Journal of Modern Medical

Introduction
Evidence-based nursing (EBN) is clinical decision-making with the help of systematic evidence, clinical expertise, and patient preferences, which provides high-quality and safe patient care. It is necessary to use it as an efficient method for clinical care. One of the factors that may affect EBN is self-efficacy. Self-efficacy is a person’s belief in their abilities to succeed in a given situation. Studies have shown that although self-efficacy is an important factor in promoting EBN, nurses’ self-efficacy is not at an optimal level. It seems that if nurses have good self-efficacy, the possibility of implementing EBN will increase.
On the other hand, based on the knowledge, attitude and practice (KAP) theory, knowledge is the foundation of behavior change and attitude is the driving force of behavior change. Improving the level of knowledge can change people’s attitudes and thereby affect their practice or behavior. Based on this theory, it is necessary to evaluate the KAP of nurses in terms of EBN to measure their competencies. A study that investigated the mediating role of knowledge and attitude in the relationship between self-efficacy and EBN practice was not found. In this regard, the present study aims to assess the mediating role of knowledge and attitude (towards EBN) in the relationship between self-efficacy and EBN practice.

Methods
This is a descriptive and cross-sectional study. The study population consists of all nurses working in hospitals affiliated to Mashhad University of Medical Sciences in Iran. Due to the presence of ten components in the path model, a minimum sample size of 200 was needed. This number increased to 250, due to the possibility of sample dropout. Multi-stage cluster random sampling was used. Two hospitals were randomly selected. Then, four departments were randomly selected from each hospital. Samples were selected from these departments. The data collection tools included a sociodemographic form, Schwarzer’s general self-efficacy scale (10 items), and Degu et al.’s knowledge (10 items), attitude (10 items), and practice (10 items) scales. Data analysis was done using descriptive statistics, Pearson correlation test, and path analysis in SPSS software, version 27 and AMOS software, version 24. The direct and indirect effect coefficients were estimated using the bootstrap method with 2000 repetitions.

Results
The evaluation of the study’s conceptual model using the fit indices showed that the model had a good fit to the data. The chi-square index was not significant (X2=9.048, df=8, P=0.338). The X2/df was equal to 1.131, the goodness-of-fit index (GFI)=0.988, comparative fit index (CFI)= 0.993, incremental fit index (IFI)= 0.994, Tucker-Lewis index (TLI)=0.988 and root mean square error of approximation (RMSEA)=0.023.
Self-efficacy had the greatest direct effect on using EBN (β=0.308). Self-efficacy through knowledge and attitude towards EBN had a positive and significant indirect effect on using EBN (P<0.001). The value of coefficient of determination (R2) for EBN practice based on self-efficacy, knowledge, and attitude was 0.14. The f2 effect size was 0.16, which is a medium size.

Conclusion
The results of this study showed that self-efficacy had a direct and positive effect on the EBN practice. Self-efficacy also had an indirect effect on the EBN practice through knowledge and attitude towards it. Therefore, it can be concluded that if nurses have a positive knowledge, attitude, or belief about their ability to perform EBN, they will be more capable and will perform better. Therefore, medical universities and medical centers should pay special attention to the self-efficacy level of nursing students or nurses, which is always affected by their practice and other individual and organizational factors. It is better to consider strategies such as holding educational workshops and training courses to improve nurses’ self-efficacy, knowledge, attitude, and EBN practice in hospitals. Adopting strategies to motivate and encourage nurses to use EBN can also be useful. It is recommended that similar research be conducted in other medical universities in Iran using other data collection tools such as interviews.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by Ferdowsi University of Mashhad (Code: IR.UM.REC.1401.212).

Funding
This article is taken from a part of the research project (Project No.: 58883), which was carried out with the support of Ferdowsi University of Mashhad.

Authors' contributions
Conceptualization, methodology, validation, review and editing: All authors; Investigation: Masoumeh Tajafari and Nasrin Fanoodi; Formal analysis and visualization: Farhad Tanhaye Reshvanloo; Writing the original draft: Masoumeh Tajafari and Nasrin Fanoodi; Supervision, project administration, and funding acquisition: Masoumeh Tajafari.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to express their gratitude to the nurses of Mashhad University of Medical Sciences for their valuable contribution to the research. The research team would also like to thank Ferdowsi University of Mashhad for its support.




References