Barriers to research utilization: the clinical setting and nurses themselves

Barriers to research utilization: the clinical setting and nurses themselves

Barriers to research utilization: the clinical setting and nurses themselves John Sitzia The advance of the evidence-based practice (EBP) movement ha...

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Barriers to research utilization: the clinical setting and nurses themselves John Sitzia

The advance of the evidence-based practice (EBP) movement has been evident in almost every Western country and health system over the past two or three decades, fuelled by an everrising demand on resources. Nurses at all levels are increasingly expected to address the key challenge of EBP, which is to use research evidence in a conscientious, explicit and judicious way when making decisions about patient care.The main aim of the paper is to encourage nurses to embrace the challenge of EBP. First, as background, this paper presents key f|ndings from the limited body of research which has examined barriers to research utilization in the nursing context. Nurses generally feel there are many barriers, with primary barriers being lack of time, lack of relevant skills, poor team-working and several aspects of nursing ‘culture’ (ritualistic care, no authority and no incentives). Some conceptualmodels in implementation of research f|ndings are introduced, and a summary presented of key areas which nurses need to address when considering research utilization. # 2001 Harcourt Publishers Ltd. Keywords: evidence-based practice, research utilization, clinical practice, nursing Barrieren zur praktischen Umsetzung von Forschungsergebnissen: die klinische Umgebung und das Plegepersonal sel selbst Das Fortschreiten der Bewegung zur evidenzbegrˇndeten Praxis (Evidence Based Practice, EBP), geschˇrt durch stÌndig steigende Anforderungen an Ressourcen, ist in den letzten zwei bis drei Jahren im Gesundheitswesen fast aller weslichen LÌnder zu beobachten. Es wird von Krankenpflegern auf allen Ebenen immer mehr arwartet, dass sie die Hauptforderung von EBP erfˇllen, nÌmlich bei Entscheidungen ˇber die Patientenpflege die Erkenntnisse der Forschung gewissenhaft, explizit und wohlˇberlegt umzusetzen. Das Hauptziel dieses Beitrags ist es, das Pflegepersonal dazu zu ermutigen, sich den Anforderungen von EBP zu stellen. Als Hintergrund dazu erlÌutert dieser Beitrag zunÌchst die Kern-Ergebnisse aus der begrenzten Forschung, die sich mit den Barrieren zur Umsetzung von Forschungsergebnissen auf dem Gebiet der Krankenpflege beschÌftigt hat. Aus der Sicht der Krankenpfleger bestehen allgemein viele solcher Barrieren, die gr˛Þten darunter Zeitmangel, der Mangel an einschlÌgigen FÌhigkeiten, mangelhafteTeamarbeit und verschiedene Aspekte der Krankenpflege-‘‘Kultur’’ (Pflegerituale, begrenzte Befugnis, Antriebsmangel). Einige Denkmodelle zur praktischen Umsetzung von Forschungsergebnissen werden vorgestellt und es wird eine Zusammenfassung von Hauptpunkten gegeben, die das Pflegepersonal bei Ûberlegungen zur Umsetzung von Forschungsergebnissen in Betracht ziehen muss. Barreras a la utilizacio¤n de investigaciones: el entorno cl|¤ nico ylos propios enfermeros Se han observado adelantos en el movimiento de la practica basada en la evidencia (EBP) en casi todos los pa|¤ ses occidentales y sistemas de sanidad durante las u¤ltimas dos o tres de¤cadas, impulsados por una demanda de recursos que aumenta sin cesar. Se espera crecientemente de los enfermeros de todos los niveles que hagen frente al desaf|¤ o principal de la EBP, que es la utilizacio¤n de la evidencia de las investigaciones de una manera escrupulosa, expl|¤ cita y sensata al adoptar decisiones relativas a la atencio¤n de pacientes. El objetivo principal del trabajo es alentar a los enfermeros a hacer frente a los desaf|¤ os de la EBP. Primero, como antecedente, este trabajo presenta resultados clave del nu¤mero limitado de investigaciones que han examinado las barreras a la utilizac|¤ on de investigaciones en el contexto de la enfermer|¤ a.Los enfermeros consideran en general que hay muchas barreras, siendo las barreras basicas la falta de tiempo, la falta de especialidades pertinentes, el trabajo deficiente en equipo, y varios aspectos de la‘cultura’ de enfermera¤n (atencio¤n ritualista, falta de autoridad y falta de autoridad y falta de incentivos). Se introducen algunos modelos conceptuales en la aplicacio¤n de los resultados de la investigacio¤n y se presenta un resumen de las a¤reas principales a las que deben hacer frente los enfermeros al considerar la utilizacio¤n de investigaciones.

John Sitzia BA MPhil, Research & Development Manager, Worthing & Southlands Hospitals NHS Trust, Lyndhurst Road, Worthing BN11 2DH, UK

INTRODUCTION Almost every Western country and health system has witnessed a growing demand for health-care

European Journal of Oncology Nursing 5 (3),154 ^164 # 2001 Harcourt Publishers Ltd doi:10.1054/ejon.2000.0115, available online at on

services over the past 20 or 30 years. The reasons for this are well documented and include the impact of an ageing population in developed countries, the continual introduction of new

Barriers to research utilization 155

technology and knowledge, a rise in patient expectations as patients have become better informed and more assertive, and a shift in professional expectations and attitudes. In many countries the rise in demand, knowledge and expectations has not been matched in terms of resources but rather by pressure on resources. As this pressure on resources continues to increase so clinical decisions will have to be made explicitly and publicly, and rather than being based principally on values and resources (opinion-based decision making) they will be have to be made upon evidence derived from research (Muir Gray 1996). In the early years of the evidence-based practice (EBP) movement in Europe, the mid and late 1980s, EBP was considered the concern only of doctors and clinical policy makers; indeed the ‘movement’ was called ‘evidencebased medicine’, a term still used by some. While there is a widely held belief that only 15–20% of clinical practice is based on research, studies examining this question suggest that much larger proportions of patients are treated on the basis of good evidence: 82% in general medicine (Ellis et al. 1995), 65% in psychiatry (Geddes et al. 1996) 85–90% in surgery (Muir Gray 1997) and 82% in general practice (Gill et al. 1996). However, the growth in EBP has been as much across disciplines as within medicine, and the movement has now reached the stage where even non-clinical aspects of health care – purchasing, estates, personnel, catering – are being forced to consider the evidence base for their practice. As Muir Gray puts it, this is the era of ‘evidencebased everything’ (NeLH 1997). EBP might be seen as a particularly strong challenge for nurses. Nurses have relatively low autonomy, some in the profession argue that nursing care is, and should be, based upon professional ‘knowledge’ developed through caring for real patients rather than research findings based upon experimental studies (Newman et al. 1998), and some perceive that nursing has been, and can therefore continue to be, inflexible and hostile to change (Brown 1995). However, while it is difficult to generalize, in some areas nurses do appear to be responding positively to this pressure to evaluate and change their practice. Upton (1999), for example, in a study of 370 nurses, midwives and health visitors in Wales, found that 80% of the nursing sub-sample considered evidence-based practice to be ‘fundamental to professional practice’, while only 6% considered it ‘a waste of time’. Research evidence is presented to clinical staff in a variety of ways, most commonly as research reports in journal papers and increasingly as clinical guidelines. The production of guidelines is helpful, as guidelines both synthesize available research evidence and structure the evidence

specifically for clinical decision making. Typically, guidelines are produced by respected ‘expert groups’ and incorporate findings from systematic reviews and meta-analyses, themselves produced by specialized research teams. Guidelines therefore carry a high degree of respectability. For many clinicians, evidencebased practice is coming to mean guideline-based practice. This shift has rekindled some resistance to EBP, as it is perceived as undermining individual clinician’s expertise and judgement based on experiential knowledge. However, this is only one blinkered view of EBP, based partly perhaps upon a misunderstanding of the EBP concept. Sackett and colleagues (1996) provide an excellent definition of EBP (note that this was written with a medical audience in mind, and so the term evidence-based medicine is used): Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice.

This definition highlights the key point that research evidence is only one factor contributing to the clinical decision-making process. Other factors which must be taken into account include the risk involved for the patient due to his individual condition and, most importantly, the patient’s own values, desires and expectations. The evidence combined with these other factors must be taken into account in order to decide on the options and finally make a decision (Fig. 1) (See Lilford et al. 1998 for an introduction to decision analysis in evidence-based practice). The definition of evidence-based practice provided by the UK Royal College of Nursing reflects this succinctly (RCN 1996): Evidence-based practice is ‘doing the right thing in the right way for the right patient at the right time’.

Fig. 1 The role of evidence in clinical decision making (adapted from NeLH 2000, Haynes & Haines 1998). European Journal of Oncology Nursing 5 (3),154 ^164


European Journal of Oncology Nursing

This paper will first provide a summary of barriers to research utilization at the individual, team and organization level and then attempt to provide a few suggestions of key actions nurses can take to develop effective research utilization. Some conceptual issues in implementation are provided to inform these strategies.

BARRIERS TO RESEARCH UTILIZATION It is universally acknowledged that to change clinical practice is typically not easy and that resistance to change is common. Resistance to change is not a characteristic of health care in particular, but of everyday human activity. This resistance has been described as ‘dynamic conservatism’, where people put a great deal of effort into staying as they are (Hunt 1987). A great deal of work has examined this resistance in the clinical context and many ‘barriers’ have been identified, at a number of levels (Box 1). Muir Gray (1997) provides a neat analysis of the effect of barriers on performance: The performance of an individual or team is determined by three variables: it is directly related to the level of motivation and the competence of the individual, and inversely related to the barriers the individual has to overcome in order to perform well.

A selection of the barriers directly relevant to individuals and clinical teams are discussed below.

Structures, processes and facilities in health-care organizations The traditional, typical structure and processes of hospitals and other health organizations obstruct research utilization in at least two ways (see Garside (1998) for an introduction to issues in organizational development and change management). First, organizations lack a clear system for the dissemination and utilization of research findings. Everyone and no-one is responsible for ‘using’ research evidence; everyone in the organization works towards providing the ‘best possible’ care for patients, yet typically no-one is charged with ensuring that care is indeed evidence based and up-to-date. Managers see it as the responsibility of clinical staff to determine their own practice – to appraise new evidence, to process and adopt or reject new guidelines – with the result that we have wild variations in standards of care not only between organizations but within organizations. Second, as multiprofessionalism is still an aspiration rather than a reality in many clinical settings, so it is in the funding, planning, undertaking and dissemination of research. The divisions visible in clinical practice are evident also in the research context, in ‘medical research’, ‘nursing research’, ‘physiotherapy research’ and so on. It is understandable that specific research questions may interest one professional group rather than another, but when it comes to dissemination and, most

Box 1 Potential barriers to implementation of evidence-based practice. Derived from: Closs & Cheater 1994, Donald & Milne 1998, Dunn et al. 1997, Haines & Donald 1998, Haynes & Haines 1998, Le May et al. 1998, Newman et al. 1998, NHS CRD 1999, Rodgers 1994,Upton 1999 Global factors Investment in ‘R’ but not ‘D’ Lack of recognition by other health professionals for nursing outcomes Organizational factors ‘Doing’ rather than ‘questioning’ culture Evidence-based practice is a low management priority No clear structures or processes for evidence-based practice or for ‘knowledge management’ or for managing innovation generally No support or incentive for clinical practice development or adaptation of services around research f|ndings Poor quality training, irrelevant to team needs and interests, one-o¡ approach, impractical to attend (often o¡-site) Poor multiprofessional teamworking Poor access to research evidence, e.g. slow (or no) computers and data base access, inadequate (or non-existent) library services, poor computing support Team and individual factors Lack of time Lack of training, and therefore expertise, in identif|cation and formulation of research questions, literature searching, reading and appraisal, change management, computing, communication Lack of incentives, especially in terms of career development Lack of f|nancial resources In£uence of opinion leaders Lack of understanding of respective roles of research, experiential knowledge and clinical judgement and lack of skills in using each e¡ectively Lack of agreed priorities Uncommitted team leader: overworked, uncertain about benef|ts, threatened by new approach Lack of motivation Ill-def|ned and competing interpretations of nursing roles and practice Nursing’s and nurses’ status in relation to other professional groups Pressure to conform to ritualistic practice European Journal of Oncology Nursing 5 (3),154 ^164

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importantly, implementation, it is vital that a multiprofessional approach is taken as this better reflects the realities of patient care. Poor multiprofessional team-working appears repeatedly as a significant barrier to research utilization in nursing. Studies from both the UK and USA found that over 70% of nurses felt research implementation would be obstructed because other professions, notably doctors, simply would not co-operate with the implementation (e.g. Dunn et al. 1997). Some commentators, such as Millar and colleagues (1996), argue that for nurses to adopt evidence-based interventions it is first necessary to exactly classify a ‘nursing intervention’ and to measure the outcomes of those interventions as a contribution to total health care. It is certainly reasonable to argue that it is difficult for nurses to relate much new treatment evidence to their specific nursing interventions as the outcome measures used are inappropriate. Corner (1996), for example, has raised the issue of survival being regarded as the only outcome of cancer treatment of any importance whereas patients and nurses see other outcomes, such as quality of life, as important indicators of therapeutic value. However, the most valuable challenge may not be to define ‘nursing outcomes’, ‘medical outcomes’, physiotherapy outcomes’ and so on, but to lobby for, and raise nurses’ involvement in, multiprofessional research so that research outcomes are measured for all relevant disciplines in the clinical team.

Lack of skills and knowledge A broad and complex set of skills are required to ‘utilize’ research findings and, on the whole, researchers have found that nurses do not possess these skills. One vital skill is that of searching effectively for research findings and then knowing how to read research documents in a critical way. European studies have found that nurses lack skills in these areas. Upton (1999), for example, in a study of nurses in Wales, found that nurses rated their ability in these areas as the lowest of all component skills of evidence-based practice. Similarly, in a study from England, Dunn et al. (1997) found that around 70% of nurses perceived themselves as unaware of the relevant research, felt they were not capable of evaluating the quality of research and that the amount of research information is overwhelming. It is worth noting that data from the USA, whilst agreeing that these are key barriers, show that a greater proportion of nurses feel competent in these areas. For example, whilst in the UK Dunn et al. (1997) found that 70% of nurses felt they were not capable of evaluating the quality of research, in the USA Carroll and colleagues (1997) found this level to be only 51%.

Some commentators argue that nurses should not concern themselves with these skills, and should focus on adopting clinical guidelines prepared elsewhere. Interestingly, some of these commentators are themselves nurses or nurse academics (e.g. Regan 1998). However, there is a strong opposing argument; as the evidence based practice agenda becomes stronger, the only way nurses will continue to develop as respected equal partners in patient care is by ensuring that they are well prepared not only to follow new guidelines but to develop and implement them.

Lack of support, motivation and incentives: nursing ‘culture’ To paraphrase Horsley (1983), implementing research findings is a demanding task, requiring intellectual rigour and discipline, creativity, clinical judgement and skill, communication and team-building skills, and – perhaps above all – perseverance. A strong recurring theme in the literature is that nurses (a) perceive evidencebased practice to be a huge task and (b) are most reluctant to embark on this task when there is a perceived lack of support and motivation and when roles are not clearly identified. Many studies identify the lack of time available to review and implement research findings as a primary barrier to research utilization. Dunn and colleagues (1997), for example, found that 75% of nurses thought lack of time a great or moderate barrier, Carroll et al. (1997) in the USA 71%, Kajermo et al. (1998) in Sweden 72%, and Walczak and colleagues, in a small study of oncology nurses in the USA, 85% (Walczak et al. 1994). A second factor, mentioned above, is that some nurses, in common with other health professionals from all disciplines, place great authority in ‘clinical experience’ and little authority in paper findings. Rodgers’ exploratory study of nurses’ views of utilization found that Research findings were often disbelieved or simply discounted if they were not congruent with beliefs held by nurses (Rodgers 1994).

Similarly, Dunn et al. (1997) found that over 50% of UK nurses did not trust research findings, and almost 40% did not feel that implementation of findings would benefit patients. Studies using Funk’s BARRIERS scale (Funk et al. 1991) have specifically asked whether the nurse is unwilling to change or try new ideas, with agreement with this statement ranging from 25–55% (Dunn et al. 1997, Kajermo et al. 1998, Rutledge et al. 1998). Another important factor in nursing ‘culture’ is that of lack of authority. Lack of authority to make change ranks highly throughout the barriers literature; Dunn et al. 1997, for example, European Journal of Oncology Nursing 5 (3),154 ^164

158 European Journal of Oncology Nursing

found that almost 60% of respondents felt they lacked this authority, while a rate of 58% was reported in a US study of oncology staff nurses, nurse managers and specialists (Rutledge et al. 1998) and 64% in a Swedish study of hospital nurses (Kajermo et al. 1998). In more than one study this inertia was expressed as a ‘fear’ of trying out new ideas (Le May 1998, Rodgers 1994). Some nurses express this as partly through lack of faith in their own judgement but Rodgers (1994) also noted a dichotomy with regard to nurse authority; ward nurses felt that power for change lay with the nurse manager, while nurse managers expected ward nurses to lead clinical change.

SOME CONCEPTUAL ISSUES IN THE UTILIZATIONOF RESEARCH FINDINGS IN CLINICAL PRACTICE Change models help explain the behaviour of individuals and organizations undergoing change, and are useful in guiding the implementation of interventions intended to change behaviour. Many models and frameworks appear in the literature from many disciplines. The value of each approach is determined in part by local context; that is, by the characteristics of the individuals and groups in that context and by the processes and structures defining that context. These approaches form two broad groups: those which focus on ‘internal processes’ and those which focus on ‘external influences’. The first includes theories such as adult learning theories, cognitive theories, health promotion, innovation and social marketing theories. The second includes general learning theory, social influence and power theories, organizational theories and coercive theories. These theories have some interesting concepts in common; this section aims to briefly introduce some which might inform strategies for research utilization.

Diffusion, dissemination and implementation The seminal work in diffusion of innovations was carried out by the American communication theorist Rogers in the 1950s (Rogers 1983). Lomas (1993a) provides a useful framework for understanding the concept and the relationship between diffusion, dissemination and implementation. . Diffusion is a passive form of communication: ‘light diffuses from a source: it is not targeted; it is haphazard: it is largely unplanned and uncontrolled’. The prime example of diffusion is publication via journal; this means the most common form of sharing research findings is also among the weakest. European Journal of Oncology Nursing 5 (3),154 ^164

. Dissemination is a more active form of communication, with the information source taking a more active role in sending the information to a specific, targeted audience. Dissemination is becoming more common in health research, most visible in the profusion of practice guidelines and consensus statements, such as those sent by organizations to members. . Implementation is a more active process still, in which the implications of the message for the target audience are taken into consideration.

Predisposing, enabling and reinforcing activities Diffusion, dissemination and implementation might also be considered in terms a framework of predisposing, enabling and reinforcing activities (Lomas 1993b): . Predisposing activities alert practitioners to a problem and introduce potential solutions. Dissemination activities can be regarded in this category: ‘they are received by the relevant audience as important contributors to changed awareness, attitudes and even knowledge, but are not sufficient to enable changes in behaviour’. . Enabling activities identify and remove specific barriers thereby facilitating change in practice . Reinforcing activities are those which aim to reward and maintain changes, and so include reminder systems, evaluation systems and incentives. It is most important to note the sense of orderly progression in this schema. This progression is perhaps the most important basic factor in change models.

Characteristics of people Rogers (1983) work on the process of the adoption of innovations has informed much of the later work in this field (e.g. Stocking 1992). This work suggests that people fall into one of four ‘adopter categories’, with each type playing a different and distinct role in change. . Innovators typically have close contact with scientific sources, have interaction with other innovators, and are willing to take risks . Early adopters are often seen as ‘opinion leaders’, are well established in decision-making bodies and groups, are influential and respected by their peers . Majority are those who follow opinion leaders, either willingly or with scepticism . Laggards are those most unwilling to change, are ‘traditional’ and oriented towards the past, often have a peer group with similar values and opinions, but are isolated from the mainstream.

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Characteristics of innovations Change is also influenced by characteristics of the innovation itself. Five characteristics of innovation which influence their adoption can be identified (Haines et al. 1996): . Relative advantage is the degree to which an innovation is perceived as better than the approach it supersedes. It is important to note the phrase ‘perceived as better’. First, perception depends on a wide array of factors, not least profession. Different professions may well have different perceptions of the benefit of an innovation depending upon the perceived impact in their own professional practice. Education is also important; those who have an understanding of the concepts of evidence-based practice, who are familiar with the concepts and skills of critical appraisal, may well perceive the benefit of an innovation differently to those who do not have those skills. Second, many factors influence the judgement as to whether or not a new intervention is ‘better’ than an existing one; the advantage may be to the health professional rather than the patient (it may save time or cost or effort, or it may give security or reassurance to professionals) or vice-versa; the innovation might be an advantage to one group of health professionals but not another, and so on . Compatibility is the degree to which an innovation is considered to be consistent with the existing values and previous experience of the potential adopters. Stocking (1992) argues that this may be one factor in the, reportedly, poor rate of utilization of research findings; findings may not be accepted simply because they are incompatible with long-held philosophies and practice . Complexity is the extent to which an innovation is perceived as being difficult to understand and implement. Complexity may be technical, as in a new surgical procedure, or Box 2 1999)

logistical, involving changes to staff working practices or premises . Trialability is the degree to which an innovation may be tested on a limited basis . Observability is the degree to which the results of an innovation are easily perceived by potential adopters.

STRATEGIES TO IMPROVE THE UPTAKE OF RESEARCH FINDINGS A number of useful reviews and other papers provide an introduction to models for change in clinical practice (Conner & Norman 1996, Dumelow & Littlejohns 1999, Freemantle et al. 1995, Granados et al. 1997, Grimshaw & Russell 1993, Grol 1997, Lomas & Haynes 1988, NHS CRD 1999, Palmer & Fenner 1999, Wensing & Grol 1994), some focusing on nursing practice (e.g. Kitson et al. 1996, Sheehan 1990). One of the most popular nursing research utilization frameworks is the Stetler model (Stetler 1994). The Stetler model uses six phases – preparation, validation, comparative evaluation, decisionmaking, translation/application, evaluation – and places an emphasis upon the strong position of practitioners, rather than managers, to facilitate practice change. This model has been found to be helpful in the context of oncology nursing (see Hanson & Ashley 1994, McGuire et al. 1994, Reedy et al. 1994, Uitterhoeve & Ambaum 1999). Rather than describe individual models, this paper will discuss a small number of key issues which appear repeatedly in the literature. These issues are not sequential and have degrees of overlap. Most importantly, note that this is not a framework in itself but a list of points to consider. Some of these points focus on ‘competencies’, which can be seen as a mix of aptitudes, attitudes and personal attributes which facilitate effective practice (Box 2). A point to stress above all is that implementation seldom entails a single

Key competencies needed in individuals or teams to support evidence-based practice (Cowling et al.

Personal attributes The personal styles, attitudes and attributes necessary for e¡ective practice of evidence-based health care Interpersonal skills The abilities necessary to communicate and interact e¡ectively with others Self-management skills The ability to e¡ectively organize and take responsibility for personal practice in the workplace Information management skills The ability to manage and make e¡ective use of information . . . . .

Recognition of information need - knowing which questions to ask and how to ask them Searching skills Critical appraisal skills Translation of research evidence to local situation Implementation.

Technical knowledge and skills The ability to execute the relevant skills and knowledge necessary to access, adopt and implement evidence-based practice European Journal of Oncology Nursing 5 (3),154 ^164

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action; it usually demands good planning and a combination of different interventions, some simultaneously (Grol 1997).

Learn to find and critically appraise research evidence Muir Gray (1997) lists these key skills required of an evidence-based decision maker: . An ability to define outcome criteria, such as effectiveness, safety and acceptability . An ability to find articles on the effectiveness, safety and acceptability of a new test or treatment . An ability to assess the quality of evidence . An ability to assess whether the results of research are applicable to your own patient group. Commentators agree that systematic improvement in nurses’ research literacy requires longterm strategies such as extending research skills taught in the nursing curriculum and the development of collaborative research strategies between clinical and academic units (Closs & Cheater 1994). However, individuals can quickly raise skills levels, for example by learning to find evidence packaged in easily digestible formats such as the Evidence Based Nursing journal series. Useful introductions to the skills and processes of searching for evidence can be found in Muir Gray (1997) and Greenhalgh (1997), and local educational institutions may provide training. Resources increasingly are found via the internet, rather than in printed form (see Box 3). Several frameworks for critical appraisal of research evidence have been published. Guides have been developed to help evaluation of the validity of evidence about a diagnostic test (Irwig et al. 1994), a treatment (e.g. Muir Gray 1997), a review of treatments (Milne & Chambers 1993, Oxman 1994) or a guideline or other clinical policy (SGHMS HCEU 2000, see also Miles et al. 1996a). Greenhalgh (1997) provides an excellent overview to critical appraisal.

Learn about systems for ‘knowledge management’ As a team or unit, think about all the stages involved from finding or receiving new evidence to putting it into practice – make a list, talk about it, decide who is responsible for what, how you will: . As a team, keep up to date with new research findings or guidelines . Process new information, either solicited or unsolicited . Appraise new guidelines . Make a decision regarding implementation of new knowledge or guidelines. European Journal of Oncology Nursing 5 (3),154 ^164

Seek consensus on local priorities for change It is important to stress again that the multiprofessional basis of patient care must be reflected in practice change. Nurses leading change should aim to involve all relevant professional groups in the identification of priorities and the result of these discussions should be a consensus on priorities, not an nonnegotiated demand for change.

Learn about effective strategies for implementation of evidence Read about strategies, discuss them as a team, think about the issues and people involved in your own context, particularly those described above as ‘barriers’ and the issues introduced above. It is also vital to consider local knowledge, being ‘the local practices, values and beliefs into which new knowledge must gradually be integrated – or risk being rejected’ (Donald & Milne 1998).

Explore barriers to change and incentives for change Some studies in the nursing context have used Funk’s ‘Barriers to Research Utilization Scale’ (Funk et al. 1991), and it seems generally to be useful (e.g. Rutledge et al. 1998).

Secure support and commitment Think about effective communication Box 4 presents a number of interventions examined in a systematic review of systematic reviews examining behavioural change in this context. The most important finding was that passive dissemination of information, despite probably being the most common approach adopted by researchers and professional bodies, was generally ineffective, ‘no matter how important the issue or how valid the assessment methods’ (Bero et al. 1998). This is an important point: it is not necessarily the quality of the material, but the quality of the package or strategy carrying the material which makes the important difference in implementation. Put simply, the evidence indicates that active, rigorous and well-planned strategies are most effective in implementing change (see also Grimshaw & Russell 1993, Littlejohns & Humphris 1999). Build a credible dissemination and implementation body This group might be different for each intervention, but in every case it should be multiprofessional, with influential and or authoritative members, both clinical and non-clinical. Upton (1998) provided an interesting piece of

Barriers to research utilization 161 Box 3

Some evidence-based practice resources on the World Wide Web (all sites accessed March 2000)

Portal sites (access and direction to several EBP-related sites) Australia Italy Spain UK UK EBP-related sites The Cochrane Collaboration The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the e¡ects of health-care interventions. The main work of the Collaboration is done by about 50 Collaborative Review Groups, within which Cochrane Reviews are prepared and maintained.These groups are multiprofessional and aim to generate reliable, up-to-date evidence relevant to the prevention, treatment and rehabilitation of particular health problems or groups of problems. The main output of the Collaboration is the Cochrane Library, which is a series of databases available via subscription on CD-ROM and via the Internet.The databases include treatment protocols, reviews of e¡ectiveness, a controlled trials register and a review methodology database. The work of the Cochrane Collaboration is facilitated by the work of more than a dozen Cochrane Centres around the world, including these European centres: Denmark France Germany Italy Netherlands Spain UK

Databases of clinical guidelines These sites provide access to clinical guidelines based on reviews of research evidence. UK Guideline: a database of critically appraised guidelines USA Agency for Healthcare Research and Quality USA National Guideline Clearinghouse Best Evidence database This database brings together quality-assessed summaries of the best current studies of diagnosis, cause, course and management of a broad range of clinical disorders. USA WISDOM Project The WISDOM project aims to provide EBP-related training via the internet.This is an excellent site. UK Other sites France Germany Switzerland Switzerland UK UK UK UK UK UK

Association de Recherche en Soins Inf|rmiers EB Medicine in Germany EB Medicine in Switzerland Stiftung Paracelsus heute NHS Centre for Reviews and Dissemination NHS Centre for Evidence-Based Medicine Centre for Evidence-Based Nursing evidence/ev-intro.htm Centre for Evidence-Based Pharmacotherapy Contact Help Advice & Information Network for E¡ective Health Care (CHAIN) chain/chain.htm European Quality in Nursing Network euroquan.htm

data in this respect. In this study of nurses’ opinions of EBP, while it was found that 91% of respondents agreed that they would act on evidence from their own practice, only 27% said they would act if the evidence was from the internet and 78% of respondents agreed that they would act on the opinions of a colleague from the same profession.

Work towards a supportive practice environment At the team or unit level, consider setting up a Journal Club or research discussion group, a

forum where research can be discussed in an educational way (Le May et al. 1998). Ask for support from a nurse tutor or local university. At the organizational level, lobby for library resources, training resources, database and computer equipment and maintenance.

Muir Gray’s mantra (one of many) Muir Gray provides several memorable mantras for those working towards EBP. I like the one presented in Box 5. Some might argue that the term ‘unproven efficacy’ needs to be interpreted European Journal of Oncology Nursing 5 (3),154 ^164

162 European Journal of Oncology Nursing Box 4

E¡ectiveness of interventions to promote professional behavioural change (Bero et al. 1998)

Consistently e¡ective Education outreach visits Reminders, manual or computerized Multifaceted interventions, which included two or more of the following: audit/feedback, reminders, local consensus process, marketing Interactive educational meetings - Workshops that include discussion or practice Mixed e¡ects Audit or feedback - Any summary of clinical performance Local opinion leaders - ‘Educationally in£uential’ colleagues Local consensus process - Inclusion of participating health care providers in discussion to ensure that they agreed that the chosen clinical problem was appropriate Patient mediated interventions - Any intervention aimed at changing the performance of health-care providers where specif|c information was sought from or given to patients Little or no e¡ect Educational materials - Distribution of printed or published recommendations for clinical care, e.g. clinical practice guidelines, electronic publications Lectures

Box 5

From Muir Gray (1997)

Stop things starting - if interventions are of unproven e⁄cacy, make sure they are not introduced. Start things stopping - if interventions of unproven e⁄cacy have already been introduced, make sure they are no longer practised. Start things startingright - start introducing interventions with proven e⁄cacy.

cautiously, that if nursing interventions of ‘unproven efficacy’ are all that exist then it is impossible to stop practising them. However, the point is this: if we don’t know that the intervention ‘works’, then why do it? If it does ‘work’, how do we know it works and how can we demonstrate that it works? Supporters of EBP would argue that, first, practising nurses have a duty to know whether or not their actions are of any benefit to the patient and, second, that researchers have a duty to demonstrate this. The question of whether or not ‘knowing’ through experience or intuition is acceptable in the absence of research evidence is of key importance and will no doubt be strongly debated as evidence-based nursing develops. In the meantime, this paper has advocated that clinical practice should be based upon a fusion of knowledge derived from research and knowledge derived from clinical experience. Muir Gray’s words should be interpreted with this balance in mind. REFERENCES Bero L, Grilli R, Grimshaw J, Harvey E, Oxman A, Thomson MA (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote implementation of research findings by health care professionals. In: Haines A, Donald A (Eds) Getting Research Findings into Practice. BMJ Publishing, London Brown GD (1995) Understanding barriers to basing nursing practice upon research: a communication model approach. Journal of Advanced Nursing 21: 154–157 Carroll DL, Greenwodd R, Lynch KE, Sullivan JK, Ready CH, Fitzmaurice JB (1997) Barriers and facilitators to the utilization of nursing research. Clinical Nurse Specialist 11: 207–212 European Journal of Oncology Nursing 5 (3),154 ^164

Closs SJ, Cheater FM (1994) Utilization of nursing research: culture, interest and support. Journal of Advanced Nursing 19: 762–773 Conner M, Norman P (1996) The role of social cognition in health behaviours. In: Conner M, Norman P (Eds) Predicting health behaviour. Open University Press, Buckingham Corner J (1997) Beyond survival rates and side effects: cancer nursing as therapy. (The Robert Tiffany Lecture, 9th International Conference on Cancer Nursing, Brighton UK, August 1996). Cancer Nursing 20: 3–11 Cowling A, Newman K, Leigh S (1999) Developing a competency framework to support training in evidence-based healthcare. International Journal of Health Care Quality Assurance 12: 149–159 Donald A, Milne R (1998) Implementing research findings in clinical practice. In: Haines A, Donald A (Eds) Getting Research Findings into Practice. BMJ Publishing, London Dumelow C, Littlejohns P (1999) Reaching general conclusions from specific projects. In: Humphris D, Littlejohns P (Eds) Implementing clinical guidelines: a practical guide. Radcliffe Medical Press, Oxford Dunn V, Crichton N, Roe B, Seers K, Williams K (1997) Using research for practice: a UK experience of the BARRIERS scale. Journal of Advanced Nursing 27: 1203–1210 Ellis J, Mulligan I, Rowe J, Sackett DL (1995) Inpatient general medicine is evidence based. Lancet 346: 407–410 Freemantle N, Grilli R, Grimshaw J, Oxman A (1995) Implementing findings of medical research: the Cochrane Collaboration on Effective Professional Practice. Quality in Health Care 4: 45–47 Funk SG, Champagne MT, Weise RA, Tornquist EM (1991) BARRIERS: the barriers to research utilization scale. Applied Nursing Research 4: 39–45 Garside P (1998) Organizational context for quality: lessons from the fields of organizational development and change management. Quality in Health Care 7 (suppl.): S8–S15 Geddes JR, Game D, Jenkins NE, Peterson LA, Pottinger GR, Sackett DL (1996) What proportion of primary psychiatric interventions are based on evidence from randomised controlled trials? Quality in Health Care 5: 215–217 Gill P, Dowell AC, Neal RD, Smith N, Heywood P, Wilson AE (1996) Evidence based general practice: a retrospective study of interventions in one training practice. British Medical Journal 312: 819–821 Granados A, Jonsson E, Banta HD, Bero L, Bonair A, Cochet C, Freemantle N, Grilli R, Grimshaw J,

Barriers to research utilization 163 Harvey E, Levi R, Marshall D, Oxman A, Pasart L, Raisanen V, Rius E, Espinas JA (1997) EUR-ASSESS Project Subgroup Report on Dissemination and Impact. International Journal of Technology Assessment in Health Care 13: 220–286 Greenhalgh T (1997) How to read a paper: The basics of evidence based medicine. BMJ Publishing, London Grimshaw JM, Russell IT (1993) Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 342: 1317–1322 Grol R (1997) Beliefs and evidence in changing clinical practice. British Medical Journal 315: 418–421 Haines A, Donald A (1998) Introduction. In: Haines A, Donald A (Eds) Getting Research Findings into Practice. BMJ Publishing, London Haines A, Freemantle N, Watt I, Lugon M (1996) Increasing the effectiveness of clinical intervention. In: Miles A, Lugon M (Eds) Effective Clinical Practice. Blackwell Science, Oxford Hanson JL, Ashley B (1994) Advanced Practice Nurses’ application of the Stetler model for research utilization: improving bereavement care. Oncology Nursing Forum 21: 720–724 Haynes B, Haines A (1998) Barriers and bridges to evidence based clinical practice. In: Haines A, Donald A (eds) Getting Research Findings into Practice. BMJ Publishing, London Horsley JA (1983) Using research to improve nursing practice: a guide (CURN project). Grune & Stratton, Orlando Irwig L, Tosteson AN, Gatsonis C, Lau J, Colditz G, Chalmers TC, Mosteller F (1994) Guidelines for meta-analyses evaluating diagnostic tests. Annals of Internal Medicine 120: 667–676 Kajermo KN, Nordstrom G, Krusebrant A, Bjorvell H (1998) Barriers to and facilitators of research utilization, as perceived by a group of registered nurses in Sweden. Journal of Advanced Nursing 27: 798–807 Kesselring AM (2000) Barriers to research utilization: Research and the way it is presented. Plenary Lecture, 2nd EONS Spring Convention, Prague, Czech Republic, April 2000 Kitson A, Ahmed LB, Harvey G, Seers K, Thompson DR (1996) From research to practice: one organizational model for promoting research-based practice. Journal of Advanced Nursing 23: 430–440 Le May A, Alexander C, Mulhall A (1998) Research utilization in nursing: barriers and opportunities. Journal of Clinical Effectiveness 3(2): 59–63 Lilford RJ, Pauker SG, Braunholtz D, Chard J (1998) Decision analysis and the implementation of research findings. In: Haines A, Donald A (Eds) Getting Research Findings into Practice. BMJ Publishing, London Littlejohns P, Humphris D (1999) How effective are clinical guidelines? In: Humphris D, Littlejohns P (Eds) Implementing clinical guidelines: a practical guide. Radcliffe Medical Press, Oxford Lomas J (1993a) Diffusion, dissemination and implementation: who should do what? Annals of the New York Academy of Sciences 703: 226–237 Lomas J (1993b) Retailing research: increasing the role of evidence in clinical services for childbirth. Milbank Quarterly 71: 439–475 Lomas J, Haynes B (1988) A taxonomy and critical review of tested strategies for the application of clinical practice recommendations: from ‘official’ to ‘individual’ clinical policy. American Journal of Preventative Medicine 4: 77–94 McGuire DB, Walczak JR, Krumm SL (1994) Development of a nursing research utilization program in a clinical oncology setting: organization, implementa-

tion and evaluation. Oncology Nursing Forum 21: 704–710 Miles A, Lugon M, Polychronis A (1996a) The development of quality in clinical practice II: The derivation and implementation of clinical standards, guidelines and research evidence. In: Miles A, Lugon M (Eds) Effective Clinical Practice. Blackwell Science, Oxford Miles A, Bentley P, Price N, Polychronis A, Grey J, Asbridge J (1996b) Auditing the totality of patient care I: Pre-requisite management structures and organizational innovations. In: Miles A, Lugon M (Eds) Effective Clinical Practice. Blackwell Science, Oxford Miles A, Bentley P, Price N, Polychronis A, Grey J, Asbridge J (1996c) Auditing the totality of patient care II: Implementation of process and measurement of outcome. In: Miles A, Lugon M (Eds) Effective Clinical Practice. Blackwell Science, Oxford Millar B, Maggs C, Warner V, Whale Z (1996) Creating consensus about nursing outcomes. II. Nursing outcomes agreed by patients, nurses and other health professionals. Journal of Clinical Nursing 5: 263–269 Milne R, Chambers L (1993) Assessing the scientific quality of review articles. Journal of Epidemiology and Community Health 47: 169–170 Muir-Gray JA (1997) Evidence-based healthcare: how to make health policy and management decisions. Churchill Livingstone, Edinburgh NeLH (National Electronic Library for Health) (2000) Newman M, Papadopoulos I, Sigsworth J (1998) Barriers to evidence-based practice. Clinical Effectiveness in Nursing 2: 11–20 NHS CRD (NHS Centre for Reviews and Dissemination) (1999) Getting evidence into practice. Effective Health Care Bulletin 5(1). [full text on: crd] O’Neill DF (1996) Increasing the appropriateness of clinical practice. In: Miles A, Lugon M (Eds) Effective Clinical Practice. Blackwell Science, Oxford Oxman AD (1994) Checklist for review articles. British Medical Journal 309: 648–651 Palmer C, Fenner J (1999) Getting the message across: Review of research and theory about disseminating information within the NHS. Gaskell, London RCN (Royal College of Nursing) (1996) Clinical effectiveness: A Royal College of Nursing guide. Royal College of Nursing, London Reedy AM, Shivnan JC, Hanson JL, Haisfield ME, Gregory RE (1994) The clinical application of research utilization: amphotericin B. Oncology Nursing Forum 21: 715–719 Regan JA (1998) Will current clinical effectiveness initiatives encourage and facilitate practitioners to use evidence-based practice for the benefit of their clients? Journal of Clinical Nursing 7: 244–250 Rodgers S (1994) An exploratory study of research utilization by nurses in general medical and surgical wards. Journal of Advanced Nursing 20: 904–911 Rogers EM (1983) Diffusion of innovations. Free Press, New York Rutledge DN, Ropka M, Greene PE, Nail L, Mooney KH (1998) Barriers to research utilisation for oncology staff nurses and nurse managers/clinical nurse specialists. Oncology Nursing Forum 23: 497–506 Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS (1996) Evidence-based medicine: what it is and what it isn’t. British Medical Journal 312: 71–72 SGHMS HCEU (St. George’s Hospital Medical School Health Care Evaluation Unit) (2000) Appraisal European Journal of Oncology Nursing 5 (3),154 ^164

164 European Journal of Oncology Nursing instrument for clinical guidelines. http:// Sheehan J (1990) Investigating change in a nursing context. Journal of Advanced Nursing 15: 819–824 Stetler CB (1994) Refinement of the Stetler/Marram Model for application of research findings to practice. Nursing Outlook 42: 15–25 Stocking B (1992) Promoting change in clinical care. Quality in Health Care 1: 56–60 Upton D (1999) Attitudes towards, and knowledge of, clinical effectiveness in nurses, midwives, practice nurses and health visitors. Journal of Advanced Nursing 29: 885–893

European Journal of Oncology Nursing 5 (3),154 ^164

Uitterhoeve R, Ambaum B (1999) Surviving the era of evidence-based nursing practice: implementation of a research utilization model in practice. European Journal of Oncology Nursing 3: 176–184 Walczak JR, McGuire DB, Haisfield ME, Beezley A (1994) A survey of research-related activities and perceived barriers to research among professional oncology nurses. Oncology Nursing Forum 21: 710–715 Wensing M, Grol R (1994) Single and combined strategies for implementing changes in primary care; a literature review. International Journal of Quality in Health Care 6: 115–132