Fink, Regina PhD, RN, FAAN, AOCN; Thompson, Cathy J. PhD, RN, CNS; Bonnes, Deborah BSN, RN
Patient care providers who practice from a scientific and research base are vital to promote positive patient outcomes. Clinical practice based on the scientific process and the prevailing evidence is still a goal to be realized. Several studies1–3 suggest that nurses in general have positive attitudes toward research and believe their practice should be based on research. However, despite their knowledge of its importance and value, the majority of nurses do not incorporate research findings into their practice. Researchers have reported that lack of administrative support and mentorship, nurses' beliefs that they lacked authority to change practice, inadequate basic research knowledge, incomprehensible statistics, and insufficient time on the job to implement change are significant barriers to nurses' utilization of research in practice.4–14
Organizational efforts to bridge the “research-practice gap” are noted.15–17 Various models of promoting quality care through the incorporation of research into practice have been proposed.18–21 The American Nurses Credentialing Center's (ANCC) Magnet Services Standards, by including research in the criteria to become a Magnet hospital, has stimulated the development of research, research utilization, and evidence-based practice throughout the country as many hospitals seek to gain the Magnet hospital services designated award. The ANCC Magnet standards have brought increased awareness of the need for nurse executives to create an organizational culture that supports nurses to value research and provides research activities and mentors staff nurses in the research process.
Individual nurse characteristics, such as a positive research attitude and involvement in research activities, have been positively correlated with intent to implement research findings in practice.22–25 Estabrooks and colleagues26 performed a systematic review of studies that examined the individual characteristics of nurses and their influence on research utilization. They identified 6 categories of potential individual determinants—beliefs and attitudes, research activity involvement, information seeking, professional characteristics, education, and socio-economic factors—and suggested that longitudinal research in the area of research utilization might better identify which factors influence research use.
It is important for an organization to develop a supportive environment in an effort to attract, identify, and encourage individuals who share a similar philosophy to positively influence the research culture of that organization. Simply addressing the knowledge barrier might not be enough to cause a lasting change in practice.27 Strategies to address the complaint of “lack of administrative support” must be multifaceted and include a strong, supportive leadership, mentorship, staff education regarding research use, time to conduct or utilize research, routine performance expectations in research use, and fiscal incentives.28–32
A challenge to closing the gap between research and practice, even in a supportive practice environment, is the uneven preparation that nurses receive in their nursing programs on skills related to research utilization and evidence-based practice. This reality places a significant burden on the healthcare facility and nurse executives to remediate nursing knowledge and skill gaps. At the University of Colorado Hospital (UCH), the chief nursing officer has role-modeled and engaged nurse administrators and staff in purposeful change to create a workplace that is innovative and embraces evidence-based practice to improve patient outcomes.
Purpose of the Study
The purpose of this study was to examine the effect of multifaceted organizational strategies on registered nurses' (RNs) use of research findings to change practice in an academic hospital. The specific aims were to (1) identify nurses' attitudes and perceptions about organizational culture and research utilization, (2) identify perceived barriers and facilitators to nurses' use of research in practice, and (3) determine which factors are correlated with research utilization.
The theoretical framework for the study was Rogers'33 Diffusion of Innovations, a behavioral theory that describes the process the user goes through in the adoption or rejection of new ideas, practices, or technology. Rogers defined the concept of diffusion as a process that involves the communication of new ideas among individuals. Main components of the Diffusion of Innovation theory are innovation, communication channels, time, and social systems. The innovation-decision process embodies these elements and is the mechanism by which the adopter learns about and evaluates the innovation for use in practice. Rogers33 described 5 stages to the innovation-decision process: the knowledge stage, the persuasion stage, the decision stage, the implementation stage, and the confirmation stage. For the purpose of this study, the knowledge and persuasion stages are the stages of interest, and the “innovation” is defined as research utilization knowledge and persuasion of its value.
A descriptive, cross-sectional, presurvey and postsurvey design was used to identify inpatient nurses' personal and professional characteristics related to research utilization, their perceived barriers and facilitators of research use, and their perceptions of organizational culture, as well as to examine the effectiveness of the proposed organizational strategies on their perceptions of the organization's research culture. The study was approved by the appropriate institutional review board. There were 2 phases of data collection: baseline data were collected in January 2001 and the postimplementation data were collected in January 2003.
A convenience sample of all RNs employed on the inpatient units at UCH, a large university-affiliated Magnet hospital, was the target population. At baseline, 880 surveys were distributed with a 24% response rate (n = 215); 890 were distributed postintervention implementation with 27% responding (n = 239).
Two reliable and valid research instruments—the BARRIERS to Research Utilization Scale34 (α = .91) and the Research Factor Questionnaire35 (RFQ) (α = .89)—were used to measure RNs' attitudes and beliefs about research utilization.
The BARRIERS tool, a 35-question Likert-type scale that elicits perceptions of barriers and facilitators of research utilization, is divided into 4 subscales: characteristics of the adopter (the nurses' research values, skills, awareness); characteristics of the organization (setting barriers and limitations; eg, time, resources, support); characteristics of the innovation (qualities of research findings and methodologies); and characteristics of the communication (presentation and accessibility of the research). The tool includes 29 fixed-response questions, 5 respondent-derived and -rated barriers, and 1 open-ended question. The BARRIERS scale, based on Rogers' theory,33 has been well-tested and documented in the literature.4,6,9–11,13,14
The RFQ, an investigator-developed tool also based on Rogers' theory,33 has been validated elsewhere35 and was used to ascertain personal and professional nurse characteristics (individual innovativeness subscale), including research attitude and involvement in research activities; the use of interpersonal and mass-media communication channels—eg, conference attendance, reading of professional journals (communication channels subscale); and the nurse's perception of organizational support for research-based practice to the use of research findings in practice (organizational climate subscale).
Attitudes toward nursing research were determined by a 4-question semantic differential scale. Respondents were asked to rate nursing research as it related to 4 word pairs of Meaningful/Meaningless, Valuable/Worthless, Useful/Useless, and Important/Unimportant on a 7-point scale (2 of the word pairs were reversed to reduce response bias). Demographic items to assess how well the staff represented the total population were also included. The postimplementation RFQ was modified to include questions about respondents' understanding of the concept of “research utilization,” their awareness of organizational efforts to promote a more research-friendly atmosphere, and their participation in and perceptions of the value of specific strategies implemented in the promotion of research utilization at UCH.
All inpatient RNs were invited to participate in the study. Following a prepared script, 3 representatives from the evidence-based practice council introduced the study at unit staff and administrative meetings. Additionally, a concurrent email describing the study was sent to participants. The research packet, consisting of an explanatory cover letter and study instruments, was placed in each nurse's mailbox with a self-addressed return envelope to assure anonymity and facilitate a timely response. Staff members were given 2 weeks to complete the surveys. The cover letter served as the informed consent; return and completion of the research instruments were considered consent to participate in this voluntary study.
After baseline data were collected, the Professional Resources Practice Outcomes Research Manual, a 125-page, user-friendly manual designed to stimulate staff nurses' learning about evidence-based practice and the research process, was distributed to all nursing units. Multiple organizational strategies were developed and implemented after identifying preintervention data collection areas of opportunity (Figure 1).
Data were entered by the study investigators into an SPSS program (Version 12.0) with accuracy checks conducted. Alpha was set at .05. Tests of difference (independent samples t tests, chi square [χ2]) and association (phi [Φ]) were used to analyze the data. Qualitative data were entered into a Microsoft Excel spreadsheet and examined for common themes. Preimplementation and postimplementation qualitative data from the surveys were grouped and categorized by one of the investigators. The research team met to reach consensus on the common themes, grouping responses accordingly. The number of comments composing each theme was noted and aided investigators in ascertaining theme importance.
There were no differences in the demographic profile between the pre and post samples. The average respondent was a 39-year-old female staff nurse employed full time with 14 years of nursing experience. The majority (67%) were prepared at the baccalaureate level; 16% held an advanced degree. Over half (55%) of the subjects were members of at least one professional organization, certified in their specialty area (30%), and read professional literature an average of 1¾ hours per week.
The reliability of the BARRIERS scale proved to be similar to the reliabilities reported by the original author34 and other studies using this instrument. For each subscale, the mean scores were summed and divided by the number of subscale items to determine group means (Table 1). Respondents in both samples perceived items related to the organization as the greatest barriers (X = 2.76 pre; 2.61 post), followed by the communication, adopter, innovation subscales. There was a statistically significant improvement in the perception of the organization as a barrier and nurse's (adopter) perception of personal research abilities as a barrier from preimplementation to postimplementation data.
Of the 29 barriers listed on the BARRIERS scale, there were only 3 research-use barriers that preintervention sample respondents identified that were of moderate to great extent (>3.0 on a 0–4 scale); these were (a) RN authority to change practice, (b) RN awareness of research, and (c) time on the job to read. Table 2 lists the barriers that significantly improved in the postimplementation period; none of the 29 barriers worsened in these samples.
Research Factor Questionnaire
Reliabilities for this study reported similar findings to author-reported reliabilities.35 A similar approach to the procedure described for the BARRIERS scale was used to score the RFQ. Organizational climate and individual innovativeness scores significantly improved from baseline (Table 3).
Positive attitudes toward nursing research were reported in both preimplementation and postimplementation groups and were not significantly different (X = 5.70, pre; 5.64, post). Fifty percent of preimplementation respondents participated in the following research activities, at least once, within the past year: shared research findings with peers (70%), attended local research conferences (67%), participated in research projects (64%), and attended evidence-based practice council meetings (55%). Of the 194 respondents who answered this question in the postintervention survey, 141 (73%) noted participation in more than 1 activity.
The research activities they participated in most frequently were as a participant in data collection (n = 123), attending journal club (n = 105), reading the Practice Outcomes Research Manual (n = 71), attending research seminars or workshops (n = 70), and participating in evidence-based practice projects (n = 65). The majority of the postintervention sample reported a low level of research activity participation (62%, n = 149); only 5% (n = 13) a high level of participation and 27% (n = 64) a moderate level of participation.
In the postimplementation RFQ, 83% of the nurses (n = 199) reported they understood the concept of research utilization (n = 199), 63% reported they were aware of organizational strategies related to research utilization over the past year (n = 150), and 65% had an increased awareness of research findings as a result of their participation in research activities (n = 155). Forty-eight percent believed their use of research findings increased as a result of participation (n = 114) and 49% (n = 118) reported the belief that their patients benefited from their research involvement in terms of positive outcomes. There was a weak but significant positive association between research attitude and understanding research utilization (Φ = 0.205, P = .002), research awareness (Φ = 0.191, P = .007), research use (Φ = 0.296, P = .000), and improved patient outcomes (Φ = 0.263, P = .000).
There were no changes reported in discussions of clinical practice research findings with fellow staff nurses or rehabilitation therapists; there were slightly greater discussions rates with other healthcare providers (clinical educators, managers, nurse practitioners, and physicians), but these changes were not statistically significant. The journals most widely read were the American Journal of Nursing (34%) and RN (22%).
Qualitative comments on the preimplementation and postimplementation BARRIERS scale and postimplementation RFQ were recorded and examined for common themes.
The last 6 questions of the BARRIERS scale included a qualitative component in which the respondents were asked to specify and rate any of the aforementioned barriers or additional barriers to research use. For example: “Are there other things you think are barriers to research utilization?” and “If so, please list and rate each on the scale.” The research team agreed on 4 common themes: (1) difficulty in changing practice, (2) lack of administrative support and mentoring, (3) insufficient time, and (4) lack of education on the research utilization process. No additional themes were noted in the postimplementation BARRIERS tool.
Difficulty in Changing Practice
Respondents indicated that difficulty in changing practice was their most problematic barrier; however the number of comments declined from 40% preimplementation to 29% of total comments postintervention implementation. Nurses reported the implementation of research into practice as being a “complicated process” in which the “steps needed to make change are extensive, time-consuming, and often discouraging.” Multiple respondents mentioned feeling powerless within the organization to change practice based on research. Their frustration with differentiating substantial change from trends is evidenced in the comment that “methods of care often go in and out of vogue.”
Lack of Administrative Support and Mentoring
It is important for nurses to feel supported and mentored by nursing leadership throughout the research utilization process. Thirty-three percent of comments pre and 28% of comments post listed the lack of support and mentoring as 1 of the top 3 barriers to the use of research in practice. After implementing the multifaceted interventions, the number of comments decreased slightly, but the nature of the comments changed from an organizational concern to feeling less supported by the management within their specific units. Preimplementation nurse respondents mentioned that there was “no support by management,” that “research time is not allotted by administration,” and there was a “lack of organized mentoring” and “no reimbursement or funds to do research.” Postimplementation comments included the respondent's desire for “manager role-models for research implementation,” and that there was “no support from supervisors.”
Lack of time was a significant barrier, increasing from 16% to 21% of total comments, and the nature of the comments was similar on both surveys. Specifically, respondents want more time within their work hours to devote toward the research utilization process. Demands of the current work environment in acute care nursing are evident in multiple comments made by respondents. Nurses felt there was “not enough time when staffing a unit to read and discuss research articles,” and that “RN's are overworked, time is limited,” and they are “too busy to implement” research findings into practice.
Lack of Education on the Research Utilization Process
The critical evaluation of nursing research and the responsible implementation of findings into practice require knowledge, patience, and mentoring. Comments related to lack of education on the research utilization process increased postimplementation of the multifaceted intervention from 11% to 21% and the nature of the comments also changed. Many preimplementation respondents questioned the inherent value of research as it “doesn't apply to what I do” and is “not related to bedside care” and that “nurses are not trained to think deductively.” Postimplementation respondents commented on their “lack of knowledge of statistical analysis,” that “most RNs are not comfortable critiquing research,” it is “difficult to analyze research studies,” and they had a “lack of familiarity of latest research influencing their clinical practice areas.”
Respondents were also asked, “What are the things you think facilitate research utilization?” The majority of respondents' comments focused on organizational support that includes improved staffing ratios to permit more time to be involved in research utilization; having “champions for change” in areas of pain, skin, and evidence-based practice; encouragement by administrators and managers to participate in research utilization and to critically examine policies and procedures based on the evidence; and having mentors (researchers and educators) to facilitate the research process. Having the “evidence” available was listed as another facilitator to research use in practice. Respondents commented that having relevant research articles posted and easily accessed online in the nursing station engages them to become more involved in the critique process. Participating in a unit-based journal club or nursing grand rounds also emphasized the importance of keeping current with the profession's increasing body of knowledge.
Research Factors Questionnaire
Ninety-nine participants (41%) responded to the question asking for an explanation of why they considered certain research activities most useful to promote research utilization. Activities considered useful because they exposed staff to relevant research and the research process were those that allowed a “hands-on” approach to critiquing research findings, allowing the participants to see how findings get translated into practice; encouraged discussion among the staff; and allowed individual versus group participation.
This study was conducted in 1 setting, thus the results may not be generalizable to nurses working in other settings. Even though no efforts were made to track the RNs who participated in the study, the “small world” of this 1 hospital setting, and the emphasis of research-based practice in the nursing media, may have influenced the participants to answer in a socially desirable way. Volunteer bias is also a limitation with any survey tool. The participants who chose to complete the survey may be inherently different than the nonresponders. The low response rate (24% pre; 27% post) may have been impacted by staff nurse respondents' participation in other research studies requiring survey completion at the same time. This decreased response rate may also reflect a negative attitude about research utilization; nonresponders may have been more negative. A higher response rate may have produced different results.
One major limitation to this study is the effect of history on the participants. Prior to the study's beginning, this institution had already started promoting awareness of the value and benefits of research utilization to its nursing staff. The arrival of a new chief nursing officer in 1996, who was nationally and internationally known for her work in research utilization and evidence-based practice movements, only increased the organization's commitment to research and evidence-based practice.
The questions added to the RFQ for the postimplementation phase were different than the questions on the preimplementation survey. Though the added questions conceptually fit with the tool generating a good reliability, there is a possibility that different results may have been obtained if the tool had not been redesigned. Additionally, “No opinion” responses on the BARRIERS scale made it more difficult for the investigators to analyze particular items also influencing the validity of the results.
The results of this study lend support to Rogers'33 Diffusion of Innovations theory constructs and validate findings from other research utilization studies.24,35 Because the surveys were not linked to individual nurses, to ascertain the extent that the postsurvey respondents were the same group as those who completed the pretest, respondents were asked to identify if they had completed the first survey. Over half reported they had (51%), 44% marked “no,” and 5% did not answer this question. Turnover rates during this 2-year time period remained stable during predata and postdata periods, therefore this was not a contributing to the lack of consistent respondents.
Nurses' research attitudes were very positive at the start of this study, which could have been the result of early efforts to increase awareness and the use of research findings in practice. Research attitudes did not change significantly, with the majority believing that their individual efforts toward research utilization affected their practice. Although most staff said they participated at a low level in research activities, these nurses reported an increase in their awareness and use of research findings, as well as a belief that their patients benefited from their research involvement in terms of positive outcomes.
The UCH is an ANCC Magnet-designated hospital that has developed a supportive environment to promote research utilization and evidence-based practice as substantiated by the significant improvement in respondents' perceptions of the organization as a barrier and nurse's (adopter) perception of personal research abilities as a barrier from preimplementation to postimplementation surveying. Many of the clinical nurses do ask, “What is the evidence?,” know what research utilization and evidence-based practice means, use it in daily practice, and challenge others to use it. The organization has developed specific activities and interventions that have captured the staff nurse's interest, excitement, and commitment to research utilization and evidence-based practice.
The evidence-based practice council has expanded to include representatives from all levels of nursing practice and multiple disciplines. The evidence-based “champions of change” group of staff nurse representatives from services across the hospital have promoted evidence-based practice in their clinical areas and are mentored by the research nurse scientists, evidence-based practice council members, and nursing faculty from the school of nursing to actively initiate evidence-based practice projects and promote journal clubs. All nursing staff members are encouraged to attend the annual research symposium, which highlights the many evidence-based practice projects that have been completed or are ongoing within the institution; the attendance at this yearly symposium continues to grow. Nurses are also supported to attend workshops on evidence-based practice and clinical research for the novice, both of which improve nurses' knowledge on critique of the evidence.
Other initiatives that have involved clinical staff nurses and other disciplines throughout the organization include the evidence-based skin care champions of change who have developed a product algorithm and protocol based on examining the evidence related to skin integrity and pressure ulcers. The skin champions collect quarterly pressure ulcer prevalence and documentation data and have been credited with decreasing pressure ulcer prevalence at UCH from 9% to 3%. Similarly, the evidence-based pain champions have improved nurse pain documentation by conducting ongoing pain medical record reviews, promoting education, and reporting pain outcomes for their units.
The resulting associations between research awareness, use, and positive patient outcomes lend support to Rogers' theoretical constructs that awareness of research leads to decisions to use the findings in practice. The belief in positive patient outcomes strengthens the nurse's value of research into practice and increases the belief that nurses have the power to make changes in practice. The significant associations of research attitude with the belief that research involvement affected nurses' awareness and use of research findings, as well as their belief that their involvement produced positive patient outcomes, were expected. The research attitude score was very positive in this sample and did not significantly change for either administration of the instruments. Nurses had positive attitudes toward nursing research, and this attitude, along with the finding that the nurses felt the identified baseline barrier of “no authority to change practice” was less of a hindrance to research utilization, is a positive sign.
This research study results suggest that nurses' beliefs and attitudes about research can be improved through an organizational commitment to the use of research in practice and also validate the findings from other studies suggesting that nurses who participate in research activities are more likely to use research in practice.24,25 The finding that the majority of nurses are only minimally involved in organizational research activities suggests that nurses may participate in only one research activity at a time, due to a variety of factors—particularly limited time. Therefore, offering and promoting activities that will give the nurse and organization the “most bang for the buck” are essential toward the promotion of research utilization. Creating an organizational climate that values research use and supports nurses to participate in such activities is crucial to the organization's success.
The authors acknowledge the mentoring of Colleen Goode, PhD, RN, FAAN, Chief Nursing Officer, and Mary Krugman, PhD, RN, FAAN, Director of Professional Resources, University of Colorado Hospital; Dr Kathleen Oman's manuscript review; and Ms Laura Sasse, ND, RN, University of Colorado School of Nursing (at the time of this study) for assistance with data entry and management.
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