, optimize clinical decision-making, and ensure the delivery of safe, high-quality care. Defined as the integration of the best available research evidence with clinical expertise and patient values, EBP is widely endorsed by healthcare institutions and policy bodies globally (Melnyk & Fineout-Overholt, 2023). In nursing, the adoption of EBP not only strengthens professional standards but also supports lifelong learning and reflective practice. Despite its recognized importance, the extent to which nurses implement EBP varies considerably, often influenced by their educational background, institutional support, and access to resources (Lizarondo et al., 2023; Saunders & Evans, 2024).

Nursing education plays a crucial role in shaping the competencies required for effective EBP engagement. Nurses prepared at the baccalaureate level are generally more proficient in understanding research methodologies, appraising evidence, and applying findings in clinical settings (Schmidt & Brown, 2024). In contrast, diploma-prepared nurses, who constitute a significant portion of the workforce in many healthcare systems, often have limited exposure to research and evidence-based learning during their initial training (Pacis et al., 2024). In response, bridging programs have been introduced in many countries, including Palestine, to facilitate the academic progression of diploma-trained nurses to Bachelor of Science in Nursing (BSN) qualifications. These programs are designed to enhance critical thinking, research literacy, and clinical decision-making skills (Al-Ma'aitah, 2024; Mohamed et al., 2024).

In the Palestinian context, the Ministry of Higher Education has accredited multiple institutions to offer RN-to-BSN programs, reflecting a growing national commitment to advancing nursing education. However, empirical evidence examining the impact of these programs on nurses’ engagement with EBP remains scarce. Comparative research that evaluates the differences in knowledge, attitudes, and EBP implementation between diploma-prepared nurses and those who have pursued further education through bridging programs is, therefore, essential. Such insights are vital for identifying educational gaps, informing curriculum development, and designing targeted professional development initiatives (Ferrer & Baliton, 2023; Khan et al., 2025).

This study seeks to compare the knowledge, attitudes, and implementation of EBP among diploma-trained nurses and bridging program nurses working in hospitals across Palestine. By exploring the influence of academic progression on EBP-related competencies, this research aims to provide evidence-based recommendations for enhancing nursing practice and education. Ultimately, strengthening EBP engagement among all levels of nurses is critical for advancing the quality and effectiveness of healthcare delivery.

Review of the Literature

EBP continues to be a cornerstone of modern healthcare, integrating clinical expertise, patient preferences, and the best available evidence to enhance nursing care and patient outcomes (Melnyk & Fineout-Overholt, 2023). The American Association of Colleges of Nursing (AACN) emphasizes the need for EBP competence among nurses to ensure quality, safety, and cost-effectiveness in healthcare delivery (Polit & Beck, 2023).

Higher education plays a pivotal role in fostering EBP competencies among nurses. Recent studies indicate that nurses with BSN degrees or those completing bridging programs demonstrate stronger EBP engagement compared to diploma-prepared nurses (Ferrer & Baliton, 2023; Pacis et al., 2024). Advanced education enhances research literacy and equips nurses with the skills necessary to critically appraise and apply evidence in clinical settings (Al-Ma'aitah, 2024).

Nurses’ knowledge and attitudes significantly impact EBP integration. A study by Atakro et al. (2023) revealed that positive attitudes towards EBP correlated with higher levels of research utilization in practice. Nonetheless, challenges remain. Barriers such as limited research training, lack of access to databases, and insufficient time are particularly prominent among diploma nurses (Lizarondo et al., 2023). These obstacles reduce nurses’ capacity to seek out and apply current evidence effectively.

Institutional support is equally vital for successful EBP implementation. Recent findings by Saunders and Evans (2024) highlight that organizational encouragement, leadership support, and access to evidence-based guidelines are key drivers of EBP compliance. In contrast, resistance to change, time constraints, and inadequate resources continue to hinder EBP adoption in many healthcare settings (Majid et al., 2024).

A growing body of literature focuses on comparing EBP competencies between diploma and bridging program nurses. For example, a 2024 study by Al-Busaidi et al. confirmed that bridging nurses scored significantly higher in knowledge, attitudes, and implementation of EBP. Similarly, Schmidt and Brown (2024) emphasized the need for structured EBP education in both undergraduate and continuing nursing programs to bridge this competency gap.

To address barriers and enhance EBP integration, recent recommendations include mentorship initiatives, participation in journal clubs, and institutional policies promoting research use in clinical decision-making (Thiel & Ghaffari, 2025). The use of digital platforms and open-access databases has also been recognized as a facilitator of timely and efficient access to research evidence (Khan et al., 2025).

In conclusion, while EBP is universally acknowledged as critical to high-quality nursing care, its application varies across educational backgrounds. Bridging program nurses consistently demonstrate higher EBP engagement, reinforcing the value of advanced education. Overcoming institutional and educational barriers through ongoing training, leadership involvement, and a culture of inquiry is essential for widespread EBP adoption. Future research should focus on measuring the long-term impact of these strategies on patient and system-level outcomes.

Aim of Study

This study aims to compare the knowledge, attitudes, and implementation of EBP between diploma and bridging nurses in Palestine. It seeks to assess the differences in EBP engagement, identify factors influencing its adoption, and explore the role of higher education in enhancing EBP integration.

Method

Study Design

This study employs a descriptive-comparative design to examine and compare the knowledge, attitudes, and implementation of EBP among diploma nurses and bridging program nurses in Palestinian hospitals. This approach facilitates an in-depth assessment of differences in EBP engagement between the two groups.

Research Objectives:

To assess the level of knowledge, attitudes, and implementation of EBP among diploma and bridging nurses.

To identify factors influencing EBP adoption within hospital settings in Palestine.

To examine the role of educational advancement in shaping EBP engagement among nurses.

Study Period

The study was conducted over a five-month period, from March to July 2024, during which both quantitative and qualitative data were collected from participants across various hospital settings.

Sampling Method

A convenience sampling method was used to recruit participants. The sample consisted of diploma nurses and bridging nurses working in various hospitals across the West Bank. Convenience sampling was selected due to its feasibility in accessing nurses during the data collection period.

Study Population and Sample Size

The target population consisted of registered nurses with either a diploma or a bridging BSN degree working in hospitals in the southern West Bank. To ensure a representative sample, nurses from various healthcare settings were included. The sample size was calculated using a 95% confidence interval (CI) and a 5% margin of error through the Raosoft sample size calculator (Raosoft, 2004). The final sample included 200 participants, with 104 diploma nurses and 96 bridging nurses.

Study Setting

The study was conducted across multiple hospitals in the West Bank, including Beit Jala Hospital, Arab Society Hospital, Al Ahli Hospital, Al Mezan Hospital, Red Crescent Hospital, Dura Hospital, Halhoul Hospital, Yatta Hospital, and Alia Hospital. These hospitals were selected to ensure the inclusion of nurses from diverse demographic and professional backgrounds.

Inclusion Criteria

Diploma or bridging nurses working in clinical practice for at least 6 months.

Nurses willing to voluntarily participate during the data collection period.

Exclusion Criteria

Nurses unwilling to participate.

Nurses with < 6 months of clinical experience.

Nurses not currently engaged in clinical practice.

Instrument

The study employed a structured questionnaire consisting of three sections. The first section collected demographic data, including age, gender, educational qualifications, years of experience, and prior research participation. The second section assessed the knowledge, attitudes, and practices (KAP) of EBP using the 24-item Evidence-Based Practice Questionnaire developed by Upton et al. (2006). This section covered three domains: knowledge/skills (14 items), attitudes (four items), and practice (six items), with responses scored on a 7-point Likert scale, where higher scores indicated stronger EBP engagement. The third section utilized the 18-item EBP Implementation Scale developed by Melnyk et al. (2006), which evaluated nurses’ ability to implement EBP. A 5-point Likert scale was used, with total scores ranging from 0 to 72, where higher scores indicated greater EBP implementation. The Cronbach's alpha reliability score of 0.86 for the entire scale showed that the study items had a high degree of consistency.

Ethical Considerations

Ethics approval was obtained from the University Ethics Review Committee (PPU-Nurse-25-24). Informed consent was obtained from each participant with an assurance of anonymity and confidentiality.

Data Analysis

Data were analyzed using SPSS Version 25. Descriptive statistics summarized participant characteristics. Independent t-tests compared EBP KAP, and implementation between diploma and bridging nurses. Binary logistic regression identified factors influencing EBP implementation, including age, gender, education, experience, and hospital. Statistical significance was set at p < .05. This analysis provided insight into how educational background and institutional factors affect nurses’ engagement with evidence-based practice in clinical settings.

Results

This study examined the knowledge, attitudes, and implementation of EBP among diploma and bridging nurses working in Palestinian hospitals. The results reveal significant differences in EBP engagement based on educational background, professional experience, and institutional setting.

Socio-Demographic Characteristics

Table 1 presents the socio-demographic characteristics of the 200 participating nurses. The majority of participants were aged between 25 and 29 years (40%) and were predominantly female (59.5%). Of the total, 52% held a diploma, while 48% were bridging program graduates. Nearly half of the participants (48.5%) had 1–5 years of clinical experience. Regarding professional roles, 40% were staff nurses, followed by practical nurses (33%) and head nurses (15%).

Table 1.

Socio-Demographic Characteristics of Participants (N = 200).

Variable	Categories	Frequency (n)	Percentage (%)
Age	25–29	80	40.0
	30–34	51	25.5
	35–39	29	14.5
	40 and over	40	20.0
Gender	Male	81	40.5
	Female	119	59.5
Education level	Diploma	104	52.0
	Bridging	96	48.0
Years of experience	1–5 years	97	48.5
	6–10 years	41	21.0
	More than 10 years	62	30.5
Role	Staff nurse	80	40.0
	Nursing in-charge	20	10.0
	Head of nursing	30	15.0
	Practical nurse	66	33.0
	Other	4	2.0

Comparison of EBP KAP and Implementation

Table 2 compares the mean scores of diploma and bridging nurses across four EBP domains. Bridging nurses consistently scored higher in all domains, with the greatest differences observed in knowledge (+ 0.86) and attitude (+ 0.74).

Table 2.

Comparison of Knowledge, Attitudes, and Implementation of Evidence-Based Practice (EBP) Between Diploma and Bridging Nurses.

Domain	Diploma nurses (mean)	Bridging nurses (mean)	Difference
Knowledge	5.09	5.95	+0.86
Attitude	5.06	5.80	+0.74
Practice	5.30	5.46	+0.16
Implementation	4.91	5.42	+0.51

Factors Influencing EBP Implementation

Table 3 summarizes the results of logistic regression analysis examining associations between socio-demographic variables and EBP implementation. Statistically significant associations were observed for gender, education level, years of experience, and hospital setting.

Table 3.

Associations Between Socio-Demographic Factors and Evidence-Based Practice (EBP) Implementation.

Variable	β	Wald	p value
Age (25–29 vs. 30–34)	1.481	2.293	.130
Age (35–39 vs. 30–34)	−0.162	0.063	.802
Gender (male vs. female)	0.916	4.337	.037*
Education (bridging vs. diploma)	2.886	1.441	.002*
Experience (6–10 vs. 1–5 years)	1.685	4.686	.005*
Hospital (Beit Jala vs. Yatta)	2.695	9.321	.002*

* Statistically significant at p < .05.

Findings

Bridging nurses demonstrated significantly higher scores across all EBP domains, particularly in knowledge and attitudes.

Male nurses exhibited a more positive attitude toward EBP (p = .037).

Nurses with 6–10 years of experience were more likely to implement EBP (p = .005).

These findings indicate that educational attainment, professional experience, gender, and institutional context significantly influence the adoption and implementation of EBP. The results emphasize the importance of continuous professional development, targeted educational programs, and supportive organizational environments to enhance EBP engagement among all nurses, especially diploma holders.

These results suggest that higher education and institutional support play a crucial role in EBP adoption. Further training programs and resource allocation should be considered to improve EBP engagement among diploma nurses.

Discussion

This study provides valuable insights into the knowledge, attitudes, and implementation of EBP among diploma and bridging nurses in Palestinian hospitals. The results indicate that nurses with a bridging education exhibit significantly higher levels of EBP engagement compared to diploma-prepared nurses. These findings align with existing literature but also provide new insights into the specific factors influencing EBP adoption in Palestine.

The study found that bridging nurses had significantly higher knowledge scores (5.95) than diploma nurses (5.09), confirming the role of educational level in shaping EBP knowledge. This result is consistent with previous research, such as Mohamed et al. (2024), which highlights that BSN-prepared nurses are typically more exposed to research methodologies, critical thinking, and evidence evaluation during their academic training. The higher knowledge level among bridging nurses is likely the result of their exposure to advanced research courses, which are emphasized in bridging programs.

This finding underscores the importance of advanced educational programs in fostering critical thinking and evidence utilization among nurses, as bridging programs often include in-depth training in research methodologies and evidence-based clinical decision-making. It also aligns with Atakro et al. (2020), who found that nurses with positive attitudes and greater knowledge of EBP are more likely to seek out and apply research findings in clinical practice.

A positive attitude toward EBP is essential for its successful implementation. Bridging nurses exhibited significantly more favorable attitudes toward EBP (mean score: 5.80) compared to diploma nurses (mean score: 5.06). This finding echoes research by Pacis et al. (2024), who concluded that higher educational levels lead to improved attitudes toward evidence-based care. Bridging nurses, who often receive more exposure to critical research evaluation, are likely more comfortable with integrating research findings into their practice.

Interestingly, gender differences were observed, with male nurses demonstrating more positive attitudes toward EBP (p = .037). This finding is intriguing, as it reflects previous studies where gender has been associated with different levels of engagement with EBP, possibly due to variations in workplace roles or educational experiences (Saunders et al., 2016). The reasons for this gender difference should be explored in future studies, particularly to determine if this is a cultural or educational phenomenon specific to Palestinian nursing.

The practice scores revealed a smaller difference between the groups, with bridging nurses scoring 5.46 and diploma nurses 5.30. Although bridging nurses scored higher, the difference was not as pronounced as in knowledge and attitude. This finding is consistent with those of Alrasheadi (2023), who highlighted that despite higher theoretical knowledge, translating this into practice is often hindered by institutional barriers such as limited resources, time constraints, and resistance to change.

The moderate difference in practice scores suggests that while bridging nurses may have better theoretical understanding, the application of EBP in clinical settings is more complex and influenced by various factors. This aligns with Lizarondo et al. (2019), who found that institutional support, access to resources, and organizational culture are key barriers to the successful implementation of EBP.

Bridging nurses also demonstrated significantly better EBP implementation (5.42) compared to diploma nurses (4.91). The statistically significant association (p = .002) between education level and EBP implementation supports the argument that higher educational qualifications improve the ability to integrate evidence into practice. This finding corroborates (Alblooshi et al. 2022; Zubedeh et al., 2016), who observed that nurses with higher education are better equipped to implement research findings in clinical practice.

However, despite this positive correlation, several barriers to implementation persist. As evidenced by the literature, the availability of institutional support, access to resources, and supportive leadership are crucial for effective EBP integration (Pérez-Campos et al., 2014; Qtait, 2023). These factors were highlighted in our study, with nurses from Beit Jala Hospital showing significantly better EBP implementation compared to those at Yatta Hospital (p = .002). This result points to the role that hospital policies and organizational support play in fostering a culture of evidence-based care. Institutional differences, such as leadership support, availability of resources, and policies, can facilitate or hinder the application of EBP in clinical practice (Saunders et al., 2016).

Younger nurses (25–29 years old) were more likely to engage in EBP than their older counterparts, reflecting a growing trend where younger, newly graduated nurses tend to be more receptive to incorporating research findings into clinical practice. This is consistent with findings by Saunders et al. (2016), who suggested that younger nurses may be more familiar with the latest research methodologies and have been trained in a more evidence-driven education system.

Strengths and Limitations

Strengths: The study's robust sample size (200 nurses) across multiple hospitals in the southern West Bank enhances generalizability. Its comparative design allows an in-depth examination of differences in EBP engagement between diploma and bridging nurses. Multiple data collection sites offer insights into the impact of institutional factors. The use of validated instruments ensures reliability, while ethical guidelines protect participant privacy and consent.

Limitations: The cross-sectional design limits conclusions about causality or the long-term effects of education on EBP. Convenience sampling may introduce selection bias, affecting representativeness. Self-reported data could lead to social desirability bias. The study's regional focus limits generalizability to other areas in Palestine, and gender imbalance may skew results. Additionally, external factors, such as political instability, were not explored, which could influence EBP adoption.

Implications for Practice and Education

The findings of this study underscore the importance of targeted educational initiatives to improve EBP knowledge and implementation among diploma-prepared nurses. The significant differences between diploma and bridging nurses in terms of EBP knowledge, attitudes, and implementation suggest that advanced education plays a pivotal role in fostering the skills needed to integrate evidence into clinical practice.

To address the disparities observed in this study, the following recommendations are proposed:

Integrating EBP into continuing education programs: Regular training and workshops should be organized for diploma nurses to enhance their understanding of EBP and its application in clinical settings.

Strengthening institutional support: Hospitals should ensure access to research databases, digital platforms, and mentorship programs to provide ongoing support for nurses in implementing EBP.

Encouraging collaborative learning: Creating environments where diploma nurses can work alongside bridging nurses, engaging in mentorship programs, and participating in journal clubs may facilitate the exchange of knowledge and the development of critical appraisal skills.

Conclusion

The study highlights the significant impact of education level on the engagement with EBP, with bridging nurses showing higher knowledge, better attitudes, and more successful implementation of EBP compared to diploma nurses. Educational initiatives, institutional support, and access to resources are essential to overcoming barriers and enhancing EBP adoption. Future research should explore the long-term impact of these interventions on patient outcomes and EBP sustainability in clinical practice.

Footnotes

Acknowledgements

We acknowledge the midwives who participated in the study.

ORCID iD

Mohammad Qtait

Ethical Considerations

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at Palestine Polytechnic University (the IRB approval no. 345).

Author Contributions

Write all paper and collect data.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data for this study would be available upon reasonable request from the principal investigator.

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Nurses’ Knowledge,Attitudes,and Implementation of Evidence-Based Practice Comparative Study

Abstract

Introduction

Objective

Method

Results

Conclusion

Keywords

Introduction

Review of the Literature

Aim of Study

Method

Study Design

Research Objectives:

Study Period

Sampling Method

Study Population and Sample Size

Study Setting

Inclusion Criteria

Exclusion Criteria

Instrument

Ethical Considerations

Data Analysis

Results

Socio-Demographic Characteristics

Comparison of EBP KAP and Implementation

Factors Influencing EBP Implementation

Findings

Discussion

Strengths and Limitations

Implications for Practice and Education

Conclusion

Footnotes

Acknowledgements

ORCID iD

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

References