Barriers to the implementation of research perceived by nurses from Osakidetza

Barriers to the implementation of research perceived by nurses from Osakidetza

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Enferm Clin. 2017;xxx(xx):xxx---xxx


Barriers to the implementation of research perceived by nurses from Osakidetza夽 M. Ángeles Cidoncha-Morenoa,∗ , Bego˜ na Ruíz de Alegría-Fernandez de Retanab a b

Subdirección de Enfermería, Dirección General de Osakidetza, Vitoria-Gasteiz, Spain Escuela de Enfermería de Vitoria-Gasteiz (Osakidetza), Universidad del País Vasco, Vitoria-Gasteiz, Spain

Received 14 October 2016; accepted 28 March 2017

KEYWORDS Nursing; Nursing research; Research utilisation; Primary health care; Hospital care

Abstract Objective: To understand the barriers to implementing nursing research findings into practice, as perceived by the nurses working in Osakidetza and to analyse if the workplace factor and time worked affect the perception of these barriers. Methods: Cross-sectional study. BARRIERS Scale questionnaire was given to a representative sample of 1572 Basque Health Service nurses, stratified and randomised, according to scope of work and job responsibility (response rate: 43.76%). Results: According to the research results, the first important barrier was ‘‘insufficient time on the job to implement new ideas’’. Nurses have perceived the organisational factor as the most important barrier in their practice. Nurses in ‘‘Special hospital departments’’ perceived more barriers in the ‘‘quality of research’’ factor than those working in ‘‘Primary Care’’. Years of service showed a slight influence. Conclusions: The nurses stated that external factors related to the organisation principally interfered in implementing results into clinical practice. They placed lack of critical reading training second. Working environment and seniority mark differences in the perception of barriers. This study may help to develop strategies for planning training programmes to facilitate the use of research in clinical practice, in order to provide quality care. © 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.

Please cite this article as: Cidoncha-Moreno MÁ, Ruíz de Alegría-Fernandez de Retana B. Percepción de barreras para la utilización de la investigación en enfermeras de Osakidetza. Enferm Clin. 2017. ∗ Corresponding author. E-mail address: [email protected] (M.Á. Cidoncha-Moreno). 2445-1479/© 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.

ENFCLE-669; No. of Pages 8




M.Á. Cidoncha-Moreno, B. Ruíz de Alegría-Fernandez de Retana

PALABRAS CLAVE Enfermería; Investigación en enfermería; Utilización de la investigación; Atención Primaria de salud; Atención hospitalaria

Percepción de barreras para la utilización de la investigación en enfermeras de Osakidetza Resumen Objetivo: Conocer la percepción de barreras para incorporar los resultados de investigación a la práctica en las enfermeras/os de Osakidetza y analizar si los factores ámbito laboral y tiempo trabajado afectan a la percepción de dichas barreras. Métodos: Estudio descriptivo, transversal, multicéntrico. El cuestionario BARRIERS fue administrado a 1.572 enfermeras de Osakidetza estratificadas y aleatorizadas según ámbito de trabajo y responsabilidad laboral (tasa de respuesta: 43,76%). Resultados: La primera barrera identificada fue «el tiempo insuficiente en el trabajo para implementar nuevas ideas». La dimensión organizacional fue la mayor barrera percibida. Las enfermeras/os del «Hospital de Servicios Especiales» percibieron más barreras en el factor «calidad de la investigación» que los que trabajaban en «Atención Primaria». El tiempo de antigüedad mostró una débil influencia. Conclusiones: Las/os enfermeras/os de Osakidetza declararon que los factores externos relacionados con la organización son los que principalmente interfirieren en la incorporación de los resultados a la práctica clínica. En segundo lugar situaron la falta de formación para hacer una lectura crítica. El ámbito laboral y la antigüedad marcan diferencias en la percepción de barreras. Este estudio puede ayudar a establecer estrategias para la planificación de programas formativos más adecuados que ayuden a facilitar la utilización de la investigación en la práctica clínica, con el fin de prestar una atención de calidad. © 2017 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.

What is known? Factors such as training, participating in research activities, structure of the organisation and experience on the job have been cited as influencing the transfer of knowledge into practice.

What does this paper contribute? This study confirms that nurses attribute the main barrier to the implementation of research on lack of time and the second on lack of training. The work setting changes the perception of barriers in putting results into practice and length of time worked is mildly influential.

Introduction Health professionals are called upon to use the results of scientific research in the healthcare they offer. In this sense, the application of results to practice is a necessary component for the improvement of peoples’ healthcare quality.1 However, the literature highlights the persistent division between research finding and their clinical application,2---9 in addition to the inappropriate dissemination of relevant results and poor practical application.10 More specifically, it

has been proven that 30% of patients do not receive healthcare based on scientific evidence, 25% of them even receive unnecessary care and on occasions care that may damage their health.11,12 There has been an attempt to probe into a resolution to this problem13---15 since in the process of incorporating research into clinical practice many interrelated complex factors may be involved.5,16---22 To identify the difficulties related to the use of research, Funk et al.21 developed the tool: BARRIERS to Research Utilisation Scale which was widely used, particularly throughout North American and the United Kingdom.23 The barriers identified in the international area17---24 and the Spanish context25---27 were lack of time to read up on research and implement new ideas during work, gaps in knowledge and lack of authority and support from nursing managers and from colleagues. This makes it clear that the decision to incorporate knowledge into practice is governed by the interrelationship of individual, organisational and environmental characteristics.28,29 Other studies examined the effect of socio-occupational events on difficulties for using research in clinical practice and found that training7 and participation in research activities24,25 promote the use of research inpractice. The structure of the organisations worked in27,29 and the organisational culture29 are also factors which have an effect on the transfer of knowledge into practice. Few studies have been found nationally25---27 and none in the context of the Basque health system. As a result we decided to conduct a study to probe into this issue. The aim of this study was to understand the barriers to implementing nursing research findings into practice as



Barriers to the implementation of research perceived by nurses


Benchmark population: 7,123 nurses

Target population: 6,027 nurses

Sample: 1,572 nurses

Hospital care: 4,609 (76,475)

Álava: 845

Vizcaya: 2,663

Figure 1

Primary care: 1,418 (23.53%)

Guipúzcoa: 1,101

Álava: 204

Vizcaya: 915

Guipúzcoa: 299

Sample size distribution of professionals.

perceived by the nurses working in Osakidetza and to analyse if the workplace factor and time worked factor affect the perception of these barriers.

Method A descriptive, transversal, multicentre study conducted by nurses from the Osakidetza-Basque health service belonging to the Autonomous Community of the Basque Country which encompasses 13 Comprehensive Healthcare Organisations (with 6 acute care hospitals and 324 primary care centres), in addition to 3 Mental Health Networks, 2 long-stay hospitals and the emergency service, all with over 25,700 health professionals of whom almost 28% are nurses. The study sample were nurses from the Osakidetza hospital and primary care setting, with selection criteria being that they formed part of the structural Osakidetza team (i.e. nurses who were employed in a hospital or health centre and not in other organisations such as: mental health networks, comprehensive healthcare organisations, emergency services or general management. Comparisons could thus be made with previous studies). According to data obtained from the structural Osakidetsa team on February 14th 2012 the total sample of nurses was 7123 and the benchmark population for sample calculation (hospital and health centre workers) was 6027 nurses. The sample size (1572 nurses) was calculated to estimate proportions with a precision of 3%, and a 50% loss percentage. Stratification was carried out by area of work in accordance with the nursing professional distribution: 76.47% for specialised care (1207 nurses), 23.53% for primary care (368 nurses) and work setting (Álava, Bizkaia, Gipuzkoa) (Fig. 1). A simple random sample was made in each stratum in accordance with nurse numbers (using a list of random numbers generated by the statistical Epidat 3.1 package).

Sociodemograpahic and employment variables comprised time working; function; employment situation; type of working day and working environment. Training and research participation variables comprised academic studies. All variables were collected through a standardised questionnaire. The work setting variable was categorised into ‘‘hospital stay hospital ward’’ either medical or surgical; ‘‘special hospital services’’ which includes ICU, emergency services, surgery, dialysis and ‘‘central hospital services’’ which were grouped together into X-ray, laboratory and consultancy services. The BARRIERS21 scale was used to convey the difficulties perceived by the professionals to implementing nursing research findings into practice. This tool has been widely used in different countries and different professional nursing situations.23,30 It consists of 29 items grouped into 4 dimensions: (D1) professional characteristics; (D2) organisation characteristics; (D3) research quality and (D4) presentation and accessibility. The response format varies from 1 = never, 2 = to a lesser degree, 3 = to a moderate degree, 4 = largely. Opinion 5 = no comment, no score. The maximum sum of all items is therefore 116. The maximum sum of the items of each dimension is 32 for the first 2 dimensions and 24 for the last 2. This scale has surpassed the adaptation process in Spanish26 and it has been applied in studies with nurses in the Spanish state.25---27 In this study the overall viability of the scale mediated by the Cronbach alpha reached a score of 0.96. Each professional randomly selected was sent the study information to their work email address together with the request for their participation and the questionnaire. Data was collected for six months (from July to December 2014) during which 3 dispatches were repeated to improve the response rate. Furthermore, the questionnaire was sent in paper format, through those in charge of the centres for any email accounts which were blocked or full. Basic descriptive statistics were used to express qualitative and quantitative information of the variables. For the




M.Á. Cidoncha-Moreno, B. Ruíz de Alegría-Fernandez de Retana

BARRIERS scale values the mean and SD were used, despite them being ordinal variables, in order to compare the results with other studies. We confirmed whether the variables used adhered to a normal distribution using the Shapiro---Wilk test. Given that the result of this test for almost all variables produced a p value under 0.05, non-parametric methods of analysis were used. Analysis of association between variables was performed using the calculation of the Kendall’s Tau rank correlation coefficient. The hypotheses which involved differences between the groups in the study were those of the KruskallWallis test for comparisons of means between more than two groups. When the result was significant, post hoc contrasts were performed to check which differences existed between these groups. A significance level of p 0.05 was used to interpret the results using the Programa R-project programme, GNU licence, version 3.2.0. The project obtained approval in wiring from the Clinical Research Ethics Committee of Basque Country. Study participation was voluntary.

Results 1572 questionnaires were sent and a response rate of 43.76% (688 nurses) was obtained. The mean age was 23.77 years (SD: 8.57). Out of the total of professional participants, the majority were located in the area of care and had a permanent contract of employment. Regarding educational level, the nurses referred to a maximum academic nursing diploma level in almost 60% of cases, with a poor level of English. They also stated that, in the last three years 85% of nurses had a training level of under 40 h, with participation in research mainly consisting of data collection (Table 1). By applying the BARRIERS scale analysis revealed higher mean scores in the ‘‘organisation characteristics’’ dimension, followed by ‘‘professional characteristics’’ (Table 2). When the items which were considered to be higher barriers were analysed (those groups with scores of ‘‘to a moderate degree’’ and ‘‘mostly’’), we identified that the greatest barrier perceived for professionals was: ‘‘there is not sufficient time at work to implement new ideas’’ (situated in the ‘‘organisation characteristics dimension’’) and the second difficulty was found to be: ‘‘the nurses are unaware of research studies’’ (in the ‘‘professional characteristics’’ dimension) (Table 3). Statistically significant differences were found in the dimensions ‘‘organisation characteristics’’ and in ‘‘research quality’’ of the BARRIERS questionnaire between the

Table 2

Table 1

Sample characteristics (n = 688). No.


Employment function Care/clinical care Management Teaching Research

599 76 12 1

87.1 11.0 1.7 0.1

Employment situation Permanent Casual/temporary/replacement

600 88

87.2 12.8

Type of working day Full-time Part time

607 81

88.2 11.8

Employment environment Primary care Hospital care

203 485

29.5 70.5

Academic studies Only diploma/further studies Specialist nurse Graduate Master Doctorate Post graduate and/or expert

399 124 32 46 0 176

57.9 18.0 4.7 6.7 0.0 25.6

Training in research during the last 3 years Under 40 h 583 Between 40 and 150 h 84 Over 50 h 21

84.7 12.2 3.1

Level of English Zero Low Medium High

225 334 112 17

32.7 48.5 16.3 2.5




Participation in research projects Main researcher Collaborator researcher Field worker

33 119 206

4.8 17.3 29.9

different areas of work studied (Table 4). However, when applying the post hoc contrasts only the dimension ‘‘quality of research’’ showed any significant differences between ‘‘primary care’’ and ‘‘special hospital services’’, so that the nurses of the ‘‘special hospital services’’ perceived of greater barriers in ‘‘quality of research’’ than those of ‘‘Primary care’’.

Values obtained in the BARRIERS questionnaire dimensions.

Dimension (maximum value)




Organisation characteristics (32) Professional characteristics (32) Presentation and accessibility of research (24) Quality of research (24) Total score (112)

21.81 21.30 15.89 14.29 71.35

22 22 16 15 73

5.70 5.40 3.79 4.89 17.11


To a minor extent

To a moderate extent


Greatest barriers

No comment

5.8 16.3 9.9

15.1 32.4 23.5

25.3 26.3 27.9

51.3 18.3 34.6

76.6 44.6 62.5

2.5 6.7 4.1

17.6 16.4 18.2 16.6 6.8

28.5 25.1 27.5 24.1 19.2

28.8 33.3 29.7 28.6 26.9

23.3 21.1 15.6 27.9 39.0

52.1 54.4 45.3 56.5 65.9

1.9 4.1 9.2 2.8 8.1

Organisation characteristics The facilities are not appropriate for their implementation Nurses have no time to read up on research Nurses do not feel they have sufficient authority to change patient care Nurses believe that results cannot be mainstreamed to their environment Doctors do not collaborate in implementation Managers do not permit implementation The other nursing staff do not support implementation There is not enough time to implement new ideas.

10.6 9.7 11.5 10.8 3.2 5.8 7.7 3.9

23. 14.4 17.9 23.0 17.4 21.8 26.6 13.1

28.1 30.2 28.5 37.2 26.0 27.8 31.7 23.7

28.8 44.3 40.3 24.6 40.1 26.9 24.1 56.8

56.9 74.5 68.8 61.8 66.1 54.7 55.8 80.5

9.3 1.3 1.9 4.5 13.2 18.0 9.9 2.1

Quality of the research The research was not contrasted Nurses have doubts about accepting as research results The research has methodological shortcomings The research articles/reports are published with great delay The conclusions reached are not duly justified The literature publicises contradictory results

16.6 12.6 9.4 6.3 12.6 8.1

33.7 29.9 31.4 23.4 32.1 33.1

21.7 31.5 24.9 28.3 32.6 27.5

8.0 20.8 11.3 16.6 6.5 14.0

29.7 52.3 36.2 44.9 39.1 41.5

20.1 5.1 23.0 25.4 16.1 17.3

Presentation and accessibility Research articles/reports are unavailable Implications for practice are not clearly presented The amount of information in research is overwhelming Statistical analysis is incomprehensible Research does not affect nursing practice The corresponding literature is not available in a single place Research is not clearly redacted and does not invite reading

12.5 4.8 10.3 4.9 45.6 4.9 4.9

29.1 24.1 27.6 21.4 20.3 16.0 23.7

33.9 33.3 25.9 31.4 17.9 24.4 32.8

18.0 30.7 22.7 37.9 14.4 38.2 32.0

51.9 64 48.6 69.3 32.3 62.6 64.8

6.5 7.1 13.5 4.4 1.7 16.4 6.5

Response percentages are highlighted in bold. Percentages of the greatest barriers are grouped together (‘‘to a moderate degree’’ and ‘‘mostly’’).


Professional opinions Nurses are unaware of research studies Nurses interpret that the advantages of applying the new ideas would be minimal Nurses are isolated compared with other professionals with whom they can comment upon research outcomes Nurses see few benefits in research for their activities t Nurses do not perceive the research findings as relevant for application in practice There is no documented need for a change in practice Nurses are not willing to change/try out new ideas Nurses do not always feel capable of assessing the quality of research


Frequency of response (%) in BARRIERS.

Barriers to the implementation of research perceived by nurses

Table 3


Comparison of means from the BARRIERS dimension according to care setting. A. Primary care [a] Me

Hospital wards [b]



Special services hospital [c]



Central services hospital [d]


Kruskall---Wallis contrast test





Post hoc

21.0 22.00 14.00 16.00

7.00 7.00 6.00 5.00

22.00 23.00 15.00 16.00

8.00 9.00 6.00 6.00

23.00 23.00 16.00 17.00

6.00 8.00 5.00 5.00

22.00 21.00 13.50 16.00

7.05 8.25 10.00 5.00

6.04 8.12 12.74 4.72

0.110 0.040 0.005 0.192

----a.c ---













Me: median; p: probability value; IQR: interquartile range;

2 :

chi squared.

0---10 years [a] Me BARRIERS Professional characteristics Organisation characteristics Quality of research Presentation and accessibility of research

21 23 15 17



IQR 6.25 7.25 5 4.5 15.5

11---20 years [b] Me 22 23 15 16 75

Me: median; p: probability value; IQR: interquartile range; 2 : chi squared.

IQR 6.25 8 6 6 22

21---30 years [c]

>30 years [d]

Kruskall Wallis contrast test 2


7 7 8 5

6.15 12.48 4.08 7.47

0.104 0.005 0.253 0.058








22 23 15 16

8 7 6 5

21 21 15 15




Post hoc

b.d c.d b.d

M.Á. Cidoncha-Moreno, B. Ruíz de Alegría-Fernandez de Retana

Comparison of means from the BARRIERS dimension according to years of experience.


BARRIERS Professional characteristics Organisation characteristics Quality of research Presentation and accessibility of research

Table 5



Table 4



Barriers to the implementation of research perceived by nurses We also found there were statistically significant differences in the dimension ‘‘organisation characteristics’’ between how long the groups had been at work. Post hoc contrasts identified differences between those who had over 30 years of working experience compared with the group with 11---20 years of experience and with those with between 21 and 30 years of experience (Table 5).

Discussion Nurses from Osakidetza identified the largest barriers in ‘‘organisation characteristics’’, mostly attributing them to lack of time at work. This barrier coincides with other national25---27 and international18,23 studies. It may therefore be said that the barriers identified by nursing professionals remain relatively stable, and are reiterated in difference contexts. With regards to the barriers relating to the ‘‘professional characteristics’’ dimension, the nurses attribute their greatest barrier to a lack of training in research and to poor criteria to enable evaluation of research quality. This fits in with the low training in research they state they have had over the last 3 years. This indicates that training in critical reading will drive the incorporation of advances and innovations into clinical practice. Coinciding with another national study30 the nurses from the Special Services in Osakidetza state there are more barriers in the ‘‘quality of research’’ dimension on incorporating research results into practice than the primary care nurses. This may make one think that the nurses of this group may be better prepared and they feel they have better criteria to assess research results. In this study the time working factor was shown as a factor which intervenes in the perception of several barriers, so that the nurses with more years of working experience tend to perceive of fewer barriers in the organisation than those with fewer years of working experience.

Limitations Several aspects may deflect from the reality of results obtained. The rate of participation may limit data generalisation. Furthermore, this study was conducted with a sample from the Osakidetza structural team and not from all nurses, and findings must therefore be regarded with precaution. The fact that research and implementation of results into practice are major elements both in health organisation, scientific societies and society in general may have had an influence on professionals. They may have wished to give socially acceptable responses instead of those which truly reflected what they felt and did. It is hoped that this bias was neutralised by the guarantee of anonymity and confidentiality. Although in this study we only analysed some of the factors affecting the perception of barriers, and bearing in mind that other variables may act as confounding variables to the perception of difficulty for implementing research into practice, future research maybe further enlightened by taking into account aspects such as gender; type of employment contract (permanent or temporary; full or part

7 time); general or specialist professional and professional training.

Conclusion Despite the limitations commented upon above, this study reveals that the nurses of Osakidetaza perceive there to be similar barriers to nurses of other contexts, attributing organisational aspects as the greatest barrier, and also revealing the influence of several factors in the perception of barriers which may help to establish strategies to facilitate the use of research in practice, and aimed at providing quality.

Financing This work was financed by the PI12/00838 project, integrated into the state plan R+D+I 2013---2016 and co-financed by the ISCIII-Sub.Directorate General of Evaluation and Research and the European Regional Development Fund (ERDF).

Conflict of interests The authors have no conflict of interests to declare.

Acknowledgements We thank the nurses of Osakidetza who with their anonymous collaboration have provided accurate information. We also thank the Osakidetza. Nursing management for its support and resources.

References 1. Brown CE, Wickline MA, Ecoff L, Glaser D. Nursing practice, knowledge, attitudes and perceived barriers to evidencebased practice at an academic medical center. J Adv Nurs. 2009;65:371---81. 2. Heydari A, Zeydi AE. Barriers to and facilitators of research utilization among Iranian nurses: a literature review. J Caring Sci. 2014;3:265---75. 3. Bonner A, Sando J. Examining the knowledge, attitude and use of research by nurses. J Nurs Manag. 2008;16:334---43. 4. Patiraki E, Karlou C, Papadopoulou D, Spyridou A, Kouloukoura C, Bare E, et al. Barriers in implementing research findings in cancer care: the Greek registered nurses’perceptions. Eur J Oncol Nurs. 2004;8:245---65. 5. Hommelstad J, Ruland CM. Norwegian nurses’perceived barriers and facilitators to research use. AORN J. 2004;79:621---34. 6. Sackett DL, Rosenberg WM, Muir JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMC. 1996;312:71---2. 7. McCleary L, Brown T. Association between nurses’ education about research and their research use. Nurse Educ Today. 2003;23:556---65. 8. Olade RA. Evidence-based practice and research utilization activities among rural nurses. J Nurs Scholarsh. 2004;36:220---5. 9. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 2004;13:913---24.



8 10. Straus SE, Tetroe JM, Graham ID. Knowledge translation is the use of knowledge in health care decision making. J Clin Epidemiol. 2011;64:6---10. 11. MyGlinn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635---45. 12. Grol RP, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225---30. 13. Damshroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:1---15. 14. Estabrooks CA, Midodzi WK, Cummings GG, Wallin L. Predicting research use in nursing organizations: a multilevel analysis. Nurs Res. 2007;564 Suppl. l:S7---23. 15. Stetler CB, Ritchie J, Rycroft-Malone J, Schultz AA, Charns MP. Institutionalizing evidence-based practice: an organizational case study using a model of strategic change. Implement Sci. 2009;4:1---19. 16. Thompson D, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L. Interventions aimed at increasing research use in nursing: a systematic review. Implement Sci. 2007;2:15. 17. Thompson DS, Moore KN, Estabrooks CA. Increasing research use in nursing: implications for clinical educators and managers. Evid Based Nurs. 2008;11:35---9. 18. Retsas A. Barriers to using research evidence in nursing practice. J Adv Nurs. 2000;31:599---606. 19. Hutchinson AM, Johnston L. Bridging the divide: a survey of nurses’ opinions regarding barriers to, and facilitators of, research utilization in the practice setting. J Clin Nurs. 2004;13:304---15. 20. Meijers JM, Janssen MA, Cummings GG, Wallin L, Estabrooks CA, Halfens RYG. Assessing the relationships between contextual factors and research utilization in nursing: systematic literature review. J Adv Nurs. 2006;55:622---35.

M.Á. Cidoncha-Moreno, B. Ruíz de Alegría-Fernandez de Retana 21. Funk S, Champagne M, Wiese R, Tornquist E. Barriers to using research findings in practice: the clinician’s perspective. Appl Nurs Res. 1991;4:90---5. 22. Squires JE, Estabrooks CA, Gustavsson P, Wallin L. Individual determinants of research by nurses: a systematic review update. Implement Sci. 2011;6:1---20. 23. Athanasakis E. The BARRIERS to research utilization scale. IJCS. 2013;6:16---28. 24. Kajermo KN, Undén M, Gardulf A, Eriksson LE, Orton ML, Arnetz BB, et al. Predictors of nurses’ perceptions of barriers to research utilization. J Nurs Manag. 2008;16:305---14. 25. Moreno T, Fuentelsaz C, de Miguel AG, González E, Clarke SP. 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. J Clin Nurs. 2011;20(13---14): 1936---47. 26. Moreno T, Fuentelsaz C, Gonzalez E, Gil de Miguel A. Barreras para la utilización de la investigación Estudio descriptivo en profesionales de enfermería de la práctica clínica y en investigadores activos. Enferm Clin. 2010;20: 153---64. 27. Bernal RJ, Rodríguez JJ, Lagos E, Cabezas L, Domínguez MT, Moreno C. Barreras para la investigación en enfermería. Rev ROL Enferm. 2014;37(7---8):520---6. 28. Macintyre S, Ellaway A, Cummins S. Place effects on health: how can we conceptualize, operationalize and measure them? Soc Sci Med. 2002;55:125---39. 29. Dijkstra R, Wensing M, Thomas R, Akkermans R, Braspenning J, Grimshaw J, et al. The relationship between organizational characteristics and the effects of clinical guidelines on medical performance in hospitals, a meta-analysis. BMC Health Serv Res. 2006;6:53. 30. Frasure J. Analisis of instruments measuring nurses’ attitudes toward research utilization: a systematic review. J Adv Nurs. 2008;61:5---18.