Squires, Janet E. PhD, RN; Reay, Trish PhD; Moralejo, Donna PhD, RN; LeFort, Sandra M. PhD, RN; Hutchinson, Alison M. PhD, RN; Estabrooks, Carole A. PhD, RN
Nursing literature is replete with calls to make nursing practice more research or evidence based, thus improving patient and system outcomes.1,2 While gaining considerable insights into research utilization, an extensive time lag exists between the availability of research evidence to update clinical practices and the actual nursing care received by patients. Over the past 30 years, many examples of this research-practice gap have been highlighted in the literature. Accelerated efforts have been adopted to develop interventions to increase nurses’ use of research in practice. Relatively few reports of these efforts exist, and the majority of those available have not yielded positive results.3 One reason for this conundrum is the failure to use theory to inform the design of research utilization interventions.
Organizational policies and procedures (P&P’s) that are based on high-quality research evidence are one vehicle for increasing research utilization by nurses.4,5 Several studies have shown that nurses’ perceptions of the existence of policies are associated with increased use of the practices reflected in P&P’s.4,5 St-Pierre and colleagues6 reported that nurses who were aware of changes to P&P’s were more likely to demonstrate organizational support for the implementation of clinical practice guidelines. Other studies demonstrate that P&P’s are important knowledge sources for nurses.5,7 Although these findings lend support to using P&P’s to promote research utilization by nurses, their existence alone is not sufficient to cause the use of research to happen.5 Careful attention by nurse leaders to the design and implementation of strategies to increase nurses’ use of research-based P&P’s is needed. Most strategies targeting increases in the use of research lack mechanisms to support understanding regarding how and why the strategies have or have not worked. This atheoretical approach makes it difficult to understand how to best implement research into nursing practice. This article describes how one research utilization framework—Promoting Action on Research Implementation in Health Services (PARiHS) framework,8 can be used by nurse leaders to inform the design of strategies to increase nurses’ use of research-based P&P’s.
The PARiHS Framework
The PARiHS framework provides a broad conceptualization of how research utilization in nursing occurs.8 The framework suggests that successful research utilization is the result of dynamic interplay and interdependence between 3 core dimensions: evidence, context, and expert facilitation. Each dimension is composed of subdimensions, which exist on a continuum ranging from weak to strong; research utilization is hypothesized to be most likely when each subdimension is strong.8
Evidence, in the PARiHS framework, refers to the information and knowledge upon which decisions about care are based. Three strands of evidence are identified: research, clinical experience, and patient preferences. Research utilization is believed to be most likely when all 3 strands are strong. With respect to research, high-quality systematic reviews and randomized controlled trials (RCTs) are considered the best evidence on the effectiveness of nursing interventions.8 The best evidence for other aspects of practice (eg, provision of psychosocial support) arise from a variety of study designs.8 Strong clinical experience occurs when there is an increased level of consensus among nurses. Weak clinical experience occurs when expert opinion is divided. Patient preferences are considered strong when partnership between nurses and patients exists, and weak when there is lack of involvement or consideration of what the patient desires.8
In the PARiHS framework, the format and design of the research is determined by the nature of the clinical issue at hand. Also, not all P&P’s necessitate the same level of research evidence. P&P’s about the most effective method to bandage a leg ulcer for optimal healing should be based on systematic reviews where available, whereas P&P’s about providing psychological support to patients with leg ulcers would be best based on qualitative studies that explore the experiences of patients with leg ulcers and the types of support they preferred. Consequently, when establishing the evidence base for P&P, nurse leaders need to bear in mind the purpose, strengths, and limitations of different research studies and not rely on the traditional medical hierarchy of evidence that dominates current health services literature.
Although all 3 evidence strands are optimal for research utilization by nurses to occur, there will be situations where research-based P&P’s will need to be implemented to maintain or improve patient care quality, which are congruent neither with the nurses’ clinical experience nor with patient preferences. This represents a unique challenge for nurse leaders. For example, there is strong research evidence to support the positive effects of regular opioid administration during the 1st 48 hours postoperatively on improved patient outcomes and decreased length of hospital stay. Despite this evidence, many nurses remain reluctant to administer these medications regularly (even when ordered)5 perhaps because of fear of dependence or concern about the development of serious adverse effects due to their clinical experiences. Similarly, some patients may wish not to be medicated. In this type of situation, education of nurses and patients will be needed. Nurse leaders need to ensure all nurses working on their units are aware of their unit’s P&P’s and, importantly, of the rationale behind them. The use of formal in-service education and informal bedside teaching sessions are context-focused strategies targeted to increase nurses’ use of research.5,9 In addition to research use by individual nurses, once aware and supportive of the practice in the P&P’s themselves, some nurses will become champions (and facilitators) of the practice, further increasing research use among nurses.
Context is a potential mediator of research utilization.10,11 Context refers to the “environment or setting in which the proposed change is to be implemented.”12(p299) This environment is believed to exist on a continuum from weak to strong on organizational culture, leadership, and evaluatative levels. The PARiHS framework postulates that research utilization is more likely to occur within strong context environments, meaning learning environments that have sympathetic cultures, strong leadership, and appropriate monitoring and feedback (evaluation) systems.8,13
Organizational culture refers to defining prevailing beliefs and values, consistency in values, and receptivity to change.14 With this view, culture and context almost become one—in essence, culture is what the unit is. Culture has important implications for nurse leaders with respect to P&P implementation. Nurses draw upon their unit’s culture to understand how to behave. This suggests they will redesign their attitude, behavior, and work to meet the shared beliefs and values held by others in the unit. Such behavior will significantly impact their adoption of research-based P&P’s. Nurse leaders need to determine and consider the prevailing culture of the unit in which they are attempting to implement research-based P&P’s. Working with (rather than changing) a prevailing unit culture is most desirable if possible. However, there are times when P&P’s, which are contrary to a unit’s existing culture, need to be implemented to improve patient care. This represents a challenge to nurse leaders. In these situations, nurse leaders need to recognize that changing a unit’s culture, although not impossible, will be a challenging and time-consuming process that will often require professional assistance (eg, from a professional facilitator or outside resource). Education for nurses regarding the change, including the research evidence underpinning the P&P’s and rationale about why it is necessary, is critical. Governance or leadership style and facilitation, are also critical where adoption of P&P’s requires changes in unit or organizational culture.
Leadership refers to the nature of human relationships with effective leadership being proposed to give rise to clear roles, effective teamwork, and effective organizational structures, as well as staff involvement in decision making and approach to learning.14 This view closely resembles a leadership style known as shared leadership, meaning a unit structure and process that legitimizes nurses’ control over their practice and permanently extends their influence to areas previously controlled by management. Integral to the success of shared leadership is a balance in power between nurses and leaders. It is important for nurse leaders to be aware of the need for this balance so they can make conscious efforts to empower nurses on their unit. For example, not all nurses have the power (or desire) to take direct action on issues affecting patient care by, for example, sitting on advisory meetings or voting on proposed legislation. Nurse leaders, following a shared leadership governance model, can empower nurses by instilling a sense of power. They can provide avenues by which nurses take an active and participatory role in policy implementation, whether it is performing a literature search, questioning practice, reviewing the P&P, or educating other unit nurses through in-services. By striving to provide all nurses with a sense of power, nurse leaders can increase the success of P&P implementation strategies, and thus research utilization and improved patient care, on their unit.
Evaluation, also referred to as measurement in the PARiHS framework, describes individual and systems level feedback mechanisms, sources, and methods for measurement. Evaluation can take many forms from the use of hard data such as cost-effectiveness, length of hospital stay, or number of falls, to the use of soft data such as patients’ experiences. Strong evaluation is believed to occur when evaluation mechanisms occur routinely in a unit. Audit, coupled with a feedback mechanism, such as a report that is fed back to nurses is one of the most common methods of intervening to implement research into practice. This approach has been shown to have modest effects with physicians,15 but its effect on nurses has been relatively untested; one RCT found that audit and feedback together with educational outreach and printed materials resulted in moderate improvements in nursing care.16 This study indicates audit and feedback may hold promise for increasing nurses’ use of research-based P&P’s. If nurses receive little or no feedback on the care they provide, or if the feedback they do receive is not tightly coupled to outcomes that are important to them (such as patient health), theoretically they are less likely to take action (use research-based P&Ps) to improve patient care. Furthermore, research utilization is likely to continue when individuals can see the positive effects (eg, on patient outcomes) of the research, making audit and feedback also an important strategy for sustainability of P&P use. For instance, if nurses see that the number of falls on their unit decreased as a result of implementing falls assessment P&P, the nurses (theoretically) are more likely to continue to perform the assessment.
Additional Components of Context
A more recent article suggests a 4th component of context may exist—resources; time, availability of equipment, and clinical skills.17 This availability (or lack thereof) of resources requires careful consideration when designing strategies to implement research-based P&P’s. First, nurses require sufficient time to review the details of specific P&P’s they do not routinely perform, prior to implementing them; this will need to be built into staffing systems and workloads. Second, nurses require specific skills to proficiently carry out activities described in some P&P’s. Nurse leaders have a responsibility to ensure that nurses are not only aware of the P&P’s but also that they have the skills to perform them safely. Third, nurse leaders need to ensure that nurses have the physical resources (eg, equipment) to carry out research-based P&P’s. Without the necessary resources (time, skills, and equipment), research-based P&P’s cannot be implemented, even where evidence, context, and expert facilitation are all strong.
Another related and important component of context (not part of the PARiHS framework) is that of organizational systems—staffing and information systems in particular. Staffing systems refers to the shifts and positions held by nurses. Nurses work a variety of shift work systems: days; nights; combination shifts; and 4-, 6-, 8-, and 12-hour shifts. Furthermore, many nurses work reduced hours, are in temporary positions, and work casual shifts on several different units and, sometimes, different organizations. These unique features of nurse staffing systems make access to the cohort of nurses working on a particular unit difficult at best. An information system refers to how information is transferred in an organization. Nurse leaders need to be aware of the staffing systems and formal and informal knowledge transfer systems (and their success) that exist in their unit and organization. The literature regarding which systems are best for disseminating and increasing the uptake of P&P’s by nurses is sparse. One study, to date, has examined P&P’s dissemination. Squires and colleagues5 examined dissemination strategies for research-based P&P’s and found that although passive modes of dissemination (eg, e-mail and posted memos) were the most frequently used modes of dissemination by nurse leaders, they were largely ineffective. Active modes of dissemination (eg, formal in-services) were shown to be the most effective but less frequently used. Other studies have reported formal in-services to be a common knowledge source for nurses, further supporting their use.18 When selecting dissemination strategies, nurse leaders need to take into account the staffing systems in existence. For example, incentives could be offered to evening/night-shift nurses to attend special daytime in-services. Social media and other innovative approaches could be utilized to capture nurses working different shifts. Nurses identified as champions of a research-based P&P should also be recruited to deliver in-services to colleagues during irregular hours. This will not only strengthen a unit’s culture and increase resources, but also empower nurses and strengthen any aspects of shared leadership in effect.
The final component of the PARiHS framework is expert facilitation. Facilitation can be viewed as the catalyst that sparks and guides the change process (ie, the use of research-based P&Ps). Facilitation refers to the process of “enabling (making easier) the implementation of evidence into practice.”19(p579) It is proposed to exist on a continuum from weak to strong on each of purpose, role, and skills and attributes. Facilitators help individuals and teams understand what they need to change and how to change it to successfully implement research into practice.8 Facilitation does not occur on its own; rather, specific characteristics, knowledge, and skills on part of the facilitator are required to make it happen. The role itself is usually formal—one that an individual is appointed to; the facilitator can be external or internal to the unit, or a combination thereof. The facilitator requires a combination of specific personal attributes and skills to be effective. These skills and attributes will vary according to the purpose of the facilitation process and how the facilitator role is operationalized. If facilitation is needed to accomplish specific tasks, then the facilitator’s role is one of providing practical help and support. If, on the other hand, the purpose of facilitation is more holistic, that is, aimed at changing practice through empowerment, then the facilitator’s role is one more of enabling individuals and teams to change their attitudes and behaviors.19 It is important that nurse leaders identify the purpose of the facilitation required; for example, do they want to teach their nurses how to carry out a research-based procedure or do they want to empower their nurses to change their practice by following a broad research-based policy? This knowledge will enable leaders to effectively select facilitators with the necessary skills and attributes to move the research (and P&Ps) into practice. Some skills/attributes of facilitators that have been identified in recent years as important to research utilization are communication skills, content knowledge, and motivation.19
Diagnostics for and Evaluation of Implementation, According to the PARiHS Framework
Most recently, the developers of the PARiHS framework have begun to consider how the framework may be used in a pragmatic way to guide diagnostic assessments for and evaluation of implementation efforts.13 A draft set of questions identifies elements of the evidence and context that require modification and the features of facilitation that would promote successful implementation.13 Nurse leaders can readily use these questions, in collaboration with members of their team, to promote understanding of nurses’ assumptions and perceptions relating to elements of specific evidence, readiness of the context for change, and facilitation. To further assist in determining a unit’s state of readiness for change, the framework developers have proposed use of a diagnostic and evaluative grid. To use the grid, nurse leaders can aggregate responses to the set of questions (Table 1) and then plot results on the grid to identify the team’s overall perception of their state of readiness for implementation of a piece of research evidence. This activity can assist nurse leaders in determining the features of facilitation that are most likely to support and promote evidence implementation on their unit. In addition, the nurse manager and/or facilitators can also use this question set to evaluate progress toward adoption of the research evidence (P&Ps).
In today’s rapidly growing healthcare environment, designing interventions that have higher likelihood of increasing research use is essential to ensure patients receive quality care and to ensure patients and organizations achieve optimal outcomes. The need to build a consistent body of knowledge regarding how and why research implementation strategies do and do not work is also of vital importance. This requires a theory-driven approach. Research-based P&P’s are a vehicle for promoting research utilization and thus patient care quality and outcomes. However, the existence of these P&P’s is not sufficient to ensure adoption by nurses. In this article, we used the PARiHS framework to illustrate how nurse leaders can use this framework to inform the design of strategies to increase nurses’ use of research-based P&P’s.
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