research utilization in nursing class 6 judith anne shaw, ph.d., r.n. october 21, 2009
TRANSCRIPT
RESEARCH UTILIZATION IN NURSING
CLASS 6
Judith Anne Shaw, Ph.D., R.N.
October 21, 2009
OVERVIEW OF CLASS #6
• Nursing Research Utilization
• Barriers to Research Utilization
• Change, a Positive Strategy for Research Utilization
• Iowa Model for Research-Based Practice
DEFINE
RESEARCH UTILIZATION
Consider
• Utilization: to make use of, to use
• Research utilization: to make use of research in clinical practice
Research Utilization
– the systematic process by which research-based knowledge becomes incorporated (or used) into practice.
PURPOSE
• RESEARCH UTILIZATION
• Application of available knowledge to improve client outcomes.
• Validation of existing nursing procedures and interventions
Evidence-Based Practice
Research Utilization
Important
all levels of nursing
Research Utilization Nurses in the clinical setting
• Promotes critical thinking
• Enhances professional self-concept
• Ensures safe and reflective practice
• Practice based on current, scientific, sound knowledge
• Enrich nurse’s self-confidence
Researcher
• Validates researcher’s efforts
• Provides motivation for scholars to continue to discover new knowledge
• Reinforces professional accountability
• Helps uncover new clinical problems for investigation
Health Care Agency
• Cost effective nursing care
• High-quality care
• Improved client outcomes
• Retention and recruitment tool
• Professionally satisfied and stimulated nursing staff
Profession of Nursing
• Enhances practice autonomy
• Positive professional image
• Strengthen professional status
• Expands nursing’s scientific knowledge base
What does history tell us about research utilization?
• A gap or time lag in the use of new knowledge in the clinical setting.
Time Lag Between Idea & Utilization
• can be 10-15 years
(Bostrom & Wise, 1994)
Narrowing the Research-Practice Gap Through Research Utilization
Step # 1. select a relevant problem area
• Problem-focused triggers
• Knowledge-focused triggers
Problem Focused Triggers for Problem Identification
• Evident to nurses in the practice setting
¤ Clinical problems
Knowledge-Focused Triggers for Problem Identification
• Knowledge obtained from:
¤ Journal clubs
¤ Attending a professional/academic
conference
¤ Reading a scientific paper
Narrowing the Research-Practice Gap Through Research Utilization
Step #2. Review the literature
¤ Sufficient quantity
¤ Sufficient quality
Narrowing the Research-Practice Gap Through Research Utilization
• Step # 3. Determine …are findings appropriate to apply in the practice setting?
Criteria for Research Utilization
• Utility to nursing
• Applicability to practice
• Replication
• Scientific merit
• Client safety
• Feasibility
Narrowing the Research-Practice Gap Through Research Utilization
Step # 4. Written plan to communicate the research-based intervention or protocol
Narrowing the Research-Practice Gap Through Research Utilization
Step # 5. Implementation of the planned innovation
¤ involve all staff¤ change process
Narrowing the Research-Practice Gap Through Research Utilization
Step # 6. Evaluation of innovation
¤ what went right?¤ what went wrong?¤ what changes are required?
Narrowing the Research-Practice Gap Through Research Utilization
Step # 7. Dissemination of findings
¤ publishing results of theresearch utilization
¤ did it make a difference?
Problems: using research findings
Barriers to knowledge “use” in nursing
Nurse Characteristics
Setting Characteristics
Research Characteristics
Innovation Characteristics
Barriers to Knowledge Use
• Study findings:– do not solve pressing clinical problems– often can not be used in practice– lack replication– communicated primarily to other researchers– not expressed in easily understood terms by
practitioners
Nurse Characteristics
Knowledge
Attitudes
Beliefs
Nurse Characteristics
Knowledge
Two Kinds of Knowledge
1. specific research studies related to practice setting
2. ability to critique reported research
Nurse Characteristics
Attitudes
Need positive attitude towards research
utilization
Nurse Characteristics
Beliefs
Correct or erroneous beliefs about research
¤ Change often begins with the articulation of negative beliefs
٠lack of time
Setting Characteristics
Five characteristics that must be present:
1. Openness to new ideas
2. Interpersonal and information linkages for open communication
3. Freedom from organizational constraints
4. Supportive leadership
5. Trust … to risk possible failure
Research Characteristics
Clearly communicated
Comprehensive
Investigation of pertinent problems
Staff nurses part of the research team
Replication of research studies
Innovation Characteristics
• Perceived improvement
• Compatibility with present practice
• Complexity
• Trialability
• Observability
How to work together and use Nursing Research Findings
Bridging The Research - Practice Gap
1. Commitment
2. Knowledge of the practice setting structure
3. Planned strategy of change/clinical setting
Pay-Off Narrowing the Research-Practice Gap
1. Improved client care
2. Developing the artistry of practice
3. Professional status of nurses
4. Status of nursing within the scientific, academic, and health service community
5. Societal relevance of professional practice
Current Conceptions of Research Utilization
A continuum in terms of the specificity or
diffuseness of the use of knowledge
conceptual instrumental
mid-ground
Research Utilization
Instrumental Utilization:
- base specific actions on research
Instrumental Utilization
• discrete
• clearly identifiable attempts
to base some specific action on the
results of research findings
Conceptual Utilization
Influences nurses’ thinking about an issue.
Conceptual Instrumental
Mid-Ground
Conceptual Utilization
Situations in which users (nurses) are influenced in their thinking about an issue based on their knowledge of one or more studies but do not put the knowledge to any specific documented use.
Mid Ground Utilization
• Knowledge creep
• Decision accretion
Conceptual Instrumental
Mid-Ground
Mid-Ground Utilization
Partial impact of research findings on nursing activities
-these nursing actions are based to some extent on research findings but other
factors are considered.
Middle Ground Research Utilization
Knowledge Creep:
-an evolving percolation of research ideas and findings
Middle Ground Research Utilization
Decision Accretion:
-momentum for a decision builds over time based on accumulated information gained through such actions as reading, discussions, and meetings
Research Utilization
Appropriate Goal for Nurses
- all points along the continuum
Conceptual Mid Ground Instrumental
Knowledge Gap in Nursing Production & Utilization
• A gap does exist in nursing , as well as other disciplines
• Some gap is inevitable given the imperfection of scientific research as a means of knowing
Possible Inflated GapNursing Knowledge
Production & Utilization
1. Technical changes
2. Risk/benefit analysis
3. Non-captured utilization
Technical Changes
Utilization studies do not always consider
changes that make the knowledge irrelevant.
(may take 2 yr. to publish findings)
Risk/Benefit Analysis
- the risks for problems if the results are implemented and prove to be incorrect
(nursing is more conservative versus medicine)
Non-Captured Utilization
Focus of utilization studies is most often on instrumental utilization; probably mid -ground utilization of the continuum not captured.
What can... YOU & OTHER NURSES DO?
• Student nurses & practicing nurses
– think, conceptually “use” research findings
– regularly read research journals
– read critical reviews of research– attend professional conferences
What can... YOU & OTHER NURSES DO?
• Researchers– conduct “quality” research– replicate– collaborate– disseminate aggressively & broadly (publish)– communicate clearly
What can... YOU & OTHER NURSES DO?
• Scholars & educators– incorporate research findings into the curriculum
– note absence of relevant research, when appropriate
– encourage research utilization
– prepare integrative research reviews with class content
What can... YOU & OTHER NURSES DO?
• Administration– foster a climate of intellectual curiosity– offer emotional or “moral” support for
utilization– reward efforts for utilization
Planned Change
Change Agent
… one who works
to bring about
a change
The Process of Change
Driving Restraining
Forces Forces
Target System
(Adapted from Lewin, K. (1951). Force Field Model)
Driving & Restraining ForcesBegin the change process by…
Analyzing the entire system involved to identify the forces for and against change
driving forces: push the system toward
change
restraining forces: pull the system away
from change
Forces
driving forces: push the system toward
change
restraining forces: pull the system away
from change
ProblemConcern: When the existing restraining
forces are the same or stronger
than the driving forces
Resolution: Use participative change
strategies to reduce the restraining
forces and increase the driving
forces for change to occur.
Assessing Opposing Forces
Need a thorough knowledge about:
- the target system
- the environment
- the characteristics of the change
- the potential responses to change
PEOPLE RESIST CHANGE SOURCES
TECHNICAL
PSYCHOLOGICAL NEEDS
THREATS TO POSITION & POWER
Change Process
Three Phases:
1. Unfreezing
2. Change
3. Refreezing
THE CHANGE PROCESS
Unfreezing Change Refreezing
Comfort Discomfort New Comfort Zone Zone Zone
(diagnostic) (moving) (consolidation & evaluation of
innovation)
Unfreezing Phase
Takes deliberate actions to “stir things up”
1. Creates disconfirmation (feelings of discomfort or dissatisfaction)
2. Introduces guilt & anxiety (demonstrate unmet goal or value)
3. Provides psychological safety (sufficient security to minimize risk)
Unfreezing Phase
At completion of the unfreezing phase:
people feel “off-balance”
people have hyper-energy
people require direction for productive action
Changing Phase
Implementation phase of change:
(the target system is unfrozen
& moving towards change)
Changing Phase
The change agent:
- introduces new information
- encourages the new behavior
- continues the supportive climate
- provides opportunities for ventilation
- provides feedback & clarification of goals
- presents self as trustworthy
- overcomes resistance
ESSENTIAL
KEEPING EVERYONE INFORMED
Refreezing Phase
To stabilize & integrate the change so that it becomes a regular part of target system
Beginning of the phase: situation still fluid
- the target system could still take another course than the planned change
Change Agent’s Action in the Refreezing Phase
The change agent:
-continues to act as an energizer
-continues to guide new behavior
-increases delegation of responsibilities for change behavior
-maintain visibility and credibility of change
-increases others’ responsibility and decreases leader-manager’s responsibility
CHANGE
• CONSIDER-
WHETHER YOU THINK YOU HAVE A CHOICE FOR CHANGE OR THINK YOU DON’T HAVE A CHOICE FOR CHANGE, YOU’RE RIGHT
Iowa Model
for
Research-Based Practice
(Gillis & Jackson, 2002; Farrington, Lang, Cullen, & Stewart; Titler et al., 2001)
Iowa Model for Research-Based Practice
Set of steps
used as a guide
to identify
practice questions
Iowa Model for Research-Based Practice
Step #1:
Determine type triggerto improve practicethrough research
(-that will initiate the need for change)
Problem-Focused Knowledge-Focused
Iowa Model for Research-Based Practice
Problem-focused triggers
1. Risk management data
2. Process improvement data
3. Internal/External benchmarking data
4. Financial data
5. Identification of clinical problem
Iowa Model for Research-Based Practice
Knowledge-focused triggers
1. New research or other literature2. National agencies or organizational
standards and guidelines3. Philosophies of care4. Observation from institutional standards
committees
Iowa Model for Research-Based Practice
Step #2:
Identification of relevant literature
Iowa Model for Research-Based Practice
Step#3:
Critique and Evaluate Research
for use in Practice
Iowa Model for Research-Based Practice
Step #4:
Determine if there is
Sufficient Research Base?
Sufficient Not Sufficient
Iowa Model for Research-Based Practice
Step # 5:
If
Sufficient Research Base
Iowa Model for Research-Based Practice
Step #5, Sufficient Research Base: PILOT THE CHANGE IN PRATICE
• Select outcome to be achieved• Design Nursing/Multidisciplinary Practice
Interventions• Implement Practice Changes on a PILOT
UNIT• Evaluate process and Outcomes• Modify Intervention as Needed
Iowa Model for Research-Based Practice
Step #5, Insufficient Research Base:
• Conduct Research
• Base practice on other types of evidence
– Case Reports
– Expert opinions
– Scientific principles
– Theory
Iowa Model for Research-Based Practice
Step #6: Ask-
Is the Change
Appropriate for Adoption
in Practice?
Iowa Model for Research-Based Practice
Step #7:
If answer is NO
Continue to evaluate quality of care
and
new knowledge
Iowa Model for Research-Based Practice
Step #7:
If answer is YES
Institute the change
in practice
Iowa Model for Research-Based Practice
Step #8
Monitor Outcomes
Patient Environment Staff Fiscal
& (Cost)
Family
Iowa Model for Research-Based Practice
Step #9:
Disseminate results
Sharing knowledge…and putting knowledge into practice