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Journal of Advanced Nursing, 2024; 0:1–18
https://doi.org/10.1111/jan.16679
1 of 18
Journal of Advanced Nursing
EMPIRICAL RESEARCH QUALITATIVE OPEN ACCESS
Facilitating an Evidence- Based Quality Improvement
Learning Culture in Nursing Teams Through Coaching
and Identification of Key Influencing Factors: An Action
Research Approach
JeltjeGiesen1 | MarjoleinBerings2 | AnnickBakker- Jacobs1 | HesterVermeulen1,3 | GettyHuisman- DeWaal1 |
AnnekeVanVught3,4
1Radboud Institute for Health Sciences, IQ Health, Radboud University Medical Center, Nijmegen, The Netherlands | 2Radboud University Medical Center,
Radboudumc Health Academy, Nijmegen, The Netherlands | 3Department on Health and Vitality, School of Allied Health, HAN University of Applied
Sciences, Nijmegen, The Netherlands | 4Dutch Healthcare Authority (NZa), Utrecht, The Netherlands
Correspondence: Jeltje Giesen ( jeltje.giesen@radboudumc.nl)
Received: 28 February 2024 | Revised: 22 November 202 4 | Accepted: 4 December 2024
Funding: This paper is part of the Improve! Project, which focuses on creating an Evidence- Based Quality Improvement (EBQI) learning culture in nursing
teams in the hospital and community care settings. The Improve! Project is funded by ZonMw (dossier no. 80- 83900 - 98- 854).
Keywords: action research| care transition| coaching| community care| Evidence- Based Practice (EBP)| Evidence- Based Quality Improvement (EBQI)|
hospital| learning culture| nursing
ABSTRACT
Aims: To explore how coaching can facilitate the development of an Evidence- Based Quality Improvement (EBQI) learning
culture within nursing teams in hospital and community care settings. This study also explores the specific contextual factors
that influence effective outcomes.
Design: Action research.
Method: Nine teams, including 254 nurses were selected from four hospitals and two community care organisations to partic-
ipate in the development of an EBQI- learning culture under the guidance of internal and external coaches. Data were gathered
from 27 focus groups with 56 unique participants (of whom 31 participated multiple times) and six individual interviews with
three external coaches. Transcripts of all interviews were subjected to abductive thematic analysis.
Results: To promote an EBQI learning culture in nursing teams, it is essential that internal coaches effectively guide their team
members. The internal coaches in this study focused on enhancing readiness for EBQI by providing support, encouraging in-
volvement and motivating team members. They deepened innovation competencies including assessing daily care, implementing
well- structured changes in care practices and embedding small steps in the change process in daily routines. It was found that
barriers and facilitators within the team's context can influence the development of EBQI- learning culture and therefore need to
be considered when seeking to make changes. The presence of external coaches served as a valuable resource and a motivator in
supporting internal coaches to apply and improve their coaching skills.
Conclusions: To stimulate the development of an EBQI- learning culture, internal coaches need to focus on team readiness to
work with EBQI. Priority needs to be given to enhancing the care change competencies of team members. Barriers to change
must also be addressed. Internal coaches require external support and motivation to continually develop coaching skills.
Reporting Method: The Standards for Reporting Qualitative Research.
Patient or Public Contribution: No patient or public contribution.
This is a n open access ar ticle under the terms of t he Creative Commons Attr ibution-NonCommercial-NoDer ivs License, whi ch permits use and d istribution in any me dium, provided th e original
work is properl y cited, the use is non- commercial and no mo difications or a daptations are ma de.
© 2024 T he Author(s). Journal of Advanced Nursing publis hed by John Wiley & Sons L td.
2 of 18 Journal of Advanced Nursing, 2024
1 | Introduction
The urgent need to transform health care is becoming in-
creasingly evident. This is driven by several key factors. These
include an ageing population, the increasing prevalence of
multimorbidity, the growing scarcity of healthcare profession-
als and rapid advances in medical care. These developments
have created an urgent demand for healthcare professionals,
including nurses, who are equipped to navigate the complex-
ities of a rapidly evolving healthcare landscape (Visser 2021).
An Evidence- Based Quality Improvement (EBQI) learning
culture within nursing teams is an effective way to ensure
continuous engagement in learning and improving care.
Ultimately, it can transform the care provided. This kind of
learning culture focuses on systematic and continuous ac-
tions to improve care based on Evidence- Based Practice (EBP;
Baker 2017). The general definition of EBP is the explicit, ju-
dicious and deliberate use of the best available (scientific) evi-
dence in making choices and performing actions. It is a proven
way to improve the quality and accessibility of care in nursing
practice (Straus etal.2020). In this study, the term ‘nurses’ is
used as an umbrella term for different types of nurses. Types
of nurses include nursing assistants, nurses with vocational
training, nurses with a bachelor's degree and nurses with a
master's degree. Where relevant, we distinguish between dif-
ferent types of nurses.
2 | Background
Evidence- Based Practice facilitates nurses' ref lection and
clinical reasoning by integrating clinical expertise, available
evidence and patient preferences. It has been shown to be a
valuable way of improving the quality of care in hospital and
community settings. EBP stimulates nursing teams to criti-
cally evaluate their practice and enables them to implement
high- value care and eliminate low- value care that is poten-
tially harmful or unhelpful (Kitson2018; Verkerk etal.2018).
Nevertheless, nurses are known to experience resistance to
working with EBP (Kerr and Rainey 2021). Nurses still prefer
to base their actions on habits, experience and their intuition,
rather than based on their actions on currently available evi-
dence (Zwakhalen etal.2018).
Barriers to working with EBP principles include perceiving
EBP as being too complex, not having enough knowledge to
evaluate evidence, or not feeling supported by employers in
terms of time and resources to be able to put new ideas into
practice (Jabonete and Roxas 2022; Kajermo etal. 2010). To
overcome these barriers, nurses need to be supported and
empowered to embrace transformational leadership. Role
modelling is essential (Bahlman- van Ooijen etal. 2023) next
to including all team members. In addition, facilitation by
a coach has been identified as essential to developing nurs-
ing practice and improving the quality of care (McCormack,
Manley, and Titchen2013). In nursing practice, coaching con-
sists of supporting nurses as they enter the profession, and
then continuing to support the development of knowledge
and skills as they progress (Richardson et al. 2023). Action
research involving 12 nursing teams from four nursing homes
found that having a motivated nurse as an internal coach,
along with support from an external coach, helps create a
learning culture within nursing teams. It was also found that
it is important to include all team members regardless of their
education level. This so the research is embraced by all team
members and that everyone's qualities and skills are utilised
(Lovink etal.2022).
In several countries, internal coaches are also known as nurse
champions. These nursing champions are frontline practi-
tioners involved in quality improvement (QI), implementing
innovations or changes in care policy (Sperling et al. 2022).
Nursing champions show leadership by energising and coach-
ing colleagues. They instil confidence in QI and help engage
the right people to grow networks (Sperling et al. 2022).
Furthermore, the previous study of White (2011) showed
that nursing champions can act as change agents in bridging
the gap between practice and research and promote the use
of EBQI.
It is not yet clear, however, which specific elements of coach-
ing contribute to the development of EBQI learning cultures
within nursing teams to improve the quality of care. It is also
important to understand which environmental factors help
or hinder coaching and the development of an EBQI learn-
ing culture. By understanding the most effective elements of
coaching and their influence, nurses can be enabled to coach
their team members more effectively in changing their daily
practice.
3 | The Study
3.1 | Aim
This study aims to explore how coaching can facilitate the de-
velopment of an EBQI learning culture within nursing teams
in hospital and community care settings. The study also ex-
plores the specific contextual factors that influence effective
outcomes.
Summary
• A transformation in health care is required to ensure
quality and affordable health care. Evidence- Based
Quality Improvement (EBQI) is a promising approach
to work towards the delivery of more appropriate care.
• To stimulate an EBQI learning culture in nursing
teams, internal coaches, also called nurse champions,
proved to be essential as they focused on increasing
readiness for EBQI and strengthening the innovation
competencies of team members.
• Internal coaches need guidance and external motiva-
tion to keep the change process going.
• Specific barriers and facilitators within the context of
the nursing team can slow down or speed up the de-
velopment of an EBQI learning culture.
• Stimulating EBQI helps nurses transition to provid-
ing more appropriate care and making healthcare
future- proof.
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4 | Methods
4.1 | Design
A general action research approach, with components of partici-
pative action research (PAR), was used to explore which elements
of coaching can contribute to developing an EBQI learning cul-
ture within nursing teams. Nine nursing teams were the subject of
this research. An action research approach was chosen because it
is collaborative, sensitive to context and iterative. This methodol-
ogy directly engages participants and promotes their involvement
and ownership. This is essential to understanding coaching in
changing the culture. The iterative nature of action research al-
lows for real- time adjustments and refinements, addressing the
complexity of healthcare environments (Waterman, Tillen, and
de Koning2001). Researchers adhered to components of PAR as
much as possible because it is important to involve participants
to do the research and to change their practice. The four main
principles of PAR consist of (1) authority of direct experience, (2)
knowledge in action, (3) research as a transformative process and
(4) collaboration through dialogue (Cornish etal. 2023). However,
a full PAR could not be conducted for this study. Reasons for this
are included in the limitations section.
The Standards for Reporting Qualitative Research (SRQR) check-
list was use d to prepare the research report and to en sure that all as-
pect of the research was carefully documented. This checklist was
chosen, as the research data were of qualitative origin and there is
no separate checklist for action research (O'Brien etal. 2014).
4.2 | Project Team
The project team included four action researchers and three
experts in action research, EBQI, learning cultures and change
management (Table 1). All members of the team had a back-
ground in nursing, with experience in a variety of settings.
They were also highly experienced in QI as well as the mento-
ring and coaching of nurses and nursing teams. Three of the
four action researchers played the role of external coaches. As
external coaches, these researchers implemented the interven-
tion within the teams (Section4.5). They were selected based
TABLE | Action research project team.
Project member Role Expertise Healthcare setting
Expert 1 Study design,
reflection
meetings,
data analysis
Nurse, nursing scientist, head
lecturer, associate professor, EBQI
Nursing Homes, University Medical
Centre, general hospital, mental health
care, primary care, community care
Expert 2 Study design,
reflection
meetings and
data analysis
Educational scientist, advisor, process
supervisor workplace learning, coach
University Medical Centre, community care
Expert 3 Study design,
reflection
meetings and
data analysis
Nurse, nursing scientist, head lecturer,
full professor, board member, EBQI
Nursing Homes, University Medical
Centre, general hospital, mental healthcare,
primary care, community care
Action researcher 1 External coach
Community
Care Teams
Nurse, nursing manager,
nursing scientist, coach
Community care
Action researcher 2 External
coach General
hospital teams
Nurse, nurse specialist, nursing
scientist, lecturer, coach
General hospital
Action researcher 3 External coach
University
Medical Centre
Teams
Nurse, nursing scientist, lecturer,
associate professor, coach
University Medical Centre, community care
Action researcher 4 Study design,
reflection
meetings, data
collection and
data analysis
Nurse, nursing scientist,
team development
Mental health care, nursing homes,
community care, University Medical Centre
Research assistant Study design,
data analysis
Medical and social
management assistant
University Medical Centre, community care
4 of 18 Journal of Advanced Nursing, 2024
on their familiarity with the nursing profession and the com-
munity care or hospital setting. The goal of this decision was
to foster trust with the participants and to mitigate resistance.
The fourth action researcher was responsible for executing the
study process. This researcher acted as the primary contact
for data collection and data analysis. The roles of the action
researchers were separated to guarantee the continuity of the
teams. Teams were given a dedicated external coach. The four
action researchers worked together closely, and the experts
were engaged at all stages of the study process. This included
the design of the study, reflection meetings and data analysis.
4.3 | Study Setting and Recruitment
The study took place between January 2021 and July 2022, with
an average intervention period of 12.3 months. It was conducted
in four hospitals (one University Medical Centre and three gen-
eral hospitals) and two community care organisations from the
middle, the east and the south of [Country name]. The nursing
teams were purposively selected by approaching project leaders
or directors from the project teams' network and ask them to
participate with one or two teams (Table2).
Teams from the hospital setting specialised in orthopaedic sur-
gery, trauma surgery, urology surgery and oncology and inter-
nal medicine. Teams from the community care setting delivered
regular or specialised care that focused on administering intra-
venous drugs or blood products. All nursing teams had a mixed-
educated staff (European Qualification Framework [EQF] levels
1–7 or in other countries referred to as nursing assistants, voca-
tional nurses, bachelor nurses and in some teams master edu-
ca ted nu rses) .
4.4 | Inclusion and Exclusion Criteria
Nursing teams that met the following inclusion criteria were
eligible for participation: (a) committed for a 12 month period
of (between May 2021 and September 2022), (b) comprised of
10–50 nurses, (c) providing direct care to adult patients on the
ward or at home, (d) supported by their management to partici-
pate, (e) have time to work on EBQI, (f) have at least two nurses
who could fulfil the role of the internal coach. Maternity care,
children's care, critical care and the psychiatry departments
were excluded from participation. This was because of the dis-
tinctive nature of these wards and the unique dynamics of the
patient- caregiver relationship.
Inclusion criteria for the internal coaches were (a) possessing a
bachelor's (BSc) or master's degree (MSc) in nursing, (b) being
able to participate in one or more data collection rounds, (c)
being able to participate in meetings with the external coach and
(d) affinity with EBQI and with coaching their team members.
The internal coaches were selected with the assistance of the
team managers. They were selected for their insight into the ca-
pabilities of the nurses in question so that they could determine
whether the nurses would meet the inclusion criteria.
4.5 | Study Process
The study was conducted in three phases. The pre- phase in-
cluded the preliminary preparations for carrying out the inter-
vention in the teams. The teams started working on developing a
learning culture under the guidance of the internal and external
coaches in the intervention phase. Finally, the intervention pe-
riod finished in the closure phase (Figure1).
TABLE | Included teams and intervention period.
Organisation Team Participants Specialisation Intervention period Action researcher
CC 1 Team 1 18 Regular CC July 2021–September 2022 External coach 1
Team 2 23 Specialised CC September 2021–
September 2022
CC 2 Team 3 15 Regular CC October 2021–
October 2022
GH 1 Team 4 40 Internal Medicine—Oncology September 2021–
October 2022
External coach 2
GH 2 Team 5 30 Urology–oncology/surgery October 2021–
October 2022
GH 3 Team 6 27 Oncology surgery November 2021–
October 2022
Team 7 25 Urology— oncolog y November 2021–
October 2022
UMC 1 Team 8 49 Orthopaedic—surgery August 2021–
September 2022
External coach 3
Team 9 32 Trauma—surger y August 2021–
September 2022
Abbreviations: CC, Community Care; GH, General Hospital; UMC, University Medical Centre.
5 of 18
4.5.1 | Pre- Phase
The pre- phase started with composing the project group. This
was done by adding action researchers serving as external
coaches within the teams. These external coaches had a back-
ground in hospital and community care. This was to ensure that
the study could be effectively integrated into the hospital and
district care setting. The purpose of these external coaches was
to offer practical guidance tailored to the needs of the internal
coaches. It was aligned with the operational procedures and pa-
tient profiles of the departments. Each external coach guided
the internal coaches of 2–4 teams and had an average of 1.5 h
a week available per team. The coaches could fill these hours
at their own discretion, in consultation with the other external
and internal coaches. This approach and the intervention of the
coaches carried out were based on previous research in nurs-
ing home teams. In this research, a learning culture was devel-
oped based on EBP (Lovink et al.2022). The teams were then
recruited and the internal coaches in these teams were selected.
Finally, a survey was completed in this phase to get insights into
the characteristics of the team.
4.5.2 | Inter vention Phase
The intervention phase started with a focus group interview
to map team members' attitudes regarding EBP and QI. These
insights determined the teams' starting point regarding EBQI
and helped their external coach to make a coaching approach.
Furthermore, discussing EBQI with nurses represents an initial
step towards implementing change. This is because it prompts
them to consider their own practice and identify potential areas
for improvement. Then a kick- off meeting was set up to intro-
duce the teams to the project. In this meeting, the objective of
the intervention and the findings of the focus groups were pre-
sented. Furthermore, the external coach and the team's inter-
nal coaches were formally introduced, thereby inaugurating the
team's intervention period.
FIGUR E | Study process.
6 of 18 Journal of Advanced Nursing, 2024
During the intervention phase, the teams concentrated on
the learning cycle, modifying and re- evaluating their actions
as required. During this phase, the external coach provided
the internal coaches with online support. They coached on
the selection of improvement topics aligned with the pa-
tient group, gave guidance on motivating team members for
change and provided direction on EBQI. The external coach
also facilitated structured approaches to improvement. The
nursing teams were encouraged to work in accordance with
the organisation's QI cycles and to utilise relevant support-
ing Evidence- Based Practice information. Furthermore, the
external coaches assisted the internal coaches in developing
their leadership abilities, enabling them to provide effective
assistance to the team. Furthermore, they assisted the teams
in addressing specific queries and challenges, such as the allo-
cation of time for EBQI. In accordance with the complexity of
the objectives and the time available for QI, one or more goals
were addressed. Key focus areas included the improvement of
handover documentation, the promotion of self- management,
the enhancement of palliative care, the identification of the
optimal pre- operative laxative and the reduction in the fre-
quency of infusion line changes. The external coaches pro-
vided assistance to the internal coaches to facilitate the
activation of team members and encourage their engagement
in EBQI. They also gave guidance in the selection of appropri-
ate change goals.
Action researcher 4 gave the internal coaches a repository of
information and resources, including articles and e- learning
materials designed to support the utilisation of EBQI, and pro-
vide inspiration for improvement goals. Additionally, the project
team conducted three sessions with the internal coaches. They
facilitated the sharing and discussion of experiences, fostering a
collaborative learning environment.
The intervention face also included data collection
(Section4.6). Several meetings were organised such as project
group meetings to discuss the purpose of the facilitation pro-
cess and to exchange ideas about the coaching approaches. In
addition, bi- monthly, reflection sessions were held both with
the full project team and with the external coaches individu-
ally. The purpose of this reflection session was to evaluate the
coaching process and to determine if any adjustments were
required.
4.5.3 | Closing the Intervention Period
The intervention period was closed during the final focus group
interview. In this interview, action researcher 4 discussed with
the participants options that could be taken to continue the de-
velopment of an EBQI learning culture. This was not part of
the official data collection. The interview was conducted with
the goal of ensuring sustainable change. The participants were
encouraged to share their ideas with their managers so that
they too would be aware of them and could offer their support.
Furthermore, individual interviews with the external coaches
were conducted to gather data and to ref lect on the interven-
tion phase.
4.6 | Data Collection
Multiple sources were used for data collection. Before the
intervention period began, a survey to gain insight into the
participants' characteristics was sent out to all participants.
Qualitative focus group interviews with the participating
teams were performed at baseline, after 6 months and at the
end of the intervention period. In the baseline interview,
questions were asked about the team composition, their expe-
riences with Evidence- Based Practice and QI and the objec-
tives they hoped to achieve throughout the project. During
the mid- term interview, participants ref lected on and gained
insights into the progress made. Objectives set for the latter
part of the intervention period were also examined. The final
interview explored what the year had yielded, whether the tra-
jectory had met their expectations, and how they intended to
proceed post- intervention to advance their EBQI practice. A
total of 56 unique nurses participated in the focus groups. Of
these, 19 participated in one round, 21 in two rounds and 11
in all three rounds. Individual interviews with the external
coaches were performed at 6 months and the end of the inter-
vention period. During these interviews, the teams' progress,
challenges and areas they needed to address for more prog-
ress were discussed. Furthermore, the external coaches kept
field notes in a logbook about the coaching process. These
reports encompass documentation of the discussions with
the internal coaches, focusing on the following key aspects:
development of EBQI motivation and skills among team mem-
bers; observations of the learning and working environment
(including the work context, autonomy, connectedness, sup-
port) and subsequent interventions carried out by both the in-
ternal and the external coaches. Focus group interviews and
individual interviews were held face- to- face, when possible
and online (due to COVID- 19 restrictions). Action researcher
4, a master- educated nurse and experienced healthcare re-
searcher, performed all interviews. Finally, project members
produced field notes (individual) about all meetings with the
external and internal coaches. These field notes cover the
critical aspects of the meetings and focal points for coaching
(Table3).
4.7 | Data Analysis
The study made audio recordings of both focus group and indi-
vidual interviews in the analysis of how coaching could facilitate
the development of an EBQI learning culture within nursing
teams. Recordings at baseline and 6 months were summarised.
Recordings of the final interviews of both teams and external
coaches were transcribed verbatim. An abductive thematic analy-
sis approach was used to a nalyse the transcr ipts of the focus groups
and individual interviews (Thompson 2022). Before the start of
the study, it was known that creating an EBQI learning culture in-
volves interventions. These are made through facilitation (Harvey
and Kitson2016). That is why this study examined the actions of
both the internal and external coaches and the elements that arise
within the context. The intention was to discover new informa-
tion and to avoid confirming an existing framework; therefore, all
data were coded openly. The steps of the abductive approach were
7 of 18
(1) Transcription and Familiarisation, (2) Coding, (3) Codebook,
(4) Development of Themes, (5) Theorising, (6) Comparison of
Data sets, (7) Data Display and (8) Writing Up (Thompson2022)
(Figure 2). Action researcher 4 and the research assistant
independently coded all transcripts. The coding took place with
the help of ATLAS.ti version 8.4.20. Codes were discussed until a
consensus was reached. If consensus was not reached, an expert
was consulted. The logbooks, field notes and summaries were
TABLE | Data collection.
Total participants
(range per
focus gr oup)/
Participant type Moment Document Purpose data collection
Survey—All participants
Team survey 182 participants Baseline SPSS file
(descriptive
statistics)
Insight into characteristic
participants and
internal coaches
Focus group inter views
Focus group interview 1
Individual teams (n = 9)
36 participants
(range 2 –7)
• 13 Internal coaches
• 23 Team members
Baseline Summary Input for kick- off meeting
Input for subsequent
focus group inter view
Data analyses (check
for additional codes)
Focus group interview 2
Individual teams (n = 9)
27 participants
(range 2 – 6)
• 13 Internal coaches
• 14 Team members
Midway Summary Input for subsequent
focus group inter view
Data analyses (check
for additional codes)
Focus group interview 3
Individual teams (n = 9)
31 participants
(range 2 –10)
• 17 Internal coaches
• 14 Team members
Final Full transcript Data analysis (full process)
Individual interviews
Individual interviews 1—
External coaches (n = 3)
Three participants Midway Summary Input for subsequent
focus group inter view
Data analyses (check
for additional codes)
Individual interviews 2—
Researchers (n = 3)
Three participants Final Full transcript Data analysis (full process)
Fieldnotes
Logbook—External coach
(n = 9)
Not applicable Continues Fieldnotes Monitoring the process
and adjusting
Data analyses (check
for additional codes)
Field notes of meetings
(n = 3)
Not applicable After a meeting Fieldnotes Monitoring the process
and adjusting
Data analyses (check
for additional codes)
Indiv idual
reflection—Bi- monthly
Action researchers After a meeting Fieldnotes Monitoring the process
and adjusting
Data analyses (check
for additional codes)
Group
reflection—Bi- monthly
All project members After a meeting Fieldnotes Monitoring the process
and adjusting
Data analyses (check
for additional codes)
8 of 18 Journal of Advanced Nursing, 2024
used to support and check the codes from the final interviews
on completeness. Descriptive statistics were used to gain insight
into the participants' characteristics using IBM SPSS Statistics for
Windows, version 27.
4.8 | Ethical Considerations
The research ethics committee of the Radboud University Medical
Centreconcluded that ethical approval was not required under
Dutch law (CMO no. 2021- 8211). Before inclusion in the study, all
participants signed a form stating that they were informed verbally
and in writing about the purpose of the study, that participation
was voluntary and that all recordings, transcripts and surveys
were confidential and anonymous. All participants were informed
that they had the right to withdraw from the study at any given
time without having to disclose a reason.
5 | Findings
5.1 | Characteristics of Participants
Nine nursing teams comprising of 254 nurses were included in
this study. At baseline, a questionnaire was sent to all participants
(n = 254). A total of 182 questionnaires were completed, resulting
in a response rate 71.6%. In total, 173 women, eight men and one
person identified as ‘other’ participated in the study. The mean age
of participants was 39.8 years (SD 14.0). Among the nurses, 2.7%
had a master's degree (EQF level 7), 36% had earned a bachelor's
degree (EQF level 6) and 47.3% were vocationally educated (EQF
level 4). In addition, 6.6% were nurse assistants (EQF levels 1–3),
and 7.1% had some other form of education. However, the distri-
bution differed per nursing team. The average length of their work
experience was 16.4 years (SD 13.4), and participants worked 27.8 h
a week on average (SD 5.4) (Table4).
FIGUR E | Coding process.
9 of 18
In each team, at least two internal coaches were selected and
in total, 24 nurses fulfilled the role of internal coach (Table5).
Of these coaches 22 were female and two were male. Their av-
erage age was 36.2 years' (SD 13.4) and they had an average of
11.7 years' (SD 11.3) work experience. While the experience of
the nurses with a bachelor's or master's degree varied, they were
all enthusiastic, motivated and willing to invest time to guide
their team members in developing an EBQI learning culture.
During the intervention period, one internal coach from team
1 was not available for an extended period. The role was seam-
lessly taken up by three nurses involved in the first change cycle.
Given that several internal coaches were appointed per team,
there was no need to recruit additional coaches in the case of a
short- term outage.
5.2 | Qualitative Findings
From the qualitative analysis of the 27 focus groups with 56
unique nurses and the six individual interviews with the three
external coaches, codes emerged that captured the successful el-
ements of coaching by internal and external coaches (Table3).
In addition, it became evident that team members and coaches
encountered various factors that both aided and impeded their
efforts within their specific context when developing an EBQI
learning culture in their team. Mind maps were created to pres-
ent the findings graphically (Figures 3–5). Furthermore, the
codes in the results text are highlighted in bold to enhance clar-
ity and highlight the discussed concepts.
5.2.1 | Facilitation by the Internal Coach
In relation to the facilitation provided by internal coaches, two
distinct themes emerged. The first theme concerns facilitation
to encourage team members' readiness to work with EBQI. The
second theme encompasses activities that support and enhance
team members' skills and abilities to effectively engage with the
principles of EBQI (Figure3).
5.2.1.1 | Facilitation on Enabling Readiness. To enable
readiness to work with EBQI, internal coaches from the hospital
and community care setting focused on involving team members
in the EBQI process. They attempted to involve their colleagues
right from the start of the EBQI thinking process and during
the implementation of the care change by actively inviting them
to participate.
Keeping team members informed and asking for their
input. Involve them and ask: what do you think is
important? As an internal coach, it is important not
to say: I decide and you must do this.
(Internal coach, hospital—transcript 7)
In addition, internal coaches involved team members by giving
a presentation about EBQI and then made sure that everyone
understood it. EBQI was also talked about during the annual
gathering. They also actively invited team members to be in-
volved by avoiding hierarchy and emphasising that their opin-
ions mattered. Internal coaches in the hospitals emphasised
TABLE | Characteristics of the participants.
Team/Total
participants/response
rate (n, %)
Gender
(F/M/O)
Age, years,
mean (SD)
Education level (n, %) Work experience, mean (SD)
Master Bachelor Voc ational Nurse ass Other
Experience
(y ear s)
Weekly
hours
Total 182 (71%) 173/8/1 39.8 (14 .0) 5 (2 .7%) 66 (3 6.3%) 86 (47.3%) 12 (6.6%) 13 (7.1%) 16, 4 (13.4) 27,8 (5.4)
CCT1 12 (66.7%) 11/1/0 43.7 (11.5) 2 3 1 6 0 15.1 (12 .9) 28. 8 (5.4)
CCT2 21 (91.3%) 21/0/0 51.0 (11.6) 010 10 0 1 29.6 (11.9) 26.0 (4.9)
CCT3 12 (80.0%) 12/0/0 43.9 (13.1) 1 3 2 6 0 21.5 (12.3) 2 1.0 (5. 5)
HT4 3 6 (90.0%) 32/4/0 38.2 (14.0) 011 24 0 1 14.0 (11.6) 28.5 (5.3)
HT5 9 (30 .3%) 9/0/0 38.7 (11.9) 0 4 5 0 0 14.5 (9.8) 28.6 (5.4)
HT6 22 (81.5%) 22/0/0 37. 5 (13 .1) 0 9 12 0 1 13.9 (11.7) 28. 6 (5. 3)
HT7 22 (88.0 %) 21/1/0 37.9 (13. 3) 0 8 14 0 0 14. 4 (12.6) 2 8.6 (5.4)
HT8 28 (57.1%) 26/2/0 37.4 (13.1) 2 9 11 0 6 14.3 (11.8) 28.8 (5.4)
HT9 20 (62. 5%) 19/0/1 38.8 (12. 3) 0 9 7 0 4 14.3 (9.3) 27.9 (5 .3)
Abbreviations: CCT, Community Care Team; F, female; HT, hospital team; M, male; O, other.
10 of 18 Journal of Advanced Nursing, 2024
the importance of EBQI and started facilitating readiness and
involvement of team members by creating awareness about what
they were already doing with EBQI. They also asked how team
members felt about EBP and explored why they provided care
the way they did. These conversations took place during care
del ivery.
We need to make team members aware of what they
are already doing with Evidence- Based Practice
and how they can use it even more. So, it is very
conscious decision to focus on the three pillars of
Evidence- Based Practice and engage them. Making
them aware that Evidence- Based Practice is not just
about literature search. That it's also about patient
perspectives and what you or other professionals
know.
(Internal coach, hospital—transcript 9)
Internal coaches indicated they supported/motivated their team
members by listening to the issues that arose for them while
working with EBQI. They actively asked questions to help them
along and organised sessions to discuss concerns. They also re-
ported stimulating team members to consult with each other or
to discuss a topic. This also stimulated collaboration between
team members. Some internal coaches mentioned paying atten-
tion to the collaboration between team members, workgroups or
interdisciplinary teams.
I hear more often: I have this problem. How can this
be solved, or do you have any advice so I can solve it
myself?
(Internal coach, hospital—transcript 6)
Sometimes, the internal coaches provided the team with im-
proved access to information. For example, by making it clear
where information from the organisation was stored or by
TABLE | Characteristics of the internal coaches.
Organisation Team Gender Age (years) Educational level Work experience as a nurse (years)
CC Organisation 1 Team 1 Female 49 Master 23
Female 34 Bachelor 10
Team 2 Female 54 Bachelor 37
Female 44 Bachelor 21
CC Organisation 2 Team 3 Female 32 Bachelor 3
Female 43 Bachelor 5
General Hospital 1 Team 4 Female 38 Bachelor 16
Female 24 Bachelor 4
Female 48 Bachelor 25
General Hospital 2 Team 5 Female 23 Bachelor 1,5
Female 26 Bachelor 3
Female 25 Bachelor 4
Female 20 Bachelor 1
Female 23 Bachelor 2
General Hospital 3 Team 6 Female 27 Bachelor 5,5
Female 62 Bachelor 42
Female 29 Bachelor 8
Team 7 Female 38 Bachelor 14
Female NP Bachelor 7
Male 60 Bachelor 19
UMC 1 Team 8 Female 25 Bachelor 4
Female 58 Bachelor 17
Team 9 Female 25 Bachelor 4
Male 25 Bachelor 4
Abbreviations: CC, community care; NP, not provided; UMC, University Medical Centre.
11 of 18
arranging a subscription to a nursing journal so that the team
had more access to EBP information. Some of the internal
coaches f rom the hospital explained to team members about EBP
and where and how to find evidence. When implementing care
changes, some internal coaches told their team members that
trial and error was a normal part of the process. When some-
thing did not work, they discussed it with the team members and
changed the approach.
I talked a lot with team members and experimented.
Always was making small improvements and
reflected with them: does this work? If the answer
was: No, this is not working at all, why not?
(Internal coach, Community care nurse—transcript 1)
Internal coaches from the community care setting said that they
focused on promoting self- confidence to support and motivate
their team members. They did this by explaining things, being a
positive example, and by working together.
Resistance often comes from fear or ignorance. But
after a while the resistance subsides a bit and team
members are more willing to join in. So, you go
further and further with that. Here we paid a lot of
attention to team members' resistance.
(Internal coach, community care—transcript 1)
Internal coaches from the hospital setting said they were more fo-
cused on their support to inspire the team members. They did this
by giving their teams insights into exactly what EBQI could yield
for them and their patients. This was done by emphasising the im-
portance of genuine change and by giving examples of how such
change could positively impact other caretakers or patients. They
also said they focused on increasing team members' motivation by
FIGUR E | Mind map internal coach.
FIGUR E | Mind map external coach.
12 of 18 Journal of Advanced Nursing, 2024
taking the time to understand where they were coming from. This
included listening to the barriers they faced and gaining insights
into how they felt about working with EBQI.
I think all nurses want to provide the best patient
care and if you know how to improve something, it
becomes easy. That's what we have been working on,
getting team members excited about EBQI.
(Hospital nurse—transcript 8)
It is critical to note that internal coaches also need to remain
motivated to inspire others to work with EBQI. During this re-
search, one internal coach from a community care team lost
motivation to work along the principles of EBQI and to support
team members. This was due to persistent resistance and nega-
tive energy within the team. This resulted in the stagnation of
the development of the EBQI learning culture.
5.2.1.2 | Facilitating the Development of Competen-
cies. Both hospital and community care coaches said that
they initiated the development of a learning culture by map-
ping what the team was already doing with EBQI, the barriers
they faced and identifying facilitators that supported a learn-
ing culture. This was done by getting insights into how they
approached EBP and QI and what the qualities of the team
members were.
Good advice for other departments is to ask team
members: How do you work with Evidence- Based
Practice? What are the helpful and hindering
factors in applying Evidence- Based Practice? After
asking these questions, we made an analysis and
identified the stakeholders. We presented those
outcomes to the team and said: look, these are the
results. Then we involved them in making an action
plan.
(Internal coach, hospital—transcript 9)
In addition, the internal coaches asked the team members which
topics they would like to change to map what should be done.
They looked at which working groups already existed and which
topics would fit. About half of the internal coaches thought it
was a good idea to pay attention to the organisational process
within the team. For example, to make good use of the work-
groups and their focus. They aimed to integrate EBQI into the
daily work routines so that it would not become an additional
burden and a standalone activity.
FIGUR E | Mind map barriers and facilitators.
13 of 18
The majority of the internal coaches underpinned the impor-
tance of structuring the EBQI process. This was done by taking
small steps, dividing big topics into smaller pieces and solving
them individually. By making the topics small and specific,
team members could relate to the need for change and were
more willing to participate. For example, a coach helped divid-
ing the topic ‘promoting self- reliance’ into smaller steps. The
team started with supporting clients to dry themselves after
showering.
If you pick a small relevant area of improvement that
everyone considers important, team members are
more motivated to contribute to it.
(Internal coach, community care—transcript 2)
About half of the internal coaches said they paid extra atten-
tion to structuring the EBQI process. For example, by looking
at how to incorporate the QI cycles in the change process, or
helping to decide which changing topics to prioritise and assess
their time investment. Some internal coaches focused on setting
goals, such as making an annual agenda or learning objectives.
Other coaches used a tool provided by the external coach to pick
essential goals for the team.
We have created an annual plan. In the coming year,
we want to pay attention to workplace themes in team
meetings. This way, they will receive attention and
remain topical.
(Internal coach, community care—transcript 1)
Some internal coaches paid attention to time management and
included instruction on this when they saw it was necessar y.
They worked with team members on how to assess whether the
tasks fitted the available time, and how they could use most ef-
fectively use their time. One of the internal coaches from the
community care setting paid attention to creating possibilities to
work on EBQI so that it did not take extra time. For example, by
incorporating EBQI into care delivery.
I think we do have to pay attention to productivity
and be careful not to spend too many hours a week
that we cannot bill. There is no room for that in the
schedule either.
(Internal coach, community care—transcript 2)
Internal coaches said that an essential aspect of coaching is
to develop the competence to embed EBQI in daily practice. A
starting point for this was making EBQI a fixed agenda item
during their team meetings. Some internal coaches said it was
important to go further and ensure that at least one moment was
created each day to discuss patient issues related to EBQI. They
reported that this approach was successful. EBQI can become a
habit if done structurally, over time.
We now have a short meeting at 9.00 AM. This is
going well and is now embedded. In this meeting,
we briefly discuss how things are going and what
everyone needs. We want to also arrange the same for
our 3.00 PM meeting. It takes some effort to get used
to, however, it's also just a change in mindset.
(Internal coach, hospital—transcript 8)
A small number of the internal coaches paid extra attention to
making agreements towards actions to embedding EBQI in daily
practice. Some internal coaches mentioned that they helped
team members celebrate achievements to keep a positive flow.
They learned this from the external coach.
In the team meeting we continuously discussed small
successes. For example, we paid special positive
attention to a high response rate to the internal
survey on working with Evidence- Based Practice that
we had launched.
(Internal coach, hospital—transcript 5)
Most internal coaches from the community care setting said
they took time to fade out and let the team members do the work
more on their own so that they could experience and develop
more ownership.
Withdrawing slowly also allows you to hand over
more and more tasks. That way, the team feels
ownership and the learning gets embedded into the
team.
(Internal coach, community care—transcript 3)
5.2.2 | Facilitation by the External Coach
Four clear themes emerged in relation to the external coach-
ing. The first theme centred on addressing the personal needs
of internal coaches so they could develop themselves as proper
EBQI coaches capable of leading a team. The next two themes
focused on coaching needs to enable team members' readi-
ness, and identifying the EBQI competencies towards that in-
ternal coaches need to discuss with the external coach. Lastly,
the fourth theme explores the advantages of having an exter-
nal coach (Figure4).
External coaches focused on meeting the internal coaches' per-
sonal needs to become effective EBQI coaches. This included
providing the internal coaches with the knowledge to tackle a
care problem or reactivate it, improving their coaching skills,
and empowering them to show transformational leadership.
They supported the internal coach by providing explana-
tions to them. For example, they discussed team members'
resistance and how to improve their EBP skills. The external
coaches said they supported the internal coaches by (co)cre-
ating a coaching strategy adapted to the team and existing or-
ganisation processes.
I think an internal coach must be intrinsically
motivated to further professionalise the field. If they
have enthusiasm, then they can also convey that to
colleagues.
(External coach—transcript 12)
14 of 18 Journal of Advanced Nursing, 2024
In addition, the external coaches discussed coaching aspects
with the internal coaches. They supported them by creating
awareness within the team and inspired them about working
with EBQI. They identified suitable topics for care change and
broke them down into small steps. They gave attention to how
internal coaches could help the team approach the EBQI process
in a structured way and ensure it was embedded in daily practice
to create a sustainable EBQI learning culture.
We anchored it within existing structural meetings
as this was time efficient and convenient. But we
also had to take a moment to think: OK, where are
we now and where do we want to go? That is also
important.
(External coach—transcript 11)
External coaches spoke with internal coaches about support-
ing the nursing teams to create time by inspiring them to de-
implement low- value care. The coaches encouraged teams
to look at how they organise care delivery within the team
and empowered them to ask for time to work on EBQI. An
essential part of the work of external coaches is to encourage
and inspire internal coaches to work along the principles of
EBQI. The availability of external coaches resulted in a deeper
commitment from the internal coaches to work on QI based
on E B P.
Because the external coach guided us, we were
motivated to plan meetings and made time for it.
(Internal coach, community care—transcript 1)
During the coaching period, the external coaches slowly faded
out. They did this by helping internal coaches to develop their
skills and, step by step, let them coach more independently.
Because I really dare to let them do it themselves,
those two teams can really continue on their own. I
am so proud of those teams and expect they will be
successful.
(External coach—transcript 10)
Finally, the internal and external coaches complemented each
other in different ways. The external coach assisted in en-
hancing the coaching competencies of the internal coach. On
the other hand, the internal coach provided insights into the
specific barriers and facilitators encountered by the team. The
external coach could then discuss with other internal coaches
and utilise these insights to support the EBQI development
process.
5.2.3 | Barriers and Facilitators
During the intervention period, it was found that not only ac-
tions from the internal and external coaches influenced the
development of an EBQI learning culture within the nursing
teams. Essential facilitators and barriers that influenced the
EBQI developing process within the teams were identified
during data analysis (Figure5). These barriers and facilitators
are essential, as they provide important guidance for the coach-
ing process used by both internal and external coaches.
5.2.3.1 | Facilitators That Promote the Development
of an EBQI Learning Culture. To develop an EBQI
learning culture, internal coaches and team members said
there must be energy to start within the team. Working on
care changes is a team effort. It boosts motivation when a team
see a care change positively influences the patients' perspec-
tives, and they experience personal advantages from it. They
mentioned that it helps when they have enough EBP knowl-
edge, and there is a balance between the team members' work-
load and time spent on EBQI.
An internal coach made a video to show us how to
apply compression stockings on a patient. That was
great. When I went to a patient, I grabbed that video,
and it worked.
(Team member CC—transcript 2)
It boosts the team members' self- conf idence if they have a posi-
tive ex ample, that they were guided and shown how t o approach
a care problem. It also helps when the team uses the individual
team members' quality. Participants say it helps when they get
attention from their organisation. It helps when there are or-
ganisational structures, such as work groups or research facili-
ties, which support working on EBQI. They can have influence,
show leadership in their team or the organisation and have the
autonomy to make decisions about care changes.
It is more motivating if we can decide the change
topics. It gives a feeling of autonomy and is a lot
more fun. If a subject is interesting, you are eager
to investigate it, and you can find the motivation to
work on it. But if the subject does not appeal to you, it
becomes a struggle to work on it.
(Hospital nurse—transcript 7)
Both internal coaches and team members highlight the im-
portance of knowing and trusting each other and treating each
other as equals regardless of the level of education. In addi-
tion, there must be a team culture in which team members
feel secure in addressing and consulting each other. It is im-
portant to be able to talk openly. They also find it important
that team members show flexibility to create opportunities to
work on EBQI.
5.2.3.2 | Barriers That Challenge the Development
of an EBQI Learning Culture. Participants also experi-
enced expressed barriers that challenge the development of an
EBQI learning culture. One of the most critical barriers is
the resistance to change by the team members. This evolves
when there is no basis within the team or the organisation to
work on EBQI or when they do not feel supported. In addi-
tion, some participants did not feel responsible for changing
care because they lacked personal interest or insight. They
expressed feeling insecure because they previously experi-
enced EBQI as something complex due to a knowledge gap or a
lack of QI structures.
15 of 18
Our survey showed that colleagues experienced
Evidence- Based Practice as complex. They struggle
with English language of scientific articles. They
think working with Evidence- Based Practice is time-
consuming, and do not know how to start
(Internal coach, hospital—transcript 5)
If change processes were made too large and there was no pros-
pect of solving them was also cited as a barrier. Some shared that
this resulted in their motivation being taken away. Especially
when expectations about outcomes and working on EBQI were
mismatched due to an imbalanced workload and available time,
they experienced no autonomy or could not persuade leadership
to change care.
If you must work in a different ward due to Covid- 19
restrictions, you do not have time and focus to work
on a project. You are just busy with your shift and
the things that are happening then. Some colleagues
were dealing with so much stress, they could not deal
with anything else like a project. That was a horrible
time.
(Internal coach, hospital—transcript 8)
Some participants said that they felt lost due to COVID- 19 re-
strictions as they had to work in another ward and felt like that
they were no longer part of the team. In addition, due to staff
shortages and schedule changes, time to work on EBQI was lim-
ited, and team members could not meet each other.
6 | Discussion
The aim of this study was to explore how coaching can fa-
cilitate the development of an EBQI learning culture within
nursing teams in hospital and community care settings. It
sought to identify which specific context factors influence
the process of developing future- proof nursing teams. The
data analysis identified the specific elements of coaching that
enable the development of an EBQI learning culture, such as
promoting the readiness to work on EBQI in nursing teams.
The internal coaches enabled this by involving, motivating
and supporting team members. Additionally, it was important
to enhance team members' EBQI competencies, such as how
to select feasible change topics, and knowing the importance
of taking small steps in the change process. Furthermore, sup-
port from an external motivator was essential for sustaining
the EBQI process and aiding internal coaches in developing
their coaching skills.
The first step in changing team attitudes towards EBQI starts
with gaining insight into the readiness of team members to
work on EBQI. The results also show that internal coaches
have a key role in supporting readiness in teams by engag-
ing, supporting and motivating team members. The study
of Hooge et al. (2022) supports the notion that mentors are
crucial in creating a sustainable EBP culture. The study also
shows that organisational Evidence- Based Practice readiness
can be improved through mentoring (Hooge et al. 2022). In
addition, improving the motivation of team members by inter-
nal coaches to support the readiness is an important aspect of
facilitating an EBQI- learning culture. The self- determination
theory supports the importance of being motivated in be-
havioural changes. It also shows how meeting the psycholog-
ical needs of having autonomy, being competent and having
relatedness promotes intrinsic motivation (Flannery 2017).
Also, the study of Bagnasco etal.(2019) supports this finding.
Bagnasco found that nurses are more motivated when they
are more aware of the importance of EBP and know how EBP
can contribute to improving the quality of care and patient
outcomes (Bagnasco etal.2019). Internal coaches can use in-
sights about motivation to advance the readiness to work on
EBQI, and to tailor their coaching.
It is essential that the internal coach takes the EBQI compe-
tencies of the team into account when developing an EBQI
learning culture. It is particularly important to consider the
feasibility of change, which can be ensured by taking small
steps towards EBQI. If insufficient attention is given to the
feasibility, topics may expand too much and become unsolv-
able. Nurses find this daunting negatively impacts their drive
to engage with EBQI initiatives and lowers their readiness.
This is confirmed by the study of Dixon- Woods, McNicol, and
Martin(2012), which shows that goals that are too ambitious
can lead to disillusionment and an early failure to reach goals.
Projects often encounter difficulties due to an underestima-
tion of the required resources needed to make the change,
including time, financial support, project management skills
or supporting infrastructure (Dixon- Woods, McNicol, and
Martin2012). In addition, the study of Brugman etal.(2022)
found that projects that are too ambitious often require a lot
of effort and become too complicated, resulting in feelings of
disappointment. The advice is to nurture participants' existing
motivation, ensure QI project goals a re realistic and achievable
(Brugman et al. 2022) and consider that nurses' motivation
and EBQI competences increase when EBP is translated un-
derstandably (Schuessler etal.2018). This is important as was
found that nurses often struggle with understanding research
articles in non- native language (Giesen et al. 2024). These
insights support the study finding that if nurses effectively
dissect subjects into smaller, more manageable segments or
steps and can address them incrementally, as well as celebrate
successes along the way, it can foster a positive workflow and
keep their motivation and readiness high.
In addition to EBP competences, leadership remains an import-
ant competence of internal coaches. Internal coaches were seen
by the nursing team as healthcare leaders. The leaders can posi-
tively influence their colleagues in developing an EBQI learning
culture and contribute to strengthening the autonomous role of
nurses. The importance of healthcare leaders is confirmed in the
review of Hult etal. (2023) stating that transformational lead-
ership has been demonstrated to be of beneficial influence on
organisational and departmental culture, as well as on nurses'
outcomes. Furthermore, it contributes to high levels of patient
satisfaction and safety.
To reach their full potential as coaches, internal coaches need
support from an exter nal coach. An externa l coach can support
as well as promote transformational leadership development.
16 of 18 Journal of Advanced Nursing, 2024
The external coach can also enhance the internal coach's
knowledge of EBP and help them gain new coaching skills.
The literature review of Richardson etal. (2023) found that
coaching can support nurses to enhance their leadership ca-
pability and improve their performances. Furthermore, the
review of Cummings etal.(2021) highlights the importance of
providing guidance and instruction to nurses on how to show
nursing leadership. In addition, our findings indicate that ex-
ternal coaches serve an important role as external motivators.
This kind of motivation increases internal coaches' (and indi-
rectly that of team members) commitment to, and responsi-
bility for, participating in EBQI efforts. The external coaches
help internal coaches to overcome any feelings of being on
their own. This is also supported by the review of Richardson
etal. (2023), which argues that nurses are more at ease dis-
cussing concerns with an external coach, thereby contribut-
ing to a more trusting work environment. The review also
suggests that an external coach can facilitate the generation
of new ideas and help maintain objectivity. Furthermore, the
study of Lovink etal.(2022) confirms the importance of ex-
ternal coaches. The study states that it is the external coaches
who are the driving force behind the internal coaches as they
guide their teams in the change proces.
Contextual aspects, such as promoting EBP knowledge by pro-
viding EBP education, avoiding too much complexity in projects,
ensuring a safe team culture and support from the organisation
in time and attention can speed up the development process.
The EBQI development process is stimulated when nurses are
given autonomy and the opportunity to lead. A safe team cul-
ture that fosters learning also stimulates the EBQI development
process. These insights are supported by the study of Hoegen
et al. (2022), which underpins the importance of leadership
support among nurses and its connection to their endorsement
of EBP in the context of their work environment. Barriers and
facilitators offer valuable information about the team's status
concerning readiness and competencies towards EBQI. Insight
into resistance in a team can be crucial to successfully devel-
oping an EBQI learning culture. A decline in motivation, es-
pecially concerning an internal coach losing motivation, could
lead to a complete standstill in the development process. The
study by DuBose and Mayo(2020) confirms the impact of resis-
tance, which is often amplified by fear of change, mistrust and
communication barriers. The study found that resistance comes
from a perceived or actual threat. It is a response to maintain a
baseline status and a normal reaction to the unknown (DuBose
and Mayo2020). These insights can be used to tailor coaching
approaches that align with the specific team's needs, which is
essential for the successful development of an EBQI learning
culture.
Lastly, healthcare organisations should act and empower nurs-
ing teams to take leadership, create a safe working culture
and allocate sufficient time to stimulate the development of
an EBQI learning culture within nursing teams. This is sup-
ported by the study of Alatawi et al. (2020) stating that pro-
viding adequate supervision and resources, as well as support
in time management, stimulates the implementation of EBQI.
This is an important but complex challenge in times of labour
shortages.
6.1 | Strengths and Limitations
A strength of this study is the employed research methodology.
Using an action research approach ensured that teams had the
opportunity, with guidance from coaches , to experience the most
effective ways to develop an EBQI learning culture (Waterman,
Tillen, and de Koning2001). It also catered to their level and
previous experiences with EBP and QI rather than imposing a
standardised intervention set by researchers. In addition, most
of the research group, and all external coaches, possessed a
background in nursing. This enabled them to connect with the
nurses more easily, understand the teams' challenges, and guide
them properly.
A limitation of this study is that it was carried out during the
COVID- 19 pandemic. This made recruiting teams and conduct-
ing action research more challenging as the primary focus in
that period was on providing COVID- 19 care. Organisations
were reluctant to expose their teams to an additional burden of
research. Consequently, we were compelled to shorten the in-
tervention period from 1.5 years to 1 year. Moreover, hospital
nurses were reassigned to COVID- 19 departments, causing stag-
nation in the development process of EBQI. Team members had
different responsibilities and were unable to meet each other.
Community care teams experienced fewer disruptions in this
regard.
Furthermore, arranging in- person appointments was difficult
due to the government's COVID- 19 measures. Most coaching
sessions and data collections took place online. Consequently,
this approach could have led to a diminished level of personal
interaction compared to what was initially intended.
All participating teams were included based on their willingness
to participate and demonstrated a high level of motivation to
participate in the study and perceived the value of developing an
EBQI learning culture. Consequently, the findings of our study
are particularly applicable to motivated teams and are also a
prerequisite for developing an EBQI learning culture. However,
we think the findings are also relevant to less motivated teams,
although in these teams more attention will need to be paid to
coaching to motivate team members.
With respect to the design, opportunities to involve nurses
more actively in all the principles of PAR were limited by the
COVID- 19 regulations that were applicable during the study
period. Nurses experienced an extreme increase in their work-
load, limiting their ability to cocreating the research and chang-
ing their practice. The regulations also adjusted the roles of
the action researchers. It was decided to delineate the roles of
researcher and coach, which is not common in action research
(Waterman, Tillen, and de Koning2001). The rationale behind
this choice was rooted in our desire to provide the teams with
an external coach who was familiar with their work environ-
ment and could therefore offer effective and tailored coaching.
This approach also offered the advantage that, during the data
collection phase, participants were able to openly express their
thoughts on the EBQI process and share their experiences with
an independent resea rcher. The independent res earcher was al so
careful to limit the risk of integration to the internal coaches'
17 of 18
own preferences and experiences by taking actions such as facil-
itating reflection sessions.
Finally, in this study, we focused on how coaching facilitates an
EBQI learning culture within nursing teams. We did not study
the impact of coaching on outcomes related to an improved
EBQI learning culture. Further research should focus on the
impact of coaching on QI, in line with the sextuple aim (Alami
etal.2023).
7 | Conclusion
Tailored coaching is of great value within nursing teams. This
has been shown in this research through the identification of
the specific elements of coaching required to facilitate the de-
velopment of an EBQI- learning culture. An essential aspect of
this coaching is creating readiness for QI. This can be enabled
by supporting, involving and motivating team members. In ad-
dition to stimulate QI using EBP within teams, it is essential to
enhance EBQI competencies. It is also critical to guide team
members to select and approach their change topics systemat-
ically. Coaches need to ensure that nursing teams take small
steps in the change process, with continuous consideration of
feasibility. The use of both internal and external coaches is help-
ful in overcoming any barriers within the nursing community.
Coaches serve as excellent motivation for the implementation
and growth of EBQI in nursing.
Author Contributions
Jeltje Giesen: conceptualization, methodology, guidance of external
coaches, investigation, formal analysis, writing – original draft, writ-
ing – review and editing, supervision. Marjolein Berings: conceptu-
alization, methodology, guidance of external coaches, writing – review
and editing, funding acquisition, supervision. Getty Huisman- De
Waa l: conceptualization, methodology, external coaching, formal
analysis, writing – review and editing, funding acquisition, project ad-
ministration, supervision. Annick Bakker- Jacobs: conceptualization,
Methodology, Formal analysis, writing – review and editing. Anneke
Van Vug ht : conceptualization, methodology, guidance of external
coaches, writing – review and editing, funding acquisition, supervision.
Hester Vermeulen: conceptualization, methodology, writing – review
and editing, funding acquisition, supervision.
Acknowledgements
We would like to thank the hospitals and community care organisa-
tions, nurses and coaches for participating in our study and for putting
their effort into developing an EBQI- learning culture in their team and
Alice Ramsay for editing the manuscript.
Ethics Statement
The research ethics committee of the Radboud University Medical
Centre concluded that ethical approval was not required under Dutch
law (CMO no. 2021- 8211).
Consent
Before inclusion in the study, all included participants signed a form
stating that they were informed both in writing and verbally of the pur-
pose of the study, that participation was voluntary, that confidentiality
and anonymit y of recordings, tra nscripts, and sur veys were assured a nd
that participants had the right to withdraw from the study at any given
time without disclosure of a reason.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
Peer Review
The peer rev iew history for this article is avai lable at https:// www. webof
scien ce. com/ api/ gatew ay/ wos/ peer- review/ 10. 1111/ jan. 16679 .
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