Creating room for evidence‐based practice: Leader behavior in hospital wards

Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway Department of Medicine, Innlandet Hospital Trust, Lillehammer, Norway Faculty of Health and Social Sciences, Centre for Evidence‐Based Practice, Western Norway University of Applied Sciences, Bergen, Norway Department of Health and Nursing Sciences, Inland Norway University of Applied Sciences, Elverum, Norway Division of Mental Health Care, Center for Psychology of Religion, Innlandet Hospital Trust, Ottestad, Norway Department of Theology and Ministry, Norwegian School of Theology, Religion and Society, Oslo, Norway

EBP is defined as integrating clinical expertize with the most current and best research evidence into clinical decision making while also considering the specific available resources and the individual patient's preferences in a given situation (DiCenso, Guyatt, & Ciliska, 2005;Polit & Beck, 2016;Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). At the organizational level, EBP may assist in developing and integrating EB guidelines. At the individual decision making level, EBP may improve patient treatment and care (Polit & Beck, 2016). It has been suggested that leaders and managers play a key role by modeling EB decisions and that it is essential to recognize clinicians' EBP accomplishments to promote a favorable EBP culture (Aasekjaer, Waehle, Ciliska, Nordtvedt, & Hjälmhult, 2016;Dogherty, Harrison, & Graham, 2010;Melnyk, 2014). Organizational factors, including the capacity for change at the organizational level, were also emphasized upon (Atkinson, Turkel, & Cashy, 2008;Flodgren, Rojas-Reyes, Cole, & Foxcroft, 2012). In line with May and Finch (2009), we understand the implementation of EBP as facilitation of the adoption or uptake of EBP within the organization. Integration means the routinizing and sustaining of new practices. In this paper, we focus on routinizing and sustaining EBP and use the term integration to refer to this process. Integrating EBP into daily work in a sustainable manner involves the routinization of new practices within a social context (May & Finch, 2009). This process is determined by the interactions between the characteristics of the evidence, the intended users, and the particular context of the practice (Titler, 2014). A more favorable context, including culture, supportive leaders, and recognition for a job well done, is related to an increase in research utilization (Estabrooks, Midodzi, Cummings, & Wallin, 2007). Organizational culture is defined by the assumptions, beliefs, ideas, and activities that are valued by the organization and expressed in the practitioners' patterns of behavior contributing to the organization's unique social and psychological environment (Scott-Findlay & Golden-Biddle, 2005).
The prerequisites for success in EBP integration include the translation of current research findings in the healthcare setting and their use by healthcare professionals to provide information about and improve their clinical performance (Melnyk, 2012). Research findings have suggested that clinical nurses' experience of support from their leaders determines their research utilization (Gurses et al., 2010;Kaplan, Zeller, Damitio, Culbert, & Bayley, 2014;Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012;Sredl et al., 2011;Yoder et al., 2014). Nevertheless, the way in which leaders promote changes in nursing practice remains unclear (Dogherty et al., 2010).
In a recent study, Bender (2016) found that strong managerial leader support and continuous quality work by clinical leaders are essential for improving healthcare quality and safety. Manager is a general term for the executive directors or frontline nurse managers responsible for the daily running of the wards and for leading the staff members who provide direct patient care. Clinical leaders may refer to clinical nurse specialists, advanced practice nurses, nurse educators, or practice developers working in patient care situations (Van der Zijpp et al., 2016). Van der Zijpp et al. (2016) have highlighted the importance of the interactions among different levels of leaders. They found that the relationship between managers and clinical leaders could hinder or enable the integration process. Nevertheless, few detailed research descriptions of nurse leaders' influence or actions for improvement have been published (Adams & Natarajan, 2016;Dogherty et al., 2010;Ovretveit, 2010). More research on the role of leaders in EBP integration should address both leaders' actions and contextual factors in actual healthcare situations (Best et al., 2012;Bolden, 2011;Greenhalgh, 2018;Van der Zijpp et al., 2016).
Several studies have disclosed barriers in clinical nurses' work environment and among leaders that may hamper the EBP integration process. Among clinical nurses, lack of time, knowledge and skills in EBP are important individual barriers (Chiu et al., 2010;Mallion & Brooke, 2016;Melnyk et al., 2012;Yoder et al., 2014). These barriers influence the leaders' possibilities to succeed when they attempt to integrate EBP in their wards. The organizational culture may also act as a barrier (Bergs et al., 2015;Flottorp et al., 2013). For example, Bergs et al. (2015) found that issues regarding communication and teamwork could hamper the use of surgical safety checklist. Leaders themselves may also be a barrier to EBP integration by not having the necessary capacity, not being engaged or not having a suitable leader behavior style (Flottorp et al., 2013). The relationship between leaders in leader teams may also hinder the integration process (Van der Zijpp et al., 2016). Negative opinion leaders or other leaders may act as barriers in the integration process (Varsi, 2016). Another important barrier is that necessary resources may not be identified or available for the team members. According to Flottorp et al. (2013) this could, for example, be limitations of the information system, lack of patient safety systems or continuing education systems, which may hinder adherence to EBP recommendations.
The context of this study involved a Norwegian hospital trust's executive director decision to implement EBP as a hospital-wide policy in 2006. EBP was implemented by applying different strategies to help clinicians develop competence in EBP and make organizational adjustments (Vandvik & Eiring, 2011). Norwegian hospitals are organized into local health trusts, which may consist of several hospitals (Spehar, Frich, & Kjekshus, 2014 methodology is particularly well-suited for performing systematic qualitative research and investigating the complex and latent patterns involved in social interactions (Glaser & Strauss, 1967).
In theory development, the participants' main concern and their patterns of behavior surrounding this concern are identified.
"Main concern" refers to something with which the participants are occupied and usually involves a challenge or problem (Glaser, 1998). Grounded theory requires researchers to be open-minded, to be aware of and suspend preconceptions, and to trust that the way the participants resolve their main concerns will emerge (Glaser, 1998(Glaser, , 2013.

| Sample and setting
This study took place in two medical wards that treat patients with different diagnoses in two locations in Eastern Norway. This hospital trust provides acute services to 400,000 people at six different geographical sites. The two wards included in the study used two different strategies to integrate EBP into daily work. In one ward, the nurses worked with an EBP project, developing local clinical guidelines, and in the other ward the nurses integrated EB guidelines through the use of huddle board sessions (Table 1). Huddle board sessions are short structural meetings among interdisciplinary health professionals (huddles) (Glymph et al., 2015) around a whiteboard used as a patient risk assessment tool (huddle board). Forms and checklists were used in risk assessments, and after making observations and measures the nurses were expected to report it by checking off the corresponding item on a report card.
The wards, participants, and methods were chosen via theoretical sampling. In theoretical sampling, a researcher collects and analyzes data, from which patterns emerge that then inform the decisions about which data to collect next, where, and the way in which it should be collected (Glaser & Strauss, 1967). Details about the theoretical sampling process are outlined in the data collection chapter. To ensure the participants' confidentiality, the cities in which the wards were localized, and specifications of their specializations remain undisclosed.
In the study, we observed 63 nurses in participant observations. From these, 18 clinical nurses participated in focus groups, and five leaders participated in individual interviews, including two head nurses, one assistant head nurse, and two teaching nurses, which were all termed "leaders" in this paper. The main areas of responsibility for the leaders are outlined in Transfer and Accumulation System (ECTS) credits and were either in management or for their wards, were in relevant advanced clinical or professional education. All the leaders had completed EBP seminars some years before the participation in this study but could not recount the content of these seminars in detail.
Specialist, registered, and assistant nurses (15, 39, and 9, respectively) were observed in this study. The specialist nurses' education beyond basic nursing education equalled 60 ECTS credits, except two who had 120 ECTS credits. Their formal roles in the wards did not differ from the roles of registered nurses, even if they had acquired an expert base and clinical competency for advanced practice. Data collection and analysis were performed concurrently based on the principles of grounded theory (Glaser, 1978). In participant observations (such as combinations of direct observation and interactions with the healthcare professionals), the researcher followed clinical nurses during their daily ward-related activities (Creswell, 2013;Polit & Beck, 2016). The researcher wrote both descriptive and reflective field notes during and immediately after the observations (Creswell, 2013). Observations were conducted in 90 hr over 13 weeks. We collected and analyzed data to fit the data collected from the individual interviews with the data collected from the observations and focus groups within the same ward (see the details in Table 4). Furthermore, scheduling time with the leaders was challenging due to their demanding workloads. The same clinical nurses and leaders were involved in the study across the entire data collection period. All clinical nurses and leaders who participated in individual interviews and focus groups were recruited from the group of observed nurses.

| Data collection
This study's first author together with a comoderator performed the first two individual interviews. The comoderator was a nurse with a master's degree and was experienced with interviews in qualitative research. Thoughtful discussions between the two moderators facilitated the development and direction of the following interviews specifically and the study in general. The next three individual interviews were conducted only by the first author. To ensure the participants' comfort, they were interviewed at their respective hospitals in rooms of their choice. The interviews lasted between 51 and 67 min and were audiotaped and transcribed by the researcher afterward. A dynamic thematic interview guide that consisted of mutual themes framed in different ways, themes adjusted to emerging codes and categories and situations observed in the wards was used (Table 3). We

| Data analysis
Data were analyzed with open and selective coding as prescribed by grounded theory (Glaser, 1978). In open coding, we coded events from the field notes and transcriptions line-by-line and compared events using the constant comparative method (Glaser, 1978;Glaser & Strauss, 1967). We analyzed the data from this data collection in two parallel arms to generate two grounded theories. First, we developed a theory about clinical nurses' patterns of behavior in EBP integration by analyzing the data from the observations and focus groups. This theory has been published elsewhere (Renolen, Høye, Hjälmhult, Danbolt, & Kirkevold, 2018). In the second arm, we did a preliminary analysis of the first individual interview with the aim of guiding the second individual interview in the first ward. We then thoroughly analyzed the first two individual interviews together with data from observations and focus groups in both wards after which we conducted individual interviews and analyzed data concurrently to generate a theory about the leaders' patterns of behavior (Table 4).
When we began to sense emerging trends, we directed the coding to events relevant for the preliminary core category, thus performing selective coding. During the analyses, the lead researcher wrote memos, which were reflective notes of the relationships between the data to be used in the theoretical coding for theory generation T A B L E 3 A dynamic thematic guide for individual interviews: Examples of questions

Situations Questions
The opening question to all participants, formulated in different ways How do you experience the integration of EBP in your ward? Can you tell what you have experienced with which to be successful and what has not been a success?
One leader says: "Sometimes the nurses may have the time and could read a guideline or update them in other ways, if it was a culture for that" How may you influence the culture so as to facilitate that?
The emerging strategy "observing nurses' level of professionalism" and under-strategy "experiences variations in use of guidelines" How do the clinical nurses use guidelines in their daily work?
Following up situations from the observation period In the observation period, I observed that you played an important role in organizing critical reflection groups. What makes such reflection successful in your view?
Abbreviation: EBP, evidence-based practice. | 95 (Glaser, 1978). Initially, ÅR coded the data and ÅR and EH discussed the preliminary codes and categories. Afterwards, all authors scrutinized and discussed the transcribed interviews, codes, and categories. In the analysis, after the fourth individual interview was completed, we came to an agreement to conduct another interview with a leader from the second ward. Due to practical reasons, this could not be done before January 2018. Data collection stopped when no new categories emerged, and theoretical saturation was achieved. The theoretical coding was continued to conceptualize the categories and strategies on a more abstract level. An example of the coding process is outlined in Table 5.

| Ethical considerations
Approval from the Regional Committee for Medical and Health The participants were informed about the study and its purpose by their leaders and the lead researcher. The lead researcher recruited the participants into the focus groups and individual interviews by asking the participants personally while concurrently obtaining written informed consent. All procedures were conducted in accordance with the Declaration of Helsinki.

| RESULTS
On the wards, the leaders' and the clinical nurses' overarching goal was to provide patient treatment and care in the best possible way.
Through generation of a substantive grounded theory, we found that the leaders' main concern regarding integration of EBP was how to achieve EB patient treatment and nursing care with tight resources and without overextending the nurses. The main strategy used to resolve this main concern could be expressed by the following general pattern of leader behavior: Creating room for EBP in management and nursing care. "Creating room for EBP" was the concept of leader behavior that involved actively making EBP capacities in their wards. The emerging grounded theory of creating room for EBP included three strategies positioning for EBP, executing EBP, and interpreting EBP responses.

| Conditions for creating room for EBP
We identified three main conditions that influenced the leaders when creating room for EBP. One condition described organizational premises, such as institutional rules, routines, and standards, as determinants for management and nursing care. The leaders operated within the boundaries set by limited resources and lacked a good system for instigating change. Second, the organizational culture was characterized by standardizing treatment and care practices and by focusing on task accomplishment. This led to a prevailing attitude of practical tasks being viewed as "real" work.
Furthermore, nurse staffing was planned according to daily practical

T A B L E 5 Data processing
Transcriptions and field notes Open coding Selective coding Category

Individual interview:
Moderator: "In the observation period, I observed that you played an important role in organizing regular critical reflection groups. What makes such reflection successful in your view?" Leader: "One has to control the reflection to adhere to the issue.
For example a patient situation experienced difficult by a nurse who wants to share this experience and get some feedback from her colleagues. I think it is important to keep the focus and not just talk." Organizing reflections Inspiring to participate in regular critical reflection

Stimulating professionalism
Guiding the reflections Stimulating professional engagement

Keeping a professional focus
Observations: Leader at the morning meeting: "Keep in mind to use the non-slip socks, but remember it is not instead of shoes." Leader at the morning meeting: "At the staff meeting yesterday we had a question regarding use of facemasks. Nurse A, could you say something about it?" A: "To protect the patient in a procedure taking two or three minutes, use the green facemask. Use the pink facemask if the procedure takes longer or in the case of airborne infections. That is the main rule."

Reminding the nurses of a clinical issue
Providing for regular professional updates Addressing the evidence precisely

Holding expert nurses responsible
Individual interview: "We have been working in groups with an EBP project that ended in some EB guidelines, which we try to implement into daily work.

| Positioning for EBP
The concept of positioning for EBP emerged as the first strategy in the process of creating room for EBP. The leaders started to create room for EBP "outside" of the clinical nurses' workflow by making themselves capable of managing EBP within the existing conditions.
The leaders managed this process by using three substrategies: ensuring their own capacity, working in leader teams, and being ready for the effort. They ensured their own capacities by capitalizing on their years of experience as leaders in their present positions and earlier participation in EBP seminars. They demonstrated an understanding of and motivation for integrating EBP.
When working in leader teams, the leaders structured their work by collaborating and strategically dividing tasks and responsibilities.
They cooperated and interacted with each other, thus taking advantage of each other's resources and ensuring that each individual knew the way in which to contribute. One leader described how they created cooperation structurally in their leader team to position themselves for EBP integration: We organized team meetings but canceled several of them because of huge workload …. According to the guidelines, this is possible here as well.
We need to change our practice. (Observation) The leaders also adjusted their own workloads to promote EBP

| Executing EBP
The executing EBP pattern encompassed stimulating the nurses professionally, struggling with daily EBP challenges, and buffering these challenges. This strategy in creating room for EBP was connected to the clinical nurses' workflow and influenced their daily practice. In the first strategy, the leaders sought to inspire the clinical nurses professionally by focusing on EBP and promoting the use of national guidelines as the basis for evidence in clinical practice. They encouraged the nurses to report patient safety incidents and participate in regular critical reflections. As one of them explained: We have considered how to make EBP advantageous. seminars. Thus, the leaders had to ask the nurses to attend training in their spare time in the afternoons or on their days off. This request contributed to the need for compensatory time-off from an already tight work schedule, which was not always easy to accommodate.
Taken together, this entire process was very challenging, as highlighted in the example below: Two clinical nurses had been revising an EB standardized care plan for months and were almost finished. They now needed some time to finish this task and asked the head nurse for 2 hr allocated time each. The answer was that it was not possible because of staff shortage. They were tired of not getting finished and decided to complete the work in their spare time this afternoon. The nurse sighs: "It is not for my sake we are doing this." (Observation) To minimize these kinds of situations, an important strategy in terms of executing EBP was the leaders' buffering of the nurses' challenges in managing EBP integration. In this context, "buffering" refers to enacting measures to intercept or moderate any adverse influences or pressures to which the clinical nurses were exposed. The following example illustrates this "buffering" strategy: The clinical nurses were frequently observed complaining that they felt more pressure to complete standardized routine procedures mandated by the hospital-wide patient security policy than addressing individual needs of their patients. In response, the leaders would help the clinical nurses address this dilemma by adjusting the expectations. When appropriate, the leaders would tell the nurses to skip a routine task and rather prioritize performing individualized EBP to a seriously ill patient. Additionally, the leaders modified routines, helped the nurses with practical tasks, and supported them by providing a sense of security when undertaking unfamiliar tasks.
They also tried to get the nurses to engage professionally with the physicians by supporting them to insist on sharing responsibilities with the physicians during pre-and regular rounds, thereby decreasing the burden on the nurses. For example, this process occurred when the leaders believed that the nurses were assigned too heavy a responsibility for unstable patients without adequate involvement of the physicians: "I have told the nurses that they have to get the physicians to define which patients they need to follow closely. Further they must have the physician affirm which checking offs they need to prioritize for each patient." (Individual interview) The leaders also tried to give the nurses some time set aside from their daily workflow to work with EBP and requested that the nurses ask for help to complete assigned tasks when needed.
As such, the leaders also organized activities without directly involving themselves into the nurses' work. The findings suggested that when the leaders were working closely with the nurses' workflow, they could better support them and identify more easily the adjustments that were needed to continuously promote EBP integration.

| Interpreting EBP responses
In the third strategy, the leaders created room for EBP by interpreting EBP responses. This strategy was an emerging concept reflecting the leaders' handling of feedback from the nurses, observing the nurses' professional performance, and considering the consequences of EBP integration. The leaders handled nurses' feedback, mostly by answering EBP-related questions arising during their daily work. For example, when the nurses asked for help finding specific knowledge, the leaders had more opportunities than the nurses to find time to search for that knowledge. The leaders also received patient safety incident reports and formal complaints from the nurses or from other departments and hospitals. Leaders acted based on these reports and complaints and discussed patient safety incidents and EBP with the nurses as a learning strategy. The following example illustrates this process: Much of what the leaders concluded from their observations was based on what they believed about the nurses' behavior, but they recognized that the current system was not optimal: "We lack a system to affirm that the nurses read a guideline, for instance a digital registration. For example, when we link a guideline in information e-mails, we don't know if anyone reads the guideline." (Individual interview) The third interpretation-related EBP substrategy used by the leaders was to consider the consequences of EBP integration-that is positive outcomes as well as no or negative outcomes. They used this information to further consider how to facilitate EBP. For example, they could see professional clinical benefits when the nurses gained an increased awareness regarding their use of knowledge or when the nurses applied EB measures during problem solving. However, sometimes the leaders observed less use of EB guidelines than they expected after the EBP integration process and they experienced patient safety issues not being discussed. The leaders discussed these results and used them to inform which strategies to use in terms of creating room for EBP.
In creating room for EBP, the leaders also needed to address the potential conflict of applying standardized EBP routines and procedures to ensure patient safety generally and ensure high quality care by addressing the needs of individual patients. From their observations, the leaders believed that the nurses often prioritized routines and standard safety reports ahead of other tasks and assumed that it was the most experienced nurses who dared to prioritize other tasks ahead of the "check offs". Although the leaders supported the application of EB routines and standardization, they also worried that there were too many "check offs" for the nurses to make and that this process would impede their ability to complete the tasks most essential for individual patients' care. Clinical nurses' and leaders' thoughts illustrate this dilemma.
Nurse A: We spend more time on "check offs" than we spend on the patient.
Nurse B: Yes, it is demanding with all the reporting, it is detrimental to basic nursing care. The leaders refer to research evidence, but I think this takes too much time.
We will not be able to follow-up, and just as you say The leaders could use these observations further to understand how to buffer the clinical nurses' challenges. When the leaders interacted with the nurses, they were able to make more direct observations and obtain greater possibilities to consider, understand, and influence practice.

| DISCUSSION
In this study, we aimed to generate a theory about the patterns of leader behavior that leaders are engaged in when attempting to integrate EBP in a clinical setting. We found that the theory of creating room for EBP was used by leaders to resolve their main concern: how to achieve EB patient treatment and care given their tight resources and without overextending the nurses. factors within the operational leader actions were identified. These included inspiring and inducing behaviors and involvement with the staff and EBP activities (Stetler et al., 2014). These findings, among others, imply that involvement and interaction with the nurses is more likely to result in successful EBP integration (Gurses et al., 2010;Ploeg et al., 2014;Stetler et al., 2014).
Our findings also suggest situations in which the leaders seemed to be less capable of considering and identifying adjustments that were needed for EBP integration. The leaders could give the nurses allocated time or tell them to ask for help when needed. The leaders' observations of clinical nurses' daily work were limited; therefore, the opportunities to adjust their responses to these observations were scarce. In line with the findings of Åkerlund (2017), leaders may have little practice or experience with observing the way in which their staff is performing and how they may influence their fellow workers. On the basis of these considerations, we argue that engagement in nurses' workflow might confer a greater likelihood of not overextending the nurses with respect to EBP integration. Another perspective indicates that involvement in clinical nurses' workflow seems to be tightly connected to facilitating EBP integration and teamwork. Leaders that facilitate their teams demonstrate support for both learning and action (Greenhalgh, 2018). Leaders that put effort into facilitating their team and the necessary tasks and are close to the team members may have success in the process of establishing new routines (Edmondson, Bohmer, & Pisano, 2001;Greenhalgh, 2018). Leaders with little emphasis on teamwork and with a focus on allocating tasks and getting results from the teams more than being a team member are less likely to succeed in changing a routine (Edmondson et al., 2001;Greenhalgh, 2018).

| Strengths and limitations
A strength of this study is that the overall empirical data from the observations, individual interviews, and focus groups reinforce the patterns of leader behavior. By being workable and having relevance, the theory explains the action and the relationships between the actions in the substantive area. Because we investigated only two hospital wards in one hospital trust, we must be cautious in terms of applicability and transferability to other hospital wards even though our study was conducted in two different geographical sites. Our sample size of leaders in this study was small. We have discussed the need for interviewing more leaders to ensure saturation (Glaser, 1978(Glaser, , 1998. However, this would have required us to go outside the wards or to include leaders without direct daily contact with the clinical nurses. This could conflict with the principles of theoretical sampling and emerging concepts.

| Implications for clinical practice and research
The grounded theory of creating room for EBP contributes to a better understanding of the patterns of leader behavior when leaders attempt to integrate EBP into their wards. The theory reveals the importance of the strategies for the leaders' capacity and ability to create room for EBP without overextending the nurses. Based on this knowledge, we suggest that the direction for future research should be to explore interactions between leaders and nurses in EBP integration. This could serve to further enhance the leaders' knowledge regarding the way in which clinical nurses respond to EBP integration activities and to better adjust EBP integration to clinical practice.

ACKNOWLEDGMENTS
We are very grateful to the ward leaders for their time and for sharing their thoughts and experiences. We also greatly appreciate the participating clinical nurses and their colleagues, who ensured on a daily basis that the wards did not suffer during the data collection. We also want to thank Kari Kjønsberg for participating as a comoderator in the two first individual interviews. Innlandet Hospital Trust, Norway and Norwegian Nurses Organization funded the study.