From research to practice: one organizational model for promoting research-based practice

JBI's approach to evidence implementation: a 7-phase process model to support and guide getting evidence into practice

ABSTRACT

In this paper, we provide an overview of JBI's approach to evidence implementation and describe the supporting process model that aligns with this approach. The central tenets of JBI's approach to implementing evidence into practice include the use of evidence-based audit and feedback, identification of the context in which evidence is being implemented, facilitation of any change, and an evaluation process. A pragmatic and practical seven-phased approach is outlined to assist with the 'planning' and 'doing' of getting evidence into practice, focusing on clinicians as change agents for implementing evidence in clinical and policy settings. Further research and development is required to formally evaluate the robustness of the approach to better understand the complex nature of evidence implementation.

Understanding the Use of Optimal Formatting and Plain Language When Presenting Key Information in Clinical Trials

Recent revisions to the Common Rule require that consent documents begin with a focused presentation of the study's key information that is organized to facilitate understanding. We surveyed 1,284 researchers working with older adults or individuals with Alzheimer's disease, supplemented with 60 qualitative interviews, to understand current use and barriers to using evidence-based formatting and plain language in key information. Researchers reported using formatting in 42% of their key information sections, and plain language in 63% of their key information sections. Perceived barriers included lack of knowledge, Institutional Review Board, other members of their team, and the burden associated with implementation. Education and training are required to increase adoption of the practices.

Perceived barriers to assessing understanding and appreciation of informed consent in clinical trials: A mixed-method study

Introduction:

Participants and research professionals often overestimate how well participants understand and appreciate consent information for clinical trials, and experts often vary in their determinations of participant’s capacity to consent to research. Past research has developed and validated instruments designed to assess participant understanding and appreciation, but the frequency with which they are utilized is unknown.

Methods:

We administered a survey to clinical researchers working with older adults or those at risk of cognitive impairment (N = 1284), supplemented by qualitative interviews (N = 60).

Results:

We found that using a validated assessment of consent is relatively uncommon, being used by only 44% of researchers who had an opportunity. Factors that predicted adoption of validated assessments included not seeing the study sponsor as a barrier, positive attitudes toward assessments, and being confident that they had the resources needed to implement an assessment. The perceived barriers to adopting validated assessments of consent included lack of awareness, lack of knowledge, being unsure of how to administer such an assessment, and the burden associated with implementing this practice.

Conclusions:

Increasing the use of validated assessments of consent will require educating researchers on the practice and emphasizing very practical assessments, and may require Institutional Review Boards (IRBs) or study sponsors to champion the use of assessments.

The only constant in radiography is change: A discussion and primer on change in medical imaging to achieve evidence-based practice

Medical imaging is an ever changing field with significant advancements in techniques and technologies over the years. Despite being constantly challenged by change, it can be difficult to introduce changes into healthcare settings. In this article we introduce the principles of change management to achieve an evidence-based practice in radiography.

The SUMAMOS EXCELENCIA Project

AIM

The gap between research and clinical practice leads to inconsistent decision-making and clinical audits are an effective way of improving the implementation of best practice. Our aim is to assess the effectiveness of a model that implements evidence-based recommendations for patient outcomes and healthcare quality.

DESIGN

National quasi-experimental, multicentre, before and after study.

METHODS

This study focuses on patients attending primary care and hospital care units and associated socio-healthcare services. It uses the Joanna Brigg's Institute Getting Research into Practice model, which improves processes by referring to prior baseline clinical audits. The variables are process and outcome criteria for pain, urinary incontinence, and fall prevention, with data collection at baseline and key points over 12 months drawn from clinical histories and records. Project funding was received from the Spanish Strategic Health Action in November 2014.

DISCUSSION

The project results will provide knowledge on the effectiveness of the Getting Research into Practice model, to apply evidence-based recommendations for the detection and management of pain, urinary incontinence, and fall prevention. It will also establish whether using research results, based on clinical audits and situation analysis, is effective for implementing evidence-based recommendations and improving patients' health.

IMPACT

This nationwide Spanish project aims to detect and prevent high-prevalence healthcare problems, namely pain in patients at any age and falls and urinary incontinence in people aged 65 and over. Tailoring clinical practice to evidence-based recommendations will reduce unjustified clinical variations in providing healthcare services. Clinical Trial ID: NCT03725774.

Using holistic interpretive synthesis to create practice-relevant guidance for person-centred fundamental care delivered by nurses

Nursing policy and healthcare reform are focusing on two, interconnected areas: person-centred care and fundamental care. Each initiative emphasises a positive nurse-patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse-patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice-relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse-patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse-patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person-centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.

Funding for evidence-based nursing practice in the UK

Evidence-based practice requires the continuing generation of new knowledge, that is, evidence. The funding to produce this new information is obtainable from a number of sources but has quite limited availability. There are slightly differing arrangements for distribution in each of the countries of the UK, although there are some programmes that are UK-wide. All of these include money previously identified for research, audit or practice development. The Culyer report, Supporting Research and Development in the National Health Service (DoH, 1994), has had an effect on funding across the countries of the UK. With increasing rigour expected, proposals for the development of evidence should be critically appraised. By identifying the methods, the sources and limitations of obtaining the resources for producing evidence, nurses are in a better position to take their practice forward.

A concept analysis of practice development

The term 'practice development' is widely but inconsistently used in British nursing, addressing a broad range of educational, research, and audit activity, but there appears to be little consensus as to what practice development actually involves. Such lack of clarity means that the increasing number of nurses whose work involves addressing practice development issues can have difficulty in focusing their efforts.

To try to clarify the concept of practice development and to describe the focuses of practice development work and the approaches used, a concept analysis was conducted. Both primary and secondary data were gathered and analysed in the study. One hundred and seventy seven items of published literature were gathered and analysed. Focus group interviews were carried out involving 60 practice developers. In addition, 25 clinical nurses were interviewed about their experiences of being involved in practice development.

This paper describes the identified purposes, attributes and outcomes of practice development. Practice development activities are described as addressing the effectiveness of care through the transformation of care practices and cultures. Practice development is described as a systematic, rigorous activity underpinned by facilitation processes. The outcomes of practice development can be described in terms of changes in the behaviours, values and beliefs of staff involved. Parallels between practice development and current policy imperatives are outlined.

Dissemination and utilization of an intervention to manage breathlessness: Letting go or letting down?

The relationship between research and practice development has not always been a close one. Researchers focus upon the production of new knowledge to create the evidence base upon which the development of practice is taken forward, usually by other people within the clinical area. Work being undertaken at the Macmillan Practice Development Unit (MPDU) in London about the dissemination and utilisation of evidence concerning the management of breathlessness has raised a number of issues. These concern the confidence of practitioners to take on new approaches within the practice sphere, their desire for accredited education, and questions about responsibility for, and ownership of, the dissemination process. Different values about the nature of learning are explored here, which may explain the dissonance between practitioner and researcher expectations about the dissemination and utilisation process.

Achieving dignified care for older people through practice development: A systematic approach

This paper presents the results of a one-year practice development project undertaken in a rehabilitation ward for older people with the intention of developing the quality of rehabilitation practice and of exploring the potential for nurses to work as case managers.

The baseline data showed that the culture of the ward reflected a custodial approach to patient care, a lack of effective clinical leadership and poor understanding of the rehabilitation needs of older people. It was concluded that changes to practice were needed before a case management approach to care could be considered. A systematic practice development approach was adopted, incorporating pre- and post-development evaluation methods. A comparison ward was used to compare the impact on clinical practice of the change strategies used.

The ensuing development strategy focused on facilitating nurses and other members of the multidisciplinary team to question their own attitudes, beliefs and values and to begin to challenge clinical practice. Ongoing work was aimed at implementing cultural and structural changes agreed by the multidisciplinary team, supported by research evidence, in order to establish new norms of clinical practice and leadership. As a result of the project, the ward team was in a much better position to develop a case management approach to patient care, and to implement the development needs identified within the post-evaluation data.

Knowing and acting — A strategic practitioner-focused approach to nursing research and practice development

Clinical outcomes, effective decision-making and the use of evidence in practice have been part of the nursing agenda for many years and a key focus of knowledge generation and utilisation activities in nursing research. However, while this focus prevails, the ability of our organizational systems to support nursing research in practice is still limited. There continues to be a divide between the 'knowledge generators' and the 'knowledge users', and while considerable progress has been made in the use of research in practice, less progress has been made in formally connecting academic and practice communities.

This paper argues for such a connection through a focus on practitioner research — a focus that can enable the sharing of academic and practice agendas at a variety of levels. It will be argued that if we are serious about creating 'research cultures' in practice settings, the most feasible way of doing so is through practitioner research, as this approach integrates knowledge-generation with knowledge-utilisation. A strategic approach to practitioner research in one organisation will be described and implications for research career structures discussed.

Primary care nursing: How can nurses influence its development?

Health service reforms emphasise the central place of the general practitioner in a primary care-led NHS, as at the same time aspects of primary care have been deregulated. Simultaneously, there is emphasis within nursing on individual accountability and professional judgement to allow responsiveness to demands for nurses to extend and develop their roles. This paper reviews the range and complexity of primary care nursing, to suggest that the profession needs to take account of the complex and heterogeneous nature of primary care nursing to develop regulatory frameworks which address the problems faced by primary care nurses at the grassroots.

Evidence-based policy making in health informatics: indications from systematic reviews of nursing record systems and telemedicine

This paper examines whether or not there is a problem for information systems evaluation in healthcare, given the contrast between the quantitative and qualitative research approaches. Experience gained on two systematic reviews on health information systems conducted under the auspices of EPOC (Cochrane Effective Practice and Organization of Care Group) demonstrates that searching strategies need to take account of the way technology is adapted, and accepted, with accompanying changes in terminology. One review concerned nursing record systems, the other telemedicine. Various frameworks for information systems evaluation emphasize the importance of a holistic view of evaluation, an apparent contrast to the evidence-based medicine model based on the randomized controlled trial (RCT). While RCTs are possible and desirable in health-care information systems evaluation, the equivocal results obtained from the reviews suggest that a pluralistic approach is highly desirable.

PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice

Background

The Promoting Action on Research Implementation in Health Services, or PARIHS framework, was first published in 1998. Since this time, work has been ongoing to further develop, refine and test it. Widely used as an organising or conceptual framework to help both explain and predict why the implementation of evidence into practice is or is not successful, PARIHS was one of the first frameworks to make explicit the multi-dimensional and complex nature of implementation as well as highlighting the central importance of context. Several critiques of the framework have also pointed out its limitations and suggested areas for improvement.

Discussion

Building on the published critiques and a number of empirical studies, this paper introduces a revised version of the framework, called the integrated or i-PARIHS framework. The theoretical antecedents of the framework are described as well as outlining the revised and new elements, notably, the revision of how evidence is described; how the individual and teams are incorporated; and how context is further delineated. We describe how the framework can be operationalised and draw on case study data to demonstrate the preliminary testing of the face and content validity of the revised framework.

Summary

This paper is presented for deliberation and discussion within the implementation science community. Responding to a series of critiques and helpful feedback on the utility of the original PARIHS framework, we seek feedback on the proposed improvements to the framework. We believe that the i-PARIHS framework creates a more integrated approach to understand the theoretical complexity from which implementation science draws its propositions and working hypotheses; that the new framework is more coherent and comprehensive and at the same time maintains it intuitive appeal; and that the models of facilitation described enable its more effective operationalisation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0398-2) contains supplementary material, which is available to authorized users.

A model (CMBP) for collaboration between university college and nursing practice to promote research utilization in students' clinical placements: a pilot study

BACKGROUND

A collaborative project was initiated in Norway between a university college and a hospital in order to improve RNs' and nursing students' research utilization in clinical placements. This paper describes the model (CMBP) that was developed, its first application, and evaluation.

AIM

The evaluation aimed at describing nurses' and students' experiences of the CMBP related to collaboration, facilitation, learning, and impact on nursing care.

METHODS

Thirty-eight students from the second and third year of nursing education, and four nurses answered questionnaires with closed and open ended questions. In addition two of the nurses wrote diaries. Data were subjected to qualitative and quantitative analysis.

FINDINGS

Almost all participants reported that collaboration between nursing college and nursing practice had been beneficial. Most students and all nurses reported about valuable learning, increased understanding of research utilization, and improved quality of nursing care. Both students and RNs recommended the CMBP to be used in all clinical placements to support academic learning and increase research utilization in clinical practice.

CONCLUSION

Despite study limitations the findings indicate that the CMBP has a potential to be a useful model for teaching RNs' and students EBP. However, further refinement of the model is needed, followed by a more comprehensive implementation and evaluation.

Research-based practice: myth or reality? A review of the barriers affecting research utilisation in practice

A research-practice gap still exists despite the promotion and strategies for research-based practice by governments and nursing organisations. Hunt (1981 Journal of Advanced Nursing 12:101-110) and Walsh and Ford (1989 Nursing rituals: research and rati onal action. Butterworth-Heinemann) report a wealth of anecdotal evidence to support the failure of nurses to use research in practice. A body of evidence confirms that the number of identified barriers to research utilisation is great. Drawing on the wo rk of Rogers (1983 Diffusion of innovations. The Free Press, New York) or the Barriers Scale (Funk et al. 1991a Applied Nursing Research 4(1):39-45), many authors (Dunn et al. 1997 Emergency Nurse 5(2):24-27; Walsh 1997a 1997b Nursing Standard 11(19):34- 37; 1997c Nursing Standard 11(29):34-39; Kajermo et al. 1998 Journal of Advanced Nursing 27(4):798-807; 2000 Journal of Advanced Nursing 31(1):99-109; Parahoo 2000 Journal of Advanced Nursing 31(1):89-98) have structured the barriers into sub-groups: the characteristics of the organisation, of the adopter, of the communication and of the research. Several studies reveal that the actual 'setting' poses the greatest barrier to the utilisation of research. Walsh (1997b) describes this as a paradox, in othe r words: practice is perceived as the biggest obstacle to change in practice. A systematic approach to research utilisation is outlined aimed at targeting these specific identified barriers, and third level institutes and practice settings are urged to c onsider strategic and focused approaches to the development of research plans.

'It's easier just to separate them': practice constructions in the mental health care and support of younger people with dementia and their families

There is no standard model of specialist care for younger people with dementia (onset before the age of 65 years) and specialist service provision varies widely throughout the UK. In order to gain a clearer picture about ways in which clinical staff work with younger people with dementia, semi-structured interviews were conducted with dementia care staff working in the north-west of England. Interviews focused on exploring daily working practices and the meaning placed on clinical decision making when involving family/carers in routine practice. Content analysis generated three core themes: (1) Maintaining Separation: how clinical staff conceptualize the meaning of 'family' in the provision of dementia care services; (2) Providing Practical Help: the focus in care provision on assisting families with aspects of daily life such as finances, education and physical care; and (3) Acknowledging the Family Context: how staff understand and interact with family members in an attempt to initiate care, utilizing biographically informed practice. By understanding how staff view their role in providing younger people with dementia with effective, high-quality dementia care, it is anticipated that a more family-centred approach can be integrated into already established patterns of working that more holistically meet the needs of this group.

Building capacity for evidence informed decision making in public health: a case study of organizational change

BACKGROUND

Core competencies for public health in Canada require proficiency in evidence informed decision making (EIDM). However, decision makers often lack access to information, many workers lack knowledge and skills to conduct systematic literature reviews, and public health settings typically lack infrastructure to support EIDM activities. This research was conducted to explore and describe critical factors and dynamics in the early implementation of one public health unit's strategic initiative to develop capacity to make EIDM standard practice.

METHODS

This qualitative case study was conducted in one public health unit in Ontario, Canada between 2008 and 2010. In-depth information was gathered from two sets of semi-structured interviews and focus groups (n = 27) with 70 members of the health unit, and through a review of 137 documents. Thematic analysis was used to code the key informant and document data.

RESULTS

The critical factors and dynamics for building EIDM capacity at an organizational level included: clear vision and strong leadership, workforce and skills development, ability to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management.

CONCLUSION

With leadership, planning, commitment and substantial investments, a public health department has made significant progress, within the first two years of a 10-year initiative, towards achieving its goal of becoming an evidence informed decision making organization.

Effectiveness of organisational infrastructures to promote evidence-based nursing practice

BACKGROUND

Nurses and midwives form the bulk of the clinical health workforce and play a central role in all health service delivery. There is potential to improve health care quality if nurses routinely use the best available evidence in their clinical practice. Since many of the factors perceived by nurses as barriers to the implementation of evidence-based practice (EBP) lie at the organisational level, it is of interest to devise and assess the effectiveness of organisational infrastructures designed to promote EBP among nurses.

OBJECTIVES

To assess the effectiveness of organisational infrastructures in promoting evidence-based nursing.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, LILACS, BIREME, IBECS, NHS Economic Evaluations Database, Social Science Citation Index, Science Citation Index and Conference Proceedings Citation Indexes up to 9 March 2011.We developed a new search strategy for this update as the strategy published in 2003 omitted key terms. Additional search methods included: screening reference lists of relevant studies, contacting authors of relevant papers regarding any further published or unpublished work, and searching websites of selected research groups and organisations. 

SELECTION CRITERIA

We considered randomised controlled trials, controlled clinical trials, interrupted times series (ITSs) and controlled before and after studies of an entire or identified component of an organisational infrastructure intervention aimed at promoting EBP in nursing. The participants were all healthcare organisations comprising nurses, midwives and health visitors.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias. For the ITS analysis, we reported the change in the slopes of the regression lines, and the change in the level effect of the outcome at 3, 6, 12 and 24 months follow-up.

MAIN RESULTS

We included one study from the USA (re-analysed as an ITS) involving one hospital and an unknown number of nurses and patients. The study evaluated the effects of a standardised evidence-based nursing procedure on nursing care for patients at risk of developing healthcare-acquired pressure ulcers (HAPUs). If a patient's admission Braden score was below or equal to 18 (i.e. indicating a high risk of developing pressure ulcers), nurses were authorised to initiate a pressure ulcer prevention bundle (i.e. a set of evidence-based clinical interventions) without waiting for a physician order. Re-analysis of data as a time series showed that against a background trend of decreasing HAPU rates, if that trend was assumed to be real, there was no evidence of an intervention effect at three months (mean rate per quarter 0.7%; 95% confidence interval (CI) 1.7 to 3.3; P = 0.457). Given the small percentages post intervention it was not statistically possible to extrapolate effects beyond three months.

AUTHORS' CONCLUSIONS

Despite extensive searching of published and unpublished research we identified only one low-quality study; we excluded many studies due to non-eligible study design. If policy-makers and healthcare organisations wish to promote evidence-based nursing successfully at an organisational level, they must ensure the funding and conduct of well-designed studies to generate evidence to guide policy.

Uncovering tacit knowledge: a pilot study to broaden the concept of knowledge in knowledge translation

BACKGROUND

All sectors in health care are being asked to focus on the knowledge-to-practice gap, or knowledge translation, to increase service effectiveness. A social interaction approach to knowledge translation assumes that research evidence becomes integrated with previously held knowledge, and practitioners build on and co-create knowledge through mutual interactions. Knowledge translation strategies for public health have not provided anticipated positive changes in evidence-based practice, possibly due in part to a narrow conceptualization of knowledge. More work is needed to understand the role of tacit knowledge in decision-making and practice. This pilot study examined how health practitioners applied tacit knowledge in public health program planning and implementation.

METHODS

This study used a narrative approach, where teams from two public health units in Ontario, Canada were conveniently selected. Respondents participated in individual interviews and focus groups at each site. Questions were designed to understand the role of tacit knowledge as it related to the program planning process. Data were analyzed through a combination of content analysis and thematic comparison.

RESULTS

The findings highlighted two major aspects of knowledge that arose: the use of tacit knowledge and the integration of tacit and explicit knowledge. Tacit knowledge included: past experiences, organization-specific knowledge, community contextual knowledge, and the recognition of the tacit knowledge of others. Explicit knowledge included: research literature, the Internet, popular magazines, formal assessments (surveys and interviews), legislation and regulations. Participants sometimes deliberately combined tacit and explicit knowledge sources in planning.

CONCLUSIONS

This pilot demonstrated that front-line public health workers draw upon both tacit knowledge and explicit knowledge in their everyday lived reality. Further, tacit knowledge plays an important role in practitioners' interpretation and implementation of explicit research findings. This indicates a need to broaden the scope of knowledge translation to include other forms of knowledge beyond explicit knowledge acquired through research. Strategies that recognize and support the use of tacit knowledge, such as communities of practice or networks, may be important components of a comprehensive approach to knowledge translation. This study provides support for further investigation of the role of tacit knowledge in the planning and delivery of effective public health services.

Spanish nurses' attitudes towards research and perceived barriers and facilitators of research utilisation: a comparative survey of nurses with and without experience as principal investigators

AIMS AND OBJECTIVE

To examine attitudes towards research and perceived barriers and facilitators of research utilisation in clinical practice in a broad cross-section of Spanish nurses.

BACKGROUND

Nurses' attitudes towards research are critical in determining whether study findings are used to improve practice.

DESIGN

Cross-sectional comparative survey in Hospitals, Primary Care Centres and University-affiliated schools of nursing.

METHODS

Surveys were completed by 917 nurses: 69 who received funding from the Spanish national agency (1998-2004) and a nationally representative sample of 848 nurses who did not have the same research experience (the Comparison group). Two instruments (BARRIERS and Attitudes towards nursing research) were translated and culturally adapted for use in Spain. A descriptive analysis of demographic and practice characteristics was performed. Total scale scores, as well as subscale scores, were computed and compared across the two groups using one-way analysis of variance (anova) and multivariate analysis of variance (manova) with post hoc tests. Pearson product-moment correlation coefficients were computed between the total tool scores and subscales measuring barriers and attitudes in both groups.

RESULTS

The investigators differed from other nurses on several demographic and work characteristics (more males, older age and more likely to work a fixed day shift schedule). On the whole, investigators showed more favourable attitudes but perceived several elements as posing greater barriers to research utilisation than the Comparison groups. Across all respondents, issues related to the quality of research were rated as the greatest barriers to research utilisation, followed by organisational barriers, barriers involving the communication of findings and finally, those related to nurses' values, awareness and skills.

CONCLUSIONS

Very similar profiles of perceptions and attitudes regarding research were found in these samples of Spanish nurses relative to those from other countries in earlier reports. Nurses who had experience conducting research demonstrated more favourable research-related attitudes and perceived barriers differently than those without such experience.

RELEVANCE TO CLINICAL PRACTICE

Understanding different organisational and experience perspectives is important to identify challenges and opportunities to ensure research utilisation in clinical practice.

Examination of the utility of the promoting action on research implementation in health services framework for implementation of evidence based practice in residential aged care settings

AIM

This study examined the relevance and fit of the PARiHS framework (Promoting Action on Research Implementation in Health Services) as an explanatory model for practice change in residential aged care.

BACKGROUND

Translation of research knowledge into routine practice is a complex matter in health and social care environments. Examination of the environment may identify factors likely to support and hinder practice change, inform strategy development, predict and explain successful uptake of new ways of working. Frameworks to enable this have been described but none has been tested in residential aged care.

METHODS

This paper reports preliminary qualitative analyses from the Encouraging Best Practice in Residential Aged Care Nutrition and Hydration project conducted in New South Wales in 2007-2009. We examined congruence with the PARiHS framework of factors staff described as influential for practice change during 29 digitally recorded and transcribed staff interviews and meetings at three facilities.

FINDINGS

Unique features of the setting were flagged, with facilities simultaneously filling the roles of residents' home, staff's workplace and businesses. Participants discussed many of the same characteristics identified by the PARiHS framework, but in addition temporal dimensions of practice change were flagged.

CONCLUSION

Overall factors described by staff as important for practice change in aged care settings showed good fit with those of the PARiHS framework. This framework can be recommended for use in this setting. Widespread adoption will enable cross-project and international synthesis of findings, a major step towards building a cumulative science of knowledge translation and practice change.

[Nursing practice settings and competence to incorporate evidence into decisions: analysis of the situation in the Balearic Islands (Spain)]

OBJECTIVES

To determine the factors that nursing professionals perceive as facilitating evidence-based clinical practice (EBCP) in the Balearic Islands Health Service (Spain) by identifying possible differences according to nurses' characteristics and their occupational settings.

METHODS

We performed a multicenter, cross-sectional, observational study of 3,129 staff nurses in the Balearic Islands Health Service in 2009, who were surveyed using the Evidence-Based Practice Questionnaire (EBPQ) and the Nursing Work Index (PES-NWI). The strategy for the analysis encompassed an exploratory analysis, bivariate analysis with parametric and non-parametric tests according to the nature of the distributions (correlation, ANOVA, Kruskall-Wallis, chi square) and multivariate analysis of the main study variables and factors on the PES-NWI and EBPQ questionnaires. The analyses had a confidence level of 95%.

RESULTS

A total of 1,753 questionnaires were received, corresponding to a participation rate of 56.02%. The results established significant differences between the two questionnaires in the analysis of the hospital setting and primary care (p<0.001). These differences remained significant when the questionnaires were compared according to professional category and experience.

CONCLUSIONS

This study compared nursing practice environments with different characteristics. Of the factors included in the questionnaires, that with the greatest influence on EBP was the support of nursing managers. This study also found that the two validated instruments are plausible tools for assessing EBCP and help to establish areas for improvement both at the individual and organizational level.

An evaluation of a benchmarking initiative in extended treatment mental health services

AIM

To evaluate the effectiveness of a benchmarking initiative in facilitating quality improvement and reform in extended care mental health services.

METHOD

Individual interviews and focus group discussions were conducted with 84 staff in 22 extended care mental health services that had previously participated in a State-wide benchmarking exercise in Queensland, Australia.

RESULTS

Staff reported positive outcomes from participation in the benchmarking exercise. Information derived from benchmarking provided a different perspective on the strengths and weaknesses of individual services and an opportunity to learn from peer services. Staff in 86% of the services identified issues that needed to be addressed and 64% of services had implemented one or more service improvement projects in response to shortcomings identified through the benchmarking exercise.

CONCLUSIONS

The collection and reporting of performance data through a process of benchmarking was successful in facilitating service improvement in most of the participating facilities. Engaging services in all stages of the process was considered useful in converting benchmarking data into knowledge that was able to be applied at the local service level.

Barriers to research utilisation by staff nurses in a university hospital

AIM

To identify self-reported perceptions of the barriers to research utilisation by Turkish staff nurses working in a university hospital and to ascertain whether involvement in research-related activities influenced their perception of the barriers.

BACKGROUND

Research utilisation in nursing has been a prominent concern for the last 30 years. While investigators in several countries have identified nurses' perception of barriers to research utilisation, this is the first study to investigate such barriers in Turkey.

DESIGN

This is a descriptive, cross sectional study with a sample of 329 staff nurses working in a university hospital. Two instruments were used; a demographics questionnaire that investigated research activities and the Barriers Scale to measure perceptions. An additional item, 'studies are published in English' was added to the scale.

RESULTS

The lack of time to implement new ideas was the most frequently, 84·5%, perceived barrier. The second most frequently perceived barrier was difficulty in reading English. The top six barriers were all related to the setting. Additionally, research-active nurses found insufficient time less of a barrier but unawareness of research findings and being isolated from knowledgeable colleagues as greater barriers to research utilisation.

CONCLUSIONS

Turkish nurses' perception of barriers is similar to the findings in other countries, i.e., that the top six barriers were related to setting. Language barrier compares similarly with studies in other countries that investigated this variable.

RELEVANCE TO CLINICAL PRACTICE

The gap between theory and practice in nursing can be minimised by identifying strategies to increase research utilisation in clinical settings. Such strategies can also improve patient care outcomes.

Exploring perceptions of a learning organization by RNs and relationship to EBP beliefs and implementation in the acute care setting

BACKGROUND/RATIONALE

Health care professionals are expected to provide patient care based on best evidence. The context of the acute care setting presents a challenging environment for registered nurses (RNs) to utilize research and implement best evidence in practice. No organizational infrastructure has been identified that offers acute care RNs the support needed for evidence-based practice (EBP). The value of "learning organizations" has long been understood by corporate leaders. Potentially, the dimensions of a "learning organization" may offer a supportive EBP infrastructure for acute care RNs.

RESEARCH QUESTIONS

(1) What is the relationship of the characteristics of the learning organization to registered nurses' beliefs regarding EBP? (2) Is there an impact of EBP beliefs on RNs' implementation of EBP?

METHODS

A descriptive, survey design study was conducted. Three established questionnaires were distributed to 1,750 RNs employed within six acute care hospitals.

RESULTS/FINDINGS

There were 594 questionnaires returned for a response rate of 34%. RNs rated their organizations in the mid-range on the dimensions of learning organization. Perceptions of the learning organization were found to be significant, although relatively small, predictors explaining 6% of knowledge beliefs, 11% of value beliefs, and 14% of resource beliefs. EBP beliefs explained 23% of EBP implementation reported by RNs.

DISCUSSION

The study results indicate relationships between RNs' reported perception of a learning organization and EBP beliefs, and between EBP beliefs and implementation. However, findings were mixed. Overall, nurses rated their organizations the lowest in the dimensions of "promote inquiry and dialogue" and "empower people toward a collective vision." Leaders have an opportunity to offer a more supportive infrastructure through improving their organization in these two areas. RN beliefs explained 23% of EBP implementation in this study with a residual 77% yet to be identified.

IMPLICATIONS

Acute care hospitals were perceived mid-range on learning organization dimensions by RNs, indicating an opportune area for leaders to strengthen their organizational infrastructure.

A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies

BACKGROUND

A knowledge broker (KB) is a popular knowledge translation and exchange (KTE) strategy emerging in Canada to promote interaction between researchers and end users, as well as to develop capacity for evidence-informed decision making. A KB provides a link between research producers and end users by developing a mutual understanding of goals and cultures, collaborates with end users to identify issues and problems for which solutions are required, and facilitates the identification, access, assessment, interpretation, and translation of research evidence into local policy and practice. Knowledge-brokering can be carried out by individuals, groups and/or organizations, as well as entire countries. In each case, the KB is linked with a group of end users and focuses on promoting the integration of the best available evidence into policy and practice-related decisions.

METHODS

A KB intervention comprised one of three KTE interventions evaluated in a randomized controlled trial.

RESULTS

KB activities were classified into the following categories: initial and ongoing needs assessments; scanning the horizon; knowledge management; KTE; network development, maintenance, and facilitation; facilitation of individual capacity development in evidence informed decision making; and g) facilitation of and support for organizational change.

CONCLUSION

As the KB role developed during this study, central themes that emerged as particularly important included relationship development, ongoing support, customized approaches, and opportunities for individual and organizational capacity development. The novelty of the KB role in public health provides a unique opportunity to assess the need for and reaction to the role and its associated activities. Future research should include studies to evaluate the effectiveness of KBs in different settings and among different health care professionals, and to explore the optimal preparation and training of KBs, as well as the identification of the personality characteristics most closely associated with KB effectiveness. Studies should also seek to better understand which combination of KB activities are associated with optimal evidence-informed decision making outcomes, and whether the combination changes in different settings and among different health care decision makers.

The need for systems change: reflections on knowledge translation and organizational change

BACKGROUND

Despite over 40 years' work on general systems theory, informed by critical social science, there is a mismatch between the theories used to explain and influence clinical practice in nursing and the way in which transferring new knowledge into practice is articulated.

DATA SOURCES

The analysis and emerging propositions were based on a critique of seminal texts published in English up to 2008 covering critical social science, action science, diffusion of innovations, practice development and the management of innovations.

DISCUSSION

There is an implicit adherence to the world view that healthcare systems operate like machines, and much of the science generated around knowledge translation research tends to be logico-deductive. This is in direct contrast to the prevailing arguments of general systems theorists, who view the system more as an organism. Five propositions are posited: knowledge translation is a necessary but not sufficient mechanism to transform systems; the 'system-as-machine' metaphor is profoundly unhelpful to knowledge translation; the healthcare system is best viewed as a complex entity; successful innovation is a function of the level of local autonomy experienced by individuals, teams and the unit involved; innovation is most effective when it involves key stakeholders.

CONCLUSION

The purposeful integration of systems theory with knowledge translation theories and models may enable the application of research and new knowledge to practice to be speeded up.

Pursuing common agendas: a collaborative model for knowledge translation between research and practice in clinical settings

There is an emerging discourse of knowledge translation that advocates a shift away from unidirectional research utilization and evidence-based practice models toward more interactive models of knowledge transfer. In this paper, we describe how our participatory approach to knowledge translation developed during an ongoing program of research concerning equitable care for diverse populations. At the core of our approach is a collaborative relationship between researchers and practitioners, which underpins the knowledge translation cycle, and occurs simultaneously with data collection/analysis/synthesis. We discuss lessons learned including: the complexities of translating knowledge within the political landscape of healthcare delivery, the need to negotiate the agendas of researchers and practitioners in a collaborative approach, and the kinds of resources needed to support this process.

Outcomes of adoption: measuring evidence uptake by individuals and organizations

BACKGROUND

The translation and diffusion of findings into health care validate the potential of evidence-based innovation to improve clinical practice and affirm the benefits of society's investment in advancing science.

AIMS

This article briefly reviews key concepts in the knowledge use process, considers theoretical implications for measuring outcomes and uptake of innovation, discusses issues to consider in planning for measurement of adoption, and provides an example of confronting those challenges from a project now in progress. THEORETICAL PERSPECTIVES AND TRANSLATION OUTCOMES: Four principal conceptual frameworks related to translational science, Lewin, Rogers, Havelock, and Promoting Action on Research Implementation in Health Services (PARIHS), explicate a process that catalyzes new knowledge adoption and use by individuals and systems to solve problems. Each conceptual perspective suggests that translation is not complete until the extent and impact of use is examined and understood. Most perspectives support evaluation of impact of evidence-based practice using process measures that integrate clinician knowledge, actual performance of the practice, and patient/clinician outcomes. Based on the Agency for Healthcare Research and Quality (AHRQ) framework, additional measures might include changes in patterns of care and changes in policies, procedures, or protocols. CASE EXAMPLE: A description of process and outcome measures used in an in-progress quality improvement demonstration project, California Nursing Outcomes Coalition (CalNOC) Partners in Quality Translating Research into Practice to Reduce Patient Falls Project, is presented. IMPLICATION(S) FOR PRACTICE, RESEARCH, AND POLICY: Since the adoption of evidence-based innovation is a process that is often described along a continuum, investigators seeking to measure the impact of an evidence-based innovation must gather evidence that uptake of the innovation has occurred. The theoretical perspective and practical measurement issues of a given project will drive selection of process and outcome measures.

CONCLUSIONS

Efforts to change practice in order to enhance evidence-based patient care must integrate monitoring and evaluation of specific target outcomes of adoption as the basis for validating the impact of the change.

A qualitative study to identify barriers and facilitators to implementation of pilot interventions in the Veterans Health Administration (VHA) Northwest Network

OBJECTIVE

To identify barriers and facilitators to implementation of pilot interventions designed to improve measurement and management of low-density lipoprotein cholesterol (LDL-c) levels in coronary heart disease patients using the evidence/context/facilitation model of implementation of evidence-based practice.

DESIGN

Theory-based conceptual content analysis of structured interviews conducted between January and April 2001.

SETTING

Six medical centers in the United States Veterans Health Administration Northwest Network.

PARTICIPANTS

Fifty-one of 64 individuals (physicians, nurses, pharmacists, dieticians, quality managers, and other clinical and nonclinical staff) who participated in planning and/or implementing pilot interventions.

MAIN FINDINGS

Barriers to successful implementation related primarily to the intervention process and secondarily to characteristics of the intervention context. Interview responses indicated that planning, including identification of resources and assessment of potential barriers and facilitators, was a critical and universally underutilized step in the intervention process.

CONCLUSIONS

Organized team process, documented plans for intervention activities, and ongoing evaluation are essential for sustaining intervention activities. A top priority for facilitating interventions should be the development of educational materials, such as "how to" guides, that teach intervention teams how to anticipate barriers and make plans to address them, as well as identifying and fostering local experts in planning and implementing interventions.

Strategic collaborative model for evidence-based nursing practice

PURPOSE

To describe a model that has been developed to guide nurses and other health professionals in collaborative efforts toward evidence-based nursing practice.

METHOD

A review of literature was conducted using MEDLINE and CINAHL to search for articles on research utilization for evidence-based practice in health care delivery. Empirical studies; reviews; and theoretical, opinion, and information articles were included in the review in order to provide a more comprehensive view of the state of evidence-based nursing internationally.

FINDINGS

Findings revealed a number of barriers to evidence-based nursing practice, which have persisted over the last two decades, including inadequate knowledge of research among practicing nurses, lack of administrative support for research activities in clinical settings, lack of empowerment of nurses, and lack of needed mentoring from nursing research consultants.

CONCLUSIONS

Barriers in the areas of nursing education and administrative support appear to be major. A need was identified for a pragmatic model that encourages cooperation and collaboration between educators/researchers in academia and the administrative leaders in the clinical facilities if evidence-based nursing practice is to become the norm. FRAMEWORK OF MODEL: The Tyler Collaborative Model is based on an eclectic approach to planned change for creating evidence-based practice. This model identifies a step-by-step process for change, while allowing for the opportunity to integrate any of the previously available methods of critical appraisal to determine the best evidence for practice in each clinical setting.

Knowledge translation for research utilization: design of a knowledge translation model at Tehran University of Medical Sciences

INTRODUCTION

The present study aimed to generate a model that would provide a conceptual framework for linking disparate components of knowledge translation. A theoretical model of such would enable the organization and evaluation of attempts to analyze current conditions and to design interventions on the transfer and utilization of research knowledge.

METHODS

This research, performed in 2006-2007 at the Tehran University of Medical Sciences (TUMS), utilized two distinct methodologies: a narrative review to identify existing knowledge transfer models and frameworks and focus group discussions to determine the views and opinions of researchers and decision makers regarding barriers to knowledge translation within the health system.

RESULTS

A knowledge translation cycle is described, with five domains: knowledge creation, knowledge transfer, research utilization, question transfer, and the context of organization.

DISCUSSION

The knowledge translation cycle offers a theoretical basis for identifying basic requirements and linking mechanisms in the translation of knowledge for research utilization.

Integrated obesity care management system -implementation and research protocol

BACKGROUND

Nearly 50% of Canadians are overweight and their number is increasing rapidly. The majority of obese subjects are treated by primary care physicians (PCPs) who often feel uncomfortable with the management of obesity. The current research proposal is aimed at the development and implementation of an innovative, integrated, interdisciplinary obesity care management system involving both primary and secondary care professionals.

METHODS

We will use both action and evaluative research in order to achieve the following specific objectives. The first one is to develop and implement a preceptorship-based continuing medical education (CME) program complemented by a web site for physicians and nurses working in Family Medicine Groups (FMGs). This CME will be based on needs assessment and will be validated by one FMG using questionnaires and semi structured interviews. Also, references and teaching tools will be available for participants on the web site. Our second objective is to establish a collaborative intra and inter-regional interdisciplinary network to enable on-going expertise update and networking for FMG teams. This tool consists of a discussion forum and monthly virtual meetings of all participants. Our third objective is to evaluate the implementation of our program for its ability to train 8 FMGs per year, the access and utilization of electronic tools and the participants' satisfaction. This will be measured with questionnaires, web logging tools and group interviews. Our fourth objective is to determine the impact for the participants regarding knowledge and expertise, attitudes and perceptions, self-efficacy for the management of obesity, and changes in FMG organization for obesity management. Questionnaires and interviews will be used for this purpose. Our fifth objective is to deliver transferable knowledge for health professionals and decision-makers. Strategies and pitfalls of setting up this program will also be identified.

CONCLUSION

This project is relevant to health system's decision-makers who are confronted with an important increase in the prevalence of obesity. It is therefore critical to develop strategies allowing the management of obesity in the 1st line setting. Results of this research project could therefore influence health care organization in the field of obesity but also eventually for other chronic diseases.

Theory and knowledge translation: setting some coordinates

In a healthcare context in which research evidence is not used routinely in practice, there have been increasingly loud calls for the use of theory from investigators working in the field of knowledge translation. Implementation researchers argue that theory should be used to guide the design of testable and practical intervention strategies, and thus, contribute to generalizable knowledge about implementation interventions. The purpose of this commentary is to critique model papers writing by a team of scholars who aimed to disentangle some of the relationships determining research utilization, by scrutinizing an existing conceptual framework that acknowledges, along with other factors, the importance of contextual factors in knowledge translation. These papers are used as a vehicle to explore theory application in knowledge translation research. As theory use and development is in its infancy, some key issues, including different ideological perspectives, factors for and against theory use, ensuring conceptual clarity, selecting coherent overarching frameworks, and choosing appropriately among theories, are considered. Finally, an agenda for theory-informed research is outlined, which highlights the need for scholarly, pluralistic, and collaborative activity if the state of knowledge translation science is to advance.

Determining the political influence of nurses who work in the field of hepatitis C: a Delphi survey

AIM

The principle aim of this study was to determine the political influence and the professional profile of nurses who work in the field of hepatitis C.

BACKGROUND

Hepatitis C has emerged as a major public health problem. Its growing impact on health services has led to the development and expansion of a range of specialist nursing roles in hepatitis C. The professional group has never been profiled in the current political and social context, although many nurses traverse patient, organizational and strategic levels of practice and service development.

DESIGN

A multi-centre survey design using the Delphi technique was undertaken to gain consensus. A total of 160 nurses who work in the field of hepatitis C, were invited to participate. The target population was located from 90 sites across the United Kingdom. Data collection comprised two questionnaire rounds. Final sample included 40 participants in round 1 and 34 in round 2.

FINDINGS

The results showed strong consensus on the necessity of structural and policy changes at national and regional levels and nurses' inclusion within that process. Of note was the need for policy group representation and engagement in the commissioning agenda. Overall, the findings demonstrate that most nurses have advanced contextual understanding of the issues. There is evidence of political activities and nursing influence at local and regional levels. This is less evident at national level, where there is only a core of active members.

CONCLUSION

These findings reveal nurses to be operating and thinking strategically without referencing their activities as political. Nurses should be more focused in translating strategic thinking into political activities. This should be coordinated and supported through the Hepatitis Nurse Specialist Forum to ensure nurses become increasingly visible in driving services forward at policy level.

RELEVANCE TO PRACTICE

Successive governments have failed to address the serious structural problems in resource allocation, lack of public awareness and policy direction. This is where patient, organizational and strategy levels interface in hepatitis C because policy affects patients and organizations, patient level care affects policy direction and nurses can influence all three.

Research utilization and clinical nurse educators: A systematic review

BACKGROUND

Clinical nurse educators and other linking agents such as clinical nurse specialists, advanced nurse practitioners, and nurses working in research leadership positions are an important link in the facilitation of evidence-based practice in health care organizations.

AIM

The purpose of this paper is to report the findings of a systematic review of the literature regarding clinical nurse educators and research utilization, using the Promoting Action on Research Implementation in Health Services framework as a backdrop for the analysis.

FINDINGS

There is a positive relationship between research utilization and attitude toward research, higher levels of education, and reading professional nursing journals among clinical nurse educators. The authors suggest that not all clinical nurse educators have the necessary critical appraisal skills and research knowledge to use research effectively in practice.

CONCLUSIONS

Few studies have examined clinical nurse educators and the determinants of their research utilization behaviour in clinical practice. Future research on clinical nurse educators needs to focus on the outcomes of research utilization, including the effectiveness of their role as facilitators and the contexts in which they practice.