research utilization in nursing class 6 judith anne shaw, ph.d., r.n. october 21, 2009

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 10-15 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 theresearch 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.

Conceptual Instrumental

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 GapNursing 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 Forces

Target System

(Adapted from Lewin, K. (1951). Force Field Model)

Driving & Restraining ForcesBegin 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

ProblemConcern: 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 for change 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

Unfreezing Change Refreezing

Comfort Discomfort New 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 triggerto improve practicethrough research

(-that will initiate the need for change)

Problem-Focused Knowledge-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 literature2. National agencies or organizational

standards and guidelines3. Philosophies of care4. 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?

Sufficient Not 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 Staff Fiscal

& (Cost)

Family

Iowa Model for Research-Based Practice

Step #9:

Disseminate results

Sharing knowledge…and putting knowledge into practice