Undergraduate Nursing Research Education and Preparedness for Evidence-Based Practice: A Cross-Sectional Study in Kenyan National Referral Hospitals

Introduction

Evidence-based practice (EBP) constitutes a cornerstone of contemporary nursing science and is broadly defined as the deliberate, explicit, and judicious integration of the best available research evidence with clinical expertise and patient values to guide healthcare decisions (Melnyk & Fineout-Overholt, 2019; Sackett et al., 1996). The adoption of EBP across healthcare systems has been associated with measurable improvements in patient outcomes, reduced rates of hospital-acquired complications, standardization of care quality, and more efficient allocation of healthcare resources (Stevens, 2013; Titler, 2018). Consequently, the capacity to locate, appraise, and implement research evidence in clinical practice has emerged as a central competency benchmark for professional nursing education worldwide (World Health Organization [WHO], 2020). In sub-Saharan Africa, including Kenya, the rapid expansion of university-level nursing education since the early 2000s has been motivated in substantial part by the imperative to cultivate a graduate nursing workforce capable of engaging meaningfully with research and implementing evidence in clinical settings (Nzengya et al., 2023). The Bachelor of Science in Nursing (BScN) curriculum, as mandated by the Nursing Council of Kenya (NCK), incorporates dedicated modules on research methodology, biostatistics, critical appraisal of literature, and the foundational principles of evidence-based care (NCK, 2019). The underlying policy assumption is that this academic exposure sufficiently equips BScN graduates to translate research knowledge acquired during training into competent, evidence-informed clinical decision-making across their professional careers. However, a growing and increasingly robust body of international nursing literature challenges this assumption. Systematic reviews and multi-site surveys consistently demonstrate that self-reported preparedness for EBP does not reliably correspond to observed EBP behavior in practice settings (Brown et al., 2009; Melnyk et al., 2012). Graduate nurses may acquire declarative knowledge of research concepts an intellectual understanding of what EBP is without developing the procedural competence to enact itthe practical skills to appraise primary literature, contextualize evidence within local patient populations, and design and justify evidence-informed changes to clinical routines (Squires et al., 2011). This preparedness-to-practice gap appears to be especially pronounced in low- and middle-income countries (LMICs), where structural constraints, resource limitations, hierarchical clinical cultures, and institutional underinvestment in research infrastructure collectively intersect with educational gaps to impede EBP implementation (Aarons et al., 2011; Omery & Williams, 1999). Within Kenya's national referral hospital system where the complexity and severity of patient presentations and the multi-specialty nature of care demand sophisticated, research-informed clinical reasoning the question of how effectively undergraduate research education translates into genuine EBP preparedness carries profound implications for patient safety, care quality, and the professional standing of nursing as a discipline (Njiru, 2018). Despite this significance, empirical evidence characterizing the preparedness of BScN-trained nurses for EBP application in Kenyan tertiary healthcare settings remains sparse. The majority of published studies on this topic originate from high-income Western healthcare contexts, or rely on single-institution convenience samples with limited methodological rigor and generalizability to the Kenyan or broader sub-Saharan African nursing context (Perez et al., 2021). This evidence gap impairs the ability of policymakers, nursing educators, and hospital administrators to design targeted, evidence-informed interventions to strengthen EBP capacity within the nursing workforce. This study was designed to address this critical gap. Guided by a pragmatic worldview and employing a concurrent embedded mixed-methods design, this investigation integrates quantitative measurement of perceived EBP preparedness across six core research competency domains with qualitative exploration of the lived educational and professional experiences that shape the relationship between undergraduate training and EBP readiness. Data were drawn from two strategically selected national referral hospitals: Moi Teaching and Referral Hospital (MTRH) in Eldoret and Nakuru County Teaching and Referral Hospital (NCTRH) in Nakuru.

Theoretical Framework

This study is anchored in two complementary theoretical frameworks: the Transtheoretical Model (TTM) of behavior change (Prochaska & DiClemente, 1983) and the Theory of Planned Behavior (TPB; Ajzen, 1991). The TTM conceptualizes behavior change as a staged process through which individuals progress across five discrete stages precontemplation, contemplation, preparation, action, and maintenance each characterized by distinct cognitive, motivational, and behavioral features. Applied to EBP adoption in nursing, the TTM predicts that formal undergraduate education may move nurses from contemplation to the preparation stage, equipping them with positive intentions and foundational research knowledge. However, attaining the action stage in which nurses consistently and skillfully implement research evidence in clinical decision-making requires additional enabling conditions beyond intention alone, including self-efficacy (confidence in one's ability to perform the behavior), mastery experiences, and environmental reinforcement (Melnyk et al., 2014; Prochaska & DiClemente, 1983). The TPB (Ajzen, 1991) complements this staged model by specifying the cognitive antecedents of behavioral intention and action. According to the TPB, a nurse's engagement in EBP behavior is jointly determined by three constructs: (a) attitude toward the behavior the degree to which EBP is viewed positively or negatively; (b) subjective norms perceived social pressure from significant others (peers, supervisors, medical colleagues) to engage in EBP; and (c) perceived behavioral control the extent to which the nurse feels capable and empowered to engage in EBP. Of particular relevance to the present study is the construct of perceived behavioral control, which functions as a proxy for self-efficacy and directly predicts not only behavioral intention but also, independently, behavioral performance (Francis et al., 2004). The TPB predicts that even where attitudes are positive and norms are supportive, low perceived behavioral control will inhibit EBP engagement a prediction that aligns closely with the preparedness-competence paradox identified in this study's findings. Together, these frameworks generate a coherent prediction: undergraduate nursing education that succeeds in building positive EBP attitudes (improving affective and normative components of the TPB) and moving nurses to the preparation stage of the TTM will nonetheless fail to produce consistent EBP behavior if it does not simultaneously build robust self-efficacy and practical research competence. This theoretical architecture provides both the interpretive lens for the study's quantitative findings and the explanatory scaffold for the qualitative narratives reported below. We determined the extent to which exposure to undergraduate nursing research education prepares nurses to apply evidence-based practice in clinical settings at two national referral hospitals in Kenya.

Methods

Study Design and Philosophical Orientation

This study employed a concurrent embedded mixed-methods design, as operationalized by Creswell and Plano Clark (2018). This design is characterized by the simultaneous collection and analysis of both quantitative and qualitative data within a single phase, with one strand assigned greater methodological weight than the other. In this study, the quantitative strand was assigned primary status (75% weighting) and employed a descriptive cross-sectional survey design to measure the extent and pattern of EBP preparedness across the eligible nurse population. The embedded qualitative strand (25% weighting) adopted a phenomenological orientation (Polit & Beck, 2021), foregrounding the lived educational and professional experiences of nurses as the unit of qualitative analysis. The philosophical foundation for this design was pragmatism (Creswell & Plano Clark, 2018; Morgan, 2014). Pragmatism prioritizes the research problem over allegiance to a singular philosophical paradigm, permitting the researcher to select and combine methods based on their fitness for purpose. The complex, multilayered nature of the research problem understanding how undergraduate education shapes EBP preparedness across a diverse nursing population operating in high-acuity clinical environments necessitated both the breadth achievable through quantitative measurement and the depth accessible through qualitative inquiry. The pragmatic orientation also foregrounds the practical utility of findings, ensuring that results are directly actionable for curriculum developers and health workforce planners in Kenya. Integration of quantitative and qualitative findings occurred at the interpretive phase through a "following the thread" approach (O'Cathain et al., 2010), in which quantitative patterns were progressively elaborated, explained, and occasionally challenged by qualitative narratives yielding a richer, more nuanced meta-inference than either strand could produce independently.

Study Setting

The study was conducted at two purposively selected national referral hospitals: Moi Teaching and Referral Hospital (MTRH) in Eldoret, Uasin Gishu County, and Nakuru County Teaching and Referral Hospital (NCTRH) in Nakuru. Both institutions are designated by the Ministry of Health Kenya as national and regional referral facilities with formal mandates encompassing specialized clinical service delivery, health professions training, and research (Ministry of Health Kenya, 2012). Their dual role as high-acuity service delivery sites and teaching institutions makes them particularly appropriate settings for investigating the translation of research education into clinical EBP practice (Njiru, 2018; Nzengya et al., 2023). The combined nursing workforce across both institutions at the time of data collection totaled 844 nurses.

Population and Sampling

The study targeted undergraduate-trained registered nurses (BScN holders) who were formally employed at either MTRH or NCTRH on permanent, contractual, or long-term engagement terms, with a minimum of one year of post-qualification clinical experience. This minimum experience threshold was established to ensure that participants had sufficient exposure to routine clinical decision-making processes to provide informed perspectives on EBP application in practice (Polit & Beck, 2021). Applying the specified inclusion and exclusion criteria to the combined workforce of 844 nurses yielded an eligible population of 238 nurses. This figure was used as the basis for quantitative sample size computation. For the quantitative component, the National Education Association (1960) formula for small population sample size determination was applied at a 95% confidence level (χ² = 3.841), assuming maximum population proportion variability (P = 0.5) and a degree of accuracy of d = 0.05. This yielded a required sample size of 147 nurses, drawn using stratified random sampling across clinical departments and professional roles to ensure representative coverage. Of the 147 questionnaires distributed, 136 were completed and returned, yielding a response rate of 92.5%, which exceeds the minimum acceptable threshold for clinical survey research (Polit & Beck, 2021). For the qualitative component, 20 participants were purposively recruited from eligible nurses who had not participated in the quantitative survey10 from each institution drawn from clinical nursing, nursing administration, and nurse education roles. Recruitment continued until data saturation was achieved, consistent with the criterion that successive interviews no longer generated novel codes or themes (Braun & Clarke, 2006; Guest et al., 2020).

Instrumentation

Quantitative data were collected using an adapted version of the Research Utilization Questionnaire (RUQ), an instrument with a well-documented history in assessing research utilization behavior and preparedness among nurses (Champion & Leach, 1989; Estabrooks, 1999; Yoder et al., 2014). For this study, the RUQ was adapted to assess six EBP preparedness competency domains: (a) problem identification and development of a problem statement, (b) literature identification and critical review, (c) research proposal development, (d) data collection and analysis, (e) interpretation and presentation of findings, and (f) recommendation of findings for practice utilization. Items were rated on a five-point Likert scale anchored at 1 (strongly disagree) to 5 (strongly agree). The instrument was supplemented with a comprehensive demographic section and items specific to the Kenyan undergraduate nursing experience. Instrument validity and reliability were established through a pilot study conducted with 15 BScN nurses at Langa Langa Hospital, Nakuru County a facility excluded from the main study assessing item clarity, cultural appropriateness, face validity, and internal consistency. Pilot feedback led to minor wording revisions in several items and the removal of one redundant attitudinal item. Internal consistency for the preparedness subscale was excellent (Cronbach's α = .9565), affirming the psychometric rigor of the adapted instrument within the Kenyan clinical nursing context. Qualitative data were collected using an unstructured interview guide comprising open-ended questions derived directly from the study objective. Each interview lasted 40–60 minutes and was conducted either face-to-face in a private location at the study hospital or via video-enabled Zoom. All sessions were audio-recorded with explicit written informed consent and subsequently transcribed verbatim. Field notes captured non-verbal cues, contextual observations, and researcher reflections throughout the data collection process.

Data Analysis

Quantitative data were entered, coded, and analyzed using IBM SPSS Version 25.0 at a significance threshold of α = .05. Descriptive statistics including frequencies, means, and percentages were computed to characterize the distribution of EBP preparedness ratings across the six competency domains and across the sample's demographic and professional attributes. Internal consistency of the preparedness subscale was assessed using Cronbach's alpha coefficient. Chi-square tests of independence (with Cramér's V effect size estimates) were applied to examine whether preparedness ratings differed significantly across demographic and professional subgroups (Kothari, 2004). Binary logistic regression was employed to explore predictive relationships between background characteristics and preparedness outcomes. Qualitative data were analyzed using the systematic six-phase thematic analysis framework developed by Braun and Clarke (2006): (1) repeated reading of transcripts and audio review to achieve familiarization; (2) systematic generation of initial codes across the full dataset; (3) collation of codes into candidate themes; (4) review and refinement of candidate themes in relation to the coded data and full dataset; (5) definition and naming of final themes; and (6) production of the analytic report with illustrative participant extracts. Trustworthiness was established using Lincoln and Guba's (1985) four criteria credibility, dependability, confirmability, and transferability operationalized through member checking, peer debriefing with supervisors, maintenance of a detailed audit trail, reflexive journaling, and provision of thick, contextualized description.

Ethical Considerations

Ethical approval was obtained from the Moi Teaching and Referral Hospital Institutional Research and Ethics Committee (Ref No: IREC/2019/000090; Approval No: 0003491) and the National Commission for Science, Technology and Innovation (Ref No: NACOSTI/P/20/3063). Institutional approvals were separately secured from the administrative leadership of both study hospitals. Written informed consent was obtained from all participants prior to data collection. Participants were assured of voluntary participation, the unconditional right to withdraw at any stage without penalty, and full confidentiality through anonymized coded identification systems and secure data storage protocols. All data were stored on password-protected computers and in locked filing cabinets, with audio recordings deleted following verbatim transcription verification.

Discussion

This study produced a theoretically significant and practically consequential finding: undergraduate nursing research education in Kenya successfully instills normative acceptance of EBP and generates high levels of subjective preparedness across six research competency domains, yet demonstrably fails to cultivate the applied, procedural competencies necessary for authentic evidence implementation in complex clinical environments. This preparedness-competence paradoxa divergence between what nurses say they can do and what they are practically equipped to do has several important implications for nursing education policy, curriculum design, clinical mentorship, and workforce development in sub-Saharan Africa. The uniformly high self-rated preparedness scores observed quantitatively (82.3%–90.4% agreement across domains) are consistent with cross-sectional findings from comparable nursing education studies in Africa and beyond that document positive EBP attitudes and self-efficacy following undergraduate training (Melnyk et al., 2018; Perez et al., 2021; Yoder et al., 2014). However, the qualitative evidence fundamentally problematizes these scores. Participant narratives reveal that the preparedness expressed quantitatively reflects declarative knowledge an understanding of research language, procedures, and steps rather than procedural competence the ability to navigate the full research cycle, critically appraise primary literature, adapt evidence to local clinical realities, and implement evidence-informed changes to care protocols. This declarative-procedural dissociation, well-established in cognitive and educational psychology (Anderson, 1982), is directly predicted by both the TTM (nurses reaching the preparation but not the action stage) and the TPB (high intention without sufficient perceived behavioral control). The finding that preparedness ratings were statistically homogeneous across all demographic and professional subgroups (p > .05 for all chi-square tests) further suggests that the subjective sense of readiness is a broadly institutionalized response to shared undergraduate curriculum exposure rather than reflecting genuine differentiation in skill development across nurses with different experience levels, training institutions, or clinical backgrounds. This uniformity may paradoxically be a marker of institutional compliance rather than educational achievement: when all graduates are exposed to the same compliance-oriented proposal-writing curriculum, they share the same preparedness narrative, regardless of their actual applied competence (Squires et al., 2011). The qualitative evidence strongly implicates curriculum architecture as the primary structural mechanism producing the preparedness-competence paradox. BScN programs appear to operationalize research education as a discrete, terminal academic exercise culminating in a proposal defense rather than as a developmental, practice-embedded, competency-verified learning trajectory (Brown et al., 2009; Polit & Beck, 2021). This design prioritizes compliance with regulatory graduation requirements over the progressive cultivation of research capability. The consequence is graduates who are procedurally familiar with the early stages of the research process problem formulation and proposal writing but who lack meaningful experience with data management, statistical analysis, critical appraisal of primary literature, and the translation of findings into clinical recommendations. From the TTM perspective, the curriculum constructs intentions and foundational attitudes (moving nurses toward the preparation stage) but provides neither the mastery experiences nor the environmental reinforcement required to activate the action stage. Benner's (1984) novice-to-expert framework is instructive here: theoretical knowledge provides the initial scaffolding for professional competence, but expert practice is developed through iterative, situated clinical experience supported by reflective mentorship. A curriculum that terminates at the proposal stage leaves nurses at the research novice level throughout their entire undergraduate preparation unable to engage independently with the messy realities of research implementation in clinical settings. The identification of postgraduate education as the primary site at which authentic applied EBP competence is developed has significant equity implications for Kenya's nursing profession. If the threshold for practical EBP competence is systematically above what BScN programs currently deliver, nurses without postgraduate credentials the vast majority of the clinical nursing workforce are structurally excluded from developing the competence that meaningful EBP engagement requires. This exclusion reproduces professional hierarchy within nursing, with postgraduate-trained nurses serving as de facto EBP resource persons for their BScN-trained colleagues, rather than a broadly distributed EBP-capable workforce. This finding calls for urgent curriculum reform at the undergraduate level. Building full-cycle research experiences including supervised data collection, analysis practicum, and structured journal club participation into the BScN curriculum would reduce reliance on postgraduate education as a compensatory mechanism and democratize access to applied EBP competence (Benner et al., 2010; Fink et al., 2005). The findings carry several actionable implications for nursing education, clinical governance, and health workforce policy in Kenya. First, the Nursing Council of Kenya should lead a formal curriculum audit of BScN research education modules, benchmarking against competency frameworks that specify applied, procedural research skills including data analysis, systematic reviewing, and guideline adaptation rather than merely proposal writing (NCK, 2019; WHO, 2020). Second, nursing schools should establish partnerships with teaching hospitals to create structured clinical EBP practicum experiences embedded within undergraduate training enabling students to apply research skills in real clinical contexts under mentored supervision. Third, at the institutional level, the creation of journal clubs, EBP committees, and research mentorship programs provides cost-effective, evidence-based mechanisms for building research culture and sustaining the applied EBP competence of graduate nurses in resource-limited settings (Fink et al., 2005; Forsman et al., 2012). Several methodological limitations warrant careful consideration. First, the cross-sectional design precludes causal inference regarding the relationship between undergraduate education and EBP preparedness; longitudinal designs tracking nurses from graduation through clinical practice would provide stronger causal attribution. Second, self-rated preparedness data are susceptible to social desirability bias, potentially inflating preparedness perceptions in response to institutionally valued professional norms (Polit & Beck, 2021). Third, the restriction to two national referral hospitals limits transferability of findings to county-level or community health facilities, where workforce composition, resource environments, and training demographics may differ substantially. Fourth, while thematic saturation was achieved within the qualitative sub-sample of 20 participants, this sample size may not fully represent the diversity of experiences across all clinical departments and specializations represented in the study population.