Behavioural intention and user acceptance of research evidence for nurses


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.


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

1.1 Introduction

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:

  1. Understandability in terms of readability and clarity.
  2. Lack of value of research, as applied to clinical practice.
  3. Lack of time.
  4. Limited authority to implement evidence based practices.
  5. Unwillingness to change.
  6. Lack of support.
  7. Access.
  8. Lack of Organisational support.
  9. 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


Discussion Domain


(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

(Stetler 2001)

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 2003)

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.

(Jones, 2000)

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 evaluation of research findings (White et al., 1995).

Moreover, insufficient data exist for evaluating the effectiveness of any one of the research utilisation models described above in terms of research use, process, cost and utility at the present time and to date no research has been conducted that would indicate whether the end user believes them to be user friendly (Brenner, 2005).

Each of the models emphasizes a systematic process of analysis to facilitate the incorporation of research findings into clinical practice. The models suggest that, for research utilisation to occur, certain system mechanisms and components need to exist. The readiness of the practitioner to use (or not to use) a particular model presupposes an existing knowledge base of the research process, critique and utilisation (Alsop, 1997).

2.5 Major themes identified in the literature

Findings from the extant literature offer further support to the theories set out by the National Institute of Clinical Studies (2005) on barriers to evidence uptake. 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).

2.5.1 Research utilisation in nursing settings

Several studies of research utilisation have been reported in Clinical settings using different methodologies compared to the studies above. Hunt (1987) employed an action research approach to study a process involving nurse teachers, charge nurses (head nurses) and nurse managers in attempting to translate research findings into practice. She found that nurse teachers found it difficult to develop the level of critical ability required to evaluate the research reports found in the literature search and that the process was highly time consuming. One of the nursing practices reviewed was mouth care. In attempting to introduce research-based practice, the involvement of other agencies within the hospital besides nursing was found to be just one of the organizational barriers to change. The existing processes for negotiating these changes were found to be cumbersome and time consuming (Hunt 1987).

Moreover, not all charge nurses adhered to the agreed changes in practice despite being involved in the policy decision and change in supplies. Hunt found no concrete reasoning for such behaviours and simply put most of this barrier down to personality, confrontation, control, and potentially elements of horizontal violence. In Hunt's conclusion, the traditionalist impulse of nursing leaders was profound and was not overcome by awareness of research based reasons for practice. Hunt discussed how nurses viewed themselves as victims of change rather than opportunistic change managers and strategists. Nursing also generally lacked confidence in making individualized evidence based practice decisions about patient care (Hunt 1987).

Dependence on established routines appears to be a means of maintaining control and ensuring constancy in unpredictable and increasingly changing conditions (Hunt 1987). Armitage (1990) utilised a small working party of nurse managers and staff nurses to examine the degree of evidence utilisation in practice and discover inhibitors affecting research utilisation in practice. The author found little evidenced based practice recommendations were being used in nurse's practice, yet where they were used, they were done so without much understanding. The nurses also appeared hampered poor journal reading skills finding the literature they offered to colleagues was not seen to be useful. Armitage concluded nurses needed to identify their own problems and find solutions themselves rather than be provided with potential solutions to problems that were not perceived to exist or to be important (Armitage, 1990).

Many debates of who and or what is responsible for an apparent failure to utilise research in nursing exist (Hunt 1987; McCloskey, 2008; Thompson, Chau, Lopez, 2006). Examples include the perception that is it the nurse's fault for failing to be able or willing to read, believe in and utilise findings. Or it is the researchers fault for failing to single out relevant areas of research and failing to publish findings to nurses in a readable and understandable form. Or perhaps it is the drivers of healthcare and nursing or the 'system' for failing to reward, encourage and support nurses for innovative research-based practice? Most of these arguments appear established on a simplistic understanding of evidenced based practice utilisation that if researchers conduct and publish research, practicing nurses will read it and use it. Clearly this is not the case nor does it advance one's understanding of the complexities of research utilisation in the nursing profession (Hunt 1987).

Nursing utilisation of research findings seem to be highly complicated, integrating issues such as autonomy and empowerment of practicing nurses, executive issues, opportunities for staff development, motivation and job satisfaction, the reporting of research, multi-disciplinary relationships, and the role of the Nurse Manager, to name but a few (McCloskey, 2008). Limited information exists about the exact extent of research utilisation in the literature. Whether research utilisation is a problem or not is difficult to judge since there is no evidence as to the extent to which nurses base their practice on research. What little research there is, is predominantly done in one unique nursing setting and any application to other countries must be made with caution. It seems clear that there is a need to look not only at the extent of research utilisation in for clinicians but also at the factors that promote and act as barriers to research utilisation. It may be tempting to look at discrete factors influencing utilisation but it seems that the interaction of multiple factors in influencing research utilisation may be of overriding importance (McCloskey, 2008).

There is much speculation about strategies to improve research utilisation (Bircumshaw 1990, Wright & Dolan 1991, Wilson Barnett et al. 1990), but until nurses are sure whether this is a real issue for the profession, and until it is known what factors may influence research utilisation, nurses can only address a hypothetical problem with hypothetical solutions. Results from previous research have indicated some potential influencing factors that may be worth exploring with a larger, more representative group of nurses. From the evidence found in the literature there would appear to be a need for nurses to self-report the extent of research-based practice and the presence of identified influencing factors. This self reporting could be used as a part of a framework which aims to demonstrate the status of nursing research utilisation which is as yet unknown. If positively and negatively influencing factors can be identified, then sound and valid strategies to promote positive factors and reduce negative ones can be employed to facilitate research-based practice by nurses. The potential impact of research-based nursing practice on standards and quality of patient care should not be underestimated (Bircumshaw 1990, Wright & Dolan 1991, Wilson Barnett et al. 1990).

2.5.2 Lessons from research:

Existing tools used to examine research utilisation have focused on research utilisation as a single entity, in particular nurses' ability to access and appraise research reports and implement research findings in practice. The Barriers to Research Utilisation Questionnaire developed by Funk etal. (1991a) has been tested extensively over the past 15years in a number of countries including the United Kingdom (UK) (Dunn etal. 1998, Nolan etal. 1998, Closs & Bryar 2001), Finland (Oranta etal. 2002), Sweden (Kajermo etal. 1998), Australia (Retsas & Nolan 1999,), (Kuuppelomäki & Tuomi 2005), and Ireland (Glacken & Chaney 2004). It has also been applied to investigate research utilisation in unique groups of nurses, for example, community nurses (Bryar etal. 2003), specialist care nurses such as midwives and forensic mental health nurses (Kirshbaum etal. 2004; Carrion etal. 2004). The questionnaire attempts to understand 29 items considered to be barriers to research utilisation. Participants are asked to rate on a 5 point Likert scale the level at which they perceive each item to be a barrier. Factor analysis has typically grouped the items around four factors, the quality of the research, the nurse's research skills, awareness, and values, the characteristics of the organization and the way in which research is communicated (Funk etal. 1991b). Comparisons of evidence based findings at an international level indicate that nurses experience similar barriers at a broader level however there is still a need for a micro- level of understanding (Shaw et al. 2005).

Studies like Kuuppelomäki & Tuomi (2005) have attempted to reproduce a similar factor analysis. They were able to confirm these factors, in comparison to other studies which have identified different groupings of items. Retsas and Nolan (1999), Kirshbaum etal. (2004) and Marsh etal. (2001) indentified three similar factors, Kuuppelomäki and Tuomi (2005) specified six different factors. Closs and Bryar (2001) and Marsh etal. (2001) conducted broad testing of the questionnaire and as a result raised significant questions about the content and construct validity of the tool when applied in the UK. It is evident that the application of such a tool cannot be generic to just any nursing culture. What is clear from the literature is that this tool must be refined to reflect the social, demographical, cultural, and independent characteristics of the nursing body being studied without compromising the true intent of the questionnaire (shaw et al. 2005).

Several other questionnaires have been constructed that have examined research utilisation, however, they have not been used as widely as the Barriers questionnaire and hence the validity and reliability of the instruments are yet to be fully tested in multiple settings. (for example Lacey 1994, Rodgers 1994, Hicks 1995, Estabrooks et al. 2003, McKenna etal. 2004). In addition, within the context of evidence-based nursing they centre on the use of research findings rather than a much wider definition of evidence identified as important in the literature and referred to above. Although in Estabrook et al's (2003) research they did consider broader ranges of information that nurses might draw upon, including multi-disciplinary and patient expertise. This was performed in order to explore the level to which sources of research evidence were utilised rather than to acknowledge the contribution of a wide range of evidence sources.

From a review of the literature and existing instruments, there would appear to be a need for an evaluation tool which could examine factors that are influencing evidence-based practice outside of the traditional forms of evidence based practice in nursing, i.e. a mutli-disciplinary approach. A common definition of evidence-based practice which has informed the development of the questionnaire in many studies has been adapted from Sackett et al's. (2000) definition which emphasizes the interplay of research evidence, clinical expertise and patient preferences. However, the definition of evidence in many studies was extended to include research products such as national guidelines and local information such as protocols and audit reports (Lacey 1994, Rodgers 1994, Hicks 1995, Estabrooks, et al. 2003, McKenna etal. 2004). Implications for nursing practice

One of the many questions stemming from the literature is how can results from research utilisation studies be translated within nursing organizations? Implications for nurses can be catastrophic as previous research findings disseminated to nurses at administrative levels and practice levels of nursing have often never been deciphered or filtered. Differences in the perceptions of nurses would appear apparent in their attitudes, use of research, and availability of time to research, and support to conduct research (McCloskey, 2008). McCloskey's (2008) research found that at an administrative level nurse leaders need to understand the different educational levels and needs of those nurses under their management and advocate modelling, mentoring, and the provision of time, skill, and knowledge necessary to become involved in research utilisation.

Although McCloskey's (2008) research found small differences, the practical application of her findings supports many popular research utilisation models where nurses are not all educationally prepared to critique or understand research. McCloskey (2008, p. 43) states, "Nurses need to be able to practice within their educational preparation. Staff nurses with a baccalaureate degree are able to critique and evaluate research and therefore able to work toward translating evidence into practice. Nurses with diplomas or associate degrees are not traditionally as well prepared to do these activities; they should be supported if attempting to do so. Staff nurses with a master's degree and advanced practice nurses are in a position to assist evidence-based practice initiatives and translate the findings into practice. They are also better prepared to assist in developing and promoting questions for future research. Managers need to embrace these differences and evaluate and promote nurses according to their educational levels."

McCloskey (2008) further emphasises that practicing nurses should translate research more proactively into practice through effective time management, increased peer support and journal clubs. McCloskey (2008, p. 43) states, "nurses at the practice level need to acknowledge the differences in the educational capacities of their peers." Overall McCloskey outlines that nurses with a degree or higher education should support each other and become advocates for evidence based practice activities within the profession. She outlines that the profession should identify nurses with appropriate post graduation qualifications, enlist their managers, and partner with quality and research nursing expertise to work together in embedding new evidence.

McCloskey (2008) is adamant that future research should continue to identify and address barriers to research utilisation in nursing, with a key emphasis on nursing perceptions that affect the conduct and the utilisation of research. She is also insistent in her findings that a key focus should be on addressing these perceived or actual barriers in a variety of nursing organizational systems. Prior research has concentrated on the entire state of nursing research and any inhibiting factors that affect research usage within nursing practice groups or nursing organizations (Funk, Champion, Tornquist, & Wiese, 1995; Funk et al., 1991b; Glacken & Chaney, 2004; McCleary & Brown, 2003b).

McCloskey (2008, p. 44) states, "Future research needs to be conducted and replicated at the organizational level because organizations are different and the systems of support are different." McCloskey (2008) also asserts that ongoing use of validated research barriers questionnaires is required, allowing for refinement and capability to benchmark results across a large number of nursing disciplines. Patient Influence

What is evident from the literature is that patients do have a clear role in evidence utilisation. What is unclear is when and in what circumstances that role either facilitates or inhibits the utilisation of new evidence and hence the nurses ability to effectively utilise an implementation model (Stacey, et al. 2008). According to the National Institute of Clinical Studies (NICS) (2006) a patient's knowledge, skill, attitude, and compliance must be taken into consideration when implementing new evidence that directly affects that individual. Research on the role a patient can have in influencing the adoption of evidence is quite scarce. Authors such as Watt-Watson, et al. (2001), Stacey, et al. (2008), and Pipe, et al. (2005) that have focused on the role patients have in evidence based decision making depict several emerging themes. Coaching the patient would appear to be advantageous as long as the methods do not cross the boundaries of coercion. The skills of the nurse utilising education methods to engage the client in such practices appear to require a very high standard, otherwise negative perceptions in the client may develop.

Watt-Watson et al. (2001) insists that prior to approaching a patient to coach them on upcoming changes to the care and treatment they are receiving the nurse should consider the current values that the patient holds. This may include their culture, spiritual belief, and in essence the faith they have in current regimes. In addition it would appear fundamental that the nurse considers any conflict that exists, whether internal or external for the patient that may compromise implementation. Researchers (Stacey, et al. 2008; Pipe, et al. 2005) have presented findings indicating that quality of life following diagnosis of a serious illness is enhanced when patients perceive they have had a voice in selecting treatment options. Understanding and then meeting a patient's preferred level of engagement in the decision-making process may be associated with higher levels of decision satisfaction for patients. A promising goal within the nursing profession is increasing patient satisfaction with specific treatment decisions. Although shared decision-making between nurses and patients may empower patients and potentially enhance satisfaction with the clinical encounter, generally there is limited evidence available that documents the more specific relationship between patients' perceived participation and satisfaction with the decision-making process itself.

A clear emerging theme from the literature is the role culminating from the dissatisfaction of a patient can have on the success of an implementation strategy. Certainly those nurses who choose not to engage a patient in evidence based practice changes do appear to be taking a significant risk. The engagement of a patient in change management practices does appear in the majority of cases to have a more positive outcome.

Watt-Watson, et al. (2001, pp4) state that 'conceptually, patient perceived involvement in decision-making may have a positive impact on satisfaction with healthcare decision-making. When patients are more satisfied with decision-making, they may be more likely to adhere to health promotion behaviors and treatment regimens. Subsequently, adherence may lead to more positive health outcomes.'

Emerging from recommendations put forward by NICS (2006) is the issue of patient health. The patient's health status according to NICS does appear to directly influence whether implementation strategies are successful. A patient's health status can alter even during the trial of an intervention. Collated findings from Watt-Watson, et al. (2001); Stacey, et al. (2008); and Pipe, et al. (2005) indicate the factors such as patient knowledge and pain are foremost influential in prompting changes to care. A patient's knowledge base would appear to shape whether or not they are compliant with suggested alterations to care. Furthermore, if suffering from pain the patient may not be prepared to engage in alterations to current practice. Evidence from these researchers indicates that only when a holistic approach is taken with the patient and all facets of that individuals needs are considered are they more likely to participate in change. The Social Context of Nursing

Nurses come in many different forms and whether the student nurse, new graduate nurse, or experienced nurse, and each posses role behaviours, norms, sanctions, and status dimensions that are unique to their specific destination. The literature advises that when a nurse changes roles, the process of learning the new role is called socialisation. One could construe from this that if a nurse is to take on a research or evidenced based role they too are going through a process of socialisation (Hardy and Conway, 1988).

The literature also refers to professional socialisation which has been used to describe the social processes that occur between the time a student enters a nursing program and graduates. The professional socialisation that goes on during education in a professional nursing program is designed to shape attitudes, values, self identity, role skills, role knowledge, and role behavior (Hardy and Conway, 1988). What is evident from the literature then is that if nurse's attitudes, values, self identity, role skills, role knowledge, and role behavior are not shaped positively towards a research culture and hence evidence based practice awareness, then current cultures in nursing may absorb and influence them in a negative fashion (McCloskey 2008).

Social nursing cultures can breed negativity and if a task such as research utilisation is deemed by a group as non-essential to daily practice then this can have a long lasting impact on the potential successes for evidence based practice implementation that many enthusiasts strive for (Randle, 2002).

Randle's (2002) findings from a three-year study exploring the self-esteem of students undertaking a diploma in nursing course imply that when students commence their training they have a moral awareness, which they perceive will guide their nursing actions. By the end of the course this moral awareness had been superseded by their willingness to conform to the nursing norms evident in the clinical area. Randle believes that this has real implications for nursing practice.

Further Randle (2002) believes that inherent in the concepts behind nursing care is the moral honour of the practising nurse, i.e., society in general expects the nurse to have a conscience, and to act appropriately. Randle (2002, p225) states "Historically, we can witness the emphasis upon this characteristic of the nurse and terms such as 'good woman', 'virtuous', 'pure', and 'motherly' are used commonly to describe nurses. However, findings from this study imply this is not always the case."

A hypothesis that nurses will take 'care' of patients and act in a moral way towards them is challenged from evidence presented by Randle (2002) and it is suggested that more powerful and complex processes shape moral action. Research suggests that many of the barriers to research utilisation within nursing stem from conforming norms within the profession and even when well educated on the importance of evidence based practice in nursing, newer nurses can still lose sight of the importance of research over time as social norms begin to take a strong hold (McCloskey, 2008). Most evident from previous research (NICS, 2005; McCloskey, 2008; Brenner, 2005) is a key theme outlining that the opinions of other nursing colleagues greatly influence a nurses own opinions, and these opinions can act in either a positive or negative manner. Nurses tend to value and are influenced by the opinions of those colleagues they work with and respect. If the majority of opinion in a nursing setting is of a negative tone towards research utilisation then it would appear that many nurses choose to conform to those opinions so they are not perceived as different.

These opinions from nursing colleagues appear to be greatly influenced by the culture within a nursing setting and the lengthy exposure a nurse may have within that culture (NICS, 2005; McCloskey, 2008; Brenner, 2005). Nurses may commence in a clinical setting with good intentions and have a clear and positive direction they wish to pursue with research and evidence based practice utilisation, however are often forced to conform to the norm of a nursing culture. This conformity can greatly alter those original good intentions to remain an evidence based clinician (NICS, 2005). Authors such as Estabrooks (2003) and NICS (2005) believe nurses can get absorbed into the cultural context that is the profession of nursing and begin to overlook the need for maintaining change as they begin to work within a comfort zone.

Integral to a positive social context is ongoing collaboration, not only amongst nurses, but also the alliance with other professions to work cohesively (McCloskey, 2008). What is clear from the literature is that when nurses to not work collaboratively either between themselves or with other professions it can greatly inhibit the successful implementation of new evidence into practice? Knowledge utilisation practices are generally deemed by many as poor in nurses, mainly due to the lack of collaboration that exists across the profession (Asselin, 2001). This is mainly attributed to the lack of communication that exists between nursing settings either in the same nursing organisation or across several. Asselin (2001; pp,115) states, 'There were no variations in utilisation processes as nurses floated across units. Sources of new knowledge were primarily informal and unit based.'

To date in the latest research, essential expressive toil outlines the strategic role nursing leaders have in research transfer. Mutually facilitative and regulatory activities appear fundamental for nursing administrators to influence the use of research (Gifford et al. 2007). Findings put forward by Gifford and Colleagues (2007) have critical implications for sprouting theoretical models describing elements that influence the process of research utilisation. In the facet of what becomes the social context of nursing moving the science forward and testing the link between leadership and outcomes becomes necessary. Gifford and Colleagues (2007, p. 126) state that 'Qualitative methods are essential for understanding the process of leadership for research transfer.'

The social context within the nursing profession would appear to have some influence on research utilisation practices. The majority of authors appear to paint much of this influence in a negative light advising that the profession as a whole needs to revise its own social climate from the ground roots up. Longitudinally the profession needs embrace a more positive research culture and in every facet of the profession positively promote research (McCloskey, 2008; Asselin, 2001; Gifford et al. 2007). The Organisational Context

Estabrooks et al. (2003) outlines that within the nursing profession it is extremely important to understand the organisational context as it facilitates or inhibits research utilisation. What is clear is that most nurses do not invest the time required to fully understand the healthcare environment which they are working in. The organisational context appears to encompass the way a health care system is structured and how it functions, inclusive of nurse manager's operative knowledge and the extent that knowledge has on relevant domains of action (Estabrooks et al. 2003). What is evident in nursing is that organisational context is continually changing which can further cloud a nurses understanding of his or her organization and the way it should operate. Corporate and clinical governance continually changes and if knowledge utilisation practices are poor within that organization nurses are often the last know of any proposed change both pre and post implementation (Estabrooks et al. 2003).

A notable restriction to research utilisation by nurses appears to be care processes. Care processes are those processes or procedures an organization has chosen that govern a standard of patient care (NICS 2005). These processes can be simplistic and very complicated depending on the given circumstance. Examples given in the literature indicate that many of these care processes are poorly written or fail to be evidence based. Another interesting factor found in the literature is the low skill mix that nurses actually posses when asked to engage in the development of new procedure (McCloskey, 2008). Care processes can be greatly affected by this low level engagement as the person closest to knowing what is truly required to improve patient care is often never part of development.

In any organization the staff working in that environment becomes integral to any successes or failures particularly when considering successful change management practices. Nursing makes up a significant proportion of the staff mix in a healthcare organization. As a group the decisions that nurses make become fundamental when considering the standards that an organization is trying to maintain. If the nursing majority disagrees with a proposed change in an organization then this can make the transition for change very difficult (NICS, 2005). Outside of nursing there are many other senior staff in an organization that might be considered barriers to successful change. The literature (Baxter and Boblin, 2008) has identified hierarchical leaders such as executive personnel in healthcare, doctors, and even allied health professionals as potential barriers to change. Where nurses require permission from more senior personnel to make such changes and maintenance of effective communication is required to instill change, it would appear implementation problems are escalated (NICS, 2005).

Staff capability would appear to be a significant issue when considering evidence base practice adoption success or failure (Rogers, 2003). The capability of nurses to engage in research practices would appear to be an issue if the literature is anything to go by. McCloskey (2008) outlines the deficit that exists in nurse training particularly at a pre graduate level. If research utilisation is to be successful then nurses need to have the confidence in themselves to engage in research activity for the benefit of the patient. The literature also refers to staff capacity as the level of staff, the skill mix, and the individual's capacity to engage in research based on time and workload as real barriers and/or enablers (Baxter and Boblin, 2008).

Some organizations are better equipped to deal with research and encourage their staff to engage in it. Evident in the nursing literature is the lack of investment in qualified research nurses many nursing organizations make and the low prioritization that is actually given to research. Although all organizations will operate under quality assurance guides, the processes and resources used to meet national and international standards are not necessarily research driven and can often just be paper based exercises (Brenner, 2005). In general the individual nurse is expected to engage in research activity on top of already busy workloads and hence research stays at the bottom of the to do pile. With growing populations, aging populations, and a restricting economy the ratio of nurses to patients continues to enlarge creating riskier care environments and less time to devote to research utilisation activity (Baxter and Boblin, 2008). Existing nursing structures appear to be under pressure due to changes in skill mix and nurse- patient ratios. Different nursing levels and qualifications are being considered as a means to address gaps in clinical need (Duffield et al. 2007).

Duffield (2007, pp 2) outlines that 'the impact of restructuring on staff is not necessarily accounted for in the process of change, which is unfortunate, as the pressures of cost containment usually lead to an emphasis on work redesign to deliver care in more efficient and cost effective ways. However as hospitals undergo restructuring there is little evidence that efficiency or outcomes actually improve. Despite this, restructuring can have significant implications for patients and the nursing workforce.'

NICS (2005) have clearly identified structures particularly those that evolve within nurses as barriers to research utilisation. If restructuring disrupts workloads and time management patterns within nursing then evidence base practice implementation can become a low priority as nurses try and readjust to new working conditions. Economic and political context

O'Byrne and Holmes (2009) surmise that nurses are political agents both as imposers through pastoral power and as recipients of the social contract that positions them as trustworthy, honest, and caring individuals. O'Byrne and Holmes (2009, p 9) state that 'indeed, an analysis of stigma, deviance, and hard/soft power explicitly shows how nursing practice is ultimately political.'

Nurses continue to work with patients to help them optimize their health by providing education and strategies for them to continue living. Alongside this continued holism is the nurse's attempts to mitigate the potential for ill health. External factors such as increasing economic influence and health care remaining a political football by which politicians will attempt to influence voters impact directly on the individual and political context by which nurses already operate (NICS, 2005). Policy decisions made at either a State or Federal health care level appear to directly correlate which decreasing standards of care and hence can inhibit nursing attempts to maintain or improve standards (O'brien, Holmes, 2009).

Estabrooks (2003) further supports the notion that external political and financial factors can greatly influence the likelihood of nurse's utlising evidence. Barriers can present in the form of insufficient funding or political decisions that directly affect nursing numbers, structures, qualifications, and pay scales. External influences such as these are often not as apparent as more obvious nurse related or patient barriers and can be overlooked as a contributing factor. NICS (2005) outlines that, financial arrangements, regulations, and corporate governance or policy as major factors that influence research utilisation from an economic and political context. Much of the issue surrounding regulation and corporate governance appear to be related to research not be recognized as core business and/or funding be diverted into specific hotspots in healthcare to gain political brownie points. Hence funding diverted into research, particularly nursing is rather poor. The combination of these factors greatly reduces the likelihood of nurses engaging in good research practices (NICS, 2005; Estabrooks, 2008) The innovation itself

The concept of innovation in nursing is necessary if the profession is to move forward as a lateral thinking body. However with innovative ideas comes the complexity of understanding something new and foreign. One relevant example in nursing is the introduction of new technologies to support patient care, documentation and communication, and decision making. When the innovation appears complicated, requires extensive education and training to utilise, and may impact upon nursing time, concerns and doubt can set in. The difficulty with introducing new innovations is that it is not easy to engage and sell a new idea to all of the nursing body. There may also be a percentage of individuals who do not agree with the change or the newer way of doing things.

Feasibility appears to be a real issue as it is one thing to have an idea, but it is another to actually implement it. Some nursing settings simply may not be ready or perhaps it is just not cost effective. In many instances in health care where initiatives are started appropriate cost analysis or cost predictions have not been conducted or adequate consultation and communication has not occurred. Due to these factors unforeseen barriers to research utilisation come to the surface and prevent the completion of the implementation.

Outside of feasibility lies the issue of credibility. According to Rogers (2003), credibility traditionally has two key components: trustworthiness and expertise, which both have objective and subjective components. Trustworthiness appears to be based more on subjective factors, but can include objective measurements such as established reliability. Expertise appears similarly subjectively perceived, but also includes relatively objective characteristics of the source or message (e.g., credentials, certification or information quality). Within the nursing profession trustworthiness and expertise are prerequisites to a positive and productive nursing team and a quality patient relationship. Where nurses feel distrust towards a new innovation and have no confidence in the expertise of the individual driving the change there is a low probability the change will be successful Rogers (2003). Rogers's views credibility of innovation as vital to successful implementation of new ideas. At times to demonstrate credibility a research team may need to work slowly and build up trust within a nursing sector, alternatively the innovator may be well known and will need to maintain credibility and a trusting working relationship.

One issue that appears to be conceptualised in much of the literature (National Institute of Clinical Studies, 2005; Rogers 2003; Hilz, 2000; & Lee, 2004) is the theme of accessibility. If an innovative idea or new piece of evidence has not been widely disseminated or information is not forthcoming to aid in decision making then the likelihood of adoption is also low. Information to guide decision making needs to be freely available to allow nurses to understand and accept a new innovation prior to implementation (Rogers, 2003). Rogers (2003) also outlines that a new innovation needs to be attractive to the intended target population. Nurses would need to see real benefit in the research innovation and through its attractiveness want to engage in change management practices as it is appealing to them. Individual professional

Evident in the literature is the need for nurses to possess knowledge on research, its processes, and particularly the importance of research in health care. If more nurses understand that with more research comes knowledge and with good research comes higher standards of evidence based practice then evidence based practice implementation projects are more likely to be successfully. With this knowledge the literature attests that more nurses are likely to want to engage in research utilisation practices (Estabrooks, 2003; Rogers, 2003).

With an expanded knowledge comes the issue of persuasion. If the profession is unable to persuade all nurses of the value that research utilisation has in clinical practice and the improvements it can have in clinical care barriers may become apparent. Each unique initiative will require persuasion which has strong links to the credibility of a researcher and the initiative (Evans and Pearson, 2001). Baxter and Boblin (2008) suggest that understanding what is best for a patient may interfere with a quality implementation project if nurses have any doubts and are unable to draw to a conclusion. They advise that nurse decision making capacity may act as a barrier if the tools that usually aid decision making are not made available.

Rogers (2003) expands on the concept of implementation, suggesting that if the process of implementation chosen by the individual is not nurse friendly and therefore removes participant choice or decision making capacity then successful research implementation is unlikely. For example if those driving the initiative adopt an authoritarian style other nurses are less likely to comply as they are not truly able to be part of a change process.

Rogers (2003) details the concept of confirmation and emphasizes the importance of this stage in an innovative change process. In this phase of the implementation process the nurse would finalize his or her decision to continue using the innovation and may use the innovation to its fullest potential. Alternatively if they have not been a party to that change they may choose to reject it.

Time appears to be a genuine issue when considering research utilisation. It is highlighted by many authors (Baxter and Boblin, 2008; Evans and Pearson , 2001; Estabrooks, 2003) as a barrier to change and has been connected to issue of workloads in nursing and the overall tasks nurses need to perform. It would appear real solutions are required by the profession to find nurses time so they might invest it in research activity. Patient care is a priority for all nurses and nurses will always put this ahead of any other activities. The literature (Baxter and Boblin, 2008) advises that until nurses are provided with off line time research utilisation practivces are not likely to improve.

Access to new information would also appear to be a real issue. With an ever increasing amount of publications occurring particularly in electronic formats nurses would appear to find it difficult to keep up with the volumes of information that are becoming available (Baxter and Boblin, 2008). In addition to this nurses do not appear to have the electronic access required to even sort through the volumes of information that do exist (McCloskey, 2008).

According to Estabrooks (2003), understanding research and therefore the need to utilize newer evidence stemming from research is not something that comes naturally to nurses. The knowledge required to achieve effective evidence utilisation practices in the past has not been instilled into nurse training programs and nursing organisations have not recognized this as core business. In the majority of instances nurses do not appear to have the knowledge required to engage in research or perceive the activity as to hard because of that lack of understanding (McCloskey2008). Communication

Throughout the research utilisation process there is evidence that not all nurses exert an equal amount of influence over other nurses (Rogers, 2003). According to Rogers (2003) there are Opinion Leaders, leaders who are influential in spreading either positive or negative information about a new piece of research evidence. Rogers relied on the two-step flow theory in developing his ideas on the influence of Opinion Leaders in the diffusion process. Nurse leaders would have the most influence during the evaluation stage of any implementation process and hence how they communicate and convey ideas will greatly influence how other nurses perceive the proposed change. In addition nursing leaders should have a set of characteristics that set them apart from their nurse followers. Nurse leaders typically have greater exposure to the mass media, more cosmopolitan, greater contact with change agents, more social experience and exposure, higher socioeconomic status, and should be more innovative (Rogers, 2003).

Fundamentally factors that appear to either enable or inhibit successful research utilisation according to Rogers (2003) are the basics to verbal communication, written communication, and in an a more reliant society on technology electronic communication. If these facets of communication are not strong in the profession of nursing, particularly with nurse leaders then research utilisation practices are destined to fail (Rogers, 2003).

2.6 Assessing nursing utilisation of evidence based recommendations

2.6.1 The BARRIERS to research utilisation questionnaire

Rogers (1983). This model identified four concepts, or factors, which are important to the adoption of change: the characteristics of the adopter (the nurse), the characteristics of the organisation (the setting), the characteristics of the innovation (the research) and the characteristics of the communication (the presentation and accessibility of the research). The BARRIERS questionnaire was developed from the literature based on the CURN project questionnaire (Horsley et al., 1983) and from informal data collection. The questionnaire consists of 29 items (Table2 ) and respondents are asked to rate each item in relation to the extent to which they perceive the item to be a barrier to research utilisation on a scale from 1, no extent to 4, a great extent. There is a no opinion option (5). The developers undertook a study to test the validity of the scale and the strength of the relationship of the 29 items to the four factors. Another smaller study examined the reliability of the scale over time. This study involved 17 students on a masters' program who completed the questionnaire on two occasions 1 week apart. It was found that there was adequate stability of the scale over this short period of time (Funk et al., 1991a).

See Appendix 1.

2.6.2 Limitations of Tool

Although the Barriers Scale itself has been proven useful in identifying barriers, Parahoo (2000, p96) found that "the high proportion of 'no-opinion' answers, related to 'research', could have affected the overall ranking of barriers". For example, Paharoo outlines the following point 'The conclusions drawn from the research are not justified' as a question which requires a respondent to possess research skills and knowldge. If the respondent does not have this knowledge or skill, then 'no-opinion' is likely to be given. A high percentage score for this question is therefore unlikely to truly reflect the barriers potential impact (Parahoo, 2000). Parahoo (2000, p 97) advises, "it would be useful to find out why a number of items, all related to 'research', attracted a high percentage of 'no opinion'." This could be indicative of lack of research skills and knowledge for nurses to outline more accurately whether this deficit is blanket across the discipline.

Parahoo (2000) also outlines another limitation with the use of this tool being the use of a convenience sample which he believes inhibits the capacity for generalization of findings to other populations. Also in Parahoo's research 47.4% people failed to respond, which lead him to the issue of motivation as a major factor. Unfortunately no research to date has collected this data on nursing profile for non-responders (Parahoo, 2000). Finally Parahoo (2000) emphasizes that little emphasis should be placed on the ranking of these barriers as the differences in scores between them can often be small.

2.7 Theoretical Underpinnings

National Institute of Clinical Studies (2005)

Rogers (2003) theoretical model

2.7.1 Diffusion of innovations theory was originally formalized by Everett Rogers in a 1962 book called Diffusion of Innovations. Diffusion is the "process by which an innovation is communicated through certain channels over a period of time among the members of a social system". An innovation is "an idea, practice, or object that is perceived to be new by an individual or other unit of adoption". "Communication is a process in which participants create and share information with one another to reach a mutual understanding" (Rogers, 2003). Rogers stated that adopters of any new innovation or idea could be categorized as innovators (2.5%), early adopters (13.5%), early majority (34%), late majority (34%) and laggards (16%), based on a bell curve. Each adopter's willingness and ability to adopt an innovation would depend on their awareness, interest, evaluation, trial, and adoption. Some of the characteristics of each category of adopter include:

* innovators - venturesome, educated, multiple info sources, greater propensity to take risk

* early adopters - social leaders, popular, educated

* early majority - deliberate, many informal social contacts

* late majority - skeptical, traditional, lower socio-economic status

* laggards - neighbours and friends are main info sources, fear of debt

Rogers also proposed a five stage model for the diffusion of innovation:

  1. Knowledge - learning about the existence and function of the innovation
  2. Persuasion - becoming convinced of the value of the innovation
  3. Decision - committing to the adoption of the innovation
  4. Implementation - putting it to use
  5. Confirmation - the ultimate acceptance (or rejection) of the innovation

2.7.2 The S-Curve and technology adoption

The adoption curve becomes an s-curve when cumulative adoption is used.

Rogers theorized that innovations would spread through society in an S curve, as the early adopters select the technology first, followed by the majority, until a technology or innovation is common.

The speed of technology adoption is determined by two characteristics- p, which is the speed at which adoption takes off, and- q, the speed at which later growth occurs. A cheaper technology might have a higher- p, for example, taking off more quickly; while a technology that has network effects (like a fax machine, where the value of the item increases as others get it) may have a higher- q.

Technology adoption in healthcare coincides with available evidence. Without a clear understanding of the evidence clinicians are less likely to adopt a new innovation. Rogers Innovation Diffusion Model is therefore very relevant to this study as a theoretical model.

For this research diffusion is defined as the process by which evidence based practice (EBP) is communicated through certain channels over time among the nurses of a clinical area. Given that decisions are not authoritative or collective, each nurse of the clinical area faces his/her own innovation-decision that follows Rogers five stage model for the diffusion of innovation.

The most relevant feature of diffusion theory to this research is that, for most members of a social system, i.e. nurses, the innovation-decision depends heavily on the innovation-decisions of the other nurses within the system. In fact, empirically the successful spread of an innovation follows an S-shaped curve.

Critics of this model have suggested that it is an overly simplified representation of a complex reality. A number of other phenomena can influence innovation adoption rates. One of these is that customers often adapt technology to their own needs, so the innovation may actually change in nature from the early adopters to the majority of users. A second is that disruptive technologies may radically change the diffusion patterns for established technology by starting a different competing S-curve. Finally, path dependence may lock certain technologies in place, as was the case with the QWERTY keyboard which is the most used modern-day keyboard layout on English-language computer and typewriter keyboards (Rogers 2003).

2.7.3 National Institute of Clinical Studies

The principles behind this theoretical model enforce that it is important to be able to ascertain the barriers to evidence uptake. The theory details that in nursing and healthcare as a whole exists evidence based practice gaps that can decrease the standards of care offered to patients. By identify barriers the first principle suggests nurses will better understand how to avoid or minimise these barriers and hence encourage a more successful utilisation of validated evidence. The theory also advises that the gap between current practice and best available evidence often is determined and influenced by these barriers. It suggests that nurses and other health professionals should utilise known tools such as brainstorming and focus group discussions to try and discover hidden barriers within their work environments. The theory operates on the same principles as root cause analysis found in integrated risk management processes (NICS, 2005).