Evidence-based practice (EBP) has changed progressively how researchers have used evidence in healthcare over the past 30 years. Aging populations, new technologies and knowledge, and high patient healthcare expectations have increased the demand for high-quality and cost-effective healthcare delivery. Whereas, in the past, nurse clinical decision making could rely on opinion and experience, clinical decision making is now guided by science, research, and evidence to deliver quality and cost-effective nursing care.
The advantages of incorporating research evidence into everyday practice are numerous and include elevated standards of nursing care, increased quality, and personal and professional growth for nurses (Ashley, 2005). Although research findings indicate that nurses around the globe share positive attitudes toward research and believe that their practice should be based on research findings (Oh, 2008; Olade, 2005; Sitzia, 2001), still most nurses do not incorporate research findings into practice (Boström, Kajermo, Nordström, & Wallin, 2008; Fink, Thompson, & Bonnes, 2005; Oh, 2008; Sitzia, 2001). Moreover, results from studies suggest a substantial time lag of 8 to 15 years between the generation of new technical information or knowledge through research and the application of such in clinical practice (Dobbins, Barnsley, Ciliska, Cockerill, & DiCenso, 2002).
Reasons why nurses do not incorporate evidence into practice have been studied extensively, especially in relation to barriers to doing so (Boström et al., 2008; Fink et al., 2005; Leasure, Stirlen, & Thompson, 2008). Although barriers to the use of evidence in clinical practice have been studied worldwide, no published research reports on this matter address the situation in Saudi Arabia. This study addressed this lack of reliable information. This study explored factors that impede or support the introduction of research findings into nursing practice in Saudi Arabia in light of its culturally diverse nursing workforce. The findings of this study may provide greater understanding of nurse-perceived barriers as well as factors that facilitate the use of research findings in practice.
EBP is the conscientious, explicit, and judicious use of current best evidence in making patient care decisions. It integrates individual clinical expertise with the best available external clinical evidence derived from systematic research and patient preferences (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).
The nursing labor force in Saudi Arabia embraces many nationalities and ethnicities. In 2010, approximately 30% of nurses were Saudi, with the remaining 70% representing over 20 nationalities. Saudi nurses comprised only 10% of the total workforce at National Guard Health Affairs hospitals and clinics where this study was conducted.
Nurses worldwide have a generally higher-than-average education, a situation supported and enhanced by World Health Organization Global Standards for Initial Professional Nursing and Midwifery Education. The nursing workforce in Saudi Arabia is better educated today than in the past, and it is natural to expect that they should be able to reflect EBP principles into their practice. Globally, this ideal is a hallmark of the nursing profession, as stated in the 1999 position statement of the International Council of Nurses: “Research-based practice is a hallmark for professional nursing, Nursing research, both qualitative and quantitative, is critical for quality cost-effective healthcare” (International Council of Nurses, 1999, p. 1).
The gap between available research evidence and the use of this evidence in practice is an issue that needs attention. The EBP paradigm movement since the mid-19th century has served to bridge the gap between research and practice by making the best possible use of available research evidence to meet the conflicting demands of today’s healthcare. However, the process of implementing available research evidence is not easy and requires numerous events and efforts by healthcare organizations and healthcare clinicians (Ehrenberg & Estabrooks, 2004).
The term “research utilization” has evolved over time in the literature since its first introduction in the 1980s. Research utilization is a systemic method of implementing, applying, and evaluating research-based intervention in practice (Ashley, 2005). It uses research to guide clinical practice and focuses particularly on using scientific study findings in clinical practice (Estabrooks, Winther, & Derksen, 2004).
Several models of research utilization have been developed and described in the nursing literature over the past three decades. These models include the Stetler Model (Stetler, 2001), the Iowa Model of Research in Practice (Titler et al., 1994), and several other models developed by nursing scholars. Several instruments and surveys have also been used to measure research utilization in the nursing field. The two most commonly used instruments are the Nurse Practice Questionnaire developed by Brett (1987) and the Research Utilization Questionnaire developed by Funk, Champagne, Weise, and Tornquist (1991). Other instruments have been used to measure research utilization outside the nursing field.
Barriers to Research Utilization
Basing healthcare practice decisions on evidence is supported today by advances in telecommunications and the World Wide Web, as well as the widespread dissemination of scientific publications among both lay and professional consumers of knowledge (Ashley, 2005). In spite of this, low levels of research utilization and research–practice gaps persist in several health disciplines including nursing.
The research–practice gap in the nursing field is attributed to several factors and barriers. A significant finding of several prior studies into factors of influence on nurse research utilization was the significant effect of nurse attitudes toward research. Several studies found a strong positive attitude among nurses toward research positively influences research utilization in clinical practice (Olade, 2005; Walsh, 1997). However, a positive attitude is insufficient to introduce research into practice. Reviewing articles published between 1991 and 2005, Hutchinson and Johnston (2006) identified barriers to research utilization as lack of time, lack of confidence in critical appraisal skills, lack of authority, organizational infrastructure deficiencies, lack of support, lack of access, and lack of evidence.
Barriers to research utilization in clinical practice raised in the literature can be identified with one of three factors, namely practitioner-related factors, setting or organization-related factors, and research-related factors. Funk et al. (1991) developed the Barriers to Research Utilization Scale (hereafter, the “Barriers Scale”) based on this framework to measure factors that act as barriers or facilitators to research utilization.
The Barriers Scale is based on Roger’s (1983) diffusion of innovations work. Roger defines diffusion as the process by which an innovation or new idea is communicated through certain channels over time among members of a social system (adopter). The scale contains 28 items describing four factors and an additional two qualitative, open-ended questions intended to allow respondents to indicate their self-perceived greatest barriers and facilitators to research utilization. The four factors are as follows:
- Factor 1: Characteristics of the adopter
These represent the nurse’s research values, skills, and awareness of research. Individual nurse characteristics are significantly related to intent and preparedness to implement research findings in practice and bridge the research–practice gap (Fink et al., 2005).
- Factor 2: Characteristics of the organization
These represent the setting, barriers, and limitations. The organizational infrastructure, systems, and process should reinforce and support the implementation of research findings. It is important for nurses to feel supported and mentored by the organizational leadership throughout the research utilization process (Fink et al., 2005).
- Factor 3: Characteristics of the innovation
These represent the qualities of the research, as the nature of the research strongly influences clinician willingness and preparedness to utilize research findings. Trying new ideas or new practices suggested by research findings is very challenging to clinicians (Thompson, Chau, & Lopez, 2006).
- Factor 4: Characteristics of communication
These represent the accessibility of research results and the ways in which results are presented. Researchers may present findings in technical language that is difficult to understand, fail to publish research articles in a timely manner, present findings that are in conflict with other published reports, or draw conclusions not clearly justified by findings (Thompson et al., 2006).
On the basis of the above, the researcher designed this study to (a) use the Barriers Scale to identify barriers and facilitators to using research findings in clinical practice and (b) examine relationships between identified barriers and several nurse demographic characteristics (i.e., age, gender, level of education, and experience).
Researchers used a nonexperimental, descriptive, and correlational design for this study and employed the Barriers Scale survey instrument.
This study targeted all nurses currently employed at three National Guard Health Affairs hospitals located at Riyadh (Central Region), Jeddah (Western Region), and Al-Ahsa (Eastern Region), Saudi Arabia. Participants included nurses from over 20 countries. The approximately 1,200 nurses at these three hospitals accounted for around 10% of the nursing workforce in the country at that time. Invitation letters were sent to all nurses working in the three target hospitals, and a convenience sampling technique was applied to select participants. Those who consented to participate and returned the completed questionnaire were enrolled as study participants.
Approval from the National Guard Health Affairs Research and Ethics Committee was obtained before data collection. Two instruments collected study data. A total of 1,200 surveys (500 to Riyadh, 400 to Jeddah, and 300 to Al Ahssa hospitals) were sent by internal mail to potential participants, along with an invitation letter and the informed consent form, in August 2009. Participant rights were ensured based on ethical principles of respect for human dignity, privacy, confidentiality, and autonomy. Invitation letters and informed consents were sent along with the instruments to ensure that participation was voluntary and the decision to participate or not would have no effect on the respondent’s employment situation. Invitation letters introduced the study purpose, research procedures, and commitment to maintain anonymity, privacy, and confidentiality for all information.
The researchers collected study data using two instruments: the Barriers Scale and a demographic datasheet.
- Demographic datasheet: This instrument was developed by one of the researchers to collect specific demographic characteristic information including respondent age, gender, marital status, care unit services, total years of work experience, nationality, number of years in Saudi Arabia, and level of education.
- Barriers Scale: Funk et al. (1991) developed this instrument. It includes 28 items and uses a Likert scale to identify the degree to which each is perceived a barrier to research utilization in clinical practice. Scale scores range from 1 to 5, with 1 indicating none, 2 indicating slight, 3 indicating moderate, 4 indicating strong, and 5 indicating no opinion. Factor analysis procedures identified factors of scale items. Four factors emerged, with each subsequently tested for validity. The instrument was tested for internal consistency and Cronbach’s alpha reliability. The four identified factors were as follows: Factor 1, adopter characteristics (eight items; α = .80); Factor 2, organization characteristics (eight items; α = .80); Factor 3, innovation characteristics (six items; α = .72); and Factor 4, communication characteristics (six items; α = .65).
Researchers used SPSS for Windows Version 16.0 to analyze data, with frequency, descriptive, and correlation analysis used for quantitative questions and thematic analysis used for qualitative questions. Of the 1,200 questionnaires distributed, 413 were filled in completely and returned (response rate = 34.42%), with 190 (46%) from Riyadh, 106 (25.7%) from Al Ahssa, and 117 (28.3%) from Jeddah.
Barriers Scale reliability for data collected for this study was considered high, with Cronbach’s alphas of .78 for Factor 1, .79 for Factor 2, .75 for Factor 3, and .74 for Factor 4. The overall Cronbach’s alpha is .871.
More than two thirds of the participants were aged 30–49 years old: 36.1% were 30–39 years old and 31.2% were 40–49 years old. Nearly 90% were women and more than half (58%) were married. Participants were mostly non-Saudi, with Saudi nurses accounting for only 5% of the study sample. The non-Saudi participants represented over 20 nationalities. All had more than 1 year of work experience in Saudi Arabia. Nearly one third (29%) worked in outpatient, and slightly over two thirds (69%) worked in inpatient departments.
Participants held a variety of qualifications. More than two thirds (65.6%) held a BSN, whereas almost one third (30.5%) held diplomas or associate degrees. A small number held postgraduate qualifications. Table 1 shows participant characteristics.
Barriers to Research Utilization
Analysis of the Barriers Scale found the highest mean related to organization characteristics (mean = 3.21, SD = 0.76), followed communication characteristics (mean = 2.98, SD = 0.72), adopter characteristics (mean = 2.77, SD = 0.70), and innovation characteristics (mean = 2.35, SD = 0.80). Table 2 shows the results.
Table 3 illustrates that the ranking of the 28 Barriers Scale items validates this result. Nearly two thirds of Barrier Scale items were rated as moderate to strong by more than half of the respondents. The first to fifth highest-ranked barriers all related to organization characteristics (setting), and the sixth to tenth highest-ranked barriers mostly related to communication characteristics (presentation). Adopter characteristics (nurse) ranked third, followed by innovation characteristics (quality of the research). Table 3 shows the order of rank of Barrier Scale items.
Researchers applied a Pearson’s correlation test to examine potential significant relationships between demographic variables and the four perceived factors. Results indicated no significant correlation between the four factors and geographic region of work, marital status, work area, nationality, or level of education. A significant correlation was found between participant age and Factor 1 (adopter characteristics; r = .109, p = .03). Also there were significant correlations between gender and Factor 3 (innovation characteristics; r = .107, p = .3) and between years of experience and Factors 1 and 2, that is, adopter and organization characteristics (r = .117, p = .02 and r = .102, p = .04).
A one-way ANOVA compared means of the four factors and participant demographic characteristics. Results showed no significant difference (p values range between .069 and .99).
Open-ended questions asked participants to list other additional barriers, indicate their self-perceived three most significant barriers, and list other factors conducive to facilitating research utilization. Qualitative data were analyzed and grouped in themes. The most important theme was lack of time to read and appraise research articles, followed by lack of authority to implement change, lack of physician cooperation, and lack of education and training to incorporate research findings into clinical practice.
Participants uniformly reported several research utilization facilitators and cited increased administrative support as crucial to incorporating evidence into clinical practice. Administrators need to both make research available and allow time for nurses to read and consider relevant articles. They underscored the importance of creating an environment receptive to research and critical appraisal. Many participants identified the important role of organizational culture as a facilitator of evidence-based changes in practice.
Participants rated nearly two thirds of Barrier Scale items as moderate to strong barriers. Organization factors earned the highest overall barrier rating, followed by communication, adopter, and innovation, respectively. Themes that emerged from the qualitative data identified additional barriers such as lack of time, lack of authority, lack of physician cooperation, and lack of education related to EBP. Implementing research findings in clinical practice should improve the quality and cost effectiveness of healthcare. Nurses have significant research utilization potential as they hold generally positive attitudes toward research. However, they encounter many barriers that prevent them from research utilization.
Results of this study are similar to studies done in the United States, including a nationwide study by Funk et al. (1991) and a recent study conducted by Karkos and Peter (2006) at Magnet Community Hospital; in Sweden by Boström et al. (2008); in Ireland by Parahoo (2000) and Glacken and Chaney (2004); and in Korea by Oh (2008). Figure 1 compares the current study with these prior studies.
The perceptions of participant nurses in this study corresponded with administrator views of barriers to research utilization (Funk, Champagne, Tornquist, & Wiese 1995). Leasure et al. (2008), whose findings are similar to those of this study, recommended that the results can be very useful in strategies designed to facilitate integration of research findings into practice settings. Baernholdt and Lang (2007) reported that chief nursing officers considered communication characteristics as the most significant barrier to research utilization.
Participants in this study identified lack of time to read research articles as one of the most significant barriers, echoing a recent study conducted in Turkey by Mehtap, Zumrut, and Funda (2011). Other organization factors include inadequate facilities, lack of authority, and lack of physician cooperation. To promote research utilization, nursing organizations should develop a formal process and strategies for research utilization. Practice and research committees can provide formal forums and take the lead to promote the implementation of research finding in practice. Providing easy access to literature, involving nursing staff in projects designed to implement EBP, and including a research component in nurse job descriptions are some suggestions to promote research utilization (Leasure et al., 2008).
This study identified no significant relationships between barriers and demographic characteristics with the exception of years of experience. Nurses with more years of experience tended to be more mature and confident to apply evidence in clinical practice. Those issues that related to their work setting and the organizational environment were of most concern for participants and were identified with the most significant barriers. This result echoes those of other nursing and nonnursing studies (Hutchinson & Johnston, 2006; Kim, 2005). On the other hand, several previous studies identified a significant difference between the mean of research utilization factors and educational background (Boström et al., 2008; Glacken & Chaney, 2004; Karkos & Peter, 2006). However, in this study, despite their disparate nationalities and educational and social backgrounds, participants did not consider demographic characteristics as adopters as the most significant barrier.
Nursing departments in Saudi hospitals are administered either under the medical or operational department, a status that reduces nursing department autonomy and helps explain the importance assigned to organization barriers.
Qualitative data identified lack of time as the most significant barrier in this study—a finding also highlighted in many other studies (Parahoo, 2000; Pravikoff, Tanner, & Pierce, 2005). Additional time is needed for nurses to access, locate, read, and evaluate research reports and then incorporate research findings into practice. The second most significant barrier, lack of authority, is largely attributable to lack of managerial support. Manager or administration interest, support, and commitment are critical to nurses who are changing their practice in order to incorporate research findings (Glacken & Chaney, 2004; Parahoo, 2000).
This and other studies also identified lack of physician cooperation as a significant barrier (Oh, 2008; Parahoo, 2000). According to research findings, changing clinical practices is a multidisciplinary task that demands cooperation and support from all members of the healthcare team.
Lack of education and training on EBP was also identified as a significant barrier. Educational resources are important tools to help prepare nurses for EBP. While they may be highly motivated to base their practice on research evidence, nurses may not have the training necessary to locate, appraise, synthesize, and apply research findings into practice with confidence (Leasure et al., 2008). The nursing education paradigm must thus move toward integrating research and EBP into the nursing curriculum (Pravikoff et al., 2005).
Limitations of this study include the response rate, which is considered low (34.42%). Also, our utilization of a convenience sampling technique limited the ability to generalize results. Further exploration of barriers to research utilization in other healthcare sectors is needed in Saudi Arabia.
Findings of this study provide policymakers and administrators with baseline information about issues that affect nurse application of research evidence in clinical practice. Supportive policies and organizational structures are necessary to facilitate nursing staff use of research in their practice. Nursing educators may reference findings when teaching research utilization in the nursing curriculum, helping train students overcome identified barriers, and teaching EBP principles and practices. Future nurses should prepare sufficient knowledge related to locating, appraising, and applying research and identify research evidence to improve patient care (Leasure et al., 2008).
Barriers to and facilitators of research utilization identified in this study are similar to those of prior studies conducted in other countries. Nurse perceptions of factors impeding the implementation of research findings in practice relate mainly to organization characteristics, followed by communication through adopters, and finally the innovation of research. Further studies are needed in other sectors to enhance result generalizability and develop formal strategies for research utilization.
Ashley J. (2005). Barriers
and facilitators to research utilization
as perceived by critical care nurses. Unpublished doctoral dissertation, University of California, San Francisco, CA.
Baernholdt M., Lang N. M. (2007). Government chief nursing officers’ perceptions of barriers
to using research on staffing. International Nursing Review, 54 (1), 49–55.
Boström A. M., Kajermo K. N., Nordström G., Wallin L. (2008). Barriers
to research utilization
and research use among registered nurses working in the care of older people: Does the BARRIERS
Scale discriminate between research users and non-research users on perceptions of barriers
? Implementation Science, 3 (24), 1–10.
Brett J. L. (1987). Use of nursing practice research findings. Nursing Research, 36 (6), 344–349.
Dobbins M., Barnsley J., Ciliska D., Cockerill R., DiCenso A. (2002). A framework for the dissemination and utilization of research for health care policy and practice. The Online Journal of Knowledge Synthesis for Nursing, 9 (7), 12–24.
Ehrenberg A., Estabrooks C. A. (2004). Why using research matters. Journal of Wound Ostomy & Continence Nursing, 31 (2), 62–64.
Estabrooks C. A., Winther C., Derksen L. (2004). Mapping the field: A bibliometric analysis of the research utilization
literature in nursing. Nursing Research, 53 (5), 293–303.
Fink R., Thompson C. J., Bonnes D. (2005). Overcoming barriers
and promoting the use of research in practice. Journal of Nursing Administration, 35 (3), 121–129.
Funk S. G., Champagne M. T., Tornquist E. M., Wiese R. A. (1995). Administrators’ views on barriers
to research utilization
. Applied Nursing Research, 8 (1), 44–49.
Funk S. G., Champagne M. T., Weise R. A., Tornquist E. M. (1991). Barriers
: The barriers
to research utilization
scale. Applied Nursing Research, 4 (1), 39–45.
Glacken M., Chaney D. (2004). Perceived barriers
and facilitators to implementing research findings in the Irish practice setting. Journal of Clinical Nursing, 13 (6), 731–740.
Hutchinson A. M., Johnston L. (2006). Beyond the Barriers
Scale: Commonly reported barriers
to research use. Journal of Nursing Administration, 36 (4), 189–199.
International Council of Nurses. (1999). Position statement: Nursing research. Geneva, Switzerland: Author.
Karkos B., Peters K. (2006). A magnet community hospital: Fewer barriers
to nursing research utilization
. Journal of Nursing Administration, 36 (7–8), 377–382.
Kim K. (2005). Perceived barriers
to research utilization
by Korean university librarians. The Journal of Academic Librarianship, 31 (5), 438–448.
Leasure A. R., Stirlen J., Thompson C. (2008). Barriers
and facilitators to the use of evidence-based best practices. Dimensions of Critical Care Nursing, 27 (2), 74–82.
Mehtap T., Zumrut A. S., Funda K. O. (2011). Barriers
of research utilization
from the perspective of nurses in Eastern Turkey. Nursing Outlook, 60( 1), 44–50. Retrieved from http://www.nursingoutlook.org/article/S0029-6554(11)00252-1/fulltext
Oh E. G. (2008). Research activities and perceptions of barriers
to research utilization
among critical care nurses in Korea. Intensive Critical Care Nurse, 24 (5), 314–322.
Olade R. A. (2005). Attitudes and factors affecting research utilization
. Nursing Forum, 38 (4), 5–15.
Parahoo K. (2000). Barriers
to, and facilitators of, research utilization
among nurses in Northern Ireland. Journal of Advanced Nursing, 31 (1), 89–98.
Pravikoff D. S., Tanner A. B., Pierce S. T. (2005) Readiness of U.S. nurses for evidence-based practice
. American Journal of Nursing, 105 (6), 40–51.
Rogers E. M. (1983). Diffusion of innovations. New York, NY: The Free Press.
Sackett D. L., Rosenberg W. M., Gray J. A., Haynes R. B., Richardson W. S. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312 (7023), 71–72.
Sitzia J. (2001). Barriers
to research utilization
: The clinical setting and nurses themselves. European Journal of Oncology Nursing, 5 (3), 154–164.
Stetler C. B. (2001). Updating the Stetler model of research utilization
to facilitate evidence-based practice
. Nursing Outlook, 49 (6), 272–279.
Thompson D. R., Chau J. P., Lopez V. (2006). Barriers
to, and facilitators of, research utilization
: A survey of Hong Kong registered nurses. International Journal of Evidence-Based Healthcare, 4 (2), 77–82.
Titler M. G., Kleiber C., Steelman V., Goode C., Rakel B., Barry-Walker J., Buckwalter K. (1994). Infusing research into practice to promote quality care. Nursing Research, 43 (5), 307–313.
Walsh M. (1997). Perceptions of barriers
to implementing research. Nursing Standard, 11 (19), 34–37.