User Acceptance of Research Evidence in Nursing
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Numerous researchers have cited a multitude of barriers for the utilisation of research in the nurse clinical context. Common factors have included the ability for nurses to read interpret and clarify reported research. Nurses have been recorded as devaluing research, particularly its applicability to clinical practice. Researchers have documented lack of time, limited authority to implement evidence based practices, lack of support and an unwillingness to change as significant contributing factors to poor research utilization practices. Nurses have reported the access to evidence based materials as meager, which has been linked to a lack of organizational support and investment in research as core business (NICS, 2005; McCloskey, 2008; Baxter and Boblin, 2008; Closs & Cheater, 1994; Estabrooks et al. 2003; Funk et al. 1991; Funk, Tornquist, & Champagne, 1995).
This research considered the behavioural intention and user acceptance of research evidence for nurses working within the Queensland context. To date no comparison had been made to determine whether those influential barriers documented by the extent literature would have the same weight within the unique demographic of Queensland. The focus of this study was to discover a set of user friendly research utilisations solutions for nurses using determinants generated from the literature and those already identified in the application of Rogers (2003) innovation diffusion theory. This suggests five attributes of an innovation, namely relative advantage, compatibility, complexity, trialability, and observability.
The intent of this mixed method research design was to gather relevant data to assist confirmation of identified determinants highlighted in the constructed provisional model (figure 1) , and the potential identification of undiscovered influential factors within the target demographic of Queensland. In addition confirmed factors from the literature were used in the generation of a survey for distribution which lead to a confirmation of research utilisation for nurses in a larger demographic. The research design encompassed firstly a comprehensively exploration of the literature to determine known barriers to research utilization. Determinants from the literature were used in exploratory semi- structured homogenous focus groups. Focus groups were chosen as the major method for collecting data in this research study as they were deemed a qualitative research method for eliciting descriptive data from nursing subgroups. Concepts discovered during thematic analysis were then merged with findings from the literature to generate a survey tool. Data analysis included a thematic analysis of transcribed focus group discussions using Leximancer software, and a quantitative analysis of survey data including, reliability analysis, descriptive statistics, correlation analysis, and factor analysis using SPSS.
Factors identified in the literature indicated several different contexts as potential barriers to successful utilisation. These include the consumer/patient, the social setting of nursing, the organisational effects, financial barriers, communication breakdown, and the idea or concept itself. Within each context appears to be several noteworthy factors, mainly knowledge (both nurse and patient), nursing skill, time, access to new evidence, speed of adoption, and evidence based practice leadership (NICS, 2005; McCloskey, 2008; Baxter and Boblin, 2008; Estabrook, 2003). These findings which were put forward as propositions in this research were confirmed through qualitative findings with the exception Queensland nurses being laggards when it came to adopting new evidence. Based on a combination of findings from qualitative data, the literature, and quantitative data it is clear that in the majority of circumstances nurses are not laggards when it comes to research utilization, but rather there are barriers that can significantly delay attempts to raise standards of practice.
Outside of the complimentary findings that this research has offered in supporting known barriers to research utilisation nursing this study has also highlighted two distinct variables that require further consideration in future endeavors to understand research utilisation practices by nurses, namely family interference and the cultural/ethnic background of nurses, with a particular emphasis on the impact of overseas trained nurses.
A combination of both qualitative and quantitative findings in this research depicted that if nurses trust towards new evidence as to develop (Particularly when nurses have been supported and shown how to succeed with research implementation) then the overload of information needed to be controlled so that nurses could see a project through to fruition. Realistic approaches need to be adopted by nurse leaders and other associates so that nurses can achieve successful and rewarding outcomes based on evidence based practice change management strategies and hence develop better confidence in themselves as research clinicians. As a major outcome then this research has found that by controlling the large number of sources dictating what new evidence should be a priority for nurses that nurses could remain focused on common goals, and out of accomplishment continue down a path of research. Nurses would only grow in confidence when engaging in research and then could share these successes with others in the profession promoting a more positive culture towards research utilisation practices.
CERTIFICATION OF DISSERTATION
I certify that the ideas, experimental work, results, analyses, software and conclusions reported in this dissertation are entirely my own effort, except where otherwise acknowledged. I also certify that the work is original and has not been previously submitted for any other award, except where otherwise acknowledged.
Chapter 1: Establishing the context of the problem
This study has focused on the Behavioural Intention and User Acceptance of Research Utilisation Models when introducing Evidence Based Practice (EBP) information tools to influence practice in the clinical setting. The facilitative model of change generated from this research is helpful in further understanding the patterns of evidence based practice changes emerging in nursing, which can be anticipated, opportunistic or emergent in nature. More importantly, the experiences gained from this research suggest that, when introducing EBP research utilisation tools, nursing must take into account the sporadic, evolutionary nature of such changes, and devote sufficient resources to effectively manage the process on an ongoing basis (Brenner, 2005).
Research utilisation throughout the history of nursing has never been a strong component of any nursing curriculum and traditionally nurses during their training have focused very little attention to research or it's linkages with patient care. Post training this aspect has continued as a trend and nurses quickly adopt a culture that typically places research in the pile that someone else is responsible for. Due to this perception healthcare research has not been recognised as core business, but rather as a task that occurs if time allows, if at all (McCloskey, 2008; Brenner, 2005).
As registered nurses often assume the role of experts in their given field and have the potential to exert great influence over patients and clinical colleagues it is important that nurses possess and have the ability to utilise research-based knowledge related to their areas of practice to ensure that influence maintains patient safety (Wilkes, Navickis, 2001).
Despite the presence of at least one specialist nurse in every hospital there appears to be a scarcity of evidenced based literature on specialist nurses overall, and even less is available to highlight how nurses gain access and utilise evidence based information. Lacking in the available literature is their research utilisation preferences such as what model should be utilised, which has the greatest impact, or the level of research skills and views regarding research (Hajjar, Kotchen, 2003).
Evidence-based practice in its best and purist form provides nursing with choices about the most effective and appropriate care. Patients in today's society expect the high standards of care and with increasing access to available information of these treatments know when they are not receiving that standard. Even with the best standards being available however, they are often poorly implemented. It would also appear that researchers and clinicians have devoted less attention to bridging the evidence based practice implementation gap and more to the generation of research outcomes which in themselves will sit on the to be adopted pile (Davis, et al, 2003).
Averis, Pearson, (2003) raise a significant question; asking what role does evidence-based practice nursing have in narrowing the research-practice gap? Surveys of nurses suggest barriers to using current research evidence are the time, effort, and skills needed to access evidence based information which is hidden in massing volumes of newly produced research outcomes (Cabana, et al, 1999). Even the ultimate nurse who maintains their skill through evidence based knowledge has the problem of maintaining currency (Haynes, et al, 1997). Each year Medline attracts 560 000 new articles, and the Cochrane Library enlists 20 000 new randomised control trials. This amounts to 1500 new articles and 55 new trials per day. Nurses then need clear strategies that can sort through, absorb, and follow through on new research likely to benefit their patients (Clarke, Alderson, Chalmers, 2002).
Many research utilisation models are available that can guide nurses in the processes required for successful adoption of evidence based practice recommendations, however these can be complicated and many assume they will only work in the context for which they were originally derived. The implied conjecture is that once the context is changed, these models may not serve well in the new context because external and internal variables will differ (Hyde, et al, 2003). In addition to this assumption there is also the level of understanding nurses will have on the use of such models. Fear of use, confusion and even information overload have been put forward in the literature as contributing factors (Shaw et al, 2005).
While previous evidence based literature outlines that research utilisation models have been trialed in various formats, Rogers (2003) Diffusion of Innovation theory appears to be providing significant advantages. Diffusion of Innovation appears to get to the true root cause as to why a new initiative is adopted or not adopted and closely mimics the nursing change strategy known as Normative-Reeducative. Shaw et al. (2005) concludes that a science of health-care innovation implementation is not yet available. In order to address this gap, Rogers (2003) model is offered as a candidate for a theory of innovation implementation. Rogers (2003) innovation diffusion theory is originated from dynamic systems theory and offers an excellent platform when consider the level at which nurses engage in research utilisation practice. Later in this chapter, core principles of diffusion innovation theory are described, and a case is made for framing the findings of past research and the design of future research on implementation in terms of this foundational theory. Much of this theory hinges on the premise of resistance to change. As is the case with Lewin's (1951) theory (cited in Schein, 2006).which outlines that individuals will strive for equilibrium. Thus in a change situation there must be a balance that calls for change and those that oppose change. This is the case with Rogers (2003) theory which aims to understand driving and restraining forces for the adoption of a new initiative..Understanding these forces in greater detail will be the basis for this study.
A key theme that generates from the above theory of innovation is that of leadership. Literature advises without effective leadership innovation diffusion and in this instance evidence based practice adoption is rarely ever successful. With a leader comes an effective change manager or champion (Shaw et al, 2005). In any process of evidence adoption, a key success factor is the ability of a select group of people to adopt and champion the new innovation to others. To take new evidence forward, an important strategy is to identify and invest in people who are willing to test and adopt change early so that others in an organisation will follow (Shaw et al, 2005).
Investment in identifying and spreading effective evidence based practice is vital. There is a need to create a system that identifies the programmes that are having an impact, understand why they are having an impact, and share this learning with other organisations across the nursing sector. The aim should be for increasing the uptake of evidence based practice to become a core competency of nursing, whereby receptiveness for change and improvement becomes a built-in feature of practice, supported by national and district-level structures and process (Rogers, 2003).
A key problem with the spread of evidence based practice in the health sector is its sheer complexity. Health is not merely complicated rather the health system is complex, as its operation is based on a web of structures, and processes and patterns where the relationship between cause and effect is often uncertain. The level of complexity means that health systems are often very resilient to pressure, even where that pressure is one for positive change (Davis, et al. 2003). The structures of nursing in health care, either at a national level or within organisations, such as nursing boards or primary health providers, are common targets for change in attempts to improve overall functioning and foster innovative evidence based practice change. However, without accompanying changes in process that are based on an understanding of issues for front line nursing services, the delivery of nursing care may not be altered significantly. Further, without consideration of the patterns of interaction between nursing in a health care system, the effectiveness of process improvements may be blunted (Davis, et al. 2003).
In recent years, there has been a growing movement in nursing to embrace the principles of evidence-based decision making to enhance clinical practice (e.g. Pearson et al, 2005). In essence, evidence-based decision making involves "a process of turning clinical problems into questions and then systematically locating, appraising and using contemporaneous research findings as the basis for clinical decisions" (Rosenberg and Donald, 1995, p. 1122). Evidence-based practice or EBP, then, is the adherence to such principles by nurses in their daily practice to ensure the judicious use of best available evidence that is valid, important and applicable to the specific patient being considered (Pearson et al, 2005).
The use of nursing literature as evidence to influence clinical practice has been well documented over the years (Pearson et al, 2005; Strauss et al, 2005). However, this approach has become increasingly difficult with the massive volume of literature generated each year, and the lack of adequate access, training, time and tools for clinicians in applying the literature to change practice (Strauss et al, 2005). According to Pearson et al. (2005), there need to be better bridges to transfer research evidence to clinical practice. Strauss et al (2005) suggest the use of health informatics to improve the retrieval, synthesis, organization, dissemination and application of patient-reported, clinician-observed and research-derived information. While such systems and tools have been reported in older literature (e.g. Balas et al., 1996; Barnes and Barnett, 1995; Liem et al., 1995), even today it is difficult to tell if they can achieve the ultimate goal of changing practice behaviors (Philipson, Roberts, 2007).
Numerous implementation and evaluation studies of information systems in healthcare have been reported over the years (e.g. Butler, Murphy, 2007). Most have advocated the need for detailed systems planning, thorough requirements analysis, rigorous project management, and direct involvement of the users in the process. Some have focused on key barriers and enablers to successful implementation of these systems (Butler, Murphy, 2007). While a few researchers have pleaded for the use of controlled trials in medical informatics research others have argued the need to consider the behavioral, organisational and social dimensions when implementing and evaluating these systems (Butler, Murphy, 2007). Gururajan, R Moloney, C and Kerr, D (2005) found that such systems in nursing (particularly in a wireless framework) are complimentary to the nursing profession for the utilisation of new evidence. Devices such as hand held computers have been found to significantly reduce the time taken to access evidence (Gururajan, R Moloney, C and Kerr, D 2005).
1.2 Evidence-based practice
The term evidence-based practice (EBP) refers to standard use of research related health care interventions for which systematic empirical research has provided valid rigorous evidence for patient care. Alternate terms with the same meaning are evidence-based treatment (EBT) and evidence based medicine (EMB) (Pearson et al, 2003). In recent years, EBP has been stressed by the nursing profession, which have also strongly encouraged nurses to carry out investigations providing evidence that supports or rejects the use of specific nursing interventions (Pearson et al, 2003). Mounting pressure to utilise current EBP has also come from healthcare insurance providers, and healthcare consumers (Sakala, 2004).
Many areas of nursing practice, such as aged care, acute medical-surgical, and mental health nursing have been confronted with occasions where practice was based on low levels of evidence. Some of this evidence was simply drawn from expert opinion, and much of it had no truly scientific evidence on which to justify various practices (Sakala 2004).
In the past this has often left the door open to dangerous practices perpetrated by individuals who had clear evidence for their practice, but who wished to convey the impression that their methods were best (Sakala, 2004). As scientific nursing research methods became increasingly popular as the means to provide sound validation for such practice, it became clear that there needed to be a way of excluding historical practices that had no scientific basis and no integrity of the field. This also became of way of ensuring patient from the dangers of their non-verified nursing practice (Sakala, 2004). Furthermore, even where non-verified nursing practice was not present, it was acknowledged that there was a value in identifying what actually does work so it could be improved and promoted (Pearson et al, 2003).
Evidence based practice (EBP) utilisation is a method which aims to specify the way in which nurses make decisions by identifying key recommendations from the literature that can direct a high standard of practice, and rates it based on its scientifically merit. Its goal is to eliminate low standard or high risk practices in favour of those that are more likely to produce positive patient outcomes (Pearson et al, 2005).
EBP stems from various research methods and is utilised in a multitude of ways (e.g. carefully summarizing research, putting out accessible research summaries, increasing nursing knowledge and applying findings from research) to encourage, and in some instances to coerce, nurses and associated decision-makers to be more aware of evidence that can inform their decision-making. In the setting it is applied, it encourages nurses to use the best available evidence, i.e. the highest standard of information available (Pearson et al. 2005).
Pearson et al. (2005, p. 1) state, 'the ongoing debate on the nature of evidence for practice across all of the health professions is influenced by the experience of clinicians in everyday practice who, in using the evidence, assert that there are diverse sources of research-based and non-research-based evidence and that the process of evidence-based practice should be placed within a broader context that is grounded in practice; recognises different evidentiary bases; and is directed towards improving global health across vasty different practice contexts'.
1.3 Scientific nursing inquiry
Scientific inquiry in health care has increased, as evidenced by the growing number of research studies reported at professional conferences and in professional journals (Duffy, 2007). In spite of this increase, a gap still exists between the generation of new information and the use of this knowledge in clinical practice (Pearson et al, 2005).
In other words, scientific knowledge is not being applied in clinical settings by nurses, even though the application of research findings can have a direct impact on optimal client outcomes (Alsop, 1997). Averis and Pearson (2005) offer an explanation for the gap between knowledge generation and its use. It has become evident that even with the increased production of evidence based information, knowledge, and improved procedures for the transfer and dissemination of this information the frequency of use and impact of knowledge has not increased substantively. Simply because relevant information which is timely, objective and in the hands of the right people becomes available does not guarantee it will be utilised. Research utilisation therefore cannot be taken for granted (Averis and Pearson, 2005). It is imperative that the end user understands the utilisation process and remains a keystakeholder in throughout the process if not a change agent themselves (Rogers, 2003).
White and colleagues (1995) stated: 'the gap must be bridged between research and research utilization' (p. 418). In order to bridge this gap, it is crucial to understand the nature and extent of the suggested change and to heighten the value of using research to guide nursing practice, which in turn will define strategies that facilitate research utilisation.
1.4 The need for nursing research
Nursing domains are characterised by cost minimisation, technology enhancement, increasingly knowledgeable patients, increasing use of outcomes and restructuring of nursing systems. This encourages nurses to provide efficient and effective care (Yorke, 2008). Research that explores evidence based care, therefore, must be appropriately disseminated, understood, integrated and assessed as an ongoing process. Research must categorise and appraise existing knowledge, answer questions, and determine new knowledge through the systematic inquiry of an identified problem. Nurses all have an individual responsibility to ensure that research is used in their practice. Failure to meet this obligation blocks the research utilisation process (Yorke, 2008)
An important reason for using research in nursing practice is that it generates significant benefits. Research can advance the nursing profession, improve patient care and enhance nursing's professional image (National Institute of Clinical Studies, 2005). Research outcomes may also result in a description of newly identified scope for nursing practice, classification of specific phenomena's of interest to the profession or the generation of new nursing theories (AHRQ, 2007).
1.5 Research utilisation
Although considerable improvements have been made in the dissemination of nursing research, a gap still remains between the development of useful research findings and their availability to those who will most benefit from them. Too often, knowledge and interventions produced through evidence based practice supported research remain largely untapped due to researchers' limited resources and a lack of identified utilisation goals and targets (Averis and Pearson, 2005). Recent efforts by the Joanna Briggs institute have focused on expanding the scope of work in utilisation and increased evidence-based utilisation strategies through integrating the needs of both international health consumers and health professional sponsored research into its design, an approach intended to maximize the effectiveness of strategies moving research to practice (Averis and Pearson, 2005).
The historical nature of nursing research exists so as to change current practice, or to confirm it. Yet the task of embedding new understandings and new products from research into practice can expand over decades or generations (McCloskey, 2008; Brenner 2005). It is worth noting caution is necessary when moving new research into practice as it needs to be evaluated, replicated, and refined for individual clinical settings based on a multitude of variables. It should not be pursued by a rigorous process of review and refinement, but rather by the gap between the research target group and the world of practice that surrounds it (McCloskey, 2008).
Research addressing evidence based practice utilisation or research utilisation as it is sometimes labeled, has produced a rich source of information advising what does and does not work. However as the gap does pre-exist, information flow for those that need the answers for the most part have not moved from the research world that have produced potential solutions (Brenner, 2005). Modern day thinking has lead to key terms such as embedding the evidence being utilized by scholars in order appeal to the language of the target audience. The overall intent is to ensure a standard of care is raised to address patient care deficits. However here lays the problem when not having pre-existing nurse skill and knowledge that will enable such recognition (McCloskey, 2008).
What is evident from the literature is that there is no common process used by institutions and due to the lack of common process nurses are confronted with a barrage of evidenced based information at their doorsteps. Presently in the majority of nursing circles effective and continuous research utilisation is an unrealistic concept. The ever expanding body of research evidence that is growing further adds to the escalating dilemma that is facing the nursing profession (McCloskey, 2008).
1.6 Advancements in Technology
In the last decade the connection between research utilisation endeavours and the desire for information technology experts to understand technology adoption within the nursing domain has been growing at increasing rates. What is clear from the literature is that computer and software technologies may play a vital role in enhancing, if not improving the rates of research utilisation by nurses (Athey and Stern, 2002). A fundamental concept stemming from available literature is the lack of access to clinical decision making information for the nursing professional. Present findings in the literature would suggest that this issue is a generic international issue (Baxter and Boblin 2008). Baxter and Boblin (2008) found through their research with baccalaureate nurses that continued education was a prerequiste to ensuring nurses developed sustained decision making skills, however access to education is always limited by factors such as time and nursing workload. In Baxter and Boblin's (2008) extensive literature review it was evident that many researchers who have explored nurse decision making have concluded that decision making is a learned skill that must be taught by nurse educators. Yet little research has been conducted to explore nursing students' decision making. Their findings suggest that if nurse educators are to teach this skill, it is necessary to have a better understanding of the kinds of decisions nurses are making in the clinical setting, and how they are sourcing the evidenced based information to make such decisions.
Standing (2007) supports the notion that decision making is a learnt behaviour and tools to assist this learnt behaviour need to be adopted. Standing's (2007) research suggests that nurse educators alone cannot assist newly registered nurses to refine and develop this skill. Specific strategies and support mechanisms need to be created to enhance and compliment this learnt skill. Knowing the kinds of decisions nurses are making and sometimes not making in the clinical setting should prompt nurse educators to reevaluate whether curricula provides the necessary tools to facilitate the development of decision making and whether nurses are sufficiently encouraged to engage in making all kinds of decisions based on research utilisation (Standing 2007). Recognising that nurses make decisions related to assessment in the beginning levels but focus less on these decisions in later years reinforces the need for nurse educators to continue to emphasise the importance role assessment plays in decision making and providing effective and safe patient care. Decision making will only improve if decision makers are taught to systematically assess, gather information, plan, implement, and evaluate nursing care (Standing 2007). In present day nursing tools do exist that help to achieve this, however access to such systems by nurses is very limitied. Contributing factors to this include PC numbers, time, and patient acuity (Gururajan, Moloney, Soar, 2005). Athey and Stern (2008) through their research efforts found that technology is a key solution to aid decision making in nursing and may also aid in research utilisation. Research also suggests that if technology is to be adopted as a solution then principles of innovation diffusion should be considered (Davies, Bagozzi, Warshaw, 1989; Gururajan, Hafeez-Bag, & Moloney, 2005; Gururajan, Moloney, Soar, 2005). Stephenson (2001) & Torisco (2000) suggest that mobile computing is the realtime solution to providing healthcare professions with information that can inform decisions. Their research has suggested that further exploration is required to not only understand how health professionals such as nurses will accept this technology, but also to determine the type of information that can be either sent or received into devices such as handheld computers. Based on previous research conducted by Gururajan, Hafeez-Bag, & Moloney (2005) and Guruajan, Moloney, Soar (2005) it is evident that research utilisation can be assisting by wireless technologies and furhter exploration of this concept is required..
1.7 Relevance to Information Systems
By providing new ways for nurses and their patients to readily access and use health information, information technology (IT) has the potential to improve the quality, safety, and efficiency of health care. However, relatively few health care providers have fully adopted IT. Low diffusion is due partly to the complexity of IT investment, which goes beyond acquiring technology to changing work processes and cultures, and ensuring that physicians, nurses, and other staff use it. However, this is also due largely to the lack of evidence and ineffective information flow to the clinician and policy maker to encourage adoption (Davis, et al. 2003). What is clear is that academics working outside of the nursing profession in disciplines such as business and information systems can play a role in paving the path for change by assisting with innovation diffusion (Gururajan, Hafeez-Bag, & Moloney 2005; Guruajan, Moloney, Soar 2005).
In addition, certain aspects of the market such as payment policies that reward volume rather than quality and the fragmentation of care delivery do not promote IT investment, and may hinder it. Because of its potential, policymakers need to better understand how information technology is diffusing across providers, whether action to spur further adoption is needed, and if so, what steps might be taken. In order for this to occur, policy makers need to better understand the evidence behind these innovative ideas to justify their implementation. In order to receive the flow on of evidence the barriers that slow the flow of this evidence need to be better understood. Any policy to stimulate further investment must be carefully considered because of possible unintended consequences—such as implementation failures due to organizations' inability to make the necessary cultural changes (Davis, et al. 2003). Information systems are the future to improving the retrieval, synthesis, organization, dissemination and application of patient-reported, clinician-observed and research-derived information. Further research is required to streamline and automate these processes for healthcare clinicians.
1.8 Intention of this research
Based on the introductory overview the intention of this research was to ascertain directly from the profession itself some of the true or hidden reasons that were averting nurses from utilising research evidence in practice. As outlined in the introduction many academics, nurses, and researchers (McCloskey, 2008; Baxter and Boblin, 2008; Brenner, 2005) have explored this phenomenon and have offered varied opinion on the most appropriate course of action. However based on much of the research conducted by Rogers (2003) and the principles of innovation diffusion this study has been conducted on the premise that to truly provide real solutions one must identify and target identified inhibitors and facilitators that exist in the unique context of individual nursing settings.
To achieve this, a mixed method of research was chosen that would firstly explore identified themes from the literature. Using the identified themes from the literature a set of open ended questions were derived that would assist in exploring this phenomenon in a selected cohort of the nursing profession. Semi- Structured homogenous focus groups were chosen as the major method for collecting data in this stage of the research study. The intention being to try and ascertain whether those factors identified in the literature were truly generic to a selected nursing setting. To obtain a good representative sample of the profession 6 focus groups were conducted with a minimum of 6 representatives per group. This quantity of focus groups was chosen to ascertain whether an element of saturation of nursing opinion and perceptions would sift through in the discussion. Each group was conducted over the period of an hour and was asked an identical set of open ended questions which were recorded. Ethics approval was obtained for this study from Queensland Health and the University of Southern Queensland prior to any participant involvement. Informed consent was obtained from individual participants prior to any line of questioning.
Once recordings were transcribed the raw text was entered into the software application Leximancer. UQ News (2008) 'Leximancer is a software platform that enables users to find meaning from text-based documents. It automatically identifies key themes, concepts and ideas from unstructured text with little or no guidance. The innovative concept map allows users to interact with the analysis – navigating the true meaning of the text'. Themes and concept maps derived from this software were then used to:
1. compare against those identified in the literature review
2. to ascertain those inhibitors and facilitators that exist in the unique context of individual nursing settings
3. to develop:
l a view from the nursing group being researched on current nursing research utilisation practices in Queensland.
l a perceived nursing research utilisation model/ Individual nursing context within their own clinical environments.
l an ideal nursing research utilisation model that would assist all nursing
4. to develop a survey tool for further comparative and confirmatory analysis of themes identified in both the literature and qualitative analysis.
To ensure validity of the survey tool it was decided to not only base the survey on those factors identified from focus groups, but rather to structure the questionnaire on a well tested tool in the literature. Indentified in the literature (Crane, 1985a; CURN Project, 1981, Closs, Bryar, 2001; Funk et al. 1991a) from several sources was the Conduct and Utilisation of Research in Nursing questionnaire. The survey tool for this research was then based on a combination of those factors found in this questionnaire and those identified through qualitative analysis.
To confirm those themes identified from nursing four basic steps to factor analysis were utilised to generate some comparative quantitative statistics:
* data collection and generation of the correlation matrix
* extraction of initial factor solution
* rotation and interpretation
* construction of scales or factor scores to use in further analyses
Descriptive statistics and those construct scales were then used to confirm those themes and concepts used to generate the recommended utilisation model and further define some solutions for the individual nursing context.
Keywords: diffusion of innovation, dynamic systems theory, effective treatment, evidence-based practices, implementation, research utilisation.
Chapter 2: An overview of current literature
2.0 Literature review
2.1 A summary
After substantial efforts at both a National and International level to produce more nurse friendly evidence based practice adoption tools and to instil confidence and knowledge in the process of research utilisation, the practice is still considered to be very poor (Closs & Cheater, 1994; Estabrooks et al. 2003; Funk et al. 1991; Funk, Tornquist, & Champagne, 1995). Factors identified in the literature indicate several different contexts as potential barriers to successful utilisation. These include the comsumer/patient, the social setting of nursing, the organisational effects, financial and political interference, communication breakdown, and the idea or concept itself. Within each context appears to be several noteworthy factors, mainly knowledge (both nurse and patient), nursing skill, time, access to new evidence, and evidence based practice leadership (NICS, 2005; McCloskey, 2008; Baxter and Boblin, 2008; Estabrook, 2003; Brenner, 2005). Based on this review further detail is provided on the current knowledge available that can assist in understanding this recognised phenomenon.
2.2 Previous research
The essential goal of nursing research is to raise the standards of patient care by increasing nursing knowledge and skill for practice by embedding substantiated and relevant research into practice. However, the present understanding of the extent to which nurses utilise research in their practice, and for that matter the factors that either promote or discourage it, are limited (Armitage 1990). Previous research has focused on the individual nurses rather than the external forces that may be at play which affect the nurse's capacity to use research and the majority have failed to consider negative or positive influential characteristics from research findings or innovations themselves (Champion & Leach 1989). It cannot be assumed that dissemination of results from research equals utilisation. Many research attempts have not taken into account the complex nursing workloads that exist. Research has also assumed that nurses are able to make free choices in the delivery of patient care, and has neglected the multi-disciplinary nature of healthcare and it organizational complexities (Brenner, 2005).
Champion & Leach (1989) conducted a survey on a sample of 59 nurses from the south-west part of the United States. The nurses were asked to rate their agreement with 10 statements about research use, such as 'I apply research results to my own practice'. The mean for this 10-item 5-point likert scale was 3.48 indicating, on average, a slight agreement with statements concerning use of research in practice. Champion & Leach interpret this as a moderate commitment to using research in practice and found that considerable research and solutions are required in order to bridge the existing research utilising gap that does exist in nursing. Champion and Leach were also able to predict that this gap would ever increase due to the escalating volumes of research that were being produced.
Brett (1987) surveyed 279 nurses on their level of adopting different nursing practices. Alarmingly in this research well over 50% of nurses were not utilising research and of those that were the adoption of nurse research evidence was on done in an adhoc manner with less then frequent intervals. Coyle & Sokop (1990) surveyed 200 nurses in North Carolina using the same instrument as Brett (1987) producing similar results with well over 70% of nurses surveyed not participating in research utilisation exercises.
The continuing use of the nursing process has been identified as a fundamental quality within the nursing profession (Mallory et al. 2003). However Mallory et al. (2003) also highlight the professions failure to acknowledge the value of using nursing research to inform and improve clinical practice, including the use of evidence summaries and therapeutic guidelines. Hence, the gap from research-to-practice exists in all levels of the nursing profession highlighting a failure to recognize the link between research and practice for many years as demonstrated by researchers such as Cole (1995) and Kenty (2001).
Numerous nurse researchers (Closs & Cheater, 1994; Estabrooks et al. 2003; Funk et al. 1991; Funk, Tornquist, & Champagne, 1995) have cited a multitude of barriers for the utilisation of research or evidence-based practice in the clinical setting. Common factors have included:
- Understandability in terms of readability and clarity.
- Lack of value of research, as applied to clinical practice.
- Lack of time.
- Limited authority to implement evidence based practices.
- Unwillingness to change.
- Lack of support.
- Lack of Organisational support.
- Incomprehensible results from research to the average staff nurse.
(Closs & Cheater, 1994; Estabrooks et al. 2003; Funk et al. 1991; Funk, Tornquist, & Champagne, 1995)
Evidence-based nursing has been described as the delivery of nursing that gives emphasis to dependence on information produced from the results of scientific research (Stevens and Pugh 1999). Jennings and Loan (2001), McKenna, Cutcliffe, and McKenna (2000), and Evans (2003) clearly demonstrate support for the pecking order of best practice evidence in nursing. A hierarchy of evidence based upon the NHMRC Development, implementation and evaluation for clinical practice guidelines published in 1999 has been adopted by many evidence based institutions, i.e. The Joanna Briggs Institute, and The Cochrane Collaboration (Averis, Pearson, 2003). These levels assess the validity of research advice stemming from research that is determined to be of an appropriate quality. Hence when published these recommendations of best practice evidence are usually be found in a hierarchy format. New research evidence is of the utmost importance in nursing as it ensures the standard of care delivery has a good chance of improving. Without a screening process for quality such as those used by the Joanna Briggs Institute it leaves open the possibility that poor levels of research advice are used to guide practice. This is one reason why research utilisation within the nursing profession is of the utmost importance, for without it patient care standards are at risk for becoming poor. Hence to maintain the gold standard research evidence is now produced using a meta-analysis of randomised clinical trials or where randomised clinical trials of sound quality have not been undertaken in the field, the use of one high standard randomised clinical trial can be used to guide nursing practice (Averis, Pearson, 2003).
According to Averis and Pearson, (2003), lower levels of evidence, which must be scrutinised closely, include poorly controlled or uncontrolled studies; conflicting evidence, poor research design, data collection practices, and poorly analysed data sets. Within nursing however the use of levels of evidence stemming from quantitative research alone was considered by many to be problematic. What became apparent in the nursing profession was that nurses needed to explore a process of systematic review which delivered more content specific evidence in a qualitative format. This is because nurses do not operate from a sole medical model, but rather have a holistic approach to patient care. Hence nursing has a duty to produce evidence which is more holistic in nature and aligned with patient and social needs (Evans, Pearson, 2001). Evans and Pearson (2001) believe the production of systematic reviews relevant to the nursing profession to be a valuable contribution in moving the profession to a higher place of recognition. Through research and the synthesis of relevant findings nursing can make a valuable contribution to patient care standards. In today's society with increasing technological development accompanied by a rapid expansion of nursing literature and an annual rate of publication as large as 47 000 in multiple formats, nursing is witnessing an evidence based information explosion. As a factor of consequence to this information explosion nursing no longer has the capacity to keep absorbing new knowledge on a steady basis. Embedding this evidence is becoming increasingly difficult and is destined to become more challenging (Evans, Pearson, 2001). Evans and Pearson (2001) also stress that another factor of consequence that has and will continue to result from this information overload is the ability find the right source of evidence to guide nursing practice amongst the expanding volumes of published materials.
The problems of escalating volumes of research and locating the correct source of evidence further exacerbate other barriers to research utilisation, such as the ability for nurses to learn. Numerous authors have detailed teaching strategies innovative in nature which teach nurses about research and its place in providing quality standards of care (Ludemann, 2003; Poston, 2002). Mandleco and Schwartz (2002) highlight strategies such as proposal development and research poster presentation as tools that may bridge the gap between research evidence production and nursing practice, whereas Angel, Duffey, and Belyea (2000) suggest using an evidence-based practice implementation project as a method to improve knowledge transfer, enhancing nursing skill base and decision making capacity. Suggestions such as those presented by Angel, Duffey, and Belyea (2000) have been tried and tested and although successful outcomes can be demonstrated as outlined by research conducted by Fallon et al. (2006) elements of time, nursing heavy workload patterns and, an limited access to evidence based information still prevail as key barriers to research utilisation (McKenna etal. 2004).
Stemming from the work of Fallon and colleagues (2006) is clear evidence that implementation projects will only work where nursing participants in the exercise feel included and possess ownership. Further to this nurses would appear to need to utilise research implementation processes they are already familiar with.
Another fundamental concept stemming from the literature (Grbich et al. 2008; Parse, 2007) which has added fuel to the increasing issue of poor research utilisation in the nursing profession is undergraduate training. Although this concept has been applied to undergraduate nursing courses, its approach in a traditional research course has been neglected (Parse, 2007). Undergraduate nurses tend to focus on developing core clinical skills rather than enhancing research knowledge and skill and therefore research becomes an afterthought. Adding to this issue is the fact that research is not viewed as core business in the majority of healthcare settings. Due to this graduating nurses entering the profession are not research savvy and tend to approach clinical care with a set of blinkers, particularly in the first few years of post graduate placement. Hence they are unable to think laterally and explore other options that may assist with their patients care. As the culture of healthcare already devalues research these nurses get absorbed into the existing cultural norms (Grbich et al. 2008).
Research is often seen in nursing as having insignificant useful applicability to nursing settings. By demonstrating the relevance and value of good evidence that stems from research a structured research course can enable nursing students to visualise changes that relate to previous clinical experience and eventually will lead to an embedding of good evidence into their clinical practice after graduation (Tavares et al. 2007). Presently however university systems have not placed enough emphasis on research knowledge and skill within their set curriculum (James et al. 2006). Tavares and colleagues (2007) discuss the need for undergraduate research courses need to be redesigned to be taught using the hierarchies of evidence as a building platform. The concept here is to start with a seed and allow it to germinate. If new nurses possessed prior knowledge on levels of evidence they should hypothetically be able distinguish between poor and high level practice guidelines when they are using them.
2.3 Change Management
Research utilisation models that include attitudes have been proposed to explain and improve the dissemination process. Rogers (2003) the most recognized of these theorists notes that studies of diffusion process have a valuable place in introducing change to healthcare. By considering nursing perception, attitude, values, ideas and including staff in the change process, Rogers (2003) diffusions of innovations model has become a popular medium for introducing change (Hilz, 2000; Lee, 2004).
Investigations of the intricacy of the inhibitors that influence change management practices reveals that the transfer of new evidence into nursing settings remains one of the most taxing areas of research based practice (McDonnell 1998). Positive nursing attitudes towards the application of new evidence in practice, whatever the nursing setting, appears a pungent indicator of research utilisation (Parahoo et al. 2000) however attitude alone is not a sufficient measure as issues such as skill, knowledge and time must be factored in (Rogers 2003). One key contribution to the challenges of transference into practice may well be because research utilisation in nursing is considered an organisational issue rather than an individual nursing issue (Pallen, Timmins, 2002). A review by Pallen, Timmins, (2002) attests that to truly achieve the perfect evidence based nursing practice setting, each practicing nurse needs to take on the responsibility and accountability to improve practice, including senior nursing leaders.
Research within healthcare (Lee, 2004; Rye, Kimberly, 2005; Rogers et al. 2005)
that has used diffusion of innovations as an element of research design has resulted in a body of evidence consisting of a plethora of publications. The innovation diffusion process is perhaps one of the most commonly researched and well documented social phenomenon. To date, research on the diffusion process has been reported in nearly two dozen distinct academic disciplines, including geography, sociology, economics, education, and healthcare and is now becoming very popular within the research world of nursing (Hilz, 2000; Lee, 2004).
Despite the extant literature on diffusion of innovations research within healthcare, there still exists a major deficit when implementing findings into nursing practice. When health researchers do complement their study with diffusion principles there still only appears to be a limited selection of principles that are being addressed and what is evident is that basics in change management principles are not being incorporated into planning (Buller, et al, 2005). What is also evident from the many studies that have utilized Rogers (2003) theory is that it is liked and understood by many nurses. This is likely to be linked with the fact that it is complementary to pre-existing quality assurance processes that are used within the healthcare sector. Also contributing to this is the fact it does consider staff opinion as opposed to some traditional change management strategies such as the power-coercive strategy which ignores staff opinion and makes the change for the welfare of the organization (Sanson-Fisher, 2004).
2.4 Research utilisation models
Several structures for nursing research utilisation have been developed over the last 4 decades (Table 1). These numerous models emerged from the professions ongoing realization efforts to use or disseminate nursing research and ultimately improve patient outcomes. The models vary in their structure and procedural format in terms of processes, structures, their target populations, and specific outcomes. As an example, the target population may be an educator, researcher, academic, registered nurse, or even a carer. Structures can sometimes be established within an organisation's corporate governance. The specific outcomes and processes of any research utilisation project may be influenced by available resources and support systems (Closs, Bryar, 2001).
Table 1: Outline of research utilisation models
Table 1: Research utilisation models
(Crane, 1985a; CURN Project, 1981, Closs, Bryar, 2001; Funk et al. 1991a)
Conduct and Utilisation of Research in Nursing Project (CURN)
a) Problem identification
b) Assess knowledge base
c) Design practice change/innovation
d) Conduct clinical trial
e) Adopt, alter or reject change
f) Diffuse innovation
g) Institutional change and maintain innovation over time
h) Outcome: change in client outcome
The Stetler-Marram Model
a) Preparation phase
b) Validation phase
c) Comparative evaluation phase
d) Decision-making phase
e) Translation/application phase
f) Evaluation phase
g) Outcome: use of findings in practice
Rogers Innovation Diffusion Model
Some of the characteristics of each category of adopter include:
a) innovators - venturesome, educated, multiple info sources, greater propensity to take risk
b) early adopters - social leaders, popular, educated
c) early majority - deliberate, many informal social contacts
d) late majority - skeptical, traditional, lower socio-economic status
e) laggards - neighbours and friends are main info sources, fear of debt
Rogers also proposed a five stage model for the diffusion of innovation:
a) Knowledge - learning about the existence and function of the innovation
b) Persuasion - becoming convinced of the value of the innovation
c) Decision - committing to the adoption of the innovation
d) Implementation - putting it to use
e) Confirmation - the ultimate acceptance (or rejection) of the innovation
(Kleiber, Titler, 1998).
The Iowa Model of Research In Practice
a) Expected outcomes documented.
b) Practice interventions designed.
c) Practice changes implemented.
d) Process and outcomes evaluated.
e) Intervention modified if required.
f) Outcome: improving clinical practice through research.
The Linkage Model
a) User system
b) Resource/knowledge-generating system
c) Transmission mechanism
d) Feedback mechanism
e) Outcome: transmission of research innovations
2.4.1 Research utilisation models: a comparative analysis
Although more and more quality research articles are being published within nursing academia, there is concern that the use of research findings in practice is not proceeding at a satisfactory pace (Ottenbacher, 1987; Eakin, 1997). Research findings are of little use to the profession if they stay on the printed page (Brown, 1997; Taylor, 1997). The gap between research and practice must therefore be closed if nursing is to develop and refine a sound body of knowledge (Lloyd-Smith, 1997). Therefore, as research evidence is used more frequently as a basis for shaping nursing practice, documenting client outcomes and illustrating how nursing services do make a difference in health care, the value of research will be evident and will be reflected with an enhanced professional and public image (Gilfoyle and Christiansen, 1987; Llorens and Gillette, 1985; Smith, 1989).
The intent of research utilisation models is providing a solid platform for collaboration and the necessary structure for research utilisation activities to be successful. Examination of the research utilisation models demonstrates more similarities than differences (Kleiber, Titler, 1998). The purpose of all of the models is to bridge the gap between research and practice. It is the nurse's responsibility to make choices about which model will be utilised to stimulate evidence adoption. After implementation, models must be reassessed to house the necessary data to provide evidence of their effectiveness in terms of research use, process, cost and utility (Titler et al., 1994).
The CURN model represented one of the first major efforts in research utilisation. It was a complex multistage endeavour intent on improving patient care in the acute care environment. It used a team approach for reviewing research on selected patient care problems, as well as for changing and evaluating practice (Closs, Bryar, 2001). In contrast, the Stetler Model was developed with individual practitioners in mind, but it is equally appropriate for groups. Approaches for individual decision making about how to use knowledge were outlined (Stetler, 2001). Similar to the CURN model, the Iowa Model (Kleiber, Titler, 1998) focused on research utilisation at the organizational level. This model proposed that problem focused and knowledge-focused triggers both provide stimuli for the review and utilisation of appropriate and relevant research findings with a change in practice ultimately resulting.
Many models (Stetler, 2001; Closs, Bryar, 2001; Funk et al. 1991a; Jones, 2000; Kleiber, Titler, 1998) focused on the dissemination of researching findings at the organisational level whereas the Innovation Diffusion Process Model (Rogers, 2003) focused on the individual and how information flows from one individual to another. According to the model, a nurse who adopts a research innovation proceeds through five stages in order to integrate the new knowledge into daily clinical practice. With many Models (Stetler, 2001; Closs, Bryar, 2001; Jones, 2000), the individual clinician was viewed as the organizational change agent who would provide the link between research and practice. In the Linkage Model, there were four component parts: (1) a user system; (2) a knowledge-generating part; (3) a transmission mechanism; and (4) a feedback mechanism for research innovations (Jones, 2000).
The CURN model and the Iowa Model identified change in practice as the main goal of research utilisation if a change was justified, whereas the Stetler Model suggested application of research findings as its primary goal (Closs, Bryar, 2001; Kleiber, Titler, 1998; Stetler, 2001). In many instances, these goals were one and the same. Applying research findings to practice often resulted in validation, modification or change in clinical practices. In other words, 'through clinical innovations, individual professionals and the organizations in which they work are presented with new avenues for answering clinical questions or solving practice problems' (White et al., 1995, p. 416).
In the Linkage Model, the user is required to have a reciprocal relationship with the research system. All the models are mainly problem-focused in nature. In other words, problem recognition initiates the research utilisation process. The CURN model and Iowa Model were developed with organizations in mind, whereas the Stetler Model was introduced for use by individual clinicians. However, any of the models could be used by either individuals or organizations. Individual clinicians must take responsibility for identification of problems that may be applicable to practice; however, reducing the research utilisation process to the individual level may inhibit the change process of adopting innovations (Closs, Bryar, 2001; Kleiber, Titler, 1998; Stetler, 2001). As White and colleagues observed: 'it may be presumptuous to expect individuals to implement change without organizational support' (1995, p. 416). Most of the models propose that the final application of the innovations should occur at the skill-practitioner level. 'The readiness of the practitioner to use (or not to use) research findings presupposes an existing knowledge base of concepts of basic research, inferential statistics, measurement, and the research utilisation process' (White et al., 1995, p. 417).
The Iowa Model identified triggers as powerful agents for improving clinical practice through research (Kleiber, Titler, 1998). In Rogers (2003) model, front-line nurses were considered to be organizational change agents. Some of the models identified the benefits of linking front-line nurses, administrators, students and researchers in the research utilisation process. Literature outlined four levels that individual practitioners move through in research utilisation activities (Jones, 2000).
All the models stress the importance of an environment that is supportive and committed to the utilisation of research findings. Similarly, it is imperative that appropriate resources be put in place to ensure success. Both the CURN model and the Stetler-Marram Model require a supportive employment setting as well as the resources to conduct research utilisation activities in order to be successful (White et al. 1995). Although semantically different, the noted research utilisation processes have a similar intent. The Stetler-Marram model includes a feedback loop. However, as White and colleagues (1995) suggested, multiple feedback loops would be helpful mechanisms for the user to revert back to a previous step when findings indicate this is necessary. The goal of some research utilisation models in practice is to assist with nurse decision making about required evidence-based practice changes and to implement required if required. It must be noted though that not all research utilisation models result in nurse practice changes.
Several different approaches, operational definitions and models for research utilisation have been reported in the nursing literature. These models have direct relevance to nursing since they outline a means for closing the research–practice gap. In turn, this promotes evidence-based nursing practice (McCloskey, 2008). Other models focus on applying findings whereas others are more concerned about the validity of the studies reviewed. Some of the models focus on the organization whereas others focus on the clinician. Some consider planned change the primary focus, others prioritize educational preparation, and yet others claim critical and problem solving are paramount (McCloskey, 2008). Despite these differences, all have similarities in that: (1) they are prescriptive models; (2) they indicate the nature of research utilisation activities; and (3) they promote
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