VOL: 103, ISSUE: 1, PAGE NO: 32-33
Ven Veeramah, BSc, MSc, Dip Nursing, CertEd, RMN, RNT
Principal lecturer, School of Health and Social Care, University of Greenwich
Despite the huge increase in the amount of research being generated within the nursing and midwifery professions, t…
Despite the huge increase in the amount of research being generated within the nursing and midwifery professions, the integration of research findings into practice remains problematic (Parkin & Bullocks, 2005) and the actual utilisation of research is still poor (Rassool, 2005). Furthermore, it is still unclear how research knowledge is transferred to clinical practice in nursing (Thompson et al, 2005).
This study is part of a multiphase research project examining the use of research findings by graduate nurses and midwives who had completed a health-related undergraduate programme at a university in south-east England. In the first phase, a cross-sectional survey using self-completed questionnaires was conducted with a sample of 340 nurse and midwifery graduates to assess the impact of research education on their attitudes towards research and their use of research findings in practice (Veeramah, 2004). This second phase aimed to explore in more depth the extent to which some of the participants use research findings in their practice, to identify some of the barriers that have prevented them and their colleagues from doing so, and to highlight strategies that could facilitate this process further.
A number of researchers have identified several barriers reported by nurses and midwives that prevent them from incorporating research findings into their practice. These include:
- A lack of awareness of relevant research findings (Retsas, 2000; Hutchinson & Johnson, 2004; Rassool, 2005);
- Lack of knowledge of the research process and the skills to access, understand, critically evaluate and implement research findings (Sitzia, 2001; Hutchinson & Johnson, 2004; Rassool, 2005);
- Insufficient time to read, evaluate and implement research findings (Veeramah, 1995; Kajermo et al., 1998; Sitzia, 2001);
- Not enough support from the organisation and from other healthcare professionals as well as a lack of autonomy and authority to change practice (Retsas, 2000; Sitzia, 2001; Parahoo & McCaughan, 2001);
- Shortage of colleagues with the expertise to discuss research (Kajermo et al., 2000).
However, most of these studies have used structured questionnaires as the main method of data collection and this may have limited the richness and quality of the data collected (Le May et al, 1998; Scott & Mazhindu, 2005).
A qualitative methodology using semi-structured interviews was used to collect the data.
The sample was chosen purposefully rather than randomly because the aim was to seek rich data about this particular phenomenon (Ezzy, 2002) and also to ensure that as many specialties as possible were represented. A number of practitioners from several specialties were invited to take part in this phase of the study and 10 agreed to participate.The sample consisted of two community mental health nurses, two adult nurses (one from a medical and one from a surgical ward), two community learning disability nurses, one community paediatric nurse, one inpatient mental health nurse, one inpatient learning disability nurse and one midwife. All of them had been practising for more than five years and there were four ‘E’ grades, two ‘F’ grades, two ‘G’ grades and two ‘H’ grades.
The interviews took place between February and March 2004. They were open-ended and interactive, using the framework below. This included a number of lead questions, although some prompt questions were also asked to encourage participants to elaborate on certain responses:
- To what extent do you use research findings in practice?
- Can you provide some examples where you have used research to inform your practice?
- Can you identify some of the barriers that have prevented you and your colleagues from using research findings further in order to inform their practice?
- Can you think of some strategies which could enable yourself and your colleagues to increase the use of research findings in practice?
All interviews were tape-recorded.Four interviews were carried out in person at the university and six were conducted by telephone. Telephone interviews were used because it was extremely difficult to arrange face-to-face meetings due to busy schedules and heavy workloads. The six participants who opted for telephone interviews were interviewed from home while they were off-duty and a special tape-recorder was attached to the interviewer’s telephone. Each interview session lasted an average of 25 minutes. To maintain uniformity, the author of this project carried out all the interviews.
The purpose and nature of this phase of the study was carefully explained to participants. They were assured that participation in the study was strictly voluntary, that they had the right to withdraw from the interview at any stage and that confidentiality and anonymity were guaranteed. In addition, they were informed that all the tapes would be securely stored and would be destroyed at the end of the project. Approval to carry out the project was also obtained from the university concerned.
Following the interviews, the tape recordings were played back a number of times and then transcribed verbatim. All the transcripts were read initially several times by the author so that he could become immersed in the data and get a sense of the whole. Content analysis was used to analyse the data (DeSantis & Ugarriza, 2000). Key ideas were identified in the first instance to organise the contents in a meaningful way and recurrent themes were identified (Patton, 2002) and supported with the most representative excerpts from interviewees’ responses (Sandelowski, 1994). A number of strategies were used to enhance truthfulness and consistency in data collection and analysis. Tape-recording of interviews and verbatim transcribing of data ensured consistent and accurate recording of the data. Another researcher cross-checked the emerging themes to minimise researcher bias.
For the purpose of confidentiality the participants will be referred to numerically from one to ten. All participants stated that they used research findings to inform their practice but not all the time. The extent they did so varied from participant to participant. Some participants said that they used it quite a lot whereas a few stated that they did so to some extent.
Examples of research utilisation in practice
Participants cited a number of fascinating and varied examples where they have implemented research findings to inform their practice. These not only included areas that have been well researched such as wound care, prevention, treatment and management of pressure sores, mouth care, pain control analgesia, care of urethral catheters, pre-operative fasting and hand-washing, but also other less well researched areas such as risk assessment and risk management, cognitive behaviour therapy, family interventions, the prevention and management of aggression.
Lack of protected time because of pressure of work
Five interviewees mentioned that there was no time allowed while on duty for staff to go to the library to search and read relevant research papers. Three people remarked that even if research papers were readily available in the clinical area, there was not enough time during working hours to access and read them because of pressure of work.In addition, two participants stated that because of the heavy workload, they felt too mentally exhausted to do any reading after work. As one participant remarked:
- If I am tired, I don’t bother to read up
- I go home and just want to go to bed or something
- I don’t want to think of work any more
Seven participants argued that there should be protected time for staff to search for and evaluate relevant research papers as well as attend journal clubs and research interest groups.
Not enough research papers in the clinical area
Five participants mentioned that there was a lack of relevant research papers in the clinical area. However, this did not seem to be a common problem as four participants said that they had internet facilities on site and staff were able to access relevant research papers if required.
Lack of knowledge
Lack of knowledge on how to search the literature and critically evaluate research was cited by all participants as having prevented not necessarily themselves but some of their colleagues from using research findings in practice. Most of them (eight) stated that there was a need for more research education. This seemed to apply more to staff who trained years ago before research education was introduced in pre- and post-registration curricula. As one participant commented:?I think new staff tend to have more updated knowledge but older staff tend to be working along old practices - they certainly can do with a lot of re-training from my own experience.
Lack of co-operation from some members of the multidisciplinary team
Five participants mentioned that working within a multidisciplinary setting could act as a barrier, although this varied from discipline to discipline and the specialty concerned.ResourcesNearly all participants (nine) mentioned lack of resources. These included staff shortages, demand on the service and lack of funding both to support staff to enhance their research knowledge and to implement new therapeutic modalities that research had shown to be more beneficial.
Strategies to make care more evidence-based
Effective clinical leader
Three participants strongly believed that effective leadership, particularly in the clinical areas, was paramount. This clinical leader should have the necessary research knowledge and skills to support, guide and motivate staff. Also, this leader should be able to create an environment conducive to learning and to encourage staff to improve their research knowledge.
Access to resources at place of work
Six participants stated that it would help greatly if there was a computer with internet access at the work place so that staff could download research papers instead of having to travel to the trust or university library.
Sharing research information
A large number (eight) mentioned the sharing of information via a journal club or research interest group.Six interviewees said that the sharing of ideas through a journal that could be circulated within the organisation, newsletters and inviting outside speakers to talk to staff would help greatly. However, the most innovative strategy highlighted by one participant was the setting up of a database that could be accessed via the intranet. This would include a list of names and addresses of staff from a particular NHS trust who could communicate with each other on a regular basis and share information about research projects.
All participants mentioned the need for staff to attend research courses so that they could develop or consolidate their research appraisal skills. Another interviewee remarked that education is necessary because some staff who trained some years agowere still mystified by the whole process of research and research utilisation.Another participant explained how research awareness through education would actually motivate staff to find the time to go and read research papers.
Four interviewees mentioned other strategies. Staff or visiting practitioners with sufficient research expertise could educate other members of the team. They could help them to develop their skills to search the literature, appraise research and implement research findings to guide their practice.
The findings were interesting despite the small size of the sample. They concur with those from previous studies on the extent to which nurses and midwives use research findings in practice as well as some of the barriers to and facilitators of research utilisation.None of the participants said that they used research findings all the time to inform their practice, which was expected, although they were able to articulate a number of areas where they had based their practice on research.Research evidence to support a number of nursing and midwifery therapeutic interventions is not yet available and many are still experience-based (Walsh & Ford, 1989). It may also be that participants were only alluding to what has been referred to in the literature as the ‘instrumental use of research findings?. This is defined as the explicit and direct use of these findings rather than their ‘conceptual use? in which research findings are used in a non-transparent way, such as changing the way practitioners approach a particular problem cognitively (Stetler, 1994; Berggren, 1996).Many of the barriers to research utilisation identified by participants are consistent with findings from a number of studies. For example, several have reported a lack of awareness of research findings in the top three barriers (Lewis et al, 1998; Retsas & Nolan, 1999). Also, lack of accessibility of research information has been cited as one of the main reasons why practitioners fail to use research (Parahoo, 2000; Retsas, 2000), although this was not a common problem for a number of participants in the study. Internet facilities were available on site for these practitioners to access relevant research papers. Other major barriers often cited in the literature, such as lack of time to search for, review and implement research findings and lack of support and cooperation from members of the multidisciplinary team (Parahoo, 2000), were articulated by some of the participants.Another notable finding was that those staff who trained some years ago were finding it difficult to use research evidence to inform their practice. This seems to echo findings from both Parahoo’s (1999) and Meah et al’s (1996) studies which also found that recently qualified nurses and midwives were more research-literate and were more competent in locating, reading and evaluating relevant research papers compared with those who trained some years ago. This indicates clearly that more effort should be directed at this particular group of practitioners to ensure that they receive the necessary education to improve their research-critical skills.Another area that might require further exploration is the fact that because of insufficient resources, new therapeutic modalities that research has shown to be more beneficial cannot be implemented, despite a number of recent government policy initiatives recommending that healthcare professionals should use up-to-date evidence in order to deliver high-quality care (DH, 1997; NHSE, 1998; DH, 1998). It may well be that this was typical of this particular trust rather than being a problem across a number of trusts.A number of strategies that could facilitate the use of research findings in practice were mentioned by participants and many, such as having an effective clinical leader who is supportive of staff using research findings in practice, access to resources such as research papers and databases on site, and more support from management, have been highlighted in the literature (Funk et al, 1995; Kajermo et al, 1998; Parahoo, 2000; Retsas, 2000; Oranta et al, 2002; Glacken & Chaney, 2004).The two strategies that were endorsed by nearly all the participants and which management should give more attention to are the sharing of information through a journal club or research interest group and the need for research education. The introduction of journal clubs and research interest groups to aid the process of research utilisation in practice has been recommended by a number of researchers (Rassool, 2005). According to Burrows & McLeash (1995) journal clubs are one way to keep up-to-date with the latest research with a view to improving the quality of care provided. Although practitioners may be able to think critically and are knowledgeable about research, they might not use research to guide their practice unless ways are identified to discuss, debate and appraise research as well as to translate research findings into practice (Seymour et al., 2003). Journal clubs and research interest groups should provide a platform for such activities to take place (Closs & Cheater, 1994).On the other hand, research education has been cited in the literature as one of the most often reported facilitators of research utilisation (Olade, 2004). Awareness of and accessibility to research findings are necessary but not sufficient for research utilisation in clinical practice. Nurses and midwives must also have the ability to assess critically the validity of these findings and determine their relevance to practice. Research utilisation takes place when the findings are translated into nursing and midwifery interventions in order to guide practice. However, it is important that the findings are critically evaluated to determine their potential contribution to practice. It is crucial that clinical staff are sufficiently skilled to appraise the validity and applicability of research information with a view to deciding whether the evidence is good enough to be utilised in practice (Cullum, 1998).One other notable strategy mentioned by one of the participants was the use of intranet facilities within the NHS trust concerned to create databases that would enable staff to communicate, disseminate and share research findings. There is no reason why this could not be extended to trusts across the country.
In order to facilitate the use of research findings in practice, nurse and midwifery managers should demonstrate a clear commitment to research. They should ensure that the necessary resources and funds are in place to have intranet and internet facilities available on site so that relevant research papers can be accessed. In addition, there should be a reduction in staff workload to guarantee protected time for nurses to make use of these facilities as well as developing their search and critical appraisal skills. This is especially important for those staff who trained when research education was not part of the pre- and post-registration curricula. However, on a more realistic note, given the current financial situation of most NHS trusts, nurses and midwives should also take more responsibility to maintain their professional skills and competencies. This might have to be in their own time and at their own expense.
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