The uptake of research evidence: a systematic review of nurses' experiences of using research evidence in their practice.

Abstract

Review question/objective The objective of this systematic review is to critically appraise and synthesise the best available evidence regarding the uptake of research evidence in clinical practice as experienced by nurses. This review seeks to answer the following questions: What are the experiences of nurses in relation to the uptake of research into clinical practice? What factors do nurses report as helpful in the uptake of research evidence into clinical practice? What factors do nurses report as limiting the uptake of research evidence into clinical practice? Background Delivering quality nursing care in today's fast paced and evolving health care system requires highly developed knowledge and skills, as well as a capacity for lifelong learning. Professionally, a stronger focus on evidence based practice has been acknowledged as fundamental to the delivery of appropriate and effective nursing care. Evidence-based practice (EBP) is defined as practice based on the best available evidence derived from high quality research, in combination with professional expertise as well as patient input 1, p.46. In recent years, nursing research outputs have grown rapidly, however there is also widespread recognition, that despite the large pool of available research evidence, the uptake of this evidence into clinical practice remains slow and nurses continue to practice using less effective interventions.2. The focus of this systematic review is on the experiences of nurses regarding the uptake of research evidence into clinical practice. It is hoped that by consolidating existing knowledge about research utilisation by nurses, a clearer picture will emerge on how nurses perceive the assistive and limiting factors, thus providing grass roots information toward the development of future research utilisation strategies. Nursing knowledge, which was once derived from traditional practices and rituals passed down from colleague to colleague, nowadays needs to evolve and expand ‘away from habits of tradition’3, p 58 and adjust to an ever changing health care system. Contemporary nursing care, whether it is situated in an acute, community or aged care setting, resides within a broad framework of knowledge and skills to guide clinical decision making for optimal client care. According to O'Neill 4, the process of clinical decision making is complex and requires nurses to be knowledgeable in their particular field, work within a supportive environment, have good patient care networks and access to reliable sources of information. Additionally nurses can no longer only rely on the knowledge obtained during their initial studies, but need to maintain their competencies through continued updating of their practice.5 Engagement with research and systematic review literature to guide nursing practice within an evidence based framework is one option to stay ahead with current nursing trends. Roylow asserts that the inclusion of high quality research into nursing practice is imperative as it influences clinical decision making which ultimately impacts patient outcomes.5 The key aim of most clinical research is to improve health outcomes, however this can only be achieved if the evidence generated from high quality research is actually incorporated in clinical practice. Research evidence describes the tangible outcome information derived from research and for the purpose of this review will include information not only obtained from primary research, but also synthesised research (systematic reviews) and clinical policies. Research utilisation on the other hand is a term broadly describing the process of adopting research knowledge into clinical practice.5 The translation and implementation of research evidence into clinical practice has itself been the subject of extensive research. According to Thompson, the concept of research utilisation has been identified in the nursing literature since the 1970's and includes a large and complex array of factors contributing to the uptake of research into clinical practice.6 Such factors may include availability of human resources, individual characteristics and organisational factors 7, 8, 9 10, the clinical setting and nursing culture11, access to information9, level of support, educational preparation, theory-practice gap 7, commitment by management toward research as well as access to appropriate resources 12. Clearly, then, the uptake of research is complex and multifaceted 6, which further highlights the need to consolidate existing knowledge on this subject. As noted earlier, It is widely recognised that despite the wealth of existing evidence and the general acceptance of nurses regarding the importance of evidence-based practice, uptake remains poor2. Consequently much of the research focus has been on identifying the existing barriers in order to improve research utilisation, with many studies using specific measuring tools.13, 9, 14, 10 In 1987, Funk and colleagues developed the Barriers Research Utilization Scale (referred to as the BARRIERS Scale), to assess the perception of clinicians, administrators and academics in relation to the use of research in practice15, p 2. The 29 items scale has four main categories, including the characteristics of the adopter, the characteristics of the organization, the characteristics of the innovation and the characteristics of the communication16. A systematic review on the BARRIERS scale conducted in 201015 resulted in the inclusion of 63 studies conducted between 1991 and 2009 which used the BARRIERS scale as a tool to measure research utilisation. However the authors of this review concluded that, despite the tool being reliable in relation to internal consistency, there was limited evidence to demonstrate its validity as a useful planning tool for the implementation of research utilisation strategies.15 Evidence regarding positive factors influencing research utilisation is also widely available. A recently completed systematic review examined the individual determinants within the nursing cohort creating a positive attitude toward research utilisation, included 45 articles.17 The review identified that nurses' beliefs, attitudes and their current role were important determinants to research utilisation, as well as ability to attend conferences, having a graduate degree, job satisfaction and working within a speciality area.17 The authors however note that relative poor methodological quality of many of the studies, thus calling for more rigorous research in the future. As outlined, much of the research undertaken in relation to the topic of research evidence utilisation, has been based within a quantitative research framework. However, as this review will focus primarily on qualitative research studies, a preliminary search has identified several studies conducted within a qualitative or mixed method research paradigm. In 2009, a qualitative study investigating the constraints Iranian nurses face to use research in clinical practice identified that although nurses were interested in using research findings, uptake was hampered by lack of time, lack of peer and manager support and limited skills to interpret research. 7 Similarly, a multi-phase study undertaken in 2007, explored the barriers and facilitators of research uptake in clinical practice and identified lack of time and knowledge, limited availability of relevant research as well as lack of support by members of the clinical team as limiting factors to research utilisation. 12 Yet, effective clinical leadership, access to resources and sharing of research information were seen to be supportive factors. 12 Furthermore, a mixed method research design study undertaken by Thompson et al investigated what research information was useful in nurses' clinical decision making. 6 The authors concluded that the medium though which research knowledge was delivered, was instrumental in the utilisation process, with text-based and electronic resources not rating as highly as access to individuals who are trusted and highly regarded for their clinical skills, such as clinical nurse specialists.6 To minimise the potential for duplication of the proposed review topic, a search of the Joanna Briggs and Cochrane Systematic Review Libraries was undertaken. The search revealed no identical previously conducted systematic reviews on the topic, but a number of related reviews were identified. As mentioned previously, one recently published systematic review investigated the individual determinants of research utilisation by nurses, based solely on quantitative studies.17 Another Cochrane systematic review was undertaken in 1998 on the effectiveness and use of research evidence for policy and practice.18 This review was included only quantitative studies and did not have a specific nursing focus. Two other systematic reviews looked at measuring research utilisation, with one review mentioned previously focusing specifically on the BARRIERS scale15 and another one analysing any instrument measuring nurses' attitude towards research utilisation.13 Funk et al. conducted a integrative review on the barriers and facilitators of research utilisation in 1995, however this review is predominately a literature review, without a specific strategy demonstrating the rigour of the review.19 In summary, there appears to be a wealth of research articles and a number of systematic reviews investigating various aspects of research utilisation, yet none of these have considered the qualitative evidence. Many of the existing reviews have included studies based on a surveys or specific measurement instruments; however these quantitative measures may not fully capture the depth and breadth on the topic of research utilisation. It is envisaged that by undertaking a systematic review on the qualitative evidence, further aspects of research utilization may come to light which have not been captured in the quantitative evidence. However there is also the possibility that the existing qualitative evidence will confirm the results of the quantitative evidence. Additionally, no existing related systematic reviews have included qualitative evidence and considering the complexity of research utilisation, the proposed systematic review seeks to rectify this. In view of this finding, it would seem that the proposed systematic review of qualitative evidence regarding the uptake of research evidence in clinical practice as experienced by nurses will be pertinent and timely in presenting a different perspective to the existing review evidence. The proposed review will update the current synthesised information in the field of research utilisation in nursing and will be a useful addition to future strategy development. Inclusion criteria Types of participants This review will consider qualitative studies that include all nurses working in any type of health care setting, including acute (hospitals), primary (community health), mental health and aged care. For the purpose of this review, the generic term ‘nurses’ will include registered nurses, enrolled nurses and assistants in nursing. The aim is to be as inclusive as possible and allow for global variations of nurse positions. Types of intervention(s)/phenomena of interest This review will consider studies that investigate the experience of nurses regarding the uptake of research evidence into clinical practice, including clinical decision making or clinical judgement. The term ‘clinical decision making’ for this review will describe any organisational aspects that influence decision making. The term ‘clinical judgement’ will describe the ‘different grounds for making judgements’. 20 (p. 1506) Additionally, for this review the terms research uptake or utilisations and evidence-based practice will be used interchangeably as they all represent the aspect of incorporating research evidence into clinical practice. Types of outcomes This review will consider any subjective accounts by nurses describing their experiences, either positive or negative, in relation to the uptake of research evidence into clinical practice. Types of studies For this review, any studies using qualitative methodology will be considered including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Any studies using a mixed method approach (quantitative and qualitative) will be also considered and if deemed suitable for inclusion, the qualitative component will be incorporated into this review if possible. Exclusion Criteria This review will exclude papers which describe: Studies undertaken using quantitative methods, as well as expert opinion text Studies on research utilisation by other health care professionals, such as doctors or allied health Studies not published in English Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English language will be considered for inclusion in this review. A preliminary search of the literature revealed only a limited number of qualitative studies relevant to this review and in order to achieve the broadest possible inclusion of all relevant qualitative studies, no publication time limit will be set for this review. The databases to be searched include: CINAHL PubMED Web of Science Informit Online PsycINFO Embase ERIC Academic Onefile Sociological Abstracts Scopus Science Direct EBSCOhost The search for unpublished studies will include: MedNar ProQuest Dissertations and Theses Open Grey Initial keywords to be used will include: research knowledge transfer research uptake research utilisation/zation clinical decision making evidence-based practice nurse* registered nurse* aged care primary care acute care mental health Community care Practice nurs* Nurse practitioners Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Conflicts of interest No conflict of interest has been identified Acknowledgements I would like to thank my supervisors, Dr Aye Aye Gyi (formerly) at the Joanna Briggs Institute Adelaide and Professor Cath Rogers-Clark at the University of Southern Queensland for their guidance and support with this review. As this review will form partial submission of a Masters in Clinical Sciences degree, a secondary reviewer will only be used for critical appraisal.