NORTHWEST COMMUNITY HOSPITAL was awarded Magnet status in February 2006. The journey to Magnet began in 2002, with an initial gap analysis and a review of the 14 Forces of Magnetism. Force 6, Quality of Nursing Care, includes 7 sources of evidence related to research and evidence-based practice.1 Organizations need to provide written narratives and supporting evidence related to the development, dissemination, and enculturation of the research infrastructure. Like many hospitals, Northwest Community Hospital was challenged to foster an environment where registered nurses (RNs) used research findings to enhance nursing practice.
Based on the review, the nursing leadership team identified the need to create an infrastructure to engage RNs in the research process. Numerous initiatives were undertaken. These included expanding journal clubs to all nursing units, selecting the Iowa Model of Evidence-Based Practice, establishing a nursing research council, and creating a center for nursing research.2 In 2005, the Nursing Research Fellowship Program was established to further advance nursing research in the practice setting.3 The purpose of the fellowship was to provide direct care RNs with an opportunity to serve as principal investigators for clinical research studies. Direct care nurses chosen to be fellows were guaranteed 16 hours of release time per month for 1 year, received mentoring from a PhD consultant, and had access to a statistician. The chief nurse executive was committed to fostering an environment where nursing research was integrated into clinical decision making and the delivery of nursing care.
One area of discussion related to factors that influenced research being conducted in a community hospital setting. The group questioned if RNs working in the community hospital would experience more or different barriers than nurses in academic medical centers.
The purpose of the study discussed in this article was to identify the barriers and facilitators of research utilization in our community hospital. The research question was: are the barriers and facilitators to research utilization in a community hospital setting the same as those identified in previous studies conducted in academic medical centers?
Barriers to a nurse's use of research in everyday practice have been cited in numerous studies.4-10 Common findings emerged from these studies. The majority of the barriers are found within the organization itself. These include difficulty in changing practice, lack of administrative support, insufficient time on the job to implement new ideas or read research works, lack of knowledgeable mentors, and insufficient time to conduct research.
Since the BARRIERS to Research Utilization Scale (BARRIERS Scale) was first published in 1991,10,11 more than 30 national and international studies have been conducted.12 Studies conducted in the United States were in academic medical centers. Community hospitals served as the setting for studies in the United Kingdom, Sweden, and Australia. Findings related to the organization have remained consistent across settings and over the years.
In a study conducted in an academic medical center, researchers used the BARRIERS Scale to evaluate organization strategies designed to increase research utilization.13 Baseline data were collected, organizational strategies to improve research utilization and evidence-based practice were implemented, and then postimplementation data were collected. Posttest findings indicated a significant improvement in the factors of the BARRIERS Scale related to characteristics of the organization and the adopter.
There was only 1 study done in a Magnet community hospital.14 Barriers to research utilization were examined by administering the BARRIERS Scale to 584 RNs. Four of the 5 top barriers were related to the organization. Although the barriers were similar to those found in previous studies, the domain means were lower, reflecting more research use that was attributed to the process of Magnet preparation, increased practice autonomy, and existence of a nursing research council.14
Traditionally, community hospitals have not focused on research or research utilization. However, these concepts are integral to obtaining and sustaining Magnet status. This study helps bridge the gap in knowledge related to research utilization in community hospital settings.
The study had a descriptive, quantitative design involving the administration of the BARRIERS Scale to 1100 RNs working in a variety of practice settings at Northwest Community Hospital. The study also explored differences in barriers related to the nursing unit, education, and certification. The hospital was on the Magnet journey when the questionnaire was administered and the data were collected and analyzed.
The BARRIERS Scale, based on Roger's Theory of Diffusion,15 was developed in 1991. It is a 29-item 4-point Likert-type questionnaire with established reliability and validity.11,12 Principal component analyses identified 4 factors on the scale. Characteristics of the adopter (factor 1) refer to the nurse's research values, skills, and awareness. Characteristics of the organization (factor 2) include settings, barriers, and limitations. Characteristics of the innovation (factor 3) refer to the qualities of the research. Characteristics of the communication (factor 4) are the presentation and accessibility of the research. Respondents are asked to rate the extent to which each item is a barrier to the use of research in their practice. The scale ranges from 1 ("to no extent") to 4 ("to a great extent"). Three open-ended questions follow at the end on other barriers to research utilization, the 3 greatest barriers to nurses' use of research and what facilitates research utilization.
A series of demographic questions were added. These included gender, age, level of nursing education, years of experience, area of employment within the hospital, and position in the organization.
Approval from the hospital institutional review board (IRB) was obtained prior to the start of the study. The questionnaire was distributed to all RNs working during a selected 6-week timeframe. There was a 25% response rate (n = 271), with 249 usable questionnaires (23%); the remainder of the questionnaires were not used because of incomplete data.
The median age of the respondents was 45 years. A majority of the respondents (72.3%) were in a staff nurse position (n = 180); 85.5% (n = 213) provided direct patient care, and a majority (34.9%) had 21 to 30 years of experience (n = 87). Almost half (46%) held a baccalaureate degree (n = 115), more than a half (54.2%) were members of a professional organization (n = 135), 47% (n = 117) were certified in their specialty area, and 29% (n = 74) read professional journals that included research studies 1 to 2 times a month.
The researchers had hypothesized that associate degree- and diploma-prepared nurses would experience more barriers than baccalaureate-prepared nurses and that master's-prepared nurses would experience fewer barriers than baccalaureate-prepared nurses. This was true only for characteristics of the organization or setting. An analysis of variance revealed that the only statistically significant difference was between the educational level of diploma- and master's-prepared nurses (F3,327 = 3.77, P = .011). Based on the difference in content in those programs on research and evidence-based practice, this result was not surprising. Second, RNs with master's degrees are less likely to provide direct patient care and have more flexibility in terms of time and autonomy in practice to use research findings, change practice, and implement new ideas. The mean scores between associate degree- and baccalaureate-prepared nurses were almost identical. Other studies have found few differences in research utilization based on educational preparation. This might be attributed to both groups working in staff nurse roles and being faced with the same organizational barriers of lack of time, resources, and administrative support.
There was no statistical difference between the overall mean score of nurses who were certified (2.35) and the nurses who were not certified (2.39). Certification denotes clinical excellence and competency; however, the areas of research and evidence-based practice are not validated via the certification examinations. Twenty-one percent of the associate degree nurses responded that they read professional nursing journals containing research studies 1 to 2 times a week compared with 9.7% of baccalaureate nurses and 23.3% of master's-prepared nurses. The researchers could not explain the lower response of baccalaureate-prepared nurses.
The researchers had hypothesized that RNs working in the critical care setting would experience fewer barriers than nurses working in the medical-surgical areas because in this particular hospital, some of the critical care nurses were participating in evidence-based projects. An analysis of variance showed no differences across the various practice settings. The complexity of the patient population and intense focus on interventions in the critical care environment might have been contributing factors to the barrier scores showing no differences across settings.
Respondent scores and barriers
Mean scores were calculated for each of the 29 items. The top 10 barriers are presented in Table 1. The respondents perceived items related to the organization as the top 3 barriers. These were as follows: (1) the nurse does not feel he or she has enough authority to change patient care procedures (M = 2.87), (2) there is insufficient time on the job to implement new ideas (M = 2.85), and (3) the nurse does not have time to read research (M = 2.84).
|Table 1. Barriers to using research in practice|
It is of interest that none of the top 10 barriers related to characteristics of the innovation or qualities of the research. This might have been attributed to the education about research that was in place at the time of the study, inception of the nursing research council, and focus on research that was part of the Magnet journey.
Factor means and barriers
For each factor, the mean scores were summed and divided by the number of subscale items to determine group means (Table 2). Column 1 represents the factors or categories and column 2 represents the top 2 barriers for each factor. Items related to characteristics of the organization or setting were the greatest barriers, and items related to characteristics of the innovation were rated low.
|Table 2. Top barriers by factor|
The researchers had hypothesized that the factor mean scores would be less than in other BARRIER Scale studies because of the hospital being on the Magnet journey. This hypothesis was supported and consistent with findings from other studies, except for characteristics of the innovation.14
BARRIERS Scale qualitative results
Respondents were asked to list any additional barriers to research utilization; 74 nurses (30%) responded to this item. The researchers reviewed the responses, grouped them into themes, and recorded how many times they reoccurred. The majority of the barriers (52%) were related to the theme of lack of time to read, discuss, implement, or evaluate research. Comments included "no time to review research," "no work time allocated to read research," "no time to talk about research findings," and "it takes time to access research journals."
The researchers identified 2 new themes that were not part of Funk's original work. These included (1) the value of a work-life balance and (2) lack of a formal research infrastructure. Comments related to work-life balance included "unwillingness to use personal time," "outside commitments take priority," "lifestyle outside of work is important," and "reading articles is secondary to a hectic life." Lack of a formal research infrastructure was defined as "not having funding for research studies," "need for consistent support structures, systems and processes to read, evaluate and incorporate new ideas," and "hospital does not have statistician readily available."
Sixty-one percent (n = 151) of the nurses responded to the question of what facilitates research. The majority of the comments (67%) related to the organizational culture. These included comments, such as "the shared governance model that is in place," "the availability of journals," "supportive colleagues and mentorship," "an environment that encourages autonomy," and "the research fellowship program."
This study was conducted in 1 community hospital setting, thus the results may not be generalizable to nurses working in other practice settings. A convenience sample with a response rate of 25% is also a limitation. The participants who chose to complete the survey might have an increased awareness of the relevance and value of nursing research for practice. Another factor was that the organization was on the Magnet journey when the questionnaire was distributed. Within the preceding 12 months, there was a heightened educational awareness on evidence-based practice and nursing research, and the Nursing Research Fellowship had been initiated.
Study findings related to barriers and facilitators of research utilization in this community hospital setting correspond to those found in the literature. The top 2 barriers are that the nurse does not have enough authority to change patient care procedures and there is insufficient time to implement new ideas; these barriers were identical to the original findings in 1991.11,12 The nursing profession has made considerable progress in bringing research into practice; however, the concepts of autonomy and time need to be part of the cultural transformation for this initiative to be both successful and sustainable.
Nurses' perceptions that they lack the ability to change practice will improve only when they experience research-based changes in nursing practice in their settings. At Northwest Community Hospital, practice changes have resulted from staff nurse-driven evidence-based practice and research projects. These included implementation of music therapy in the postanesthesia care unit; revision of skin care protocols for oncology, neonatal, and perioperative patients; and use of a pain assessment tool for patients with cognitive impairment.3
Time limitations have been addressed by providing direct care RNs with dedicated release time to work on research projects.3,12,13 However, this is usually limited to a small number of RNs. Strategies to reduce the amount of time it takes to search the literature and make research readily accessible to all nurses include providing Internet access via computers based on nursing units and subscribing to online databases that provide succinct reviews of current literature findings.12 In a national study, staff nurses reported a low use of databases and limited resources to learn how to access resources for evidence-based practice.16 Mentorship and education are essential to increase research utilization at the point of care.
The new finding of work-life balance presents a challenge for nursing leaders. Gen X nurses (age range, 30-45) value the coexistence of family and work; Gen Y nurses (age range, 20-30) seek options at work and want to customize work to meet the needs of their personal lives.17 For those nurses to be satisfied and challenged, the application of research and evidence-based practice needs to be transparent and part of innovative clinical practice. This requires the full integration of research findings throughout the organization in terms of administrative and clinical decision making. Research and evidence-based practice cannot be viewed as activities separate from daily nursing practice and are implemented only if time allows.
The second new finding of the lack of a formal research infrastructure was surprising to the researchers because the hospital has a formal Nursing Research Fellowship Program in place. The program is new, and only 6 RNs had been part of the formal program when the questionnaire was administered. Since Magnet status was awarded, the focus has been on sustaining and increasing the momentum. Communication was enhanced, so all RNs were aware of the available mentoring, educational sessions, statistical consultation, and funding for posters and presentations even if they were not part of the formal research fellowship. The number of educational sessions on evidence-based practice and nursing research offered in the hospital has increased.
As a result, the nursing research council has expanded in membership and scope. Membership has expanded from 14 members during inception in 2003 to 22 members in 2007. Scope has increased to include 3 subcommittees of education/journal club, IRB protocol review, and evidence-based practice. The number of evidence-based projects and journal clubs has increased, and nursing research projects have expanded from the inpatient setting to diabetes education, home health, and perioperative services. Two nursing research days have been held at the hospital to afford staff RNs the opportunity to present posters. Five nurses have presented posters at national conferences over the past year. The third Nursing Research Fellowship will begin in the spring of 2008.
Areas for future research based on the findings from this study include replication of the study within 2 years to assess if the expansion of the Nursing Research Fellowship and nursing research council has made a sustainable difference. A second area of research could be a correlational study between perceived barriers and a practice environment where work-life balance is fostered. As information technology is advanced to make point-of-care retrieval of research evidence possible and practical, nurse administrators could study the cost-benefit analysis in terms of patient outcomes or minimization of barriers.
Achieving quality outcomes, best practices, and nursing excellence requires new dissemination of knowledge. Translating research into practice advances professional nursing practice, provides patients with care that is evidence based, and fosters an environment grounded in the tenets of the ANCC Magnet Recognition Program.