Development and validation of a derived measure of research utilization by nurses

The Definitions and Conceptualizations of the Practice Context in the Health Professions: A Scoping Review

INTRODUCTION

Health care professionals work in different contexts, which can influence professional competencies. Despite existing literature on the impact of context on practice, the nature and influence of contextual characteristics, and how context is defined and measured, remain poorly understood. The aim of this study was to map the breadth and depth of the literature on how context is defined and measured and the contextual characteristics that may influence professional competencies.

METHODS

A scoping review using Arksey and O'Malley's framework. We searched MEDLINE (Ovid) and CINAHL (EBSCO). Our inclusion criteria were studies that reported on context or relationships between contextual characteristics and professional competencies or that measured context. We extracted data on context definitions, context measures and their psychometric properties, and contextual characteristics influencing professional competencies. We performed numerical and qualitative analyses.

RESULTS

After duplicate removal, 9106 citations were screened and 283 were retained. We compiled a list of 67 context definitions and 112 available measures, with or without psychometric properties. We identified 60 contextual factors and organized them into five themes: Leadership and Agency, Values, Policies, Supports, and Demands.

DISCUSSION

Context is a complex construct that covers a wide array of dimensions. Measures are available, but none include the five dimensions in one single measure or focus on items targeting the likelihood of context influencing several competencies. Given that the practice context plays a critical role in health care professionals' competencies, stakeholders from all sectors (education, practice, and policy) should work together to address those contextual characteristics that can adversely influence practice.

Barriers and Facilitators to Implementing Web-Based Dementia Caregiver Education From the Clinician's Perspective: Qualitative Study

Background

Internet-based dementia caregiver interventions have been shown to be effective for a range of caregiver outcomes; however, little is known about how to best implement them. We developed iGeriCare, an evidence-based, multimedia, web-based educational resource for family caregivers of people living with dementia.

Objective

This study aims to obtain feedback and opinions from experts and clinicians involved in dementia care and caregiver education about 1 iGeriCare and 2 barriers and facilitators to implementing a web-based caregiver program.

Methods

We carried out semistructured interviews with individuals who had a role in dementia care and/or caregiver education in several key stakeholder settings in Southern Ontario, Canada. We queried participants’ perceptions of iGeriCare, caregiver education, the implementation process, and their experience with facilitators and barriers. Transcripts were coded and analyzed using a grounded theory approach. The themes that emerged were organized using the Consolidated Framework for Implementation Research.

Results

A total of 12 participants from a range of disciplines described their perceptions of iGeriCare and identified barriers and facilitators to the implementation of the intervention. The intervention was generally perceived as a high-quality resource for caregiver education and support, with many stakeholders highlighting the relative advantage of a web-based format. The intervention was seen to meet dementia caregiver needs, partially because of its flexibility, accessibility, and compatibility within existing clinical workflows. In addition, the intervention helps to overcome time constraints for both caregivers and clinicians.

Conclusions

Study findings indicate a generally positive response to the use of internet-based interventions for dementia caregiver education. Results suggest that iGeriCare may be a useful clinical resource to complement traditional face-to-face and print material–based caregiver education. More comprehensive studies are required to identify the effectiveness and longevity of web-based caregiver education interventions and to better understand barriers and facilitators with regard to the implementation of technology-enhanced caregiver educational interventions in various health care settings.

Research utilization in municipality nursing practice in rural districts in Norway: a cross-sectional quantitative questionnaire study

BACKGROUND

Scientific knowledge and theory constitute part of the nurse's competence and evidence-based nursing practice. To obtain and maintain these skills, nurses require access to research utilization. The aim of the present study was therefore to describe and compare nurses in nursing homes and home-based nursing care and their use of research knowledge in their practice in elderly care in Norwegian rural districts.

METHODS

The Research Utilization Questionnaire (RUQ) was employed in cross-sectional quantitative design. One hundred nurses were recruited from ten rural municipalities that participated in the study. Inclusion criteria for participating were registered nurses and employees working in the municipal elderly care service for 6 months or more.

RESULTS

Most participants were younger than 55 years old, worked in permanent jobs, and were educated more than 5 years ago. The result showed that nurses in nursing homes were significantly more positive compared to nurses in home-based nursing care when analyzing all three domains in the RUQ together, as well as for attitudes towards research when testing each domain separated. Overall, each item in the domains revealed opinions that were more positive for nurses in nursing homes. The regression analysis showed that attitudes towards research, as well as availability and support of research utilization predicted the use of research in daily practice.

CONCLUSIONS

Positive attitudes, availability, and support for research utilization can contribute to greater use of research in nursing practice and improve the quality of service. Younger nurses' knowledge about using research should be shared with senior colleagues, who possess much experience in practice. In collaboration, they can develop evidence-based practice by the implementation of research seen in the context of nurses' experiences, user involvement, and person-centred practice. The i-PARIHS (Promoting Action on Research Implementation in Health Services) framework can be a useful tool in this implementation process.

The use of the PARIHS framework in implementation research and practice-a citation analysis of the literature

BACKGROUND

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was developed two decades ago and conceptualizes successful implementation (SI) as a function (f) of the evidence (E) nature and type, context (C) quality, and the facilitation (F), [SI = f (E,C,F)]. Despite a growing number of citations of theoretical frameworks including PARIHS, details of how theoretical frameworks are used remains largely unknown. This review aimed to enhance the understanding of the breadth and depth of the use of the PARIHS framework.

METHODS

This citation analysis commenced from four core articles representing the key stages of the framework's development. The citation search was performed in Web of Science and Scopus. After exclusion, we undertook an initial assessment aimed to identify articles using PARIHS and not only referencing any of the core articles. To assess this, all articles were read in full. Further data extraction included capturing information about where (country/countries and setting/s) PARIHS had been used, as well as categorizing how the framework was applied. Also, strengths and weaknesses, as well as efforts to validate the framework, were explored in detail.

RESULTS

The citation search yielded 1613 articles. After applying exclusion criteria, 1475 articles were read in full, and the initial assessment yielded a total of 367 articles reported to have used the PARIHS framework. These articles were included for data extraction. The framework had been used in a variety of settings and in both high-, middle-, and low-income countries. With regard to types of use, 32% used PARIHS in planning and delivering an intervention, 50% in data analysis, 55% in the evaluation of study findings, and/or 37% in any other way. Further analysis showed that its actual application was frequently partial and generally not well elaborated.

CONCLUSIONS

In line with previous citation analysis of the use of theoretical frameworks in implementation science, we also found a rather superficial description of the use of PARIHS. Thus, we propose the development and adoption of reporting guidelines on how framework(s) are used in implementation studies, with the expectation that this will enhance the maturity of implementation science.

Context, complexity and process in the implementation of evidence-based innovation: a realist informed review

Background

This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process.

Methods

Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors.

Results

A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries.

Conclusions

The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

Predictors of Nurses' Research Use in Canadian Long-term Care Homes

OBJECTIVES

We examined the influence of individual characteristics and organizational context features on nurses' self-reported use of research evidence in long-term care (LTC) homes.

DESIGN

A cross-sectional analysis of survey data collected in the Translating Research in Elder Care program.

SETTING AND PARTICIPANTS

756 nurses (registered nurses and licensed practical nurses) from 89 LTC homes in Western Canada.

METHODS

Generalized estimating equation modeling was used to identify which individual characteristics and organizational context features significantly predicted (P < .05) 3 kinds of self-reported research use by nurses: instrumental (the direct application of research findings), conceptual (using research findings to change thinking), and persuasive (using research findings to convince others).

RESULTS

Nurses reported a moderate to high level of research use. There were no significant differences in mean research use scores by nursing role. Only 2 variables were associated with all 3 kinds of research use: having a positive attitude toward research, and availability of structural and electronic resources. Additional variables associated with instrumental research use were problem-solving ability, engaging in formal interactions (eg, education sessions), and better perceptions of organizational slack-staff (the availability of sufficient staff). Additional variables associated with conceptual research use were self-determination and job efficacy. Finally, additional variables associated with persuasive research use were belief suspension (the ability to suspend previously held beliefs), organizational citizenship behavior (one's voluntary commitment to the organization), self-determination, job efficacy, evaluation, and better perceptions of organizational slack-time (perceived availability of extra time).

CONCLUSIONS AND IMPLICATIONS

Conceptual and persuasive research use were most strongly influenced by individual characteristics, whereas instrumental research use was predicted equally by individual and organizational variables. Nurses working in LTC are positioned in leadership roles; by targeting both the individual- and organizational-level predictors of nurses' research use, they can improve conditions for individuals living in LTC.

The Influence of Context on Utilizing Research Evidence for Pain Management in Jordanian Pediatric Intensive Care Units (PICU)

PURPOSE

The purpose of this study was to gain a beginning understanding of the contextual factors that influence the use of research for pain management in Jordanian Pediatric Intensive Care Units (PICUs).

DESIGN AND METHODS

A paper or online questionnaire was used to collect data on instrumental research use (IRU) and conceptual research use (CRU) and ten contextual variables from 73 registered nurses working in four Jordanian PICUs. The Pearson product-moment correlation coefficient was used to test the relationship between continuous (demographic and contextual) factors and IRU and CRU. One way ANOVA and independent t-test were used to examine the differences between sociodemographic variables and IRU and CRU. Generalized Estimating Equations (GEE) was used to determine the demographic and contextual factors that influenced research use. We modeled the significant variables identified by bivariate correlation, t-test, and ANOVA at (p≤0.10).

RESULTS

Nine of the contextual factors significantly and positively correlated with the IRU for pain assessment, eight with the IRU for pain treatment, and six with the CRU for pain management (including assessment and treatment). Hospital type (public) predicted the IRU for pain assessment. Social capital, structural, and electronic resources predicted the IRU for pain treatment. Social capital predicted the CRU for pain management.

CONCLUSION

Context influences Jordanian PICU nurses' use of research for pain management.

PRACTICE IMPLICATIONS

Concentrating on modifiable contextual factors may positively influence Jordanian PICU nurses' use of research for pain management. This influence may extend to reduce children's pain in Jordanian PICUs.

Readiness for Implementation of Lung Cancer Screening. A National Survey of Veterans Affairs Pulmonologists

RATIONALE

To mitigate the potential harms of screening, professional societies recommend that lung cancer screening be conducted in multidisciplinary programs with the capacity to provide comprehensive care, from screening through pulmonary nodule evaluation to treatment of screen-detected cancers. The degree to which this standard can be met at the national level is unknown.

OBJECTIVES

To assess the readiness of clinical facilities in a national healthcare system for implementation of comprehensive lung cancer screening programs, as compared with the ideal described in policy recommendations.

METHODS

This was a cross-sectional, self-administered survey of staff pulmonologists in pulmonary outpatient clinics in Veterans Health Administration facilities.

MEASUREMENTS AND MAIN RESULTS

The facility-level response rate was 84.1% (106 of 126 facilities with pulmonary clinics); 88.7% of facilities showed favorable provider perceptions of the evidence for lung cancer screening, and 73.6% of facilities had a favorable provider-perceived local context for screening implementation. All elements of the policy-recommended infrastructure for comprehensive screening programs were present in 36 of 106 facilities (34.0%); the most common deficiencies were the lack of on-site positron emission tomography scanners or radiation oncology services. Overall, 26.5% of Veterans Health Administration facilities were ideally prepared for lung cancer screening implementation (44.1% if the policy recommendations for on-site positron emission tomography scanners and radiation oncology services were waived).

CONCLUSIONS

Many facilities may be less than ideally positioned for the implementation of comprehensive lung cancer screening programs. To ensure safe, effective screening, hospitals may need to invest resources or coordinate care with facilities that can offer comprehensive care for screening through downstream evaluation and treatment of screen-detected cancers.

Impact of Managers' Coaching Conversations on Staff Knowledge Use and Performance in Long-Term Care Settings

BACKGROUND

Extended lifespans and complex resident care needs have amplified resource demands on nursing homes. Nurse managers play an important role in staff job satisfaction, research use, and resident outcomes. Coaching skills, developed through leadership skill-building, have been shown to be of value in nursing.

AIMS

To test a theoretical model of nursing home staff perceptions of their work context, their managers' use of coaching conversations, and their use of instrumental, conceptual and persuasive research.

METHODS

Using a two-group crossover design, 33 managers employed in seven Canadian nursing homes were invited to attend a 2-day coaching development workshop. Survey data were collected from managers and staff at three time points; we analyzed staff data (n = 333), collected after managers had completed the workshop. We used structural equation modeling to test our theoretical model of contextual characteristics as causal variables, managers' characteristics, and coaching behaviors as mediating variables and staff use of research, job satisfaction, and burnout as outcome variables.

RESULTS

The theoretical model fit the data well (χ² = 58, df = 43, p = .06) indicating no significant differences between data and model-implied matrices. Resonant leadership (a relational approach to influencing change) had the strongest significant relationship with manager support, which in turn influenced frequency of coaching conversations. Coaching conversations had a positive, non-significant relationship with staff persuasive use of research, which in turn significantly increased instrumental research use. Importantly, coaching conversations were significantly, negatively related to job satisfaction.

LINKING EVIDENCE TO ACTION

Our findings add to growing research exploring the role of context and leadership in influencing job satisfaction and use of research by healthcare practitioners. One-on-one coaching conversations may be difficult for staff not used to participating in such conversations. Resonant leadership, as expected, has a significant impact on manager support and job satisfaction among nursing home staff.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care--a cluster randomised study

BACKGROUND

Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention.

METHODS

The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention.

RESULTS

No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal.

CONCLUSIONS

The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44819426.

Integrative review of implementation strategies for translation of research-based evidence by nurses

OBJECTIVES

The purpose of this review was to synthesize and critique experimental and/or quasi-experimental research that has evaluated implementation strategies for translation of research-based evidence into nursing practice.

BACKGROUND

Successfully implementing evidence-based research can improve patient outcomes. Identifying successful implementation strategies is imperative to move research-based evidence into practice.

RATIONALE

As implementation science gains popularity, it is imperative to understand the strategies that most effectively translate research-based evidence into practice.

DESCRIPTION

The review used the CINAHL and MEDLINE (Ovid) databases. Articles were included if they were experimental and/or quasi-experimental research designs, were written in English, and measured nursing compliance to translation of research-based evidence. An independent review was performed to select and critique the included articles.

OUTCOME

A wide array of interventions were completed, including visual cues, audit and feedback, educational meetings and materials, reminders, outreach, and leadership involvement. Because of the complex multimodal nature of the interventions and the variety of research topics, comparison across interventions was difficult.

CONCLUSION

Many difficulties exist in determining what implementation strategies are most effective for translation of research-based evidence into practice by nurses.

IMPLICATIONS

With these limited findings, further research is warranted to determine which implementation strategies most successfully translate research-based evidence into practice.

Sources of knowledge used by intensive care nurses in Norway: an exploratory study

This study explored the sources of knowledge that intensive care nurses used in their daily nursing practice. It used a qualitative design based on four focus group interviews with 20 intensive care nurses, from four intensive care units in Norway. Data were analysed using systematic text condensation. The following condensed meaning units were identified: research, theoretical knowledge, experiential knowledge, work place culture, clinical expertise and patient participation. This study illustrates the complexity and variety of the knowledge bases of intensive care nurses. Despite some variation in nurses' familiarity with research literature, nursing interventions found by research to be useful were given priority, and research affected daily practice through changes in guidelines and procedures.

Using theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization-wide implementation of two nursing-centric best-practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence-informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.

Monitoring and managing metabolic effects of antipsychotics: a cluster randomized trial of an intervention combining evidence-based quality improvement and external facilitation

BACKGROUND

Treatment of psychotic disorders consists primarily of second generation antipsychotics, which are associated with metabolic side effects such as overweight/obesity, diabetes, and dyslipidemia. Evidence-based clinical practice guidelines recommend timely assessment and management of these conditions; however, research studies show deficits and delays in metabolic monitoring and management for these patients. This protocol article describes the project 'Monitoring and Management for Metabolic Side Effects of Antipsychotics,' which is testing an approach to implement recommendations for these practices.

METHODS/DESIGN

This project employs a cluster randomized clinical trial design to test effectiveness of an evidence-based quality improvement plus facilitation intervention. Eligible study sites were VA Medical Centers with ≥300 patients started on a new antipsychotic prescription in a six-month period. A total of 12 sites, matched in pairs based on scores on an organizational practice survey, were then randomized within pairs to intervention or control conditions.Study participants include VA employees involved in metabolic monitoring and management of patients treated with antipsychotics at participating sites. The intervention involves researchers partnering with clinical stakeholders to facilitate tailoring of local implementation strategies to address barriers to metabolic side-effect monitoring and management. The intervention includes a Design Phase (initial site visit and subsequent development of a local implementation plan); Implementation Phase (guided by an experienced external facilitator); and a Sustainability Phase. Evaluation includes developmental, implementation-focused, progress-focused and interpretative formative evaluation components, as well as summative evaluation. Evaluation methods include surveys, qualitative data collection from provider participants, and quantitative data analysis of data for all patients prescribed a new antipsychotic medication at a study site who are due for monitoring or management of metabolic side effects during the study phases. Changes in rates of recommended monitoring and management actions at intervention and control sites will be compared using time series analyses.

DISCUSSION

Improving monitoring for metabolic side effects of antipsychotics, as well as promoting timely evidence-based management when these effects emerge, will lead to improved patient safety and long-term outcomes. This article discusses key strengths and challenges of the study.

TRIAL REGISTRATION

NCT01875861.

Building the research capacity of clinical physical therapists using a participatory action research approach

BACKGROUND

This 2-year study explored the experiences of clinical physical therapists who used a participatory action research (PAR) approach to learn about the practice of clinical research.

OBJECTIVES

The aim of this study was to explore the experiences of physical therapists who were conducting clinical research, facilitated by a PAR approach.

DESIGN

A mixed-methods research design was used.

METHODS

Physical therapists completed questionnaires, were interviewed, and participated in focus groups prior to and after the 1-year intervention and 1 year later. The research facilitator took field notes. Questionnaire data were analyzed descriptively, and themes were developed from the qualitative data. Twenty-five therapists took part in 4 self-selected groups.

RESULTS

Three groups actively participated in the PAR research projects (n=14). The remaining 11 therapists decided not to be involved in clinical research projects but took part in the study as participants. After 1 year, one group completed the data collection phase of their research project, and a second group completed their ethics application. The third group ceased their research project but hosted a journal club session. At completion of the study, the experiences of the physical therapists were positive, and their confidence in conducting research and orientation toward research had increased. The perceptions of physical therapists toward research, relationships among individuals, and how the clinical projects were structured influenced the success of the projects.

LIMITATIONS

Only physical therapists of one hospital and no other health care practitioners were included in this study.

CONCLUSIONS

Fourteen physical therapists divided among 3 PAR groups were overall positive about their experiences when they conducted a research project together. This finding shows that a PAR approach can be used as a novel tool to stimulate research participation in clinics.

Influence of socio-demographic, labour and professional factors on nursing perception concerning practice environment in Primary Health Care

AIM

To analyze the perception of nursing professionals of the Madrid Primary Health Care environment in which they practice, as well as its relationship with socio-demographic, work-related and professional factors.

DESIGN

Cross-sectional, analytical, observational study.

PARTICIPANTS AND CONTEXT

Questionnaire sent to a total of 475 nurses in Primary Health Care in Madrid (former Health Care Areas 6 and 9), in 2010.

MAIN MEASUREMENTS

Perception of the practice environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI) questionnaire, as well as; age; sex; years of professional experience; professional category; Health Care Area; employment status and education level.

RESULTS

There was a response rate of 69.7% (331). The raw score for the PES-NWI was: 81.04 [95%CI: 79.18-82.91]. The factor with the highest score was "Support from Managers" (2.9 [95%CI: 2.8-3]) and the lowest "Workforce adequacy" (2.3 [95%CI: 2.2-2.4]). In the regression model (dependent variable: raw score in PES-NWI), adjusted by age, sex, employment status, professional category (coefficient B=6.586), and years worked at the centre (coefficient B=2.139, for a time of 0-2 years; coefficient B=7.482, for 3-10 years; coefficient B=7.867, for over 20 years) remained at p≤0.05.

CONCLUSIONS

The support provided by nurse managers is the most highly valued factor in this practice environment, while workforce adequacy is perceived as the lowest. Nurses in posts of responsibility and those possessing a higher degree of training perceive their practice environment more favourably. Knowledge of the factors in the practice environment is a key element for health care organizations to optimize provision of care and to improve health care results.

Psychometric evaluation of a questionnaire and primary healthcare nurses' attitudes towards research and use of research findings

AIM

This article investigates attitudes towards and awareness of research and use of research findings among primary healthcare nurses, determinants of attitudes and evaluation of psychometric properties of an instrument measuring nurses' attitudes.

BACKGROUND

The production of new knowledge is ongoing and the amount of research of relevance for health care has increased, but there remains a gap between what is known and what is done in practice. To enhance evidence-based practice and patient safety, the use of research findings needs to be encouraged and promoted.

METHOD

An explanatory study using a cross-sectional survey was conducted in 2005-2006. The survey included items about background data and the instrument attitudes towards and awareness of research and development in nursing. 1054 nurses participated in the study. Factor analyses and Cronbach's alpha were used to evaluate internal structure and internal consistency of the instrument.

RESULT

The nurses generally held positive attitudes towards research. Although most of the nurses reported using research in practice, 37% claimed that they never or rarely used research findings. Half of the respondents perceived they had the ability to analyse scientific reports/articles. This ability and research use were significant determinants of attitudes. Factor analysis of the scale resulted in a three-factor solution, which differs from the seven-factor structure previously identified by the originators of the instrument.

CONCLUSION

Our results support the view that implementation of research is a complex process involving several factors. The different factor structure identified suggests that further work is needed on this instrument.

Patterns of research utilization among Certified Hand Therapists

STUDY DESIGN

Mixed methods, cross-sectional.

INTRODUCTION

Nearly 30% of Certified Hand Therapists rarely or never use research findings when treating carpal tunnel syndrome.

PURPOSE OF THE STUDY

To identify groups of CHTs with common research utilization patterns.

METHODS

National randomized mail survey of 600 CHTs (n = 308, RR = 55%). Latent class and thematic analysis of eight questions assessing research use and beliefs.

RESULTS

Four groups of CHT research users were identified: Analytic (n = 135, 45%); Skeptic (n = 65, 22%); Pragmatic (n = 53, 18%); and Traditional (n = 46, 15%). Highest research use was reported among Analytics and Pragmatics although Skeptics willingly relied on research evidence when it contradicted other sources of knowledge. Age, not experience or population density, was a significant covariate of group membership.

CONCLUSIONS

Empowering CHTs to use research findings by increased understanding of their group membership, and understanding others' groups, may increase progress toward evidence-based practice.

Swedish translation, adaptation and psychometric evaluation of the Context Assessment Index (CAI)

BACKGROUND

The strength of and relationship between the fundamental elements context, evidence and facilitation of the PARIHS framework are proposed to be key for successful implementation of evidence into healthcare practice. A better understanding of the presence and strength of contextual factors is assumed to enhance the opportunities of adequately developing an implementation strategy for a specific setting. A tool for assessing context-The Context Assessment Index (CAI)-was developed and published 2009. A Swedish version of the instrument was developed and evaluated among registered nurses. This work forms the focus of this paper.

PURPOSE

The purpose of this study was to translate the CAI into Swedish, adapt the instrument for use in Swedish healthcare practice and assess its psychometric properties.

METHODS

The instrument was translated and back-translated to English. The feasibility of items and response scales were evaluated through think aloud interviews with clinically active nurses. Psychometric properties were evaluated in a sample of registered nurses (n = 373) working in a variety of healthcare organisations in the Stockholm area. Item and factor analyses and Cronbach's alpha were computed to evaluate internal structure and internal consistency.

RESULT

Sixteen items were modified based on the think aloud interviews and to adapt the instrument for use in acute care. A ceiling effect was observed for many items and the originally identified 37 item five-factor model was not confirmed. Item analyses showed an overlap between factors and indicated a one-dimensional scale.

DISCUSSION

The Swedish version of the CAI has a wider application than the original instrument. This might have contributed to the differences in factor structure. Different opportunities for further development of the scale are discussed.

CONCLUSIONS

Further evaluation of the psychometric properties of the CAI is required.

The NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy

BACKGROUND

In response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.

DISCUSSION

The paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.

SUMMARY

Designing and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.

The relationship between organizational culture and implementation of clinical practice guidelines: a narrative review

The context in which critical care providers work has been shown to be associated with adherence to recommendations of clinical practice guidelines (CPGs). Consideration of contextual factors such as organizational culture may therefore be important when implementing guidelines. Organizational culture has been defined simply as "how things are around here" and encompasses leadership, communication, teamwork, conflict resolution, and other domains. This narrative review highlights the results of recent quantitative and qualitative studies, including studies on adherence to nutrition guidelines in the critical care setting, which demonstrate that elements of organizational culture, such as leadership support, interprofessional collaboration, and shared beliefs about the utility of guidelines, influence adherence to guideline recommendations. Outside nutrition therapy, there is emerging evidence that strategies focusing on organizational change (eg, revision of professional roles, interdisciplinary teams, integrated care delivery, computer systems, and continuous quality improvement) can favorably influence professional performance and patient outcomes. Consequently, future interventions aimed at implementing nutrition guidelines should aim to measure and take into account organizational culture, in addition to considering the characteristics of the patient, provider, and guideline. Further high quality, multimethod studies are required to improve our understanding of how culture influences guideline implementation, and which organizational change strategies might be most effective in optimizing nutrition therapy.

Developing the practice context to enable more effective pain management with older people: an action research approach

BACKGROUND

This paper, which draws upon an Emancipatory Action Research (EAR) approach, unearths how the complexities of context influence the realities of nursing practice. While the intention of the project was to identify and change factors in the practice context that inhibit effective person-centred pain management practices with older people (65 years or older), reflective critical engagement with the findings identified that enhancing pain management practices with older people was dependent on cultural change in the unit as a whole.

METHODS

An EAR approach was utilised. The project was undertaken in a surgical unit that conducted complex abdominal surgery. Eighty-five percent (n = 48) of nursing staff participated in the two-year project (05/NIR02/107). Data were obtained through the use of facilitated critical reflection with nursing staff.

RESULTS

Three key themes (psychological safety, leadership, oppression) and four subthemes (power, horizontal violence, distorted perceptions, autonomy) were found to influence the way in which effective nursing practice was realised. Within the theme of 'context,' effective leadership and the creation of a psychologically safe environment were key elements in the enhancement of all aspects of nursing practice.

CONCLUSIONS

Whilst other research has identified the importance of 'practice context' and models and frameworks are emerging to address this issue, the theme of 'psychological safety' has been given little attention in the knowledge translation/implementation literature. Within the principles of EAR, facilitated reflective sessions were found to create 'psychologically safe spaces' that supported practitioners to develop effective person-centred nursing practices in complex clinical environments.

Individual determinants of research utilization by nurses: a systematic review update

BACKGROUND

Interventions that have a better than random chance of increasing nurses' use of research are important to the delivery of quality patient care. However, few reports exist of successful research utilization in nursing interventions. Systematic identification and evaluation of individual characteristics associated with and predicting research utilization may inform the development of research utilization interventions.

OBJECTIVE

To update the evidence published in a previous systematic review on individual characteristics influencing research utilization by nurses.

METHODS

As part of a larger systematic review on research utilization instruments, 12 online bibliographic databases were searched. Hand searching of specialized journals and an ancestry search was also conducted. Randomized controlled trials, clinical trials, and observational study designs examining the association between individual characteristics and nurses' use of research were eligible for inclusion. Studies were limited to those published in the English, Danish, Swedish, and Norwegian languages. A vote counting approach to data synthesis was taken.

RESULTS

A total of 42,770 titles were identified, of which 501 were retrieved. Of these 501 articles, 45 satisfied our inclusion criteria. Articles assessed research utilization in general (n = 39) or kinds of research utilization (n = 6) using self-report survey measures. Individual nurse characteristics were classified according to six categories: beliefs and attitudes, involvement in research activities, information seeking, education, professional characteristics, and socio-demographic/socio-economic characteristics. A seventh category, critical thinking, emerged in studies examining kinds of research utilization. Positive relationships, at statistically significant levels, for general research utilization were found in four categories: beliefs and attitudes, information seeking, education, and professional characteristics. The only characteristic assessed in a sufficient number of studies and with consistent findings for the kinds of research utilization was attitude towards research; this characteristic had a positive association with instrumental and overall research utilization.

CONCLUSIONS

This review reinforced conclusions in the previous review with respect to positive relationships between general research utilization and: beliefs and attitudes, and current role. Furthermore, attending conferences/in-services, having a graduate degree in nursing, working in a specialty area, and job satisfaction were also identified as individual characteristics important to research utilization. While these findings hold promise as potential targets of future research utilization interventions, there were methodological problems inherent in many of the studies that necessitate their findings be replicated in further research using more robust study designs and multivariate assessment methods.

A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework

Background

The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations.

Methods

We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus.

Results

Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.'

Conclusions

While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.

Individual nurse and organizational context considerations for better Knowledge Use in Pain Care

Nurses are involved in many of the painful procedures performed on hospitalized children. In collaboration with physicians, nurses have an exceptional responsibility to have knowledge to manage the pain; however, the evidence indicates this is not being done. Issues may be twofold: (a) opportunities to improve knowledge of better pain care practices and/or (b) ability to use knowledge. Empirical evidence is available that if used by health care providers can reduce pain in hospitalized children. Theory-guided interventions are necessary to focus resources designated for learning and knowledge translation initiatives in the area of pain care. This article presents the Knowledge Use in Pain Care (KUPC) conceptual model that blends concepts from the fields of knowledge utilization and work life context, which are believed to influence the translation of knowledge to practice. The four main components in the KUPC model include those related to the organization, the individual nurse, the individual patient, and the sociopolitical context. The KUPC model was conceptualized to account for the complex circumstances surrounding nurse's knowledge uptake and use in the context of pain care. The model provides a framework for health care administrators, clinical leaders, and researchers to consider as they decide how to intervene to increase knowledge use to reduce painful experiences of children in the hospital.

The relationship between characteristics of context and research utilization in a pediatric setting

Background

Research utilization investigators have called for more focused examination of the influence of context on research utilization behaviors. Yet, up until recently, lack of instrumentation to identify and quantify aspects of organizational context that are integral to research use has significantly hampered these efforts. The Alberta Context Tool (ACT) was developed to assess the relationships between organizational factors and research utilization by a variety of healthcare professional groups. The purpose of this paper is to present findings from a pilot study using the ACT to elicit pediatric and neonatal healthcare professionals' perceptions of the organizational context in which they work and their use of research to inform practice. Specifically, we report on the relationship between dimensions of context, founded on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, and self-reported research use behavior.

Methods

A cross-sectional survey approach was employed using a version of the ACT, modified specifically for pediatric settings. The survey was administered to nurses working in three pediatric units in Alberta, Canada. Scores for three dimensions of context (culture, leadership and evaluation) were used to categorize respondent data into one of four context groups (high, moderately high, moderately low and low). We then examined the relationships between nurses' self-reported research use and their perceived context.

Results

A 69% response rate was achieved. Statistically significant differences in nurses' perceptions of culture, leadership and evaluation, and self-reported conceptual research use were found across the three units. Differences in instrumental research use across the three groups of nurses by unit were not significant. Higher self-reported instrumental and conceptual research use by all nurses in the sample was associated with more positive perceptions of their context.

Conclusions

Overall, the results of this study lend support to the view that more positive contexts are associated with higher reports of research use in practice. These findings have implications for organizational endeavors to promote evidence-informed practice and maximize the quality of care. Importantly, these findings can be used to guide the development of interventions to target modifiable characteristics of organizational context that are influential in shaping research use behavior.

Bridging the gaps among research, policy and practice in ten low- and middle-income countries: development and testing of questionnaire for health-care providers

BACKGROUND

The reliability and validity of instruments used to survey health-care providers' views about and experiences with research evidence have seldom been examined.

METHODS

Country teams from ten low- and middle-income countries (China, Ghana, India, Iran, Kazakhstan, Laos, Mexico, Pakistan, Senegal and Tanzania) participated in the development, translation, pilot-testing and administration of a questionnaire designed to measure health-care providers' views and activities related to improving their clinical practice and their awareness of, access to and use of research evidence, as well as changes in their clinical practice that they attribute to particular sources of research evidence that they have used. We use internal consistency as a measure of the questionnaire's reliability and, whenever possible, we use explanatory factor analyses to assess the degree to which questions that pertain to a single domain actually address common themes. We assess the questionnaire's face validity and content validity and, to a lesser extent, we also explore its criterion validity.

RESULTS

The questionnaire has high internal consistency, with Cronbach's alphas between 0.7 and 0.9 for 16 of 20 domains and sub-domains (identified by factor analyses). Cronbach's alphas are greater than 0.9 for two domains, suggesting some item redundancy. Pre- and post-field work assessments indicate the questionnaire has good face validity and content validity. Our limited assessment of criterion validity shows weak but statistically significant associations between the general influence of research evidence among providers and more specific measures of providers' change in approach to preventing or treating a clinical condition.

CONCLUSION

Our analysis points to a number of strengths of the questionnaire--high internal consistency (reliability) and good face and content validity--but also to areas where it can be shortened without losing important conceptual domains.

Development and assessment of the Alberta Context Tool

Background

The context of healthcare organizations such as hospitals is increasingly accepted as having the potential to influence the use of new knowledge. However, the mechanisms by which the organizational context influences evidence-based practices are not well understood. Current measures of organizational context lack a theory-informed approach, lack construct clarity and generally have modest psychometric properties. This paper presents the development and initial psychometric validation of the Alberta Context Tool (ACT), an eight dimension measure of organizational context for healthcare settings.

Methods

Three principles guided the development of the ACT: substantive theory, brevity, and modifiability. The Promoting Action on Research Implementation in Health Services (PARiHS) framework and related literature were used to guide selection of items in the ACT. The ACT was required to be brief enough to be tolerated in busy and resource stretched work settings and to assess concepts of organizational context that were potentially modifiable. The English version of the ACT was completed by 764 nurses (752 valid responses) working in seven Canadian pediatric care hospitals as part of its initial validation. Cronbach's alpha, exploratory factor analysis, analysis of variance, and tests of association were used to assess instrument reliability and validity.

Results

Factor analysis indicated a 13-factor solution (accounting for 59.26% of the variance in 'organizational context'). The composition of the factors was similar to those originally conceptualized. Cronbach's alpha for the 13 factors ranged from .54 to .91 with 4 factors performing below the commonly accepted alpha cut off of .70. Bivariate associations between instrumental research utilization levels (which the ACT was developed to predict) and the ACT's 13 factors were statistically significant at the 5% level for 12 of the 13 factors. Each factor also showed a trend of increasing mean score ranging from the lowest level to the highest level of instrumental research use, indicating construct validity.

Conclusions

To date, no completely satisfactory measures of organizational context are available for use in healthcare. The ACT assesses several core domains to provide a comprehensive account of organizational context in healthcare settings. The tool's strengths are its brevity (allowing it to be completed in busy healthcare settings) and its focus on dimensions of organizational context that are modifiable. Refinements of the instrument for acute, long term care, and home care settings are ongoing.

Translating research in elder care: an introduction to a study protocol series

Background

The knowledge translation field is undermined by two interrelated gaps – underdevelopment of the science and limited use of research in health services and health systems decision making. The importance of context in theory development and successful translation of knowledge has been identified in past research. Additionally, examination of knowledge translation in the long-term care (LTC) sector has been seriously neglected, despite the fact that aging is increasingly identified as a priority area in health and health services research.

Aims

The aims of this study are: to build knowledge translation theory about the role of organizational context in influencing knowledge use in LTC settings and among regulated and unregulated caregivers, to pilot knowledge translation interventions, and to contribute to enhanced use of new knowledge in LTC.

Design

This is a multi-level and longitudinal program of research comprising two main interrelated projects and a series of pilot studies. An integrated mixed method design will be used, including sequential and simultaneous phases to enable the projects to complement and inform one another. Inferences drawn from the quantitative and qualitative analyses will be merged to create meta-inferences.

Outcomes

Outcomes will include contributions to (knowledge translation) theory development, progress toward resolution of major conceptual issues in the field, progress toward resolution of methodological problems in the field, and advances in the design of effective knowledge translation strategies. Importantly, a better understanding of the contextual influences on knowledge use in LTC will contribute to improving outcomes for residents and providers in LTC settings.

Use of Evidence-Based Practice in School Nursing: Survey of School Nurses at a National Conference

Primary and acute care settings are the focus of a concerted effort to implement evidence-based practice (EBP) in health care; yet, little attention has been given to use of EBP among school nurses. The aims of this study were to (a) describe current use of EBP among school nurses attending a national school nurse conference, (b) describe demographic, individual, and organizational factors associated with EBP use, and (c) identify resources needed to enhance EBP use. A survey designed for this study was distributed during a national school nurse conference. Descriptive statistics, correlations, and independent t tests were used to analyze respondent data regarding the current level of EBP use, awareness, skills, and information sources. Respondents also identified resources needed to increase use of EBP, which included networking opportunities, predeveloped EBP guidelines, and education on outcome evaluation. The results from this study will be used to develop strategies to increase the use of EBP in the school setting.

Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges

BACKGROUND

The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified.

DISCUSSION

This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model - important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation. Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place. In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally.

SUMMARY

The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches. We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.

A gaze through the lens of decision theory toward knowledge translation science

Research findings become evidence when an individual decides that the information is relevant and useful to a particular circumstance. Prior to that point, they are unrelated facts. For research translation to occur, research evidence needs filtering, interpretation, and application by individuals to the specific situation. For this reason, decision science is complementary to knowledge translation science. Both aim to support the individual in deciding the most appropriate action in a dynamic environment where there are masses of uncensored and nonprioritized information readily available. Decision science employs research theories to study the cognitive processes underpinning the filtering and integration of current scientific information into changing contexts. Two meta-theories, coherence and correspondence theories, have been used to provide alternative views and prompt significant debate to advance the science. The aim of this article is to stimulate debate about the relationship between decision theory and knowledge translation. Discussed is the critical role of cognition in clinical decision making, with a focus on knowledge translation. A critical commentary of the knowledge utilization modeling papers is presented from a decision science perspective. The article concludes with a discussion on the implications for knowledge translation when viewed through the lens of decision science.

Influence of organizational characteristics and context on research utilization

BACKGROUND

Despite three decades of empirical investigation into research utilization and a renewed emphasis on evidence-based medicine and evidence-based practice in the past decade, understanding of factors influencing research uptake in nursing remains limited. There is, however, increased awareness that organizational influences are important.

OBJECTIVES

To develop and test a theoretical model of organizational influences that predict research utilization by nurses and to assess the influence of varying degrees of context, based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework, on research utilization and other variables.

METHODS

The study sample was drawn from a census of registered nurses working in acute care hospitals in Alberta, Canada, accessed through their professional licensing body (n = 6,526 nurses; 52.8% response rate). Three variables that measured PARIHS dimensions of context (culture, leadership, and evaluation) were used to sort cases into one of four mutually exclusive data sets that reflected less positive to more positive context. Then, a theoretical model of hospital- and unit-level influences on research utilization was developed and tested, using structural equation modeling, and 300 cases were randomly selected from each of the four data sets.

RESULTS

Model test results were as follows--low context: chi2= 124.5, df = 80, p <. 001; partially low: chi2= 144.2, p <. 001, df = 80; partially high: chi2= 157.3, df = 80, p <. 001; and partially low: chi2= 146.0, df = 80, p <. 001. Hospital characteristics that positively influenced research utilization by nurses were staff development, opportunity for nurse-to-nurse collaboration, and staffing and support services. Increased emotional exhaustion led to less reported research utilization and higher rates of patient and nurse adverse events. Nurses working in contexts with more positive culture, leadership, and evaluation also reported significantly more research utilization, staff development, and lower rates of patient and staff adverse events than did nurses working in less positive contexts (i.e., those that lacked positive culture, leadership, or evaluation).

CONCLUSION

The findings highlight the combined importance of culture, leadership, and evaluation to increase research utilization and improve patient safety. The findings may serve to strengthen the PARIHS framework and to suggest that, although it is not fully developed, the framework is an appropriate guide to implement research into practice.

Theory and knowledge translation: setting some coordinates

In a healthcare context in which research evidence is not used routinely in practice, there have been increasingly loud calls for the use of theory from investigators working in the field of knowledge translation. Implementation researchers argue that theory should be used to guide the design of testable and practical intervention strategies, and thus, contribute to generalizable knowledge about implementation interventions. The purpose of this commentary is to critique model papers writing by a team of scholars who aimed to disentangle some of the relationships determining research utilization, by scrutinizing an existing conceptual framework that acknowledges, along with other factors, the importance of contextual factors in knowledge translation. These papers are used as a vehicle to explore theory application in knowledge translation research. As theory use and development is in its infancy, some key issues, including different ideological perspectives, factors for and against theory use, ensuring conceptual clarity, selecting coherent overarching frameworks, and choosing appropriately among theories, are considered. Finally, an agenda for theory-informed research is outlined, which highlights the need for scholarly, pluralistic, and collaborative activity if the state of knowledge translation science is to advance.

An alternative approach to addressing missing indicators in parallel datasets: research utilization as a phantom latent variable

When doing secondary data analysis, it is not uncommon to find that a key variable was not measured. Often the researcher has no option but to do without the missing indicator, but when nearly parallel datasets exist, the researcher may have other options. In an earlier article leading up to this special issue, this research team was confronted with the problem that research utilization had been measured in only one of two similar datasets, namely, in the 1996 but not the 1998 Alberta Registered Nurse survey. The 1998 dataset had a larger sample size (6,526 compared to 600 nurse respondents in 1996) and a stronger set of measured variables, but was missing the key variable of interest--research utilization. To overcome this, a regression-based strategy was used to create a research utilization score for each nurse in the 1998 survey by exploiting the availability of several anticipated causes of research utilization in both datasets. Presented here is an alternative and more complicated procedure that might be applied in future investigations. The article presents a methodological understanding of how to use a phantom variable to account for the unmeasured research utilization variable in a two-group structural equation model. This approach could be used to overcome several of the limitations connected to using a regression-based approach to creating a key missing variable when nearly parallel datasets are available.

Predicting research use in nursing organizations: a multilevel analysis

BACKGROUND

No empirical literature was found that explained how organizational context (operationalized as a composite of leadership, culture, and evaluation) influences research utilization. Similarly, no work was found on the interaction of individuals and contextual factors, or the relative importance or contribution of forces at different organizational levels to either such proposed interactions or, ultimately, to research utilization.

OBJECTIVE

To determine independent factors that predict research utilization among nurses, taking into account influences at individual nurse, specialty, and hospital levels.

DESIGN

Cross-sectional survey data for 4,421 registered nurses in Alberta, Canada were used in a series of multilevel (three levels) modeling analyses to predict research utilization.

METHODS

A multilevel model was developed in MLwiN version 2.0 and used to: (a) estimate simultaneous effects of several predictors and (b) quantify the amount of explained variance in research utilization that could be apportioned to individual, specialty, and hospital levels.

FINDINGS

There was significant variation in research utilization (p <.05). Factors (remaining in the final model at statistically significant levels) found to predict more research utilization at the three levels of analysis were as follows. At the individual nurse level (Level 1): time spent on the Internet and lower levels of emotional exhaustion. At the specialty level (Level 2): facilitation, nurse-to-nurse collaboration, a higher context (i.e., of nursing culture, leadership, and evaluation), and perceived ability to control policy. At the hospital level (Level 3): only hospital size was significant in the final model. The total variance in research utilization was 1.04, and the intraclass correlations (the percent contribution by contextual factors) were 4% (variance = 0.04, p <.01) at the hospital level and 8% (variance = 0.09, p <.05) at the specialty level. The contribution attributable to individual factors alone was 87% (variance = 0.91, p <.01).

CONCLUSIONS

Variation in research utilization was explained mainly by differences in individual characteristics, with specialty- and organizational-level factors contributing relatively little by comparison. Among hospital-level factors, hospital size was the only significant determinant of research utilization. Although organizational determinants explained less variance in the model, they were still statistically significant when analyzed alone. These findings suggest that investigations into mechanisms that influence research utilization must address influences at multiple levels of the organization. Such investigations will require careful attention to both methodological and interpretative challenges present when dealing with multiple units of analysis.

Implications for implementation science

Implementing evidence into healthcare practice is essential to maximize the benefits of research and billions of dollars spent generating new knowledge. Implementation science is the investigation of methods, interventions (strategies), and variables to influence adoption of evidence-based healthcare practices by individuals and organizations to improve clinical and operational decision making, and includes testing the effectiveness of interventions to promote and sustain use of evidence-based healthcare practices. Estabrooks and her research team are to be applauded not only for the excellent contributions to the understanding of research utilization but also for setting forth a series of articles to stimulate thinking and comments across national boundaries and lines of inquiry. Described here are the implications for implementation science with regard to conceptual frameworks, measurement issues, and research designs, stimulated by the papers of the Estabrooks investigative team set forth in this special issue.

Evidence-based practice and determinants of research use in elderly care in Sweden

RATIONALE AND OBJECTIVE

Evidence-based practice is a strategic ingredient in today's health care. Despite extensive efforts to produce and disseminate clinical guidelines, research uptake is still a difficult task. In Sweden, elderly care (EC) has shifted from hospital care to community-based care, and the major nursing-staff group in EC has no university education. These and other factors make implementation of evidence-based care particularly challenging in EC settings. The purpose of this study was to identify determinants of research utilization in EC.

METHOD

Two questionnaires that cover research utilization and organizational climate were mailed to all staff (n = 132) working in seven EC units. The response rate was 67%.

RESULTS

Of all respondents, 28% reported that they used research findings in daily practice (the RU group). Remaining respondents constituted the non-RU group. Significant differences existed between the RU group and the non-RU group as per six individual and six organizational factors. Using logistic regression models, four factors were significantly related to research utilization, namely: attitudes toward research (OR = 5.52, P = 0.004); seeking research that is related to clinical practice (OR = 5.56, P = 0.019); support from unit manager (OR = 4.03, P = 0.044) and access to research findings at work place (OR = 6.65, P = 0.005).

CONCLUSIONS

Individual and organizational factors were associated with the use of research in EC. Despite distinguishing conditions in EC settings, identified factors reflect well-known determinants of research use that, as in many other health care contexts, should be considered in the endeavours of evidence-based practice.