RESEARCH UTILIZATION IN NURSING CLASS 6 Judith Anne Shaw, Ph.D., R.N. October 21, 2009

OVERVIEW OF CLASS #6 Nursing Research Utilization Barriers to Research Utilization Change, a Positive Strategy for Research Utilization Iowa Model for Research-Based Practice

DEFINE RESEARCH UTILIZATION

Consider Utilization: to make use of, to use Research utilization: to make use of research in clinical practice

Research Utilization –the systematic process by which research-based knowledge becomes incorporated (or used) into practice.

PURPOSE RESEARCH UTILIZATION Application of available knowledge to improve client outcomes. Validation of existing nursing procedures and interventions

Evidence-Based Practice

Research Utilization Important all levels of nursing

Research Utilization Nurses in the clinical setting Promotes critical thinking Enhances professional self-concept Ensures safe and reflective practice Practice based on current, scientific, sound knowledge Enrich nurse’s self-confidence

Researcher Validates researcher’s efforts Provides motivation for scholars to continue to discover new knowledge Reinforces professional accountability Helps uncover new clinical problems for investigation

Health Care Agency Cost effective nursing care High-quality care Improved client outcomes Retention and recruitment tool Professionally satisfied and stimulated nursing staff

Profession of Nursing Enhances practice autonomy Positive professional image Strengthen professional status Expands nursing’s scientific knowledge base

What does history tell us about research utilization? A gap or time lag in the use of new knowledge in the clinical setting.

Time Lag Between Idea & Utilization can be years (Bostrom & Wise, 1994)

Narrowing the Research-Practice Gap Through Research Utilization Step # 1. select a relevant problem area Problem-focused triggers Knowledge-focused triggers

Problem Focused Triggers for Problem Identification Evident to nurses in the practice setting ¤ Clinical problems

Knowledge-Focused Triggers for Problem Identification Knowledge obtained from: ¤ Journal clubs ¤ Attending a professional/academic conference ¤ Reading a scientific paper

Narrowing the Research-Practice Gap Through Research Utilization Step #2. Review the literature ¤ Sufficient quantity ¤ Sufficient quality

Narrowing the Research-Practice Gap Through Research Utilization Step # 3. Determine …are findings appropriate to apply in the practice setting?

Criteria for Research Utilization Utility to nursing Applicability to practice Replication Scientific merit Client safety Feasibility

Narrowing the Research-Practice Gap Through Research Utilization Step # 4. Written plan to communicate the research-based intervention or protocol

Narrowing the Research-Practice Gap Through Research Utilization Step # 5. Implementation of the planned innovation ¤involve all staff ¤change process

Narrowing the Research-Practice Gap Through Research Utilization Step # 6. Evaluation of innovation ¤what went right? ¤what went wrong? ¤what changes are required?

Narrowing the Research-Practice Gap Through Research Utilization Step # 7. Dissemination of findings ¤publishing results of the research utilization ¤did it make a difference?

Problems: using research findings Barriers to knowledge “use” in nursing Nurse Characteristics Setting Characteristics Research Characteristics Innovation Characteristics

Barriers to Knowledge Use Study findings: – do not solve pressing clinical problems – often can not be used in practice – lack replication – communicated primarily to other researchers – not expressed in easily understood terms by practitioners

Nurse Characteristics Knowledge Attitudes Beliefs

Nurse Characteristics Knowledge Two Kinds of Knowledge 1. specific research studies related to practice setting 2. ability to critique reported research

Nurse Characteristics Attitudes Need positive attitude towards research utilization

Nurse Characteristics Beliefs Correct or erroneous beliefs about research ¤Change often begins with the articulation of negative beliefs ٠lack of time

Setting Characteristics Five characteristics that must be present: 1.Openness to new ideas 2.Interpersonal and information linkages for open communication 3.Freedom from organizational constraints 4.Supportive leadership 5.Trust … to risk possible failure

Research Characteristics Clearly communicated Comprehensive Investigation of pertinent problems Staff nurses part of the research team Replication of research studies

Innovation Characteristics Perceived improvement Compatibility with present practice Complexity Trialability Observability

How to work together and use Nursing Research Findings

Bridging The Research - Practice Gap 1. Commitment 2. Knowledge of the practice setting structure 3. Planned strategy of change/clinical setting

Pay-Off Narrowing the Research-Practice Gap 1. Improved client care 2. Developing the artistry of practice 3. Professional status of nurses 4. Status of nursing within the scientific, academic, and health service community 5. Societal relevance of professional practice

Current Conceptions of Research Utilization A continuum in terms of the specificity or diffuseness of the use of knowledge conceptual instrumental mid-ground

Research Utilization Instrumental Utilization : - base specific actions on research

Instrumental Utilization discrete clearly identifiable attempts to base some specific action on the results of research findings

Conceptual Utilization Influences nurses’ thinking about an issue. ConceptualInstrumental Mid-Ground

Conceptual Utilization Situations in which users (nurses) are influenced in their thinking about an issue based on their knowledge of one or more studies but do not put the knowledge to any specific documented use.

Mid Ground Utilization Knowledge creep Decision accretion Conceptual Instrumental Mid-Ground

Mid-Ground Utilization Partial impact of research findings on nursing activities -these nursing actions are based to some extent on research findings but other factors are considered.

Middle Ground Research Utilization Knowledge Creep: -an evolving percolation of research ideas and findings

Middle Ground Research Utilization Decision Accretion: - momentum for a decision builds over time based on accumulated information gained through such actions as reading, discussions, and meetings

Research Utilization Appropriate Goal for Nurses - all points along the continuum Conceptual Mid Ground Instrumental

Knowledge Gap in Nursing Production & Utilization A gap does exist in nursing, as well as other disciplines Some gap is inevitable given the imperfection of scientific research as a means of knowing

Possible Inflated Gap Nursing Knowledge Production & Utilization 1. Technical changes 2. Risk/benefit analysis 3. Non-captured utilization

Technical Changes Utilization studies do not always consider changes that make the knowledge irrelevant. (may take 2 yr. to publish findings)

Risk/Benefit Analysis - the risks for problems if the results are implemented and prove to be incorrect (nursing is more conservative versus medicine)

Non-Captured Utilization Focus of utilization studies is most often on instrumental utilization; probably mid - ground utilization of the continuum not captured.

What can... YOU & OTHER NURSES DO? Student nurses & practicing nurses –think, conceptually “use” research findings –regularly read research journals –read critical reviews of research –attend professional conferences

What can... YOU & OTHER NURSES DO? Researchers –conduct “quality” research –replicate –collaborate –disseminate aggressively & broadly (publish) –communicate clearly

What can... YOU & OTHER NURSES DO? Scholars & educators –incorporate research findings into the curriculum –note absence of relevant research, when appropriate –encourage research utilization –prepare integrative research reviews with class content

What can... YOU & OTHER NURSES DO? Administration –foster a climate of intellectual curiosity –offer emotional or “moral” support for utilization –reward efforts for utilization

Planned Change

Change Agent … one who works to bring about a change

The Process of Change Driving Restraining Forces Target System (Adapted from Lewin, K. (1951). Force Field Model)

Driving & Restraining Forces Begin the change process by… Analyzing the entire system involved to identify the forces for and against change driving forces: push the system toward change restraining forces: pull the system away from change

Forces driving forces: push the system toward change restraining forces: pull the system away from change

Problem Concern:When the existing restraining forces are the same or stronger than the driving forces Resolution: Use participative change strategies to reduce the restraining forces and increase the driving forces forchange to occur.

Assessing Opposing Forces Need a thorough knowledge about: - the target system - the environment - the characteristics of the change - the potential responses to change

PEOPLE RESIST CHANGE SOURCES TECHNICAL PSYCHOLOGICAL NEEDS THREATS TO POSITION & POWER

Change Process Three Phases: 1. Unfreezing 2. Change 3. Refreezing

THE CHANGE PROCESS UnfreezingChangeRefreezing ComfortDiscomfortNew Comfort Zone Zone Zone (diagnostic)(moving)(consolidation & evaluation of innovation)

Unfreezing Phase Takes deliberate actions to “stir things up” 1. Creates disconfirmation (feelings of discomfort or dissatisfaction) 2. Introduces guilt & anxiety (demonstrate unmet goal or value) 3. Provides psychological safety (sufficient security to minimize risk)

Unfreezing Phase At completion of the unfreezing phase: people feel “off-balance” people have hyper-energy people require direction for productive action

Changing Phase Implementation phase of change: (the target system is unfrozen & moving towards change)

Changing Phase The change agent: - introduces new information - encourages the new behavior - continues the supportive climate - provides opportunities for ventilation - provides feedback & clarification of goals - presents self as trustworthy - overcomes resistance

ESSENTIAL KEEPING EVERYONE INFORMED

Refreezing Phase To stabilize & integrate the change so that it becomes a regular part of target system Beginning of the phase: situation still fluid - the target system could still take another course than the planned change

Change Agent’s Action in the Refreezing Phase The change agent: -continues to act as an energizer -continues to guide new behavior -increases delegation of responsibilities for change behavior -maintain visibility and credibility of change -increases others’ responsibility and decreases leader-manager’s responsibility

CHANGE CONSIDER- WHETHER YOU THINK YOU HAVE A CHOICE FOR CHANGE OR THINK YOU DON’T HAVE A CHOICE FOR CHANGE, YOU’RE RIGHT

Iowa Model for Research-Based Practice (Gillis & Jackson, 2002; Farrington, Lang, Cullen, & Stewart; Titler et al., 2001)

Iowa Model for Research-Based Practice Set of steps used as a guide to identify practice questions

Iowa Model for Research-Based Practice Step #1: Determine type trigger to improve practice through research (-that will initiate the need for change) Problem-FocusedKnowledge-Focused

Iowa Model for Research-Based Practice Problem-focused triggers 1.Risk management data 2.Process improvement data 3.Internal/External benchmarking data 4.Financial data 5.Identification of clinical problem

Iowa Model for Research-Based Practice Knowledge-focused triggers 1.New research or other literature 2.National agencies or organizational standards and guidelines 3.Philosophies of care 4.Observation from institutional standards committees

Iowa Model for Research-Based Practice Step #2: Identification of relevant literature

Iowa Model for Research-Based Practice Step#3: Critique and Evaluate Research for use in Practice

Iowa Model for Research-Based Practice Step #4: Determine if there is Sufficient Research Base? SufficientNot Sufficient

Iowa Model for Research-Based Practice Step # 5: If Sufficient Research Base

Iowa Model for Research-Based Practice Step #5, Sufficient Research Base: PILOT THE CHANGE IN PRATICE Select outcome to be achieved Design Nursing/Multidisciplinary Practice Interventions Implement Practice Changes on a PILOT UNIT Evaluate process and Outcomes Modify Intervention as Needed

Iowa Model for Research-Based Practice Step #5, Insufficient Research Base: Conduct Research Base practice on other types of evidence –Case Reports –Expert opinions –Scientific principles –Theory

Iowa Model for Research-Based Practice Step #6: Ask- Is the Change Appropriate for Adoption in Practice?

Iowa Model for Research-Based Practice Step #7: If answer is NO Continue to evaluate quality of care and new knowledge

Iowa Model for Research-Based Practice Step #7: If answer is YES Institute the change in practice

Iowa Model for Research-Based Practice Step #8 Monitor Outcomes Patient Environment StaffFiscal &(Cost) Family

Iowa Model for Research-Based Practice Step #9: Disseminate results

Sharing knowledge… and putting knowledge into practice