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Department: NURSING RESEARCH

Identifying international barriers and facilitators to research utilization

Younas, Ahtisham MN, RN

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doi: 10.1097/01.NURSE.0000668460.98211.39
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Abstract

RESEARCH UTILIZATION (RU) is a process of “transforming research knowledge into practice,” with knowledge referring to both conducting and analyzing research.1 It enables nurses to improve patient care by informing practice on interventions that may no longer be useful.2-4 Despite the clinical and practical importance of research, studies have indicated that nurses seldom use it to guide practice. Instead, they rely on personal experience, peer support, and trial and error.5,6 This may be attributed to several organizational, educational, and individual barriers, as well as a lack of facilitators enabling RU.7

Increased knowledge regarding the barriers to and facilitators of RU may inform organizational implementation strategies and improve nursing care. This article examines an international review of these barriers and facilitators and discusses the impact of RU on nurses across different geographic, cultural, and clinical backgrounds.

Literature review

Several studies and reviews have reported on the barriers and facilitators to RU, but the findings have been inconsistent across clinical settings. For example, one integrative review analyzed 35 studies and reported that organizational and educational barriers play a larger role in limited nursing RU than personal barriers such as lack of knowledge, support, and time.8 Another review of 37 studies found that time constraints were the primary barrier, while an Iranian review of 11 studies reported organizational barriers as the perceived primary obstacle.9,10

A systematic review of 63 studies conducted between 1991 and 2007 examined the extent and state of research related to the BARRIERS scale, a an instrument commonly used for measuring the barriers to RU.11 The authors reported that both personal and organizational barriers prevent nursing research. Although these reviews discussed the barriers to RU, they did not describe the facilitators.11 Similarly, they were limited due to the inclusion of studies that came from only one country or that used only the BARRIERS scale, as well as by minimal comparisons of the barriers and facilitators between healthcare settings.8-11

The BARRIERS scale measures 28 items under four subscales:

  • personal barriers
  • organizational barriers
  • innovation barriers
  • research accessibility and communication.

These subscales were developed based on the diffusion of innovations theory, which describes the decision-making process at an organizational level, including innovation, communication, time, and social systems.12 Other tools were adapted from the BARRIERS scale to include additional domains to measure attitudes toward research and RU practices. The facilitator scale measures funding resources, organizational support, research participation, research process and experience, and professional attitudes.13

Methods

An integrative review and search of the literature was conducted using platforms such as PubMed, CINAHL, ERIC, Ingenta Connect, and Science Direct. The researchers used search phrases such as “nurses' barriers to RU,” “nurses' facilitators to RU,” and “facilitators and barriers to RU in nursing.” An initial search yielded 6,738 results across all databases.

The inclusion criteria were characterized as studies related to nursing barriers and facilitators to RU that were published:

  • between January 2007 and November 2017
  • in English
  • in peer-reviewed journals.

After removing duplicates, book results, and articles on the development and testing of different scales, 1,142 studies remained. Further screening excluded 696 manuscripts, including theoretical papers, dissertations, commentaries, and concept analyses. An additional 397 papers were excluded because they explored physical and physiologic areas of care. The remaining 49 studies were assessed, and 7 were excluded because they were not published in English. In total, 42 were selected. Summary tables were developed for data analysis to allow the researchers to break down barriers and facilitators across settings.

Results

Of the 42 studies, 36 were cross-sectional and three were reviews.14-51 The remaining literature included a mixed-methods study, a secondary data analysis, and a grounded theory study.52-54 In total, 21 studies were conducted in Asia and the Middle East (China, Hong Kong, Taiwan, India, Iran, Korea, Maldives, Nepal, Egypt, Saudi Arabia, and Bahrain), 11 were conducted in Europe (Spain, Sweden, Greece, Norway, Turkey, and Austria), 5 were conducted in the US, 3 were conducted in Africa (Nigeria, Kenya, and Trinidad), and 2 were conducted in Australia.

Study samples ranged from 21 to 1,301 participating nurses. Several data collection tools were used, including the BARRIERS scale, the facilitator scale, the research utilization questionnaire, the empowerment questionnaire, the professional self-description form, the research factor questionnaire, the evidence-based questionnaire, the questionnaire on utilization of nursing research, and the attitudes toward research and development scale. Many research teams used one or more of these, and a few developed new tools. In-depth interviews and focus groups were also utilized for data collection.

The studies were critically evaluated using an appraisal tool kit.55 Researchers described the problem, purpose, and sample characteristics of their respective studies, and the inclusion and exclusion criteria were made explicit. Probability sampling techniques were used in nine studies; others used convenience or purposive sampling. With the exception of 11 studies that used a single setting for data collection, such as the ED, most studies collected information from multiple settings. Participant response rates ranged from 3.6% to 100%, with rates of 50% or more in 21 studies.

Validity and reliability of the data collection tools were established in all but five studies, which used more recent tools. These newly developed tools did not undergo rigorous validity testing, however; for example, one 2015 study assessed content validity and internal consistency with a sample of only 10 nurses.41 Sixteen studies used electronic or mailed data collection tools. In seven studies among those that used paper-based tools, the data collectors were not trained and there were missing data; inappropriate data analysis was conducted in one.14,16,17,28,30,32,36,38,39,48,49,52

The quality rating was strong in 6 studies, weak in 7 studies, and moderate in the remaining 28 studies.8,22,26,29,39-41,43,46,51-53

Barriers and facilitators

Issues included organizational barriers, research accessibility and communication, and personal barriers. Common organizational barriers included insufficient time to read research (noted among 30% to 97% of participants, depending on the study under review); inadequate facilities for implementation (noted among 19% to 95% of participants); insufficient time for implementation (noted among 32% to 85% of participants); uncooperative administrations and physicians (noted among 29% to 95% of participants); and a lack of nursing authority to change patient-care procedures (noted among 32% to 82% of participants). Barriers to research accessibility and communication included literature access and compilation (noted among 13% to 88% of participants), findings that are not generalizable (noted among 28% to 91% of participants), and incomprehensible statistical analyses (noted among 26% to 88% of participants). Personal barriers included insufficient knowledge of research and proposal writing (noted among 25% to 94% of participants) and poor awareness of research (noted among 11% to 94% of participants).

Fourteen study samples were recruited, identifying 10 clinical settings: critical care and the ED, community health, geriatric, oncology, pediatric, psychiatric, med-surg, primary care, burn centers, and traditional and complementary practices.14,15,19,33,36,39,40,43,46,48,50,52,53

The process of identifying barriers was challenging. As such, research describing a major population from a specific setting was analyzed under that setting. For example, one study of 510 nurses included 229 nurses from medical-surgical units and 141 from critical care units.44 The findings were analyzed as both medical-surgical and critical care settings.

Five barriers were consistently indicated (see Barriers and facilitators):19,36,38,46

  • insufficient time to implement new ideas
  • no time to read and conduct research
  • limited nursing authority to change patient-care procedures
  • inadequate facilities for implementation
  • nurses unaware of research.

Facilitating factors were analyzed in 17 studies.9,15,16,20-22,24,25,28,29,31,34,39,44,48,49,51 Of these 17 studies, 1 weak study was excluded from the synthesis, and 2 were review articles in which the authors did not compare their findings across settings. Based on the analysis of the remaining 14 studies, the most commonly reported facilitators were increased nurse education and awareness about RU and how it impacts patient care (noted among 6% to 88% of participants); increased managerial and organizational support to conduct research (noted among 15% to 87% of participants); and support from peers, expert colleagues, and other healthcare professionals (noted among 10% to 85% of participants).

Table
Table:
Barriers and facilitators

Discussion

Regardless of the study quality, the nurse participants perceived the role of the organization as significant in initiating and propelling RU. Further, in all geographic regions, cultures, and clinical settings, the participants identified a lack of reading time, uncooperative physicians, inadequate facilities, and a lack of nursing authority as consistent barriers. These barriers also resonate with the reported facilitators, as the participating nurses reported a need for organizational and institutional support for RU.

The lack of authority and organizational support may also be attributed to limited confidence among the nursing staff. Only one study determined confidence levels, reporting that 57% of the participating nurses lacked confidence in searching literature to answer clinical questions and 75% lacked confidence in critiquing literature for clinical use.48 Further research on self-confidence among nurses regarding RU is necessary. Healthcare facilities may also consider revisiting organizational expectations concerning RU and developing strategies to foster self-confidence in the nursing staff.

Further, organizational policies should be adapted to different clinical, cultural, and geographic settings. For example, limited availability of literature was a frequently reported barrier in the African studies, whereas lack of nursing authority to change practices was common in the US.

Nurse leaders and managers should ensure that their staff is provided with the appropriate resources. Study participants often reported time, support, opportunities, and funding as facilitators for research. These are consistent with facilitators identified by a previous review, which reported that enhanced research knowledge and skills, support from knowledgeable nursing colleagues, improved reading and locating of research, sufficient economic resources, and increased access to the internet and peer-reviewed articles could improve RU. Because only 14 studies compared facilitating factors across healthcare settings, further research is warranted.

Conclusion

Although the barriers to RU have been studied for many years, their perception among nurses has not changed. Similarly, while perceived barriers differ across cultures, nurses generally lack facilities, authority, and time for RU and require more support, funding, and education. These barriers and facilitators are international in scope and demonstrate a global need for renewed efforts to promote and implement RU in healthcare organizations. Otherwise, ineffective or less effective practices will continue.

Despite advancements in research, many nurses cannot integrate their findings into everyday practice and do not receive adequate support from the healthcare team. In many countries, nurses are not directly responsible for applying research in practice and must rely on protocols and policies developed by organizations, policy makers, and nurse managers. Accordingly, future research should determine the perception of these barriers and facilitators among nursing associations, regulatory bodies, healthcare organizations, policy makers, and managers to provide the necessary resources.

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