testing the effectiveness of a practice development...
TRANSCRIPT
Testing the effectiveness of a Practice Development intervention
on changing the culture of evidence-based practice in an acute care
environment
Volume 1
Sonya Ranee Osborne, RN Bachelor of Science in Nursing
Graduate Certificate in Nursing (Perioperative Nursing) Graduate Certificate in Higher Education
Master of Nursing
Queensland University of Technology School of Nursing
Institute of Health and Biomedical Innovation
Doctor of Philosophy 2009
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Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the best
of my knowledge and belief, the thesis contains no material previously published or
written by another person except where due reference is made.
Signature: _______________________________________________________________________ Date: _______________________________________________________________________
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KEY WORDS
nursing development, practice development, practice change, evidence-based practice,
barriers to research utilisation, culture of inquiry, research culture, evidence-based
practice culture, culture change
ABSTRACT
In this age of evidence-based practice, nurses are increasingly expected to use research
evidence in a systematic and judicious way when making decisions about patient care
practices. Clinicians recognise the role of research when it provides valid, realistic
answers in practical situations. Nonetheless, research is still perceived by some nurses as
external to practice and implementing research findings into practice is often difficult.
Since its conceptual platform in the 1960s, the emergence and growth of Nursing
Development Units, and later, Practice Development Units has been described in the
literature as strategic, organisational vehicles for changing the way nurses think about
nursing by promoting and supporting a culture of inquiry and research-based practice.
Thus, some scholars argue that practice development is situated in the gap between
research and practice. Since the 1990s, the discourse has shifted from the structure and
outcomes of developing practice to the process of developing practice, using a Practice
Development methodology; underpinned by critical social science theory, as a vehicle
for changing the culture and context of care.
The nursing and practice development literature is dominated by descriptive reports of
local practice development activity, typically focusing on reflection on processes or
outcomes of processes, and describing perceived benefits. However, despite the volume
of published literature, there is little published empirical research in the Australian or
international context on the effectiveness of Practice Development as a methodology for
changing the culture and context of care - leaving a gap in the literature.
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The aim of this study was to develop, implement and evaluate the effectiveness of a
Practice Development model for clinical practice review and change on changing the
culture and context of care for nurses working in an acute care setting. A longitudinal,
pre-test/post-test, non-equivalent control group design was used to answer the following
research questions:
1. Is there a relationship between nurses' perceptions of the culture and context
of care and nurses' perceptions of research and evidence-based practice?
2. Is there a relationship between engagement in a facilitated process of
Practice Development and change in nurses' perceptions of the culture and
context of care?
3. Is there a relationship between engagement in a facilitated process of
Practice Development and change in nurses' perceptions of research and
evidence-based practice?
Through a critical analysis of the literature and synthesis of the findings of past
evaluations of Nursing and Practice Development structures and processes, this research
has identified key attributes consistent throughout the chronological and theoretical
development of Nursing and Practice Development that exemplify a culture and context
of care that is conducive to creating a culture of inquiry and evidence-based practice.
The study findings were then used in the development, validation and testing of an
instrument to measure change in the culture and context of care. Furthermore, this
research has also provided empirical evidence of the relationship of the key attributes to
each other and to barriers to research and evidence-based practice. The research also
provides empirical evidence regarding the effectiveness of a Practice Development
methodology in changing the culture and context of care.
This research is noteworthy in its contribution to advancing the discipline of nursing by
providing evidence of the degree to which attributes of the culture and context of care,
namely autonomy and control, workplace empowerment and constructive team
dynamics, can be connected to engagement with research and evidence-based practice.
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TABLE OF CONTENTS
Statement of Original Authorship ................................................................................ iii
Key Words ............................................................................................................... v
Abstract ............................................................................................................... v
Table of Contents .......................................................................................................... vii
List of Figures ............................................................................................................ xiii
List of Tables ............................................................................................................ xiv
List of Abbreviations .................................................................................................... xv
List of Appendices ........................................................................................................ xvi
Acknowledgement List ............................................................................................... xvii
CHAPTER 1 INTRODUCTION ............................................................................... 1
1.1 Background ...................................................................................................... 1
1.1.1 A Short History of Nursing Research and Evidence-Based Practice .... 1
1.1.2 A Short History of Practice Development in Nursing .......................... 3
1.2 Study Thesis ..................................................................................................... 4
1.2.1 Problem and Significance ..................................................................... 4
1.2.2 Aims and Objectives ............................................................................. 5
1.3 Outline of the Document ................................................................................. 5
1.4 Conclusion ........................................................................................................ 9
CHAPTER 2 EVOLUTION AND EFFECTIVENESS OF PRACTICE
DEVELOPMENT: A REVIEW OF THE LITERATURE ....................................... 11
2.1 Introduction ................................................................................................... 11
2.2 Evolution of Practice Development: Chronological and Theoretical ....... 11
2.2.1 Revolution ........................................................................................... 11
2.2.2 New Nursing ....................................................................................... 14
2.2.3 From Exploration to Excellence.......................................................... 18
2.2.4 Demonstrating Best Practice ............................................................... 20
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2.2.5 Ingredients for Change ......................................................................... 23
2.2.6 In Search of Theory ............................................................................. 25
2.2.7 Same Road, Different Paths ................................................................. 28
2.3 Effectiveness of Practice Development: State of the Science ..................... 35
2.3.1 Background .......................................................................................... 36
2.3.2 Objectives of the Review ..................................................................... 36
2.3.3 Criteria for Considering Studies for this Review ................................. 37
2.3.4 Search Methods for Identification of Studies ...................................... 38
2.3.5 Methods of Review .............................................................................. 39
2.3.6 Analysis................................................................................................ 41
2.3.7 Description of Studies .......................................................................... 42
2.3.8 Methodological Quality ....................................................................... 46
2.3.9 Narrative Analysis and Data Synthesis ................................................ 48
2.4 Practice Development – A Model for Change ............................................. 51
2.4.1 Synthesis of Evolving Concepts .......................................................... 51
2.4.2 Research and Evidence-based Practice ................................................ 52
2.4.3 Control and Autonomy in Practice Environment ................................. 53
2.4.4 Workplace Empowerment ................................................................... 53
2.4.5 Constructive Team Dynamics .............................................................. 54
2.5 Conclusion ...................................................................................................... 56
CHAPTER 3 THEORETICAL FRAMEWORK ................................................... 57
3.1 Introduction .................................................................................................... 57
3.2 Alternative Theories, Models and Frameworks for EBP ........................... 57
3.3 Critical Social Science .................................................................................... 59
3.4 Theoretical Model for Practice Development ............................................... 63
3.4.1 False Consciousness............................................................................. 63
3.4.2 Crisis .................................................................................................... 63
3.4.3 Education ............................................................................................. 63
3.4.4 Transformative Action ......................................................................... 64
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3.4.5 Embodiment ........................................................................................ 64
3.4.6 Tradition .............................................................................................. 65
3.4.7 Force .................................................................................................... 65
3.4.8 Reflexivity ........................................................................................... 65
3.5 Emancipatory Practice Development (ePD) ............................................... 67
3.6 Implementing ePD: Intervention Development ......................................... 70
3.6.1 Staff Commitment ............................................................................... 73
3.6.2 Skilled Facilitation .............................................................................. 73
3.6.3 Shared Values and Prioritised Agenda for Change ............................. 74
3.6.4 Infrastructure - Dedicated Time and Space ......................................... 75
3.6.5 Evidenced-based Practice and Research Training .............................. 76
3.6.6 Clinical Practice Governance Committee ........................................... 77
3.7 Conclusion ...................................................................................................... 78
CHAPTER 4 METHODOLOGY AND METHODS ............................................ 79
4.1 Introduction ................................................................................................... 79
4.2 Objectives ....................................................................................................... 79
4.3 Research Questions ....................................................................................... 80
4.4 Scientific Hypotheses .................................................................................... 80
4.5 Research Design ............................................................................................ 81
4.6 Variable Definitions ...................................................................................... 83
4.6.1 Independent Variable .......................................................................... 83
4.6.2 Dependent Variable ............................................................................. 83
4.6.3 Descriptive Variables .......................................................................... 83
4.7 Methods .......................................................................................................... 84
4.7.1 Participants and Setting ....................................................................... 84
4.7.2 Target Population ................................................................................ 85
4.7.3 Inclusion and Exclusion Criteria ......................................................... 87
4.7.4 Sample ................................................................................................. 87
4.7.5 Recruitment ......................................................................................... 91
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4.7.6 Intervention .......................................................................................... 91
4.7.7 Study Protocol - Experimental Group .................................................. 92
4.7.8 Study Protocol - Control Group ........................................................... 99
4.7.9 Outcomes ........................................................................................... 100
4.8 Instrument Development, Implementation and Evaluation .................... 104
4.8.1 Background ........................................................................................ 104
4.8.2 Aim and Objectives............................................................................ 104
4.9 Survey Instrument Design ........................................................................... 105
4.9.1 Background ........................................................................................ 105
4.9.2 Measuring Perceptions of Barriers to Evidence-based Practice ........ 105
4.9.3 Measuring Perceptions of Skills in Evidence-based Practice ............ 109
4.9.4 Measuring Perceptions of Control and Autonomy over Practice ...... 110
4.9.5 Measuring Perceptions of Workplace Empowerment ....................... 112
4.9.6 Measuring Perceptions of Constructive Team Dynamics .................. 115
4.9.7 Validity .............................................................................................. 118
4.9.8 Reliability ........................................................................................... 121
4.10 Survey Implementation Plan ...................................................................... 121
4.10.1 Background ........................................................................................ 122
4.10.2 Dillman's Tailored Design Method .................................................... 122
4.10.3 Protocol for Survey Implementation Plan.......................................... 124
4.11 Statistical Methods ....................................................................................... 128
4.11.1 Data Preparation ................................................................................. 128
4.11.2 Influence of Research Design on Analytical Approach ..................... 136
4.11.3 Significance Level Applied to Analyses ............................................ 139
4.12 Pilot Study..................................................................................................... 140
4.12.1 Background ........................................................................................ 140
4.12.2 Pilot Study Results ............................................................................. 141
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4.13 Ethical Considerations ................................................................................ 150
4.13.1 Consent and Information to Participants ........................................... 150
4.13.2 Risks to Participants .......................................................................... 150
4.13.3 Confidentiality .................................................................................. 151
4.14 Conclusion .................................................................................................... 152
CHAPTER 5 STUDY RESULTS .......................................................................... 153
5.1 Introduction ................................................................................................. 153
5.1.1 Response Rate ................................................................................... 153
5.1.2 Study Attrition ................................................................................... 153
5.2 Baseline data ................................................................................................ 155
5.2.1 Demographic Characteristics of Study Sample at Baseline .............. 155
5.2.2 Education and Training of Study Sample at Baseline ....................... 156
5.2.3 Perceptions of Culture and Context of Care and EBP at Baseline .... 158
5.3 The Culture and Context of Care .............................................................. 159
5.3.1 Attributes of the Culture and Context of Care .................................. 159
5.3.2 Skills in EBP and Barriers to EBP .................................................... 160
5.3.3 Culture and Context of Care and Research and EBP ........................ 160
5.4 Practice Development and the Culture and Context of Care ................... 162
5.5 Additional Analyses .................................................................................... 165
5.5.1 Representativeness of Study Sample to Hospital Population ........... 165
5.5.2 Stability of Study Cohort over Time ................................................. 165
5.5.3 Characteristics of Study Units ........................................................... 168
5.6 Conclusion .................................................................................................... 170
CHAPTER 6 DISCUSSION .................................................................................. 171
6.1 Introduction ................................................................................................. 171
6.2 Perceptions of the Culture and Context of Care ...................................... 172
6.2.1 Autonomy and Control in the Practice Environment ........................ 172
6.2.2 Workplace Empowerment ................................................................. 175
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6.2.3 Constructive Team Dynamics ............................................................ 177
6.2.4 Barriers to Research and EBP ............................................................ 182
6.3 Practice Development and the Culture and Context of Care.................... 185
6.4 From Practice Development to Developing Practice ................................. 189
6.5 Measuring the Culture and Context of Care ............................................. 190
6.6 Strengths and Limitations ........................................................................... 193
6.7 Conclusion .................................................................................................... 197
CHAPTER 7 CONCLUSIONS AND RECOMMENDATIONS ......................... 201
7.1 Introduction .................................................................................................. 201
7.2 Conclusions ................................................................................................... 202
7.3 Recommendations for Practice ................................................................... 203
7.4 Recommendations for Further Research ................................................... 204
7.5 Closing Comments ....................................................................................... 205
REFERENCES ............................................................................................................ 207
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LIST OF FIGURES
Figure 2.1 Criteria for University of Leeds NDU/PDU Accreditation Programme ......... 22
Figure 2.2 Nursing and Practice Development timeline .................................................. 34
Figure 2.3 Themes from synthesis of findings from PD literature .................................. 50
Figure 3.1 Amended framework for Critical Social Science ........................................... 62
Figure 3.2 Research framework ....................................................................................... 72
Figure 3.3 Organisational infrastructure support for Practice Development ................... 76
Figure 4.1 Non equivalent control group design .............................................................. 81
Figure 4.2 Schematic of procedure for visual record verification check ....................... 130
Figure 4.3 Scatter plot of correlations between outcome variables ............................... 134
Figure 4.4 Pilot study participant flow ........................................................................... 142
Figure 4.5 Cumulative response for pilot study survey ................................................. 143
Figure 5.1 Main study participant flow and attrition ..................................................... 154
Figure 5.2 Main study participant flow and attrition ..................................................... 169
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LIST OF TABLES
Table 2.1 Influencing trends on the genesis of the NDU movement in the UK ................15
Table 2.2 Results of search strategy on effectiveness of Nursing/Practice development 44
Table 3.1 Relationship between society and nursing in healthcare ..................................68
Table 4.1 Comparison of the study hospital with Australian and Queensland hospitals .86
Table 4.2 Breakdown of sampling frame for study ..........................................................89
Table 4.3 Operational descriptions Practice Development programme components ......94
Table 4.4 Proposed Practice Development programme timetable ..................................102
Table 4.5 Distribution protocol for survey implementation ...........................................126
Table 4.6 Nursing, research and EBP education of pilot sample at baseline ..................144
Table 4.7 Demographic characteristics of responders versus non-responders ...............145
Table 4.8 Demographic characteristics of early versus late responders .........................145
Table 4.9 Internal consistency reliability scores (Cronbach's Alpha).............................149
Table 5.1 Demographic and nursing background of study sample at baseline ...............156
Table 5.2 Nursing, research and EBP education and/or training ....................................157
Table 5.3 Baseline descriptive statistics for nurses’ perceptions ....................................159
Table 5.4 Correlations between outcome variables by groups at baseline .....................161
Table 5.5 Means and standard deviations of change differences in the perceptions ......163
Table 5.6 Parameter estimates / estimated standard errors for perception of barriers ....164
Table 5.7 Comparison of demographic characteristics and nursing background ...........166
Table 5.8 Comparison of nursing, research and EBP education .....................................167
Table 5.9 Comparison of nurses' perceptions of culture and context of care .................168
Table 5.10 Characteristics of study units (2004-2005) ...................................................169
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LIST OF ABBREVIATIONS
CDU (N) Clinical Development Unit (Nursing)
CNU Clinical Nursing Unit
CPD Clinical Practice Development
NDU Nursing Development Unit
NLIP Nurse-Led In-Patient Unit
PD Practice Development
PDU Practice Development Unit
RN Registered Nurse
CN Clinical Nurse
CNC Clinical Nurse Consultant
NUM Nurse Unit Manager
NM Nurse Manager
ND Nursing Director
DON Director of Nursing
EDNS Executive Director of Nursing Services
CBA Controlled Before-and-After study
CCT Controlled Clinical Trial
ITS Interrupted Time Series study
RCT Randomised-Controlled Trial
UCBA Uncontrolled Before-and-After study
UK United Kingdom
USA United States of America
NSW New South Wales, Australia
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Volume 2
LIST OF APPENDICES1
Appendix 1 Criteria for including studies based on design description 1
Appendix 2 Search strategy for review of the literature 2
Appendix 3 Table of excluded studies from state of science review 3
Appendix 4 Criteria for assessing quality of included studies 13
Appendix 5 Table of included studies 21
Appendix 6 Key supported findings from included studies 41
Appendix 7 Unsupported findings from included studies 75
Appendix 8 Program for Practice Development facilitation workshop 82
Appendix 9 Values clarification exercise (template and example) 85
Appendix 10 Ground rules (example) 88
Appendix 11 Mission statement (template and example) 89
Appendix 12 Evidence-based practice mentoring programme 92
Appendix 13 Governance committee terms of reference 93
Appendix 14 Ethics approvals 95
Appendix 15 Participant information sheet and consent 98
Appendix 16 Final survey instrument 104
Appendix 17 Contact 1: pre notice letter 117
Appendix 19 Contact 2: letter with first survey 118
Appendix 17 Contact 3: reminder/thank you post card 119
Appendix 20 Contact 4: letter with follow up survey 120
Appendix 21 Contact 5: final letter 121
Appendix 22 Pilot study questionnaire item development 122
Appendix 23 Permissions to use existing instruments 141
Appendix 24 Report from demonstration pilot study 146
1 Appendices are located in Volume 2 of this document.
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ACKNOWLEDGEMENT LIST
Firstly, I would like to thank the study organisation and the senior nursing staff for their
support and contributions throughout the research process. I'd like to also especially
thank the nurse participants, for their commitment and willingness to participate in the
research process - without them, the study would not have been possible..
I would like to express my thanks, wholeheartedly, to my supervisory team. This paper
would not have been possible if not for their commitment, dedication, guidance, support,
and understanding throughout this journey. To Professor Glenn Gardner, whose
unwavering interest in the topic and unfaltering belief in me to get the job done was
always an inspiration. To Dr Diana Battistutta, whose patience and encouragement were
calming; her colourful feedback – revitalising.
I would also like to express my deepest and sincerest gratitude to my family for their
ongoing, unfailing and unflinching encouragement and support and their sacrifices over
the years to allow me to complete this journey. To Roger, your inspiration, motivation,
and belief in me continually brought renewed life to the quest for my goal. To Megan,
your dreams and aspirations helped me to keep moving forward; no going backward. To
Melissa, your constant encouragement and positive outlook kept a smile on my face and
in my heart.
Finally, I would like to acknowledge and thank the Centaur Memorial Fund for Nurses
and the Queensland Nursing Council for their confidence in my ability to conduct this
research, their financial support, and their appreciation of the important contribution the
findings will make to nursing.
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1
CHAPTER 1. INTRODUCTION
1.1 Background
1.1.1 A Short History of Nursing Research, Research Utilisation and Evidence-Based Practice
The meticulous and systematic assessment, collection and analysis of data; the critical
interpretation and application of the results, the improvement in patient morbidity and
mortality outcomes following implemented changes in nursing practice; and the
dissemination of findings to the wider community of nurses gives credence to the widely
acknowledged distinction of Florence Nightingale (c1856) as the first nurse researcher.
Between 1900 and 1940, and influenced by an apprenticeship model of nursing, there
was recognition of inadequacies in educational backgrounds of nurses. The focus of
nursing research was on nursing students and their need for advanced educational
preparation. The focus on educational preparation continued through the 1940s and was
joined by research exploring the functions, roles and attitudes of nurses, nurse-patient
interactions and the hospital environments (Polit and Beck 2004). In the 1950s nursing
researchers were preoccupied with introspective studies on the 'who', 'what', 'why', and
'how' of what it is to be a nurse. Nursing scholars and leaders in the 1960s took up the
mantle of Florence Nightingale with renewed vigour and called to attention the need to
base nursing practice on empirical, scientific evidence in order to improve quality of
care and patient outcomes. In the 1960s, the focus of nursing research was practice-
oriented clinical research and linking theory to practice (Polit and Beck 2004). This
carried forward an interest in the 1970s on improvement in patient care and the need for
a scientific base (Polit and Beck 2004).
In the 1980s, nursing research was raised to a higher level with the availability of more
trained nurse researchers, availability of computer technology for more efficient data
collection, management and analysis, the acknowledgment and acceptance of nursing
research as integral to professional nursing practice and the continued momentum
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toward clinical research and increasing utilisation of research findings in practice (Polit
and Beck 2004). The 1980s also saw the advent of a paradigm shift in health decision-
making that not only supported the notion of practice based on scientific evidence, but
also openly professed that scientific research findings were superior to authoritative
opinions and experts. Thus, the era of Evidence Based Medicine (EBM), actualised by
Sackett in the 1980s (Sackett et al 1996), stimulated the awareness and use of scientific
research in guiding clinical decision making in practice and promoted the use of an
identifiable, systematic process for finding and implementing the best available
evidence. The process of evidence-based practice (EBP) is typically described in five
steps: turning clinical problems into focused clinical questions, finding the available
evidence to answer the question, critically appraising the available evidence, translating
and implementing the best evidence in practice and evaluating the practice change.
Clinicians recognise the role of research when it provides valid, realistic answers in
practical situations (Clarke and Proctor, 1998; 1999). Evidence-based practice is a
process of using the best available evidence in conjunction with clinical expertise and
judgment and patient knowledge and preferences in making health care decisions that
result in the delivery of efficient and effective care. Although a relationship between
research evidence and effective practice is acknowledged, the nature of that relationship
is confusing. Research is still perceived by most nurse clinicians as external to practice
and implementing research findings into practice is often difficult (Kitson 2002).
Reasons for this difficulty have been documented in the literature since the early 1990s
(Miller and Messenger 1978; Funk, Champagne et al 1991a; Funk, Champagne et al
1991b).
This short history serves as a signpost toward Practice Development in the context of
nursing. It is not intended to be a comprehensive review of the origins and development
of nursing research, research utilisation or evidence-based practice. Nor is it intended to
engage in the discourse surrounding the nature of evidence. It is intended to provide one
of many stepping stones to assist the reader to follow the evolution of contemporary
Practice Development in nursing.
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1.1.2 A Short History of Practice Development in Nursing
Nursing has been in a constant state of growth and development since Florence
Nightingale first gave us 'Notes on Nursing' in the 1880s. Discussion and description of
innovative methodologies to develop and advance nursing practice are not new. The
emergence of Nursing Development Units, and later Practice Development Units,
coincided with other developments in nursing, such as growth in post graduate nursing
education, proliferation in nursing theory and the rise of the women's movement, which
triggered a desire in nurses to be liberated from the traditional oppressive structures of
healthcare (Draper 1996; Lorentzon 1994). Clarke and Procter (1999) argue that practice
development is situated in the gap between research and practice.
In the early 1960s, in response to a need to make obvious the therapeutic nature of
nursing and re-establish nursing as a discipline in its own right, Lydia Hall set up the
Loeb Center in Montefiore, New York. The Loeb Center was an experiment in a
nursing led in-patient unit (NLIP), whereby the main therapeutic modality was nursing
(Hall, 1963). Since its conceptual platform in the 1960s, the notion of Practice
Development has been shaped by distinguished nurse leaders around the world and its
current form has been influenced by the socio-cultural and political climate of
healthcare. In the 1970s, social-cultural trends toward consumerism and feminism and
nursing trends toward professionalism and therapeutic nursing influenced the upstart and
proliferation of dedicated Nursing Development Units. The work of Lydia Hall was the
basis for the establishment of a nursing-led unit at Burford Hospital in Oxfordshire,
England, which was recognised as the first Nursing Development Unit (NDU) in the UK
in the 1980s (Pearson 1992; Pearson, Durant and Punton 1989).
The premise of early NDUs was on improving nurses, professionally and personally, in
order to improve and strengthen the discipline of nursing. In the 1980s nursing was in
'crisis' and dissatisfied with medical dominance stemming from ongoing changes to
modernise nursing, firstly, by linking nursing to medicine, but later to the detriment of
the profession, by perpetuating a belief that nursing was adjunct to medicine (Pearson,
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Punton and Durant 1992). The focus of Nursing and Practice Development was to
explore and evaluate new nursing roles, develop recognised benchmarks and standards
for practice and monitor practice quality improvements. NDUs evolved into Practice
Development Units (PDUs), whose focus is on improved patient outcomes through
multidisciplinary team development (Kitson, Ahmed, Harvey, et al 1996; Manley, 1999,
2000; Manley and McCormack, 2003; McCormack et al 1999).
The evidence-based practice movement emerging at the end of the 1980s coincided with
trends in healthcare toward cost efficient and effective practice sending nursing into the
1990s in the midst of an emerging focus on accountability, quality assurance and clinical
governance. In Australia, NDUs emerged as Clinical Development Units (Nursing) and
Clinical Practice Development Units (FitzGerald and Solman, 2003; Greenwood, 1999,
2000; Walker, 2002) whose focus is on developing patient-focused and research-based
nursing practice in managerially permissive climates (Greenwood, 2000).
The primary focus of various Nursing and Practice Development Units discussed in the
literature can be reduced down to one of two aims - benefits for patients or benefits for
nurses and nursing. None the less, the intended purpose, aims and outcomes of
developing nursing practice have yet to be clearly articulated in order to establish the
basis for a study of its effectiveness. Now, particularly in this era so dominated by the
evidence-based practice paradigm, the effectiveness of any practice development model
or theoretical framework must be established to increase the scientific knowledge of a
discipline.
1.2 Study Thesis
1.2.1 Problem and Significance
Practice Development, as a methodology for changing practice, is aimed at supporting
nurses to critically examine their practice using an evidence-based approach in order to
bring about patient-centred, efficient and effective practice change through research
utilisation. Gaps in the literature are apparent. Although a comprehensive literature
review identified a plethora of literature on the nature and benefits of Practice
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Development (Greenwood, 2000, Greenwood, 1999, Kitson et al., 1996, Manley and
McCormack, 2003, McCormack and Garbett, 2003, McCormack et al., 1999, Unsworth,
2000), the term remains nebulous with clinicians (Clarke and Proctor, 1999, Tolson,
1999).
This study critically examined the development of the concept of Practice Development
and synthesised the disparate views to enable the identification of common themes and
attributes in order to propose a sustainable model for increasing nurses' utilisation of
research findings. In addition, there is little published empirical research systematically
evaluating nursing Practice Development as a methodology in the Australian or
international context, highlighting the difficulties in evaluating the effectiveness of a
model of practice change using a Practice Development methodology. Despite the
abundance of literature espousing the benefits of Nursing and Practice Development, for
both nurses and patients, there is wide acknowledgment in the literature that the
effectiveness and sustainability of Nursing and Practice Development programmes has
not been subjected to robust evaluation (Gerrish, 2001; Draper 1996), particularly on the
macro outcomes of developing nursing practice, changing the culture and context of
care and increasing nurses' engagement with the research and evidence-based practice
agenda for innovative practice change.
1.2.2 Aims and Objectives
The aim of the research was to address the gaps in the literature regarding effectiveness
of a Practice Development methodology in changing the culture and context of care.
This study addressed the gaps in the literature by developing and implementing a
strategic programme model of Practice Development for nurses throughout a major
teaching hospital in Australia and evaluated a programme of nursing Practice
Development using an evidence-based and rigorously tested evaluation strategy.
1.3 Outline of the Document
This chapter introduced the concepts of nursing research, research utilisation and
evidence-based practice, and the concepts of Nursing and Practice Development. It
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provided signposts and a 'quick sketch' road map of the respective historical and
evolutionary paths toward developing a culture of inquiry in nursing, highlighting along
the journey where socio-cultural, healthcare and nursing trends began to exert influence
on the direction of the paths. It also placed two stepping stones along the path; marking
firstly, the place where the two paths became intertwined and mutually influential on
each other, and secondly, the well-timed place to stop for considered reflection on
firstly, the need to continue the journey, and secondly the direction.
Chapter 2 explores the chronological, theoretical and scientific evolution of
contemporary Practice Development, in two parts, through a comprehensive, robust and
critical review of literature documenting this influential movement. A narrative
synthesis undertaken in the first part of the review follows Practice Development along
a historical thread gathering a collective pattern of attributes, supported with tangible
and genuine resources that a Nursing or Practice Development environment should
endeavour to achieve, and maintain, in order to realise and sustain a culture of inquiry.
Using the framework for reviewing complex interventions devised by the Effective
Practice Organisation and Care Group (EPOC) of the Cochrane Collaboration, the
second part of this chapter investigates the state of the science on the effectiveness of
Practice Development methodology in changing the culture and context of care.
Although there are some robust theoretical arguments, there is limited empirical
evidence supporting the relationships between desired attributes in the context of
developing practice, the impact of linkages between sustaining innovation and practice
change, or confirmation of the theoretical framework as an effective process for change.
Thus, in the midst of the global enthusiasm for developing innovations in nursing
practice, and the empirical support of the benefits of practice based on evidence, the
review of the literature substantiates this research as not only essential but timely.
Chapter 3 presents a discussion about the theoretical underpinnings assigned to the
methodology of Practice Development in its aim for emancipatory practice change; that
is Critical Social Science. Practice Development is about enabling nurses to transform
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the culture and context of the world in which they work through a facilitated process of
critical reflection and action. One of the endpoints or outcomes of contemporary
Practice Development is emancipatory change, thus situating it in a Critical Social
Science framework seems appropriate.
Critical Social Science requires that nurses are first enlightened, that is, not only
reminded of the therapeutic nature of nursing and the influence nursing has on patient
outcomes but also the impact of evidenced-based nursing care on patient outcomes.
Thus, engagement in the evidence-based practice agenda becomes an enabling and
empowering tool. Evidence to support practice is stronger than authority, opinion or
outdated policies anchored in ritual and tradition. This chapter is intended to provide
clarity on the interrelationships between the theoretical framework, the study aims and
outcomes and the building of the intervention - a model based on Practice Development
principles and processes aimed at creating a culture of inquiry and evidence-based
practice in nursing.
Chapter 4 presents a comprehensive account of the research methodology and design.
Designs that follow individuals or groups over time are aptly suitable for obtaining data
required for the measurement of programme effects and identification of factors
contributing to differential patterns of change across groups – thus, the justification for
the selection of a longitudinal, pre-test/post-test, with non-equivalent control group
design to quantitatively measure the culture and context of care before, during and after
implementation of a Practice Development programme. This chapter contains thorough
descriptions of the intervention, including operational definitions of component parts;
selected outcomes, derived from and supported by the review of the literature; and study
protocols, including a description of 'routine processes' for practice review and change.
It also presents a description, discussion and explanation of the design of the survey
instrument and the evidence-based survey implementation strategy, designed to
maximise response rates.
8
Chapter 4 also provides an account of the statistical analysis plan in sufficient detail to
assist the reader in drawing conclusions about the findings. Key issues, such as methods
for data preparation and data quality assurance; definitions of variables considered in the
analyses, including descriptive variables and variables assessed for confounding and/or
effect modification; and description of and justification for bivariate and multivariate
analysis choices will be disclosed. This section will end with clean picture of the data,
highlighting modifications such as removal of cases, missing value imputation and data
transformations, ready for analysis using a combination of per-protocol (PP) analysis
and modified intention to treat (MITT) analysis. Chapter 4 will end with a presentation
and discussion of the pilot study, including results of the pilot study conducted prior to
main study data collection.
Chapter 5 presents the findings in texts, tables and figures. Representativeness of the
sample to the hospital population, similarity of control and experimental groups at
baseline, stability of the study cohort over time, and characteristics of non responders
versus responders and non completers versus completers is presented first to set the
scene for generalisations to be made in the discussion. The next findings presented are
those in the context of the research questions and their associated hypotheses: namely,
'Is there a relationship between attributes of the culture and context of care and barriers
to evidence-based practice?' and 'Does a program using Practice Development
methodology and processes have an effect on changing the culture and context of care?'
Chapter 6 provides a scholarly discourse on the study aims, findings, and implications
for practice and research. Study results will first be summarised. Interpretations and
suggestions for explanations of the results will be offered. Comparisons between the
study findings and what is already known about the problem will be made obvious as
study results are situated in the literature. This chapter will end with suggestions for
generalisation of results, implications of the results and limitations of the study.
9
Chapter 7 concludes the thesis with recommendations, mapped out to each hypothesis,
and supported by the study findings. It provides the starting point for the next step in the
continuing development and evolution in developing practice in nursing.
1.4 Conclusion
The development of a model for nursing practice development and an appropriate
evaluation strategy will support future comparison studies and benchmarking in nursing
practice development programmes worldwide. Thus, this study is a significant
contribution to improving patient care outcomes as well as advancing the discipline of
nursing through potentially increasing nurses' engagement in research utilisation and
translation in practice.
10
11
CHAPTER 2. EVOLUTION AND EFFECTIVENESS OF PRACTICE DEVELOPMENT: A REVIEW OF THE LITERATURE
2.1 Introduction
There is a substantial and diverse body of literature on nursing and practice
development spanning almost four decades. Close analysis of the literature from
1966 to 2003 provides two distinct outcomes. One is a report of the chronological
and theoretical development of developing nursing practice. The other provides
information on the state of the science of the effectiveness of Practice Development.
This chapter will be organised within the context of these two overarching topics.
The previous chapter presented an introduction to this thesis on the effectiveness of
nursing and practice development, with particular focus on the effectiveness of a
Practice Development model for change. This chapter provides a robust critical
examination of this influential movement. It explores the historical origins of
contemporary Practice Development, the philosophical shifts in ideology, emphasis
and aims that characterise and distinguish the evolving schools of thought and
development of the concept (see Figure 2.2, p.34, for a graphic timeline). Common
features that have been maintained throughout the evolution toward Practice
Development will be highlighted. This chapter provides the necessary backdrop of
the changing models, philosophies and goals of nursing and practice development in
evolving towards its contemporary aim of changing the culture and context of care.
2.2 Evolution of Practice Development: Chronological and Theoretical
2.2.1 Revolution: Lydia Hall and the Loeb Center in the USA
In the early 1960s, nurse theorist Lydia Hall had the vision of a programme of
professional nursing service in an in-patient setting that was the transition between
hospital and home (Hall 1963). This vision was brought to fruition at the Loeb
Center for Nursing and Rehabilitation at Montefiore Hospital in New York. The
Loeb Center was a nurse directed nursing and rehabilitation facility established in
12
1963 at Montefiore Medical Center in Bronx, New York. It was developed to solve
the problems of fragmented care typical in the USA in the 1950s and 1960s by
providing around the clock nursing care to patients no longer requiring acute medical
treatment but still requiring rehabilitative care (Hutchinson and Donaldson 2004).
Building infrastructure funding was provided by the Solomon and Betty Loeb Trust,
staff was provided by the Montefiore Hospital; in addition, the Center was leased
from Montefiore Hospital for one dollar (USD) per year on a 99-year lease
(Hutchinson and Donaldson 2004).
The philosophy driving delivery of patient-centred care and emphasising
interpersonal nurse-patient relationships at the Loeb Center was operationalised as
Hall's 'care, cure, core' model (Hall 1966). Hall's model was composed of three
interlinking circles representing the person (CORE), the body (CARE) and the
disease (CURE) (Hall 1975). By way of bodily CARE through nurse-patient
interaction, which facilitates the interpersonal process, the professional nurse invites
the person of the patient to learn, through therapeutic use of self, to get at the CORE
of his or her difficulties (that is the 'disease') while the nurse sees the patient and the
patient's family through the CURE, or medical care, that is possible (Hall 1966; Hall
1975; Marriner-Tomey 2006).
Hall proposed that patients need more professional nursing care and health teaching
once they are past the acute and medically managed stage of their recovery. It was a
model of nursing care predicated on involvement of the patient in decisions
regarding their return to maximum health and ensuring a learning experience for the
patient for maintenance of their health. The key premise of this model of care was
that the professional nurse is "the chief therapeutic agent and the final effector" in
providing patient care, and medical and allied health professionals were consulted
when ancillary support was required (Hall 1963, p.806).
Hall emphasised the autonomous function and contribution of the professional nurse
to patient outcomes and the goal for the patient was rehabilitation and the successful
development and use of personal talents and abilities, otherwise known as self-
actualisation (Marriner-Tomey 2006).
13
Hence, the key features of the model of nursing care delivery at the Loeb Center
were (1) nursing as the main therapeutic modality, and (2) engagement of the patient
and their family in a learning process for body healing. The anticipated main
outcome of this 'care, cure, core' model was that on discharge, the patient and their
family went back to their "world of living better prepared to cope with it than before
the period of illness" (Hall 1963, p.806).
The Loeb Center saw the introduction of the idea of 'nursing beds', that is, beds to
which patients who primarily needed therapeutic nursing care were admitted by
nurses (Hall 1969). This model of care of primary nursing, a term attributed to Marie
Manthey in the late 1960s, allowed nurses to practice professionally, focusing on
patients' needs and stressing the importance of the nurse-patient relationship and the
therapeutic nature of nursing, rather than practice in a bureaucratic-dominated, task-
oriented way (Pontin 1999). The Loeb Center was aiming for a culture where
professional nursing practice was valued for its therapeutic contribution to patient
outcomes, where the patient was an active decision-maker in the care required and
the care provided.
The Loeb Center operated from 1963 to 1984, when the Boards of both the Loeb
Center and Montefiore Hospital decided in 1985 to change the focus of the Center
(Hutchinson and Donaldson, 2004). The Loeb Center was converted to a nursing
home with a focus on custodial care and its time as a nurse-led inpatient unit (NLIP)
officially came to an end. In a 2004 news release on the Montefiore Medical Center
website, Gregory Brown, the facility's director at the time stated that the Loeb Center
was converted into the Loeb Nursing Home because of a desperate and urgent need
for beds to treat long-term and short-term nursing home patients (Montefiore
Medical Center Public Relations Department, 2004). This suggested that the Loeb
Center was an unfortunate victim to the ever-changing health care arena and the need
for different services to meet the demands of the changes in patient demographics.
However, some nurse authors suggest that its demise was due to political and
financial pressure as well as lack of nursing motivation, leadership and power
(Atsalos, 2004; Griffiths, 1997).
14
Despite the closure of the Loeb Center for Nursing and Rehabilitation, Hall's primary
nursing as a philosophy and a model of professional nursing subsequently influenced
the development of the first NLIP in the United Kingdom (UK) at Burford
Community Hospital, a nine-bed hospital under the jurisdiction of Oxfordshire
Health Authority in the UK.
2.2.2 New Nursing: Alan Pearson and Steven Wright -Pioneering Nursing Development Units in the UK
The concept of Clinical Nursing Units (CNU), or Nursing Development Units
(NDU) as they came to be known in the UK, was conceived by a small team of nurse
leaders who wanted to progress Lydia Hall's pioneering goal to demonstrate the
value of nursing. Nursing was basically a significant activity, highly valued and
distinctly different from medicine; however, reforms instigated by Nightingale near
the end of the 19th century led to the emergence of 'modern' nursing (Pearson, Punton
and Durant 1992).
Changes from modernisation of nursing included firstly, linking nursing to medicine,
and subsequently, perpetuating a belief that nursing was adjunct to medicine;
coupled with the pressures of time and technology, nurses were hindered from
fulfilling their core caring and nurturing roles (Pearson, Punton and Durant 1992).
But, contemporary trends saw British nursing advocating abandonment of the task-
oriented nursing for holistic, patient-centred approaches (Pearson, Punton and
Durant 1992).
With the introduction of university schools of nursing and a growing interest in
examining and valuing the impact of nursing practice, clinical nurse leaders and
nurse academics were calling for a change in nursing (Pearson 1992; Vaughan 1998;
Pearson 2003). The 'force for change' (Salvage, 1995, p.53) was influenced by social,
health care and nursing trends (Salvage 1995; Redfern, Christian, Murrells et al
2000) over the last three and a half decades (as illustrated in TABLE 2.1).
15
TABLE 2.1 INFLUENCING TRENDS ON THE GENESIS OF THE NDU MOVEMENT IN THE UK (FROM SALVAGE 1995, P. 53; REDFERN, CHRISTIAN, MURRELLS ET AL 2000)
SOCIAL TRENDS HEALTH CARE TRENDS NURSING TRENDS 1970s - feminism
- consumerism - New Age ideas - belief in personal growth - small is beautiful
- trade unionism - collectivism - better professional education
- professionalism - American influence - home grown - pressure for reform
1980s - managerialism - coping with chaos - high tech - monetarism - swing to right - move toward politically and managerially‐led evaluation and quality assurance
- move toward evidence‐based practice
- management culture - dissatisfaction with medical dominance
- patients' rights - low morale - cost‐consciousness - attacks on health care system
- move away from medically‐led evaluation and audits
- resource management, total quality management and continuous quality improvement
- expanding knowledge - clinical leadership - more publications - more conferences - New Nursing - disillusionment - 'crisis' - Nurse professional bodies setting standards for practice
1990s - 'high touch' is back - '24/7 society' - stress‐related illnesses increase
- ageing population with increase in chronic co‐morbid illnesses
- improved access to knowledge via internet (for example, broadband)
- consumers becoming more demanding
- higher acuity in acute care facilities
- evidence‐based healthcare decisions
- value for money - focus on outcomes - clinical audit ran parallel with yet separate to medical audit (for example, separate funding) and concerned with service quality
- therapy professions also developing guidelines for practice
- nurse‐led initiatives - promotion of good nursing practice and centres of excellence
- recognition of need to develop research capacity
NURSING DEVELOPMENT UNITS
Nurse leaders wanted to create a culture of inquiry and encourage a critical mass of
nurses to embrace a 'New Nursing' philosophy (Salvage 1990; Malby 1996); a
philosophy re-espousing the therapeutic nature of nursing and advocating primary
16
nursing and the primacy of the nurse-patient relationship as central to improving
patient outcomes. Context is the factors that influence and constrain the way nurses
practice in reality. Nurse leaders advocated a major reform in nursing based on
reorganising work so nursing care was delivered by professional, trained nurses;
flattening hierarchical nursing team structures; building stronger relationships with
patients and involving patients in planning care; basing practice on a model that
clearly articulates the contribution of nursing to healthcare; and using a problem-
solving approach to care (Pearson 1992; Salvage 1995). The movement of 'New
Nursing' focussed on empowerment of nurses, management of change and patient-
centred care (Wright 1995).
In the early 1980s, Burford Community Hospital, a small, nine-bed community
hospital under the jurisdiction of Oxfordshire Health Authority and the direction of
one of those nurse leaders, Alan Pearson, became the first demonstration site for an
innovative change in patient care delivery - the first NLIP in the UK. Reports of the
development work at the Burford NDU in both professional journals and in
publications aimed at the interests of the general public led to an acceptance of the
concept of NDUs in the UK (Pearson 1997).
Key factors of the Burford Model were the nature of caring, the internal and external
environment for practice and social viability and outcomes focused on effective care,
meeting and developing the needs of the community and raising the status of
nursing. A second NDU was soon opened in 1986, also under the guidance of Alan
Pearson, at the Radcliffe Infirmary in Oxford, soon followed by the official opening
of a third unit in 1988 at Tameside (Malby 1996), under the guidance of another of
the nurse leaders of the time, Steve Wright. The philosophy of nursing espoused by
both Alan Pearson, Steve Wright and other nurse leaders in the UK at the time,
embraced feminist perspectives in nursing issues with a return back to a focus on
'high touch', patient-centred and caring behaviours.
From the beginning, NDUs across the UK began to establish themselves as 'test beds'
(Salvage 1989) of innovation, thus progressing the philosophy of 'New Nursing' and
building upon past successful innovations with innovations of their own. Although
the original philosophy of primary care was used as a basis for the model of care
17
delivery in the early successful NDUs, each successive NDU conceptually,
contextually and operationally adapted the philosophy and became recognised for
their own unique contributions to the way nurses think about and do nursing.
While health care trends for better professional education and recognition of the
professional and therapeutic nature of nursing were tenets advocated and supported
by Lydia Hall at the Loeb Centre, early NDU leaders in the UK continued advocacy
for demonstrating the therapeutic nature of nursing by moving toward expanding
knowledge and clinical leadership, and encouraging links and collaborations with
Schools of Nursing to evaluate nursing care and imbed empirical evidence into the
nursing school curriculum. For example, the Burford NDU introduced the first
nurse-led inpatient beds in a community hospital setting and was recognised for not
only conceptualising and practising therapeutic nursing but also for establishing a
teaching and research programme (Johns 1991). In the same way, the Oxford NDU
was recognised for progressing the innovation of nursing-led inpatient beds to an
acute care setting and aspiring to closing the theory-practice gap by engagement in
research (Ersser 1988). Similarly, the Tameside NDU, established in the late 1980s,
was instrumental in establishing the first nurse consultant role as well as advancing
the development of primary nursing which enhanced the clinical credibility of nurses
(Malby 1996). It also had as one of its major features a strong commitment to staff
development, team building and collaborative health care and valuing staff input
(Wright 1989; Malby 1996). The focus of NDUs was the recognition that to develop
nursing, it is also necessary to develop nurses (Wright 1995).
The early NDUs encouraged staff to challenge their assumptions about nursing and
patients and introduced primary nursing (Johns 1991; Griffiths and Wilson-Barnett
1998). There was also an emphasis on a research-based approach to nursing,
evaluation of the impact of nursing care and dissemination of development work
(Malby 1996). The NDU was guided by a unit leader who took on the composite
roles of manager, teacher, practitioner, and researcher (Malby 1996). These early
British NDUs, like the Loeb Center, strived for a culture where professional nursing
and nursing practice were valued for their therapeutic contributions to patient
outcomes, of which the primacy of the nurse-patient relationship was central. They
also wanted to create a culture of inquiry whereby nurses engaged with research and
18
scholarship to improve patient care by developing the clinical nursing team in order
to develop practice (Gerrish 1999).
Although these early NDUs generated much interest in a renewed philosophy and
model of patient care, they also generated anxiety in the way traditional concepts of
patient care were challenged, namely, without full collaboration and joint ownership
with senior hospital administrators and other disciplines. In addition to political
pressure applied by the threatened dominant medical profession, lack of overt public
support, lack of integrating nursing practice developments into the theoretical basis
of nursing in nursing school curricula and lack of developing leadership at all levels
of nursing have all been attributed to the closing down of the Oxford, and eventually
the Tameside, NDUs (Malby 1996).
2.2.3 From Exploration to Excellence: King's Fund Centre
While developments at the Burford, Oxford and Tameside NDUS were evolving, the
King's Fund Centre Development Programme and Nursing Development Network in
London, whose aim was to improve health care, was drawn to the idea of NDUs as
meeting their aim. The King's Fund Centre set up a nursing development programme
in 1989, headed by Jane Salvage (a colleague of Pearson and Wright), to fund a
further four Units (Salvage 1989; Pearson 1995; Salvage 1995). The King's Fund
Centre's definition of a Nursing Development Unit is
…a care setting which aims to achieve and promote excellence in nursing. It is committed to improve patient care by maximising the therapeutic potential of nursing; nurses work in partnership with a health care team in which the patient is the key member, in a climate where each person's contribution is valued and an open, questioning, supportive approach is fostered, certain activities are regarded as being essential to the unit's mission: offering the best possible standards of care, monitoring the quality of care and taking appropriate follow-up action, exploiting every means of improving the quality of care, evaluating the effects of the unit's activities on patients and staff, enabling nurses to develop personally and professionally, and sharing knowledge with a wider audience.
The King's Fund Centre, 1989
19
The impetus driving the commitment to NDUs was a response to the under-
investment in the development of nurses' knowledge base and skill development,
despite the fact that nurses make up the majority of the health care workforce
(Salvage 1989). Salvage (1989) goes on to say that nurses often "lack the skill,
education or opportunity to acquire expertise, to scrutinise their work or to introduce
changes that may benefit patients" (p. 25).
Although the philosophy of nursing promoted by Salvage was similar to Pearson and
Wright, that of primary nursing and promoting the therapeutic nature of nursing, the
aim of the King's Fund Centre shifted from exploring innovations in patient care
delivery to promoting excellence in nursing through replication of good practice
(Salvage 1989). One major difference between earlier Units and these new NDUs
was the sizeable amount of external funding available for development work, much
of which was used to fund additional positions or posts of nursing development
coordinators (Malby 1996, Turner-Bosanquet and Shaw, 1993). Whereas, the earlier
units at Burford, Radcliffe and Tameside were established mostly within existing
funds, the UK government quarantined over three million dollars (UK) to assist in
this endeavour.
The competitive nature of funding led to the development of criteria to describe
NDUs so that Nursing Units nearer to matching the criteria were short-listed for
funding (Malby 1996). Units undertook a self-assessment to be considered for NDU
status and thus qualify for funding (Flint and Wright 2001). Those units meeting the
criteria had a clearly identifiable clinical leader to drive development work and staff
who were willing to take ownership of development projects and demonstrate a
commitment to change (Salvage 1989). Although there was little change in the
philosophy of primary nursing driving NDUs from that of Hall, Pearson and Wright,
major differences were related to dependence on external funding. Host
organisations did not have to make any substantial contribution and, essentially,
transferred ownership, evaluation, dissemination, and strategic support for the
development work over to the King's Fund Centre (Malby 1996).
The funding provided by the King's Fund Centre began to run out around 1994 but
by the time the funding scheme closed in 1996, over 200 NDUs had been
20
established. The successful growth of the NDU movement has been attributed to the
national health care policy changes occurring in the UK at the time; however, the
simultaneous effect of political pressures from the dominant medical hegemony and
the gradual loss of external funding, affecting transferability, ownership and
sustainability of practice development work, contributed to the demise of NDU
status of most of these units (Malby 1996).
2.2.4 Demonstrating Best Practice: Yorkshire Health Authority/Institute of Nursing Programme at the University of Leeds
In 1991, at the same time King's Centre Fund in London was being established,
Yorkshire Health Authority began to implement its vision of putting nursing practice
in the forefront of healthcare by developing principles for best nursing practice
(Gerrish, Clayton et al 1999) with the idea of establishing NDUs as a vehicle for
showcasing nursing work (Malby 1996; Vaughan 1998). The chief nurses wanted to
retain ownership of the concept and established criteria for NDU peer accreditation.
The main aim of the Yorkshire approach was to develop NDUs as a vehicle for
promoting best practice and disseminating innovation, with the secondary aim of
developing practitioners, all as part of a strategy for developing nursing (Malby
1996; Vaughan 1998; Gerrish 1999). The overarching premise was that developing
practitioners enabled them to develop professional practice in order to benefit patient
care which then enabled practitioners to develop professional knowledge and use this
to impact health policy (Gerrish 1999). Responsibility for the Yorkshire Health
Authority NDU programme, launched in 1993, was subsequently transferred to the
Institute of Nursing at the University of Leeds (Institute of Leeds 1995), later to be
renamed the Centre for the Development of Nursing Policy and Practice at the
University of Leeds (Institute of Leeds 1995, Gerrish 1999).
The Centre for the Development of Nursing Policy and Practice at the University of
Leeds was established to develop and maintain an accreditation programme that
would ensure objectivity in the accreditation process. A Nursing Development Unit
was defined as:
21
…a practice setting, which is recognised as being a 'test bed' or 'laboratory' for innovation, creativity and leading-edge practice for the organisation in which it is based and for the wider profession of nursing. The purpose of an NDU is to advance the effectiveness of health care services within its host organisation, and to share those advances to the benefit of all patients.
Institute of Leeds 1995, p.4
The Centre initially developed a set of fifteen criteria (summarised in FIGURE 2.1)
that nursing units had to meet before they were awarded the title of NDU (Malby
1996; Gerrish 1999). NDUs were assessed by external accreditors who, in most
cases, acted as facilitators to prepare the units for accreditation. The process of
external assessment by facilitators differed from the self-assessment processes of the
King's Fund Centre's NDUs.
One of the other key differences of the Leeds NDUs was that the NDUs were not
dependent on external funding and sustainability of development work was achieved
from already allocated resources of the host organisation (Malby 1992). There was a
shift in focus away from development of individual nurses to developing nursing by
focusing on the development of the nursing unit. Like the King's Fund Centre's
NDUs, the Leeds NDUs had to demonstrate a commitment to change, nursing staff
development and education and dissemination of innovative practice initiatives
(Malby 1992).
Although a dual-purpose model for nursing practice development, incorporating the
importance of both patient benefit and nurse benefit components had been promoted
by the Institute of Nursing, most of their criteria for meeting and gaining
accreditation as a nursing development unit heavily favoured the nurse benefit
component. There was also a move towards a focus on developing multidisciplinary
Practice Development Units (PDU) (Institute of Leeds 1995; Gerrish 2001). The idea
of advancing nursing practice in isolation from other disciplines was seen by some
nurse leaders as unrealistic because healthcare is ultimately a multidisciplinary
endeavour.
22
FIGURE 2.1 SUMMARY OF CRITERIA FOR UNIVERSITY OF LEEDS NDU/PDU ACCREDITATION PROGRAMME The main aim of PDUs was to bring all clinical professions together to achieve
collaborative, patient-focused goals through collaborative practice. This important
national development moved nursing and practice development into the mainstream
with articulated outcomes for success. Thus, the same criteria for accreditation were
used for both NDUs and PDUs.
Although the Leeds' accreditation programme gained momentum quickly after its
launch, resulting in the establishment of many more accredited NDUs (Gerrish
1999), interest in the programme began to wane in the mid 1990s in light of "an
increasingly competitive culture developing in the health service creating an ethos
that militated against [precluded] sharing best practice" (Gerrish, 1999, p.4).
However, the programme gained renewed energy in the late 1990s, which has been
attributed to "new [Department of Health] policy directives which emphasise[d] a
collective responsibility for quality patient care and encourage[d] sharing best
practice" (Gerrish, 1999. p.4).
Summary of Criteria for NDU/PDU Accreditation by the CDNPP‐University of Leeds#
the unit had to be identified as a defined team who had chosen the
accreditation process and had an identified leader with authority for practice in the unit;
the team recognised a conceptual framework for organising and developing best practice through decentralised decision‐making and staff and patient empowerment;
each team member had to have a personal development plan in place; developments within the unit were evaluated and reviewed in terms of
impact on patients and staff, with reports made to senior management; the team had to have a research‐based approach to practice, incorporating a
spirit of inquiry, critique, application of research findings, participation in research and collaboration with the higher education sector; and
the team also had to have a business plan and operate within existing resources
#Summarised from original 15 criteria for accreditation of NDUs/PDUs by CDNPP described by Gerrish (1999).
23
2.2.5 Ingredients for Change: Kitson, Rycroft-Malone and Royal College of Nursing Institute at Oxford
The increasing cost of healthcare, the economic rationalism of value for money, a
drive for quality improvement and a management culture of 'doing things right', and
a focus on outcomes thrust us into the emerging paradigm of evidence-based practice
(Salvage 1995, Rycroft-Malone 2004). By the 1990s, the evidence-based practice
movement was taking hold and being incorporated into national health care policies
in the US (Institute of Medicine 2001) and in the UK (Department of Health 1991;
Chin 2003).
This manifested itself in the NHS "embarking on a radical package of actions"
designed to close the gap from research to practice (Kitson, Ahmed et al 1996,
p.430) and to ensure that delivery of care was evidence-based and clinically effective
(Rycroft-Malone, Harvey et al 2002b). The proliferation of Nursing and Practice
Development Units was seen as a framework for achieving this end (Chin 2003). In
1993, National Institute for Nursing in Oxford was commissioned by Oxford
Regional Health Authority to review clinical practice development and research
activities in four district health authorities in the UK.
Research activities were defined as
[A]ctivities that should provide new knowledge needed to improve the performance of the [health system], have peer reviewed protocols, ethical approval as required and have published results which are applicable elsewhere in the [health system].
Kitson and Currie 1996, p.42
Clinical practice development activities were differentiated from research activities.
As such, clinical practice development was defined as:
[T]he planned systematic process of the implementation of change systematically undertaken, with clearly specified goals, end points or outcomes and mechanisms for dissemination…based on research-based evidence, [and] the implementation of which would be carefully evaluated.
Kitson and Currie 1996, p.42
24
One of the findings from the review was that generally nurses did not think about
developing practice in a structured way by drawing on research evidence but saw it
as a required expectation of their role as nurses (Kitson and Currie 1996), a point
Kitson made in an earlier scholarly publication (Kitson 1987). The authors argued
that nurses' approach to developing nursing practice reflects their inclination towards
experiential and tacit knowledge rather than scientific knowledge. They
recommended the need for more supervision, preparation, training and infrastructure
support for nurses engaged in development work and a shift in the organisational
culture toward developing nursing practice as a core activity (Kitson and Currie
1996).
Following this review, a conceptual and theoretical framework for research
implementation, known as the PARiHS framework (Promoting Action on Research
Implementation in Health Services), was developed by the Royal College of Nursing
(RCN) Institute, Oxford (formerly known as the National Institute for Nursing at
Oxford) (Kitson, Ahmed et al 1996; Rycroft-Malone 2004). The PARiHS framework
was designed to combine traditional research activities (based on deductive
approaches or hypothesis testing) and more practice-based development work (based
on inductive or hypothesis generating approaches) with the aim of integrating
research, development and practice (Kitson, Ahmed et al 1996). There was a strong
cultural norm of creativity, innovation and reflective practice in the late 1980s which
was reflected in a proliferation of unsystematic development work by the Institute
(Kitson, Ahmed et al 1996). This formed the impetus for the development of the
conceptual model which aimed to make the move toward grounding nursing practice
development work in describing practice practicable, and then, using a systematic,
evidence-based approach, to develop and evaluate that practice (Kitson, Ahmed et al
1996).
Other papers from the Institute's team argue the case, and test the theory, of the
interrelationship of core elements, that is, the level and nature of evidence, the
context or environment into which research is placed and the methods in which
processes are facilitated, for successful implementation of research into practice
(Kitson, Harvey, and McCormack 1998 ; Rycroft-Malone 2004; Rycroft-Malone,
Harvey, Kitson, et al 2002b; Kitson 2002; Kitson, Harvey, Loftus-Hills, Rycroft-
25
Malone et al 2002a; Rycroft-Malone, Harvey, Seers, et al 2002b; Rycroft-Malone,
Kitson, McCormack, et al 2002a; Rycroft-Malone, Seers, Titchen, et al 2004).
…the most successful implementation seems to occur when evidence is scientifically robust and matches professional consensus and patient's preferences (high evidence), the context is receptive to change with sympathetic cultures, strong leadership, and appropriate monitoring and feedback systems (high context), and when there is appropriate facilitation of change, with input from skilled external and internal facilitators (high facilitation). Rycroft-Malone, 2004, p. 298
Since the conceptualisation of the original framework for integrating research,
practice and evidence by Kitson, Harvey and McCormack at the RCN Institute in
Oxford, ongoing development and refinement of the PARiHS framework has been
shaped by a larger team led by Jo Rycroft-Malone (2004) enabling the achievement
of some "theoretical rigor and conceptual clarity" (Rycroft-Malone 2004, p. 298).
However, analysis of publications from this group revealed another major shift in the
focus of nursing practice development was again emerging, a shift from a conceptual
yet operational framework to one based on theory.
2.2.6 In Search of Theory: McCormack, Manley and Garbett School of Practice Development
The move away from the term Nursing Development Unit to Practice Development
Unit was becoming obvious in the literature. The term 'Practice Development' was
now well entrenched in the language of healthcare in the UK and practice
development posts or positions, although varying in scope and level in organisational
hierarchies, were now commonplace (Garbett and McCormack 2001).
The main differences between operational models for NDUs and operational models
for PDUs were that the clinical leader no longer had to be a nurse and there was a
turn toward a research-based approach to practice predicated on collaborative
research with other health disciplines (Williams, Lee et al 1993). A problem
acknowledged but yet to be resolved was the ambiguity surrounding the term which
manifested the wide range of activities undertaken in the name of practice
development; including activities related to evidence-based practice and research,
quality assurance, audit and educational and professional development.
26
Some members from the original team at RCN Institute at Oxford published a
scholarly discussion paper based on "an inductively-derived analysis" in an attempt
to clarify what it means for an organisation to "have practice development"
(McCormack, Manley et al 1999, p.255). This signalled a shift from talking about an
operational model for developing practice to a process-driven theory of Practice
Development. This shift in the discourse of nursing and practice development
resulted in a defining and re-defining, within the Institute, of the constructs of a
potential theory to guide a process of developing practice; that theory being critical
social science (McCormack, Manley et al 1999).
As the new nomenclature of PDU continued to replace NDU, the explicit
identification of a theoretical framework was argued to be important to understand
nursing and practice development work and embed this newly growing ideology, and
nomenclature, into the discipline of nursing science (McCormack, Manley et al
1999).
An outcome of this development was the most quoted definition in contemporary
literature, the RCN Institute's definition which describes Practice Development as:
…a continuous process of increased effectiveness in person-centred care through enabling of nurses to transform the culture and context of care…enabled and supported by facilitators committed to a systematic, rigorous and continuous process of emancipatory change.
McCormack, Manley et al 1999, p. 256
This definition was later amended following a concept analysis based on the
dispositional model of Morse (1995) to:
Practice [D]evelopment is a continuous process of improvement towards increased effectiveness in patient-centred care. It is brought about by helping healthcare teams to develop their knowledge and skills and to transform the culture and context of care. It is enabled and supported by facilitators committed to systematic, rigorous continuous processes of emancipatory change that reflects the perspectives of service-users. Garbett and McCormack 2002, p.3
27
Although the premise of development work now was still about improving
healthcare practice, the push was more toward a process of 'changing the culture and
context of care' and less about an operational model in a defined place for the
development of nurses, nursing practice and the discipline of nursing. Culture is
what defines practice. It is "the way things are done around here" or as Bates (1994)
says, "…not something an organization has but something an organization is" (p.
12). Context is the complex setting in which practice takes place; a setting defined
by geographical, political, financial, managerial and socio-professional relationships
and boundaries. Thus, the shift in the discourse on developing nursing practice
continued to drift in a different direction from that embodied in the PARiHS
framework - that is, from outcome-oriented to process-oriented. However, the
ambiguity in the nomenclature remained.
Even though use of the term 'Practice Development' was becoming wide spread, the
meaning of the term continued to be challenged. Manley and McCormack (2003)
initiated an evolving discourse differentiating types of Practice Development based
on divergent approaches. They introduced two additional concepts into the discourse,
Technical Practice Development [tPD] and Emancipatory Practice Development
[ePD] (Manley and McCormack 2003) mirroring Habermas' theory of knowledge
and human interest (Habermas 1971). Technical Practice Development was defined
as a management-driven, 'top-down' approach, with a focus on knowledge and
technical skills, for example in the research process and evidence-based practice,
with an emphasis on outcomes; while emancipatory Practice Development was a
clinician-driven, 'bottom-up' approach, and was concerned mainly with processes of
reflection (Manley and McCormack 2003).
Although the Manley/McCormack/Garbett definition of Practice Development
maintains the key word "effectiveness", which is inextricably linked to evidence-
based practice throughout the literature, emancipatory change in thinking about
nursing through a critique and understanding of the social world which empowers
individuals to transform their social order (Fay 1987) was the direction in which the
UK nursing and practice development discourse seemed to be heading by the
beginning of the 21st century.
28
2.2.7 Same Road, Different Paths: The Australian Experience in Nursing and Practice Development
Coinciding with the emergence of the 'Practice Development as ideology' in the UK,
the concept of developing nursing practice was having an influence in Australia.
However, while the evolution of developing nursing practice was somewhat linear in
the UK, it did not progress so neatly in Australia. The shift in direction in the UK
nursing and practice development discourse was actually beginning to emerge more
as a rift in Australia.
An operational model for developing nursing practice and the theory of Practice
Development, while both influenced by Pearson's earlier UK NDUs, diverged into
those that claim Pearson's Nursing Development Unit model as their influence, those
that followed the path of the Manley/McCormack/Garbett Practice Development
school of thought, those that claim to have spawned from the literature; and those
that were hybrids of the three. Thus, development of nursing practice in Australia
has been highly influenced by the movement in the UK, but emerging once again
under different names and with variations in philosophy.
2.2.7.1. Influence of Alan Pearson crosses the Atlantic
The appointment of Alan Pearson as the first Australian Professor of Nursing
resulted the NDU movement being adopted in Australia. Two NDUs in which
nursing was responsible for patient admissions were formed in 1988-1989 at
hospitals in Victoria (Baker and Pearson 1991). A newly formed research unit with
joint academic appointments laid the foundation for developing a research culture
among the nursing staff (Baker and Pearson 1991).
In South Australia, other units were established. The Julia Farr Centre NDU was
established in 1991 (O'Brien and Pope 1994) and an NDU was established at
Flinders University Medical Centre in 1993 (Pearson 1995).
Individual units began to appear in the Western Sydney area of New South Wales
(NSW) in 1995 (Greenwood and Kearns 1996), as well as in the Hunter Valley Area
Health Service District with the establishment of the Buchanan NDU, a collaborative
29
partnership between Wallsend Nursing Home and the University of Newcastle
(Keatinge and Scarfe, 1998). Other units appeared in Western Australia, and again,
in South Australia in 1996, most of which were not sustainable. These units
subsequently closed their doors mostly related to lack of interest by staff, lack of
funding, nursing staff attrition, and/or loss of clinical leaders and/or external
academic drivers (Keatinge and Scarfe 1998; O'Brien and Pope 1994). The literature
supports the notions that staff motivation and institutional constraints, such as
financial support, were key influences on sustainable practice development work. In
addition, a changing health care environment has placed increased pressures on
available time for nursing staff – time needed for cultural change to occur.
An injection of government funding in the late 1990s, made available in NSW to
develop a nursing research culture, helped revive the NDU movement in NSW by
clustering together the individual NDUs under the auspices of a collaborative
venture between Western Sydney Area Health Service and the University of Western
Sydney (Greenwood and Gray 1998). This network of Clinical Development Units,
Nursing was launched in 1997 and led by Jennifer Greenwood (Greenwood and Gray
1998).
2.2.7.2. Jennifer Greenwood and the Western Sydney approach
Clinical Development Units, Nursing (CDU, N) were established in Sydney, New
South Wales under the leadership of Jennifer Greenwood, whose approach to their
establishment was informed "at least partly, by intelligence relating to CDU
leadership stressors, derived mainly from the United Kingdom" (Greenwood 2000,
p338). These stressors, documented in the published literature, included the amount
of funding needed to establish and sustain NDUs (Salvage 1995), the slow and
stressful process of becoming an NDU (Salvage 1995; Malby 1996), negative staff
attitudes and lack of staff commitment (Booth and Davies 1991; Christian and
Redfern 1996; Redfern, Normand et al 1997; Bell and Procter 1998; Christian and
Normand 1998), lack of support from doctors, allied health professionals, managers
and nurses outside of the NDU (Pearson 1995; Christian and Redfern 1996; Malby
1996; Allsopp 1998; Wright 1998), hierarchical and disempowering management
structures (Booth and Davies 1991; Allsopp 1998), lack of autonomy (Avallone and
Gibbon 1998) and poor or lack of sustained leadership (Christian and Redfern 1996).
30
CDU(N)s were described as identifiable care settings that concentrated on
developing consumer-focused and research-based nursing practice and the new
nomenclature reflected all at once the multidisciplinary nature of health care (for
example, 'CDU' component) and the importance of the contribution of the nurse (for
example, 'N' component) in the health care team (Greenwood 1999). Nursing teams
involved in the first CDU(N) in south-western Sydney, a Transcultural Nursing Unit
(TNU), claimed their unit was highly effective after only six months. They
highlighted such outcomes as a more open and questioning approach to care,
delivery of more culturally-sensitive care, improved team-work and more
participatory decision-making, enhanced morale and feelings of self-worth and
heightened appreciation of the complex nature of nursing (Greenwood and Kearns
1996).
Despite the injection of funds in 1997 to support CDU(N)s, the awareness of past
stressors and the clinical leadership development programme, many of the units did
not last in Western Sydney because of unanticipated work pressures, high turnover
of clinical leaders, decreasing management support and unrealistic expectations
(Atsalos and Greenwood 2001); reasons similar to those responsible for the demise
of the many of the UK units and the earlier Australian units.
2.2.7.3. Mary FitzGerald and the NSW Central Coast experience
While the CDU(N) concept was developing in Western and Northern New South
Wales, the Manley/McCormack/Garbett Practice Development ideology was
spreading in influence and being established on the NSW Central Coast Health as
'Clinical Practice Development' (CPD) under the auspices of Professor Mary
FitzGerald. While the literature to date described the importance of a 'bottom-up'
approach to developing nursing practice, the strategic plan at Central Coast Health
encompassed both a 'bottom-up' and a 'top-down' approach as it was seen as crucial
to involve people at every level of the organisation to support improved service
delivery (FitzGerald and Solman 2003).
31
Clinical [P]ractice [D]evelopment, defined as a process of engagement that enabled teams to plan change that is important to its members, can occur without official recognition such as meeting published criteria for designation as a [C]linical Practice Development [U]nit. FitzGerald and Solman 2003
Previous literature describes the role of external facilitators to support nursing and
practice development work and the establishment of newly-created nursing and
practice development posts or positions in the UK. The strategic plan for Clinical
Practice Development designed for Central Coast Health acknowledged the role of
the facilitator and the clinical leader in project success. However, the importance of
supporting nurses within existing resources was also important at Central Coast
Health and thus, currently-employed nurse educators as well as clinical nurse
consultants were used as facilitators (FitzGerald and Solman 2003). Support at the
highest organisational level was also important for success and thus senior nurses
and executive members were included in the strategy (FitzGerald and Solman 2003).
Team ownership and commitment were also seen as important for sustainable
change. There was greater emphasis on supporting multidisciplinary professional
teams engaged in the clinical practice development process. It was thought that
teams with well-balanced collaboration, whereby one health discipline perspective
did not dominate the team, could provide a service that meets patients' needs and
allow nurses to develop the confidence and interpersonal skills required to "take up
their appropriate place within the team" (FitzGerald and Solman 2003, p.11).
Clinical Practice Development was classified into three levels in order to recognise
and appreciate development work that had already been achieved and to identify
progress (FitzGerald and Solman 2003). The three levels varied in relation to scope
and scale of development activity, extent of collaborative partnerships, source of
funding, extent of dissemination activity, and closeness of fit to published criteria for
meeting Clinical Practice Development Unit (CPDU) status. Level one, where most
of the existing clinical practice development work took place, concentrated on values
clarification, team building and professional practice and was achieved through
facilitation, critical reflection, and investigating specific patient-focused, clinical
problems through small projects or audits using an evidence-based approach
32
(FitzGerald and Solman 2003). Clinical Practice Development at level two was
conducted within a research framework with links to the university and met most of
the criteria for designation as a CPDU; and at level three was manifested through a
strong programme of clinical research with a high level of integration between the
health service, the university and the community and meets all of the criteria of a
CPDU (FitzGerald and Solman 2003).
Critical reflection of development work already conducted at Central Coast Health
and the work of other Practice Development scholars informed a strategic plan for
Clinical Practice Development at Central Coast Health to be designed to maintain the
characteristic features of nursing and practice development discussed in the
literature; that is, person-focused, facilitative, supported, systematic, team-building,
participative, communicative and action-oriented (FitzGerald and Solman 2003).
2.2.7.4. Other pockets of Practice Development
The influence of the McCormack/Manley/Garbett school of thought was also evident
in Victoria, again at Monash University, in the form of doctoral nursing students
researching various aspects of Practice Development and the convening of the first
Practice Development conference. However, there is little published literature prior
to 2003 on development work in this area. Four Nursing Clinical Development Units
were established through a collaborative partnership between University of
Melbourne and the Mental Health Programme of Melbourne Health in Victoria
based on the Western Sydney approach (Happell and Martin, 2002).
Since its conceptual platform in the 1960s, the notion of developing nursing practice
has been shaped by distinguished nurse leaders around the world and its form has
been influenced by the socio-cultural and political climate of healthcare. The
variation in aims, objectives and philosophies (which are summed up in Figure 2.2,
p.34), of nursing and practice development throughout its evolution is indicative of a
"lack of clarity of purpose within the movement" (Draper 1996, p. 268). This is also
evident in the publication of several concept analysis papers to clarify the concept.
In their concept analysis, based on the dispositional model of Morse (1995), Garbett
and McCormack (2002), with their premise of emancipatory action and change,
33
aimed to describe the focus of and various approaches to Practice Development as
well as develop a framework to clarify Practice Development work. Unsworth
(2000), on the other hand, argued that the focus on action in practice development
resulted in the difficulty in categorising and defining the concept, with the end result
being a proliferation of publications describing practice development work.
Unsworth (2000) used a concept analysis technique developed by Walker and Avant
(1995), which involved the progressive focus on concepts leading to the
identification of critical attributes. Thus, Unsworth (2000) aimed to produce a
definition that focused on the process of practice development and a conceptual
framework that could be used to define or measure when practice development
occurred.
Later, Hanrahan (2004), also using Walker and Avant's (1995) framework for
concept analysis, argued that there was too much focus on organisational systems,
such as facilitators, to address individuals' practice development. Hanrahan (2004)
aimed for an exploration of the concept to generate a more empirical concept. This
would offer an operationalisation of the concept; demonstrating the essence of what
practice development is in order to aid individuals in their own practice development
- in the absence of facilitators and other organisational infrastructure (Hanrahan
2004).
Some authors state that the purpose of nursing practice development is to achieve
improved patient outcomes by improving nursing (Salvage 1989) and that improved
patient outcomes is an indication of the effectiveness of a Practice Development Unit
(McMahon 1988). Other authors claim that the purpose of nursing practice
development is to firstly develop nurses and then develop nursing practice with the
goal of not only improving patient outcomes but also elevating the role of the
professional nurse (Wright 1989; Williams, Lee et al 1993). More contemporary
authors moved the discourse from an operational model for practice development to
a theory of practice development, arguing that a theoretical basis for practice
development would help nurses better understand the process of practice
development and practice changes as a result of this process would be sustainable
.
34
FI
GURE 2.2 N
URSING AND P
RACTI
CE DEV
ELOPM
ENT CHRONOLO
GIC
AL AND THEO
RET
ICAL DEV
ELOPM
ENT TI
MEL
INE
35
The primary focus of various Nursing and Practice Development Units discussed
in the literature can be reduced down to one of two aims - benefits for patients or
benefits for nurses and nursing. None the less, the intended purpose, aims and
outcomes of developing nursing practice must be articulated clearly in order to
establish the basis for a study of outcomes. In addition, particularly in this era of
evidence-based practice, the effectiveness of any practice development model or
theoretical framework must be established to increase the knowledge base of the
discipline. The next section will explore the scientific literature on the
effectiveness of using a nursing/practice development approach to practice change
2.3 Effectiveness of Practice Development: State of the Science
Practice Development remains the prevailing nomenclature and development of
practice remains the intent. This sets up practice development, then, as both a
philosophy and model for change, both with the ultimate primary aim being better
patient outcomes. The last section presented an account of the historical and
ideological development of practice development in nursing from its early roots in
the Loeb Center under the direction of Lydia Hall through its inception in the UK
under the auspices of Alan Pearson through the period influenced by the evidence-
based practice movement and evident in the work of Kitson and Rycroft-Malone
through the turn in its linear development in the UK under the guidance of Kim
Manley and Brendan McCormack through the divergent paths it took in Australia
with Jennifer Greenwood and Mary Fitzgerald.
This section will present a review of the state of the science of practice
development. It will begin with a brief synopsis of the literature on practice
development and then describe the methodological framework used to guide the
review process. The section will end with a conclusion about the effectiveness of
strategic or organisational practice development programmes and
recommendations for research and practice.
36
2.3.1 Background
The practice development literature is dominated by descriptive reports of local
practice development activity, typically focusing on reflection on process or
outcomes of processes and describing perceived benefits. Despite the volume of
published literature, there have been few large-scale studies attempting to evaluate
practice development on a more strategic or organisational level (Redfern and
Stevens 1998; Redfern, Christian et al 2000; Gerrish 2001). Most evaluative work
on nursing practice development has either been small in scale or narrow in focus,
thus making it difficult to draw conclusions about the effectiveness of a nursing
practice development programme from such studies (Draper 1996). This review
will attempt to establish the impact or effectiveness of practice development
programmes and processes on improving patient and/or staff outcomes, changing
practice following an evidence-based approach to practice development, and
changing the culture and context of care.
A review of the literature was conducted using a systematic approach guided by
the methodology used by the Cochrane Effective Practice and Organisation of
Care (EPOC) Group, whose focus is on
…reviews of interventions designed to improve professional practice and the delivery of effective health services, including organisational interventions that can affect the ability of health care professionals to deliver services more effectively and efficiently. Organisational interventions are those which involve a change in the structure or delivery of health care. In other words, an organisational intervention is a change in who delivers health care, how care is organised, or where care is delivered.
Cochrane Effective Practice and Organisation of Care [EPOC] Group 2008
2.3.2 Objectives of the Review
The overall aim was to conduct a comprehensive review that identified the best
available evidence on the impact of a model of practice development underpinned
theoretically by critical social science.
37
The objectives of this review were:
1. To identify rigorous evaluations of practice development in nursing; and
2. To determine effectiveness of implementing a practice development
programme (intervention) to improve patient and staff outcomes, to change
practice using and evidence-based approach, and to change the culture and context
of care using practice development processes.
2.3.3 Criteria for Considering Studies for this Review
2.3.3.1. Types of studies
The following study designs were included in this review: randomised-controlled
trials (RCT), controlled clinical trials (CCT), interrupted time series (ITS) studies,
and controlled before-and-after (CBA) studies. However, it was evident from the
initial search that there was a lack of RCT, CCT, ITS or CBA studies on the
effectiveness of Practice Development programmes or Practice Development
processes. A decision was thus made by the study investigator to expand the
search to include evaluation studies (EVAL) of Practice Development,
particularly since there were many seminal evaluation studies during the genesis
and early growth of the Nursing/Practice Development movement in the UK.
Evaluation studies included outcome evaluations examining the impact or
effectiveness of organisational practice development programmes (intervention)
or process evaluations examining Practice Development processes and/or its
acceptability, and/or explaining how or why a Practice Development programme
may or may not have been successful. A summary of criteria used to include
studies based on design is presented in Appendix 1, Volume 2, p. 1.
2.3.3.2. Types of participants
The following health professionals were included in the review: nurses, midwives,
and/or multidisciplinary teams that included nurses or midwives as team
members. Participants had to be working in/with a team and not in isolation.
Participants had to be working in acute care settings, aged or extended care
settings, mental health settings, critical care settings, ambulatory settings or
community settings, including general practice surgeries.
38
2.3.3.3. Types of interventions
The following types of interventions were included in the review: any explicit
Nursing or Practice Development programme (strategic intervention) based on
using reflective, participatory, emancipatory processes (critical social science or
Practice Development) aimed at (1) using an evidence-based practice approach,
(2) developing a research and evidence-based practice culture, and/or (3) effecting
a change in the culture and context of care, in order to improve staff and/or patient
outcomes. Specifically the organisation must have acknowledged, promoted
and/or supported evidence-based practice and/or the practice development
programme (which must be described in the study report) through the provision
for infrastructure, resources and support necessary to develop and sustain a culture
of inquiry.
2.3.3.4. Types of outcome measures
Studies were included if they reported objective assessments of:
(1) patient and/or staff outcomes related to practice development programme;
(2) patient and/or staff outcomes related to practice development processes;
(3) change in practice following an evidence-based approach to practice
development; and/or
(4) actual or perceived change in culture and/or context of care following
implementation of practice development programme/processes.
2.3.4 Search Methods for Identification of Studies
The search strategy was developed by incorporating the methodological
component of the Cochrane Effective Practice and Organisation of Care Group
(EPOC) search strategy with selected MeSH terms and free text terms relating to
practice development (see Appendix 2, Volume 2, p.2). Using the appropriate
controlled vocabulary the search strategy was translated for use with several
databases. This review was limited to study settings in North America, the United
Kingdom, Australia and New Zealand, tracing the historical development path of
nursing and practice development to Australia. In light of this, the search was
limited to English language journals. A cut-off date of 1960 was imposed to
capture any nursing or practice developments reported since the establishment of
39
Lydia Hall's Loeb Center. The search extended to 2003, the year this study began.
The initial search was conducted on title and abstract only. The following sources
were used:
- searches of electronic databases for primary studies from 1960-2003 including:
The Cochrane Library, MEDLINE, CINAHL, PsycINFO, and Academic Search
Elite;
-searches of electronic databases of related reviews: Joanna Briggs Collaboration
and NHS Centre for Reviews and Dissemination, including DARE (Database of
Abstracts of Reviews of Effectiveness) and Health Technology Assessments: no
additional studies were identified from these sources;
-bibliographies and reference lists of retrieved full text studies: 12 additional
articles were identified from this source, including studies (n=1) or commissioned
reports (n=2) that duplicated information already contained in previously
published included studies2, commissioned evaluations presented in reports (n=1),
commissioned evaluations presented in books (n=2); studies that were excluded
from the review (n=5); studies that were included in the review (n=1); and
- personal contact with internationally recognised practice development experts at
the start of the study who were asked for relevant unpublished studies on
effectiveness of practice development processes which may be relevant and for
details of other useful contacts: no included studies were identified from this
source.
2.3.5 Methods of Review
2.3.5.1. Selection of studies for inclusion
Titles and abstracts resulting from the search process were initially screened by
the study investigator to identify and eliminate any obviously irrelevant studies
2Where findings from individual studies were presented in more than one publication, each publication was
included in the review if complementary/supplementary/subsequent data was reported. Where more than one publication presented the same data related to the same study only the most comprehensive report was included to prevent overestimation of effects from incorporating duplicate data.
40
and articles clearly of no relevance to the study. Abstracts were retrieved,
reviewed and judged for eligibility for inclusion in the review according to the
criteria stated above and included if a full article (published or unpublished) could
be obtained. After the initial elimination process, the remaining studies were
retrieved in full text and assessed for inclusion. Retrieved papers were then
reviewed and categorised by the study investigator into discussion papers on
practice development concepts, issues, barriers and facilitators; descriptive papers
on local practice development initiatives/activity; practice development
programme structures; practice development processes; and practice development
outcomes; and papers on empirical clinical research studies not related to practice
development processes.
Details of studies excluded at this stage of the process are reported in the excluded
studies table (see Appendix 3, Volume 2, p.3). Twelve studies, reported in
eighteen papers, reported on intervention, comparison or evaluation studies of
practice development programmes and/or the effect of practice development
processes on patient and/or staff outcomes, practice change and/or change in the
culture and context of care and, thus, were included in the review. The results of
the search strategy are presented in Table 2.2 (p.44).
2.3.5.2. Assessment of methodological quality
Criteria for assessment of methodological quality were based on EPOC criteria
(EPOC 2008) and EPPI-Centre criteria (Rees, Harden et al 2001) and are
summarised in Appendix 4, Volume 2, p.13. As per the above mentioned
guidelines, the minimum acceptable methodological criterion across all study
designs was the objective measurement of outcomes, presented as relevant and
interpretable data. Each criterion was scored as DONE (2), NOT CLEAR (1), or
NOT DONE (0). An overall quality rating (HIGH, MODERATE, or LOW
PROTECTION AGAINST BIAS) was assigned based on these criteria. Studies
were assigned a rating of HIGH protection against bias if the first three criteria
were scored as DONE, and there were no important concerns related to the last
three criteria, MODERATE if one or two criteria were scored as NOT CLEAR or
NOT DONE, and LOW if more than two criteria were scored as NOT CLEAR or
NOT DONE.
41
2.3.5.3. Data extraction
Data were extracted using an EPOC data collection checklist (modified by the
researcher for this study) that used information on study design, type of
intervention, presence of controls, type of targeted behaviour, participants,
setting, methods (including unit of allocation, unit of analysis, study power,
methodological quality, consumer involvement), outcomes and results. The data
extraction process also used JBI-QARI software from the Joanna Briggs Institute,
which will be discussed further in the next section in relation to meta-synthesis of
non quantitative data.
2.3.6 Analysis
Quantitative synthesis or meta-analysis can only be applied to reviews where the
interventions, participants, outcomes and study designs are similar enough to
suggest that results can be pooled. It was planned for quantitative research study
results to be pooled in statistical meta-analysis using Review Manager software
from the Cochrane Collaboration (Review Manager 4.3). Odds ratio (for
categorical data) and weighted mean differences (for continuous data) and their
95% confidence intervals were to be calculated for each analysis. Where possible,
heterogeneity between similar studies was to be assessed using the standard chi-
square analysis. However, statistical pooling was not possible and findings could
only be presented in a narrative form using a process of meta-synthesis.
Meta-synthesis involves the aggregation of findings and/or conclusions from
qualitative or textual data made in relation to the intervention, activity or
phenomenon that is the subject of the review (Pearson et al 2006). Study findings
were categorised, aggregated and synthesised using JBI-QARI software from the
Joanna Briggs Institute. The JBI -QARI software program, designed to manage
and analyse textual data (Pearson et al 2006), was used in the critical appraisal,
data extraction and synthesis of the findings from the studies in order to interpret
the data and provide a meta-synthesis that encapsulated the essence of the
phenomenon of interest (Pearson 2004). The process, described by Pearson (2006)
involved translating themes and concepts from the study findings; identifying text
data in the reports that validated or supported the themes and concepts; and then
42
re-classifying the data to obtain a synthesis. This JBI-QARI software allowed the
researcher to "exercise some degree of judgement"…to "use interpretative [sic]
techniques [such as content analysis and discourse analysis] to summarise the
findings of individual studies into a product of practical value" (Pearson et al
2006, p. 7). Meta-synthesis allowed the researcher to compare and contrast studies
on aspects such as, delineation of the validity and size of the study, the exact
nature of the intervention (for example, structure, process and intended
outcomes), participants in the programme (for example, number, health
profession, experience), any other differences which might impact on the results,
and study-specific outcomes reported.
2.3.7 Description of Studies
A total of 164 reports/papers were reviewed; 18 reports/papers reporting on 12
studies3 meeting the inclusion criteria for this review were identified (see
Appendix 5, Volume 2, p.21). Three papers, initially believed to meet the criteria,
were rejected at the data extraction phase4. The most common reasons for
excluding studies from the review was that there was no outcome evaluation of
the impact of a programme based on Practice Development methodology or
process evaluation of how or why the Practice Development programme worked
or did not work. A list of excluded studies is presented in Appendix 3, Volume 2,
p. 3)
3 Documents related to the Loeb Center are archived at the Foundation of New York State Nurses - Bellevue
Alumnae Center for Nursing History (Hutchinson 2004). Original Final Report on the evaluation of the Loeb Center by Lydia Hall were difficult to obtain and was only retrieved after several attempts using several resources over the course of four years. This is in line with the observation by Griffiths and Wilson-Barrett (1998) that although the original unpublished study report (Hall et al.1975) is widely cited in the work of earlier researchers in the field (for example, Ersser 1988, Pearson et al 1988, Pearson 1989), few details of the study have been reported in the published literature. This compelled Griffiths and Wilson-Barrett to include a detailed review of Hall's study in their literature review on the effectiveness of 'nursing beds' (1998). Therefore, data on the Loeb Center was extracted from this secondary source before the original document was obtained and thus observations from Wilson-Barrett remain in the thesis as supplement for findings from the original report.
4 The remainder of discussion in this section will be based on the 12 studies, not the 18 reports/publications, although all relevant references for each study will be cited.
43
All of the included studies evaluated the impact of a nursing/practice development
approach to practice change; however, there was variation in scope, aims and
objectives, targeted behaviour or events, focus and setting relative to the impact of
using such an approach. Characteristics of interventions ranged from vague or
implied to detailed descriptions of Practice Development processes or aims, with
the primary focus of some studies on change in practice evidenced by improved
patient outcomes and change in nurse and patient satisfaction. Study settings
included nurse-led inpatient units; acute hospital units; mental health inpatient
units; aged care and psycho geriatric inpatient units; outpatient clinics; ambulatory
care units; midwifery units; community nursing and primary care settings; and
disability settings. Ten studies were set in the UK, one in the USA and one in
Australia.
Four studies, reported in six reports/papers evaluated the impact at the individual
unit level (Hall et al 1975; Hall 1975, cited in Griffiths and Wilson-Barrett 1998;
Pearson 1992; Pearson, Durant and Punton 1989; Pearson, Punton and Durant
1992; Griffiths and Evans 1995). Four other studies, reported in six
reports/papers, evaluated the impact at the program level (Turner-Shaw and
Bosanquet 1993; Pearson 1997; Redfern et al 1997; 1998; Gerrish 1999; 2001).
One study evaluated the impact at the program level by exploring the change in
one four-unit NDU (Black 1993). One study, reported in three reports/papers,
evaluated the impact at the program level using an evaluation of nine individual
evidence implementation projects undertaken by nine individual units within one
health service district (Redfern et al 2000; 2003a; 2003b). In one study the
intervention was described as a 'program of change', but change was actually
evaluated at the individual unit level (McCormack and Wright 1999). One study
evaluated the impact of a 'practice development project'; however the 'project' was
implemented on four individual units in one hospital (Taylor, Coombes et al
2002).
44
TABLE 2.2 R
ESULT
S OF SE
ARCH STR
ATE
GY ON EFF
ECTI
VEN
ESS OF NURSING/P
RACTI
CE DEV
ELOPM
ENT
Sour
ce
Cinah
l, MED
line,
PsycINFO
, Aca
demic Sea
rch
Elite, Coc
hran
e Libr
ary
Joan
na Brigg
s Collabo
ration
NHS Cen
tre for
Rev
iews an
d Disse
min
ation
Referen
ce lists/
bibliogr
aphies
from
retriev
ed
pape
rs
Total
Referen
ces loca
ted us
ing sear
ch strat
egy
142
0 0
22
164
• original fina
l rep
orts
0 0
0 (7)
(7)
• stud
y inform
ation from
secon
dary sou
rce
0 0
0 (1)
(1)
Exclud
ed – ir
releva
nt
‐11
0 0
0 ‐11
Exclud
ed – dup
lica
te (s
ame as ano
ther pap
er)
‐5
0 0
0 ‐5
Exclud
ed – did not m
eet inclus
ion criter
ia
‐120
0 0
‐7
‐127
Refer
ence
s ex
clud
ed after data ex
trac
tion
0 0
0 ‐3
‐3
TOTA
L REF
EREN
CES
6 0
0 12
18
Refer
ence
s pr
esen
ting sam
e or add
itiona
l inform
ation
or data on a stu
dy pre
sented in ano
ther pap
er
‐1
0 0
‐5
‐6
TOTA
L ST
UDIE
S 5
0 0
7 12
45
The purpose of the seminal study in the nursing/practice development literature was
to investigate alternatives to patient care which would maintain and improve
appropriateness and quality of care while evaluating the processes on patient and
staff outcomes (Hall et al 1975). Other included studies explored actual or perceived
changes in nurses' perceptions of job satisfaction, access to staff/professional
development, quality of patient care, changes in nursing practice, and barriers to
research utilisation (Black 1993, Turner-Shaw and Bosanquet 1993, Redfern et al
2000, Redfern et al 2003a, Redfern et al 2003b). One study also included nursing
students' perceptions of their experience while undertaking a clinical practicum in an
NDU (Black 1993), while other studies explored patients' experiences and
perceptions of change in the quality of care provided (Black 1993; Redfern et al
2000; 2003a, 2003b). Two studies explored actual change in practice following an
evidence-based approach to practice development by examining compliance with
evidence-based guidelines (Redfern et al 2000; Redfern et al 2003a; Redfern et al
2003b) and effectiveness of strategies used or practice changes made (Taylor,
Coombes et al 2002).
Four of the included studies were concerned with identification and perceptions of
needs, facilitators and barriers to establishment of nursing/practice development
units, development and update of practice changes, and/or changes in engagement
with research and evidence-based practice (Redfern et al 2000; 2003a, 2003b; Pearson
1997; Redfern et al 1997; 1998; Gerrish 1999; 2001). Some studies focused on
identification, implementation and evaluation of practice development strategies and
practice changes to improve patient outcomes, including quality of care (McCormack
and Wright 1999; Taylor, Coombes et al 2002) and/or nurses' perceptions of
relevance, worth and social acceptability of practice developments and practice
change (Taylor, Coombes et al 2002; Redfern et al 2000; 2003a, 2003b). Finally,
three studies aimed to identify NDU 'criteria for success', units meeting criteria for
NDU status, and progress of NDUs (Pearson 1997; Gerrish 1999; 2001; Redfern et al
1997; 1998).
46
2.3.8 Methodological Quality
The methodological characteristics of each of the 12 included studies are displayed
in the included studies table (see Appendix 5, Volume 2, p.21). Six studies used
prospective research designs using either a comparison unit (for example, RCT) or
the unit under evaluation as their own control (for example, CBA, pretest/posttest)
and six studies used retrospective evaluation designs. Using the EPOC assessment
criteria and accounting for the type of study design of the 12 included studies, six
studies were assessed as high quality, three studies were assessed as moderate
quality, and three studies were assessed as low quality.
Two of the RCTs were assessed as having moderate protection against bias (Griffiths
and Evans 1995; Pearson, Punton and Durant 1992) and the other was assessed as
having low protection against bias (Hall et al 1975). Randomisation concealment was
done in one study (Pearson, Punton and Durant 1992) but was not clear in the others
(Griffiths and Evans 1995; Hall et al 1975). Although patients were followed up in
all three RCTs, one study reported that only 74% of the final sample was available
for data collection at the final data collection point (Hall et al 1975). Healthcare
professionals were only followed up in one RCT (Griffiths and Evans 1995). In all
RCTs, blinded outcome assessment was either not clear (Griffiths and Evans 1995;
Hall et al 1975) or not done (Pearson, Punton and Durant 1992). Reliable primary
outcome measures and protection against contamination was done in all but one RCT
(Hall et al 1975). There was no difference in baseline measurement in one RCT
(Pearson, Punton and Durant 1992) but baseline differences were present in the other
two RCTs. Griffiths and Evans (1995) reported that although "randomization was not
completely successful in eliminating differences between treatment and control
groups", adjustment for differences was incorporated into the analysis (p.37).
Similarly, Griffiths and Wilson-Barrett (1998) report that in the Hall study, there
were baseline differences between treatment and control groups; and although post
hoc analyses were performed to correct some variables, "this was not done for any of
the significant findings" (p. 1186).
The ITS study (Taylor, Coombes, et al 2002) was assessed as having high protection
against bias. Program documentation, context analysis, purpose, aims and procedures
47
were all described; valid and reliable information from defensible information
sources was analysed; conclusions justified and reporting impartial.
One study, reported in three papers (Redfern et al 2000; 2003a; 2003b), used a
pretest/posttest design within a clinical audit framework and was assessed as having
high protection against bias. Program documentation, context analysis, purpose,
aims and procedures were all described. Valid information from defensible
information sources was analysed, however, it was unclear whether the information
was reliable. In addition, conclusions were justified and reporting impartial.
Although this is a study of a large scale Practice Development program, each of the
nine project sites operated independently; but all were guided by the same program
description, followed the same pre-test/post-test design, and were assessed for the
same macro outcomes.
One study (Pearson 1992), using a modified action research design with a proxy pre-
test, was assessed as having high protection against bias. Programme documentation,
context analysis, purpose, aims and procedures, analysis of reliable and valid
information from defensible information sources, justification of conclusions, and
impartial reporting were all present in the study report.
The one CBA study (McCormack and Wright 1999), also using an action research
methodology, was assessed as having low protection against bias. Baseline
measurement and protection against contamination were done; however, blinded
primary outcome assessment, reliable primary outcome measures, and follow up of
patients and professionals were either not clear or not done.
The five evaluation studies generated mainly descriptive data on characteristics of
NDUs, highlighting those factors deemed necessary for 'success' (Black, 1993;
Turner-Shaw and Bosanquet 1993; Pearson 1997; Redfern et al 1997; 1998; Gerrish
1999; 2001). One evaluation study (Turner-Shaw and Bosanquet 1993) was
considered to have low protection against bias. Context analysis, purpose, aims and
procedures were all described, although documentation of the program was not clear.
In addition, although valid information was obtained, it was not clear whether the
information was from defensible information sources or was reliable. Finally,
48
information analysis, justified conclusions or impartial reporting was not clear or not
done. Another evaluation study, reported in two papers (Gerrish 1999, Gerrish 2001)
was of moderate quality with moderate protection against bias. Program
documentation, context analysis, purpose, aims and procedures were described.
Defensible information sources were used and conclusions justified from the findings
were reported impartially; however, it was not clear whether the information was
valid or reliable.
The remaining three evaluation studies, reported in four papers (Black, 1993;
Pearson 1997; Redfern, Normand et al 1997; Redfern, Murrells et al 1998) were of
high quality with high protection against bias. In each of these studies, program
documentation, context analysis, purpose, aims and procedures were described.
Analysis of information and justification of conclusions mostly occurred in each
study, but with some differences, such as lack of clarity or reliability of information
(Redfern, Normand et al 1997; Redfern, Murrells et al 1998), use of defensible
information sources was not always done (Black 1993), and lack of clarity of
justified conclusions (Pearson 1997). In all cases, however, there was impartial
reporting.
While all but one (Taylor, Coombes et al 2002) of the included studies report
positive benefits associated with practice development, limitations in research
design, recruitment, measurement and analysis limit the confident acceptance of the
results.
2.3.9 Narrative Analysis and Data Synthesis
The difficulty in comparing the outcomes of these studies arises from differences in
participant characteristics (for example, age, gender, nursing or health professional
experience), organisational setting characteristics (for example, unit management and
leadership style, staff skill mix), research design and approach (for example, RCT
versus pluralistic evaluation; single site versus multiple site; local Nursing/Practice
Development project evaluation versus large scale programme evaluation; and
Nursing/Practice Development project outcome evaluation versus Practice
Development process evaluation. Differences also vary in definition, purpose and
aims of Nursing/Practice Development, identification of appropriate endpoints,
49
validity and reliability of measurement instruments, and outcome measures.
Therefore, the findings of the included studies will be reported in a narrative analysis
and data synthesis (as described in Section 2.3.6, p.41). A more detailed description
of each of the included studies is presented in Appendix 5, Volume 2, p. 21.
What is clear from the literature are the recurrent themes throughout the evolution of
nursing and practice development. Findings from the included studies were reduced
to categories and synthesised into themes. As suggested by Pearson et al (2006),
findings were assigned levels of credibility: unequivocal [E], credible [C], and
unsupported [U]5. A total of 105 findings were extrapolated from the included
studies. Of these, 61 unequivocal or credible key findings, supported in the included
studies' reports, were identified. The key findings of each study and the evidence or
“illustration” (Pearson, 2006, p.21) to support these findings are presented in
Appendix 6, Volume 2, p. 41. The unsupported findings are provided in Appendix 7,
Volume 2, p. 75.
The 61 supported key findings were sorted into 26 categories; from which five
synthesised themes emerged: patient-centred care, research and evidence-based
practice, autonomy and control over practice, workplace empowerment and
constructive team dynamics (see Figure 2.3, p.50). These five synthesised themes are
illustrated in Figure 2.3 and will be discussed in more detail in Section 2.4.
5Pearson et al (2006, p. 47) describes levels of credibility as follows: [E] = UNEQUIVOCAL: evidence beyond reasonable doubt that may include findings that are directly reported/observed [C] = CREDIBLE: evidence that, although an interpretation, plausible in light of the data and theoretical framework used [U] = UNSUPPORTED: when neither ‘unequivocal’ or ‘credible’ apply or when findings are not supported by data .
50
Figu
re 2.3 T
hemes fr
om syn
thes
is of finding
s from
Nur
sing
/Practice de
velopm
ent e
valuations
Nurs
ing
/ Pra
ctice
De
velo
pmen
t
Them
e 1
Patie
nt C
entre
d Ca
re
Them
e 2
Rese
arch
and
EBP
The
me 3
Pr
ofes
siona
l Pra
ctice
En
viron
men
t
Them
e 4
Wor
kplac
e Em
powe
rmen
t
Cate
gory
1.1
Nurse
Awa
rene
ss of
Nee
d to
Chan
ge P
racti
ce
Cate
gory
2.1
Critic
al Inq
uiry -
Qu
estio
ning P
racti
ce
Cate
gory
2.2
Enga
geme
nt -
Rese
arch
and
EBP
Cate
gory
2.3
Skills
- EB
P an
d Res
earch
Pro
cess
Cate
gory
2.4
Best
Prac
tice -
Im
prov
ed C
linica
l Outc
omes
Cate
gory
3.1
Acad
emic/
Clini
cal/P
rofes
siona
l Co
llabo
ratio
n
Cate
gory
3.2
Auton
omy i
n Pati
ent C
are
Decis
ion M
aking
Cate
gory
3.3
Orga
nisati
onal
Supp
ort a
nd
Reso
urce
s
Cate
gory
4.1
Staff
Per
sona
l and
Pro
fessio
nal
Deve
lopme
nt
Cate
gory
4.2
Infor
mal a
nd F
orma
l Pow
er in
Or
ganis
ation
Them
e 5
Cons
truct
ive te
am d
ynam
ics
Cate
gory
5.1
Supp
ort fr
om P
eers/
M
entor
s / C
ollea
gues
Cate
gory
5.2
Team
Com
mitm
ent /
Colla
bora
tion /
Res
pect
Cate
gory
5.3
Comm
on G
oals
and V
ision
for
Raisi
ng an
d Main
tainin
g Pro
file
Cate
gory
5.4
Staff
Moti
vatio
n
Cate
gory
5.5
Safe
Shar
ing of
Idea
s /
Ope
n Com
munic
ation
Cate
gory
4.3
Re-th
ink an
d Re-
Orga
nise W
ork
Prac
tices
Cate
gory
3.4
Satis
factio
n with
Wor
k life
Cate
gory
4.4
Infra
struc
ture/
Reso
urce
s/ Or
ganis
ation
al Su
ppor
t
Cate
gory
1.2
Nursi
ng V
alues
vs.
P
racti
ceRe
ality
Cate
gory
1.3
Patie
nt/Fa
mily
Involv
emen
t
Cate
gory
4.5
Skille
d and
Com
mitte
d Fa
cilita
tors/
Chan
ge A
gents
Cate
gory
1.4
Patie
nt Sa
tisfac
tion w
ith C
are
Cate
gory
1.5
Ther
apeu
tic N
urse
/Pati
ent
Relat
ionsh
ip
Cate
gory
3.5
Self-
and O
thers-
Rec
ognit
ion of
Im
pact
and V
alue o
f Nur
sing
Cate
gory
3.6
Contr
ol ov
er P
racti
ce
Cate
gory
2.5
Diss
emina
tion -
In
nova
tions
and R
esea
rch
51
2.4 Practice Development – A Model for Change
2.4.1 Synthesis of Evolving Concepts
There is clear synergy between the chronological development of Practice
Development, as demonstrated in the previous section, and the research literature.
The themes in Figure 2.3 clearly show this link. As demonstrated in the previous
section, the tenets of practice development in nursing evolved over time and the
evolution cannot be assigned to one person. An analysis of the chronological and
theoretical evolution of practice development has demonstrated how nursing scholars
have built upon each other's work in refining and developing a bedrock of concepts
that have provided a foundation for developing nursing practice. A consistent theme
and evolving concepts run throughout the Nursing and Practice Development
discourse across all periods of development – empowering teams to introduce
practice change that improves the effectiveness of the service to patients. A
consensus view has held steadfast throughout the evolution of Nursing and Practice
Development that a culture and context of care that is conducive to effectively
developing practice in nursing should not only endorse, engender and nurture
patient-centred care, but also:
stimulate, support and sustain nurses' active engagement with research and
evidence-based practice;
acknowledge, advocate and allow nurses to exercise control and autonomy in
their professional practice environment;
provide equity and access to resources, support and opportunities to empower
nurses in the workplace; and
create and cultivate cohesive and collaborative teams characterising
constructive team dynamics.
Although these themes can be described individually, collectively they embody a
culture of inquiry which must transcend individual motivations and abilities if it is to
succeed and be sustained in any given context. These themes6 will now be discussed
in more detail and situated in the Nursing and Practice Development literature.
6 The delivery of patient-centred care is accepted as an assumption of quality nursing care and in-depth review of
the literature surrounding this theme is not in the scope of this study.
52
2.4.2 Research and Evidence-based Practice
Nurses are expected to engage in research and evidence-based practice and research
engagement has been linked to nursing and practice development from its earliest
beginnings and promoted throughout its evolution. Meta-analyses of research
findings have demonstrated that patients who are the recipients of research and
evidence-based nursing practice have better outcomes than patients who are the
recipients of standard or routine nursing care (Heater, Becker et al 1988; Picone,
Hathway et al 1996; Picone, Lawler et al 2000) thus supporting the assumption that
engagement in the evidence-based practice and research agenda improves patient
outcomes – an ultimate goal of developing nursing practice. However, research is
still perceived by most nurse clinicians as external to practice and implementing
research findings into practice is often difficult (Kitson 2002).
Reasons for the difficulties (that is, barriers) to research utilisation and evidence-
based practice have been well documented in the literature, which is as replete today
as it was three decades ago. Barriers tend to be categorised into (1) barriers related to
the research itself (such as, research quality), (2) barriers related to the individual
nurses (such as, values, skills and awareness), (3) barriers related to the
communication of the research (such as, presentation of findings and accessibility),
and (4) barriers related to the organisation or work setting (such as, time, resources,
and support or cooperation of medical officers, senior management or peers).
Furthermore, these barriers typify key elements described in change theories and
models of diffusion of ideas and innovations (Greenhalgh, Robert, MacFarlane et al
2004).
Aspects of the organisational setting and practice environment continue to represent
the greatest perceived problem areas. In a survey of the barriers research from North
America, Europe, the United Kingdom and Australia, lack of time to read and apply
findings, lack of organisational and peer support to implement findings, and lack of
authority to change practice continue to rank highest in the list of barriers (Miller and
Messenger 1978; Funk, Champagne et al 1991a; Funk, Champagne et al 1991b;
Closs and Cheater 1994; Funk, Tornquist et al 1995; Walsh 1997; Dunn, Crichton et
al 1998; Kajermo, Nordstrom et al 1998; Retsas and Nolan 1999; Kajermo,
53
Nordstrom et al 2000; Parahoo 2000; Retsas 2000; Griffiths, Bryar et al 2001;
Parahoo 2001; Oranta, Routasalo et al 2002; Bryar, Closs et al 2003; McCleary and
Brown 2003; Hommelstad and Ruland 2004; Hutchinson and Johnston 2004;
Lapierre, Ritchey et al 2004). Practice Development aims for acquisition,
understanding and application of new knowledge, resulting in change in the culture
and context of care (McAllister and Osborne 2006). This in turn, results in
empowering nurses to improve practice and increase effectiveness in patient care.
Inherent in empowering nurses to pursue and translate knowledge into practice
change is autonomy in decision-making and control over the practice environment.
2.4.3 Control and Autonomy in Practice Environment
Control and autonomy over practice in a professional practice environment is
another theme carried across the various iterations in the evolution of nursing and
practice development. A professional nurse practice environment has been defined as
one that supports and empowers nurses by providing opportunities for autonomy and
accountability, control over the delivery of nursing care in the environment where
that care is delivered, and collaborative nurse-doctor relationships (Grindel,
Peterson, Kinneman, and Turner, 1996; Hoffart and Woods, 1996; Zelauskas and
Howes, 1992).
Autonomy represents the ability to be self-governing and exercising professional
judgment in a timely fashion (Aiken and Sloane 1997) and control over practice is
manifested in sufficient organisational status to influence others and deploy
resources (Aiken, Havens et al 2000). Sufficient organizational status can be linked
the concept of authority, which Blanchfield and Biordi (1996) defined as the
sanctioned or legitimate power of an individual in an organization that allows the
individual to make decisions.
2.4.4 Workplace Empowerment
The theme of empowerment has also been carried through in the evolution of nursing
and practice development. Empowerment refers to the ability to make goal-directed
decisions and to implement actions to meet desired goals (Blanchfield and Biordi
1996). According to Kanter's Theory of Organisational Structures, organisational
54
structures in which staff members feel empowered are beneficial in terms of
employee attitudes and organisation effectiveness (Kanter 1993). Empowered work
environments with formal and informal systems of power are those in which
employees feel that they have access to information, support, resources necessary to
do their job, and opportunity to learn and develop (Kanter 1993; Laschinger, Almost
et al 2003). Formal power is manifested in job definition, discretion or flexibility in
job, recognition or visibility of work, and relevance or centrality of employee's work
to the organisation; while informal power is manifested in connections made inside
the organisation, such as alliances with peers, subordinates, and cross-discipline
functional groups, and connections outside the organisation (Kanter 1993).
Employees who feel empowered are more likely to contribute effectively to the goals
of the organisation. This theory has been tested and supported in several studies in
relation to significant organisational outcomes such as organisational commitment,
job autonomy, participation in organisation decision-making, and perceived control
of nursing practice (Wilson and Laschinger 1994; Laschinger and Havens 1996;
Laschinger, Sabiston et al 1997; Laschinger, Almost et al 2003). If one of the goals
of the organisation is to become a research and evidence-based practice culture, then
the staff must feel empowered in their work environment to strive to achieve that
goal.
2.4.5 Constructive Team Dynamics
The fourth recurring theme in the nursing and practice development literature - and a
feature of professional practice environments - is that of team cohesion,
collaboration and collegiality, typifying constructive team dynamics. Work-based
teams in an acute hospital setting are typically identified geographically, as in a unit
or clinic, and as such are the most likely defining 'boundaries' of a team. Analogous
with Anderson and West's (1998) definition of 'team', but in the context of a nursing
practice environment, a team is a group to which a nurse is assigned, with whom the
nurse identifies and with whom the nurse interacts regularly in order to perform
work-related tasks. More to that point, however, a team exists when its members
accept the way of organising their work, want to be a part of the team and are
committed to the team's success (Millward and Jeffries 2001).
55
Teamwork and an organisational culture that supports teams has been asserted as one
of the essential components of successful nursing and practice development and
change (Black, 1993; Salvage and Wright, 1995; Walsh and Walsh, 1998).
Anderson and West (1998) theorised that innovations often resulted from team
activities undertaken by groups which were exemplified by a shared vision,
participative safety, task orientation and support for innovation (Anderson and West
1998; Kivimaki and Elovainio 1999; Bower, Campbell et al 2003).
In an acute care environment a shared vision can develop from a shared recognition
of the disparity between practice philosophy and the reality of practice and a shared
desire to move from a state of disparity to one of parity. In a climate of participative
safety involvement in decision-making in the unit is encouraged, supported and
strengthened while occurring in a safe, non-threatening environment in which team
members feel at ease engaging in dialogue, discussion and debate. A practice
environment that is receptive, amenable and supportive of an open exchange of ideas
can set the stage for the establishment of a climate of collaboration and teamwork.
Task orientation can be manifested as a shared concern with achieving excellence in
the work of the unit and evaluating a unit's performance in relation to the shared
vision (Anderson and West (1998). A professional practice environment that
stimulates an eagerness and acceptance for innovation and change can inspire team
members to reflect on and explore innovations in practice. Lack of support for
innovation and change by senior managers, nursing colleagues and other health care
disciplines is one of the most prominent barriers to research utilisation, evidence-
based practice and change reported in the literature.
The literature on nursing and practice development identified individual,
organisational and multidisciplinary support for research and evidence-based
practice, control and autonomy over the practice environment, workplace
empowerment, and constructive team dynamics as frequently recurring themes. The
effectiveness of the interaction of these components (within the context of team) is
achieving, maintaining and sustaining a culture that supports innovation and change,
that is, a culture of inquiry is yet to be explored.
56
2.5 Conclusion
A comprehensive integrative review of the evolution of Nursing and Practice
Development reveals a collective pattern of attributes, supported with tangible and
genuine resources that a culture and context of care should endeavour to achieve and
maintain in order to be effective in realising and sustaining a culture of inquiry
through engagement in research and evidence-based practice. An effective culture
and context of care is synonymous with an effective practice climate. Although there
are some robust theoretical arguments, there is limited empirical evidence supporting
the relationships between these attributes in the context of developing practice in the
practice climate, the impact of these linkages on sustaining innovation and practice
change, or the confirmation of a theoretically-based, process-driven framework as an
effective process for change.
What the literature has shown and continues to show is that positive outcomes are
reported but methodological weaknesses, lack of detailed and reproducible
descriptions of programmes or interventions and measurable outcome indicators
limit the confidence with which findings of effectiveness can be accepted. Thus, in
the midst of the global enthusiasm for developing innovations in nursing practice
and the empirical support of the benefits of practice based on evidence, this research
is both essential and timely. The following chapter will provide a description and
analysis of the theoretical framework that informs this study, and also serves as a
theoretical explanation guiding the evolution toward conceptualisation of a Practice
Development methodology, whether explicitly stated or implied in the nature of the
aims and objectives articulated over time.
57
CHAPTER 3. THEORETICAL FRAMEWORK
3.1 Introduction
Chapter 2 presented an examination of the chronological and theoretical evolution of
the development of nursing practice toward the conceptualisation of a Practice
Development methodology for change, as well as a critical discussion of the state of
the science on the effectiveness of a Practice Development methodology in changing
the culture and context of care. This chapter will provide a discussion of the
theoretical underpinnings of contemporary Practice Development. Further, the
chapter shall present a case for the use of critical social science as a framework for
the development and testing of an intervention predicated on critical social science
and aimed at creating a culture of inquiry and evidence-based practice in nursing.
This chapter will provide clarity about critical social science and its relationship to
Practice Development by presenting a brief description of the science and outlining
key components of a Practice Development model that fits within a framework of
critical social science. It will begin with a discussion about alternative models and
their underlying conceptual and/or theoretical frameworks that have been identified
in the literature as a framework for evidence-based practice and research translation.
3.2 Alternative Theories, Models and Frameworks for Evidence-based Practice and Practice Development
One of the oldest theories associated with the research utilisation and uptake of
innovations in nursing is the Diffusion of Innovation Theory (Rogers 1983, 2003,
2004) which postulates a process by which communication of new ideas, practices or
ways of thinking (innovations) through a social system over time by its members
(diffusion) occurs. Rogers theorises there are four key elements in the process: the
innovation, the communication channels, time and the social system.
Diffusion of Innovation Theory, first formally researched in 1943 (Murray 2009), is
widely used in a variety of academic and professional disciplines because it has a
“pragmatic appeal in getting research results utilized… [by]…connecting research-
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based innovations with the potential [end] users in a knowledge utilization process”
(Rogers 2003, p104). Rogers (2004) holds that the theory can be applied in different
contexts because diffusion is not limited by the innovation, the adopter or the
culture. Greenhalgh, Robert, MacFarlane, et al (2004), in a systematic review and
meta-narrative of 213 empirical and 282 non-empirical sources, found that literature
supported this and concluded that although earlier models were well supported with
robust research, they were limited by unyielding assumptions that the innovator and
the innovation were the only pertinent components in the model, that the trends of
adoption reflect static personality traits of the individual adopter, and that the
individual innovation was taken for granted to be better than the previous practice
(Greenhalgh, Robert, MacFarlane et al (2004).
Since its early beginnings, the Diffusion of Innovation Theory has undergone review
and refinement over the past six decades and has emerged in this decade in a
reorganised and modernised conceptual framework aimed at spreading and
sustaining innovations in the health service industry. The conceptual model for
considering determinants of diffusion, dissemination and implementation of
innovations, proposed by Greenhalgh et al (2004) has incorporated more attributes of
the system, such as readiness for innovation. After undergoing review and
refinement in the 1990s (Rogers 1995), this theory has emerged in this decade a
reorganised and modernised version of its former self.
Several alternative models for research utilisation and evidence-based practice in
nursing have been discussed in the literature (Barbara 2002), including the Stetler
Model (Stetler 2001, 2003), the Ottawa Model (Graham 2004), the Iowa Model
(Titler, Kleiber, Steelman et al 2001; Titler 2007), the Rossawurm and Larrabee
Model (Rossawurm and Larrabee 1999), the John Hopkins Nursing Model
(Newhouse et al 2007), the PARiHS Framework (Kitson et al 1998; Rycroft-Malone
2004), and the Tyler Collaborative Model (Olade 2004), to name a few. At least one
of the listed frameworks or models is based explicitly or loosely on theoretical
frameworks. For example, Critical Social Science theory has been linked to the
PARiHS framework, most notable during its earlier discourse.
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Despite this, most models, including the PARiHS framework, are predominantly
operational frameworks implemented within an organisational infrastructure, some
based on change management principles and others based on derivations or
compilations of other models. Some models are local-setting specific and some have
been used extensively in international contexts; however, evidence of effectiveness
of most of the models is limited.
Greenhalgh et al (2004) conducted a systematic review on diffusion of innovations in
service organisations to develop a conceptual model for considering determinants of
diffusion, dissemination and implementation of innovations. They found that
empirical studies had been taken from a pragmatic rather than academic perspective
and it was difficult to separate the studies on implementing and maintaining
innovations from change management literature. Greenhalgh et al (2004)
recommended that future studies should focus on by what processes particular
innovations are implemented and sustained, how these processes can be enhanced,
and how can organisations assess their 'readiness' (p.619) to anticipate the impact of
an innovation.
The literature is repetitive on the notion of evidence for effectiveness. There is
limited evidence for effectiveness of frameworks and models for evidence-based
practice and practice innovation and change (Cheater et al 2009; Foxcroft and Cole
2009). Greenhalgh et al (2004) has also concluded that there is limited evidence of
effectiveness of some theories, namely Diffusion of Innovations, used to underpin
some operational models and frameworks. The next section of this chapter will
attempt to provide clarity regarding the theoretical framework attached to Practice
Development, Critical Social Science, and the relationship in the context of building
an operational model for implementing a Practice Development program.
3.3 Critical Social Science
Critical social scientists are strongly influenced by critical theory (Schwandt 2001).
In the field of social inquiry the term 'critical theory' has two, often confused,
meanings: the first meaning, ascribed to by the Frankfurt School, represents a theory
of modern society, based on the neo-Marxist theory of advanced capitalism; and the
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second meaning represents a theory of science, specifically a metatheory of social
science (Fay 1987, p.4). Following the analysis of the Nursing/Practice Development
literature, and aligned with the prevailing discourse, the design of this study was
situated in a critical social science framework.
As with most critical theories, critical social science aims to explain and critique a
social world in such a way that the understanding or enlightenment of the social
world becomes the catalyst of empowerment which results in the transformation of
this social order through emancipation (Fay 1987). The theory holds that there is
some fundamental structural conflict within this world that causes dissatisfaction or
'suffering', resulting in a breakdown or crisis of the social world. Inexplicably linked
to this dissatisfaction and crisis is a systematic ignorance or 'false consciousness' of
self in the social world among those who are dissatisfied (Fay 1987, p.23), which
unfortunately serves to maintain the social situation.
Fay (1987) asserts that the dissatisfied want the suffering to end but can only achieve
this by coming to a different understanding of self in the social world. This
'consciousness raising' (p.23) empowers the dissatisfied to organise themselves into
an effective group with power to change basic social arrangements and relieve
suffering (Fay 1987). The dissatisfied group must be educated about their situation
and their potential capacity to change it [enlightenment] and motivated into
transformative action to change their situation [empowerment]; resulting in "a state
of collective autonomy in which they have the power to determine rationally and
freely the nature and direction of their collective existence" (p.205) [emancipation]
(Fay 1987).
Fay explains that the basic structure of critical social science is comprised of several
key elements, all of which must be present in a theory in order for a theory to fit
within a critical social science framework (Fay 1987). There must be an explanation
of false self-understandings or 'false consciousness' of a group and how this self
misunderstanding is maintained in conjunction with the presentation of an alternative
self-understanding that is better than the false consciousness. There must also be a
social crisis, something that threatens social cohesion and that is related to the sense
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of false-consciousness. A brief outline of Fay's Critical Social Science Theory is
summarised in Figure 3.1.
Fay (1987) recognised his original framework for critical social science was limited
in the assumption that people can come to new understanding of themselves and can
change their existence in the social world through rational analysis, scientific inquiry
and critical reflection. However, there are embodied, traditional, historical and
embedded limitations to this power of human reason (Fay 1987).
A person may be able to cognitively come to a new understanding of self but
oppression may be more physical than cognitive and the embodiment of the
oppressed relates to those physical limitations (Fay 1987). In addition, no matter
how aware and willing members of a group are to change their situation, it is
unlikely consensus will be reached in all members of the group (Fay 1987).
Similarly, embedded traditions, which form part of the identity of a group, and
traditional power hierarchies are reality; thus, those with power can exert a force that
impedes the ability and capacity for transformative change (Fay 1987). Embedded
traditions, who we are as nurses, and those with power can exert a force that impedes
our ability and capacity for transformative change. In order to address these
limitations to the critical social science framework, Fay amended the original
framework (Figure 3.1, p. 62) to recognise these limitations.
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Amended Framework for Critical Social Science
Element 1: false-consciousness o demonstrates ways in which self-understandings of a group of people is false or incoherent o explains how members of group came to have these false self-understandings and how they are
maintained o contrasts the false self-understandings with an alternative self-understanding that is better than
the current self-understanding Element 2: crisis o defines social crisis and demonstrates how a particular society is in crisis and how social
cohesion is threatened by dissatisfaction of a group which cannot be alleviated in the presence of the current self-understandings and organisation of the society
o presents an historical account of the development of the crisis and its relation to the false self-understandings and organisation of the society
Element 3: education o presents an account of the conditions necessary and sufficient for enlightenment o demonstrates how these conditions are met in the given current social situation Element 4: transformative action o isolates those aspects of the society which need to be changed to resolve social crisis and lessen
dissatisfaction o details plan of action: who are the change agents and how will the change be accomplished
Amendments to original schematic framework of critical social science Element 5: embodiment o develops explicit account of nature and role of inherited dispositions and somatic knowledge o formulates a theory of body therapy o explains limits which inherited dispositions and somatic knowledge place on emancipation Element 6: tradition o identifies which parts of a particular tradition are at any given time changeable or worthy of
change o identifies which parts of a particular tradition are at any given time are not changeable or worthy
of change Element 7: recognition of force o develops account of the conditions and the historical legitimate use of force and action in
particular socio-political settings o explicitly recognises the limits to the effectiveness of a critical theory in the face of certain kinds
of force Element 8: reflexivity o provides an explanation of its own historical emergence, and in this portrays itself as a
necessarily one-sided construction in a particular historical setting o explicitly abstains from lofty aspirations regarding the experience of all humans of some
oppressed group and gives up all pretensions of the 'essence' of emancipation (that is, rational self-clarity and complete autonomy
o offers account of ways it is inherently and essentially contextual, partial, local, and hypothetical
FIGURE 3.1 AMENDED FRAMEWORK FOR CRITICAL SOCIAL SCIENCE (FAY, 1987)
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3.4 Critical Social Science and a Theoretical Model for Practice Development
Using the amended schematic framework of critical social science, a theoretical and
practical model for Practice Development has been developed for this study.
3.4.1 False Consciousness
Nurses engaged in practice development must understand ways in which their self
understanding is false, how they came to believe and maintain these self
misunderstandings and better alternative self-understandings. This would involve
dialectic discussions about (1) perceived dissonance between current practice and
desired practice (for example, holistic, patient-centred, evidenced-based); (2)
perceived lack of ability to change practice (for example, no time to critically reflect
and implement changes, lack of cooperation with managers and other health care
professionals, lack of true collaborative decision-making authority); (3) barriers to
engagement with research and evidence-based practice; (4) perceived lack of control
in patient care environment (for example, organisational hierarchy and medical
dominance); and (5) perceived lack of value placed on nursing experience, insight
and knowledge (for example, superficial collaborative decision making).
3.4.2 Crisis
Nurses engaged in practice development must be made aware of the seriousness of
their situation. This would involve dialectic discussions about the social crisis in
health care, with particular focus on (1) nursing shortage, (2) recruitment and
retention issues (3) ageing workforce (4) medical errors and patient safety issues;
and (5) evidence of nurse dissatisfaction with the current state of practice.
3.4.3 Education
Next, nurses engaged in practice development must be educated on the conditions
necessary for enlightenment by (1) defining and discussing evidence-based practice
and how evidence-based practice can level the playing field for decision making; (2)
practical skill development and training in evidence-based practice; (3) mentoring
and experiential learning in the research process; (4) training facilitators in
transformative learning and practice development; (5) facilitating clinicians in
64
critically interrogating practice; (6) facilitating clinicians learning in collecting
evidence of current practice and collecting evidence to support or change practice;
(7) facilitating clinicians to formulate action plans for change, including evaluation
strategies to measure and evaluate outcomes; and (8) guide clinicians to answer
questions they want answered and in formulating documents to support practice
change.
3.4.4 Transformative Action
Nurses engaged in practice development must engage in dialectic discussion about
those aspects of the health care society that need changing and developing; and to
implement action plans to achieve that change. Some of these areas that need
changing include (1) perceptions of barriers to engagement with research and
evidence-based practice; (2) perceptions of autonomy and control over practice in a
professional practice environment; (2) perceptions of the conditions for workplace
empowerment; and (3) perceptions of the degree of constructive team dynamics.
Strategic plans for action include (1) provision of a skilled facilitator, including role
description for internal and external facilitators, senior management, clinicians and
team leaders in process of practice development; (2) identification of shared values
and development of shared vision and prioritised agenda for research and
development; (3) provision of physical resources with dedicated space with internet
access and guidance for team in organising dedicated time for practice development
work; (4) provision of training in evidence-based practice and research methods and
processes; (5) establishing a communication strategy for dissemination of
information locally, hospital wide, nationally and internationally, including support
of clinicians to disseminate own information; and (6) establishment of clinical
governance processes to support forward movement toward goals. Nurses will be
guided to develop the most suitable local and specific action plans to address issues
on their change agenda.
3.4.5 Embodiment
Nurses engaged in practice development need to develop awareness about the
physical limitations that serve to control their practice environment and develop
plans of action to lessen these limitations. One of the strategic plans of action in this
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study was to secure dedicated time and space with internet access. The nurses were
encouraged and facilitated in finding and securing these physical resources. The
nurses were made aware that this was their responsibility although they would be
supported in their endeavours. It was important that the dedicated space and time be
negotiated early in the practice development process.
3.4.6 Tradition
Nurses engaged in practice development must have a realistic expectation of the
potential to change practice. There was dialectic discussion on which challenges they
could reasonably expect to win, what tools they needed to help them win, and which
challenges would be best left alone. Sometimes, it was a matter of choosing the
appropriate time to take on the challenge and sometimes it was best to leave the
challenges for a more opportune time.
Critical thinking through the items on the agenda for change involved not only
identifying problems or issues for change, but also a critical discussion of benefits of
change, expected outcomes of change, resources needed for change, facilitators of
change and barriers to change. A strategic plan of action was the establishment of a
clinical governance committee as a resource for change, particularly to circumvent
those most stubborn barriers steeped in tradition.
3.4.7 Force
Nurses engaged in practice development must be made aware that others in the
social world of health care, through a historically legitimated power or force, have
the potential for action as well; action that can act as a force to impede
transformative change. Thus, nurses were engaged in discussions about these
potential or actual forces. In some cases, the clinical governance committee would be
a valuable resource; in other cases, the effectiveness in moving forward with change
would continue to be challenged by the dominant hierarchy.
3.4.8 Reflexivity
Nurses engaged in practice development must be engaged in honest discussion about
the nature of practice development, prefaced with a description about its historical
and political origins. It was made explicit that Practice Development was one
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methodology aimed at increasing nurses' engagement with research and evidence-
based practice; with the ultimate target being change in the culture and context of
health care. It was stressed that practice development should not be seen as a
panacea for utopian nursing practice. The processes and the outcomes were mostly
local, contextual, partial and hypothetical.
The amended scheme of critical social science theorises an argument that is able to
recognise nursing in its own right as a contributor to patient care but also recognise
nurses as legitimate members of the multidisciplinary health care team; while at the
same time recognising that true autonomy over the practice environment is
unattainable because of the interrelatedness of multiple members of the health care
team. Thus, critical social science is a theory of practice that proposes each member
of the society be respected by that society and that society values situations where
each member can contribute to play their proper role (Fay 1987). Critical social
science values the elimination of those situations in which, because of domination by
another, one group, namely, the group that is dissatisfied, is prevented from being
what it can be and should be – that is, the role they perceive is theirs (Fay 1987).
Nursing has been viewed as the group that is dissatisfied in the social world of the
health care environment (Carr and Kemmis 1986; Pearson 1992) in terms of their
role in the health care system (Pearson 1992). The fundamental structural conflict
may be attributed to a combination of hierarchical dominance in organisations,
medical dominance in patient care decision-making and economic rationalism
forcing nurses into a task-oriented, order-taking method of practice. This may result
in not only feelings of dissonance between how nurses feel they should be practising
and the reality of practice but also in nurses' perceptions of having no control over
their practice, no autonomy or authority to change patient care practices, and no true
partner status in collaborative decision-making.
In its varied forms, contemporary Practice Development is about enlightening and
enabling nurses to transform the world in which they work through a facilitated
process of critical reflection and emancipatory change (Kitson, Harvey et al 1998;
Manley 1999; McCormack, Manley et al 1999; Manley 2000; McCormack, Kitson et
67
al 2002; Rycroft-Malone, Harvey et al 2002b; Rycroft-Malone, Kitson et al 2002a;
FitzGerald and Solman 2003; Manley and McCormack 2003; Rycroft-Malone,
Harvey et al 2004). The relationship between society and nursing in health care from
a critical social science perspective is illustrated in Table 3.1.
3.5 Emancipatory Practice Development (ePD)
Earlier explanations of the underpinnings of contemporary Practice Development by
(McCormack, Manley et al 1999; Manley and McCormack 2003) describe a
philosophy that more specifically resembles critical theory, most notably associated
with theorists of the Frankfurt School, such as Habermas (1971). Critical theory in
this case can be described as an approach to the study of society in which human
interests shape and guide the quest for knowledge and which has an overt political
goal: a rational and decent society (Habermas 1971). Habermas (1971) posits three
kinds of knowledge intrinsically linked to human interest and necessary to critical
research: technical cognitive interests (aimed at control), practical interests (aimed at
mutual understanding) and emancipatory interests (aimed at liberation from
constraints) (Bohman 1999).
Critical social science extends the premise of critical theory by not only adding the
elements of awareness of a social crisis and a false consciousness that causes, and at
the same time, perpetuates the social crisis, but also, contend McCormack, Manley et
al (1999), by adding the dimension of emancipatory action. Hence, it is not enough
to just be aware of the situation but to be moved to action. Thus, McCormack,
Manley et al (1999) have situated Practice Development in a critical social science
framework.
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TABLE 3.1 RELATIONSHIP BETWEEN SOCIETY AND NURSING IN HEALTH CARE FROM CRITICAL SOCIAL SCIENCE PERSPECTIVE
Society Nursing in Health care
Fundamental structural conflict - Hierarchical dominance in healthcare - Medical dominance in health care - Economic rationalism - Empirical vs. tacit knowledge - Task‐oriented model of practice - Non professional nurses "doing" nursing
work
Suffering by members - Nurses dissatisfied with status quo - High stress / sick leave - High staff turnover
Breakdown of society - Nursing in crisis - Recruitment and retention deficiencies - Aging workforce worldwide - Nurses role erosion
One of the causes is systematic ignorance about self and society – "false consciousness"
- Nurses are our own worst enemy - Accept role of subordinate decision‐
maker or 'behind the scenes' decision‐maker
- Relinquish control over nursing practice - Loses sense of responsibility and
accountability
Members want suffering to end - Nurses want to change practice but bound by barriers
Members develop different understanding of themselves – "raising the consciousness"
- Nursing is therapeutic - Nursing has an impact on patient
outcomes - Innovative strategies to decrease
barriers to changing practice - Nursing autonomy and control over
practice
Members would then be able to organise themselves into an effective group with power to change basic social arrangements and relieve suffering
- EBP combines empirical knowledge with tacit knowledge and patient knowledge
- EBP linked to better patient outcomes - EBP provides opportunity for change - Nurse‐initiated practice change - Nurse role development, extension and
expansion - Nursing practice development
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Manley and McCormack (2003) make a distinction between 'technical' Practice
Development (tPD) and 'emancipatory' Practice Development (ePD ) (p.23). In tPD,
derived from Habermas' concept of technical interests, the focus is on gaining
technical knowledge and skill to improve practice, and "the development of staff
…is a consequence of [Practice Development] rather than a deliberate and
intentional purpose" (Manley and McCormack 2003, p.25). In ePD, "the
development and empowerment of staff is deliberate and inter-related with creating a
… transformational culture" (Manley and McCormack 2003, p 25). Thus, the
ultimate aim of ePD then is emancipatory change in the culture and context of care
(McCormack, Manley et al 1999; Manley and McCormack 2003).
Manley and McCormack (2003) acknowledge that throughout its evolution
developing nursing practice in the past has been of the tPD nature and mostly
concerned with the technical aspects of improving care by becoming aware of the
most effective interventions and enhancing clinical skills. They argue that this is a
narrow focus and that ePD is more aimed at sustainable developments and change
and changing the culture and context of care (Manley and McCormack 2003).
However, a critical social science theoretical framework requires that nurses are first
enlightened, that is, not only reminded of the therapeutic nature of nursing and the
influence nursing has on patient outcomes but also the impact of evidenced-based
nursing care on patient outcomes. Thus, engagement in the evidence-based practice
agenda becomes an enabling and empowering tool. Evidence-based practice has a
great levelling effect. Evidence to support practice is stronger than authority, opinion
or outdated policies anchored in ritual and tradition. Engagement with the evidence-
based practice and research agenda has the potential to empower nurses to take
action to change practices that are not patient-centred, not effective and not
responsive to the needs of the service users.
The aim of critical social science is to all at once explain the social world, critique it
and empower its members to change it through a process of emancipatory change
70
(Fay 1987). Features of the social world for nursing have been described in terms of
access to information, resources, support and opportunities in the workplace (Wilson
and Laschinger 1994; Laschinger and Havens 1996; Aiken and Sloane 1997;
Laschinger, Sabiston et al 1997; Aiken, Havens et al 2000; Laschinger, Almost et al
2003), degree of formal and informal power in the workplace (Laschinger, Sabiston
et al 1997; Laschinger, Almost et al 2003), degree of autonomy and control over the
practice environment (Aiken and Sloane 1997; Aiken, Havens et al 2000), quality of
relationships with other members of the health care team (Aiken and Sloane 1997;
Laschinger, Sabiston et al 1997; Anderson and West 1998; Aiken, Havens et al
2000; Laschinger, Almost et al 2003) and degree of team cohesiveness and
collegiality among members who work together (Anderson and West 1998;
Millward and Jeffries 2001; Bower, Campbell et al 2003).
A theoretical framework for emancipatory Practice Development, with its
underpinnings in critical social science, would hold that if nurses are enlightened to
the features of the social order that are causing dissatisfaction and crisis, and
empowered to change the social order or culture, then nurses will be emancipated
from the old ways of seeing self as passive care givers. Nurses would move away
from practicing in a non-critical, task-oriented and 'that's the way things are done
around here' manner and come to realise that they do have an impact, and they can
make a difference, in patient outcomes for the better.
A critical social science framework supports and advocates for healthcare team
members to be respected by the health care organization for their capacity and
contribution whereby situations are valued in which each member of the health care
team is permitted to fulfil the role they perceive is theirs. Enlightenment of the
situation then empowers the dissatisfied group to organise themselves into an
effective group with power to change basic social arrangements (Fay 1987).
3.6 Implementing ePD: Intervention Development
A critical social science framework is the scaffold upon which the Practice
Development intervention was constructed in this study. Aligned with
recommendations of previous scholars, ownership and empowerment to change was
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located with and maintained by the clinicians (Funk, Champagne et al 1991a; Harvey
1996; Dunn, Crichton et al 1998; Humphris 1998; Kitson, Harvey et al 1998;
Dopson, Gabby et al 1999; Redfern and Christian 2003). The intervention was
implemented through direct engagement with clinicians in order to maintain
motivation and momentum. Any changes implemented needed to be owned and
maintained for it to be meaningful and sustainable, resisting the tendency for the
status quo to re-emerge (Walsh, McAllister et al 2002).
The literature supports several key elements necessary for successful, sustainable
change in health care behaviour and practice, including:
• staff commitment and organisational support,
• skilled facilitation by a credible change agent,
• development of shared values and vision,
• infrastructure, including time and space
• evidence-based practice and research training; and
• a process for autonomy and clinical practice governance.
The relationship between the theoretical framework, the intervention and the
outcomes of interest are evident in the research framework, which is illustrated in
Figure 3.2. This relationship will be explored in the next section in greater detail in
the context of a theory of critical social science.
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FIGURE 3.2 RESEARCH FRAMEWORK
Does a facilitated programme using a Practice Development methodology change nurses'
perception of the culture and context of care?
Critical Social Science
Culture and Context of Care
Culture of Evidence-based Practice
Emancipation
Practice Development Process
Research Question
Theoretical Framework
Concepts in Theoretical Framework
Focus of Research
Outcomes of Interest
INTERVENTION
MEASUREMENT
Autonomy & Control
Workplace
Empowerment
Team Cohesion & Collaboration
Barriers to EBP
Skills in EBP
Empowerment Enlightenment
Commitment Facilitation
Shared Values Infrastructure EBP Training Governance
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3.6.1 Staff Commitment
A learning- and values-oriented culture, together with transformational leadership,
may enhance successful change to an evidence-based practice and research-engaged
culture (Rycroft-Malone, Harvey et al 2002b; Rycroft-Malone, Kitson et al 2002a). If
an organisation is to become an evidence-based practice organisation, then top
management must be committed to support and model the valuing of incorporating
evidence into practice (West 2001). Any changes implemented need to be owned and
maintained by the staff for it to be meaningful and sustainable, resisting the tendency
for the status quo to re-emerge (Wright 1995; Walsh, McAllister et al 2002).
Involving people in the decision-making process about issues that will affect them
may lead to their having more of a sense of ownership and a greater commitment to
adhering to the decision reached (Lomas 1993). This process of negotiation,
consensus and ownership are consistent with the principles of Practice Development
(Murray 1999; Hinchcliffe 2000). This process is also amenable to critical social
science intent. Fay (1987) talks about the consensual power inherent in leadership
relationships. Leaders get others to act in a certain way and followers agree to do
what the leader asks of them. In this situation, consent is the basis of the consensual
power because refusal of consent 'can be an effective weapon against the power of
the leaders' (Fay 1987, p123). The nurses on staff were given the choice of consent,
and could refuse to participate in the programme, regardless of the desires of the
nurse unit manager.
3.6.2 Skilled Facilitation
One of the crucial components of successful development of practice is a trained and
experienced facilitator committed to enabling nurses (McCormack, Manley et al
1999; Unsworth 2000; Manley and McCormack 2003) to critically interrogate their
practice. Clinically credible nurses within the practice environment provide the most
effective route to enabling nurses to use research in practice (McCormack, Manley et
al 1999; Unsworth 2000; Thompson, McCaughan et al 2001; Manley and
McCormack 2003). Thus, the Nurse Educators with responsibility directly to the
hospital service areas were in the best position to facilitate development of practice
for several reasons. Firstly, these Nurse Educators were considered 'insiders' by the
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clinicians, had more flexibility in their role than other nurses and interfaced with
other areas of the hospital through informal and formal networks.
The theory of critical social science holds that the group that is dissatisfied must be
educated to their situation (Fay 1987). This can occur through skilled facilitation,
whereby nurses can be guided in discussions about the state of decision making
regarding healthcare decisions, nursing's role in that decision making, possible
reasons for dissatisfaction with the status quo, and strategies for moving forward.
Re-defining the responsibilities of these key change agents by the addition of
facilitation responsibilities required a change in the way they viewed their work and
specific training in facilitation skills. In attempting to engage and recruit the support
and commitment of an existing group of key change agents to become facilitators of
development of practice, it was important to prepare them experientially with
innovative, interactive and creative strategies they could then use in their new roles
as facilitators of change (McAllister and Osborne 2006).
3.6.3 Shared Values and Prioritised Agenda for Change
How we perform or behave as nurses depends on our philosophy; and our beliefs and
values form the basis of that philosophy (Uustal 1978). Consistent with critical
social science, if individuals are only behaving in accordance with own values and
priorities, conflict within a group may ensue and prevent a group from moving
forward with change. It was therefore important to identify a mutual set of values
and beliefs that was shared by individual members of a team to enable the
articulation of a shared team vision (Arnold and Sullivan 2007). Making shared
values explicit can be instrumental in facilitating a team to move forward in a
decided direction (FitzGerald 1989; FitzGerald 1991) and a values clarification
exercise is useful for working through issues linked to cultural change (Manley,
1997). Although Fay acknowledges that it is highly unlikely that consensus can be
reached with every member of a group, critical social science holds that the
'consciousness raising' (Fay 1987, p23) can nonetheless empower the team to
organise themselves into an effective group with power to change the way things are.
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Critical social science is interested in the idea of "collective autonomy" whereby a
group, after considered and rationale reflection, determines the policies and practices
it will follow and acts in accordance with them (Fay 1987, p. 77). Development of a
prioritized, within-team agenda for change, based on the identification of a shared
vision, was deemed important to focus collective action toward practice change.
Increased and sustainable practice change can then be seen as an indicator of cultural
change, a change in the way nurses view and 'do' their practice.
3.6.4 Infrastructure - Dedicated Time and Space
Dedicated time and space for development work was deemed necessary. Critical
social science holds that a person may be able to cognitively come to a new
understanding of self but oppression may be more physical than cognitive, thus
embodiment of the oppressed relates to those physical limitations (Fay 1987). This
has particular implications in relation to how the social system dictates the use of
time and physical space to control the physical environment in which nurses work.
Aligned with critical social science, nurses engaged in developing practice need to
develop awareness about the physical limitations that serve to control their practice
environment and develop plans of action to lessen these limitations. One of the
strategic plans of action was to secure dedicated time and space with internet access.
The nurses were encouraged, supported and facilitated in finding, negotiating and
securing these physical resources early in the Practice Development process. In
addition, the dedicated organisational infrastructure, as depicted in Figure 3.3, was
communicated to the nurses in order to make explicit the available support from
senior management and both internal and external facilitators.
76
FIGURE 3.3 ORGANISATIONAL INFRASTRUCTURE SUPPORT FOR PRACTICE DEVELOPMENT
3.6.5 Evidenced-based Practice and Research Training
Continual evaluations of routine procedures and protocols are necessary to ensure
that nursing treatment and interventions are supported by current evidence and
clinical judgement and reflect the patent's preferences and values. Nurses are well
placed to contribute towards clinically-effective and cost-efficient patient care and
outcomes. However, as Fay (1987) contends, embedded traditions, which form part of the
identity of a group, and traditional power hierarchies are reality; thus, those with
power can exert a force that impedes the ability and capacity for transformative
change. As discussed earlier, engagement with the evidence-based practice agenda
has the potential to empower nurses to take action to change practice because
evidence to support practice is stronger than authority, opinion or outdated policies
anchored in ritual and tradition.
Although an evidence-based approach to practice has been demonstrated to enhance
the effectiveness of nursing care (Heater, Becker et al 1988; Picone, Hathway et al
1996; Picone, Lawler et al 2000), one of the frequently cited barriers to the use of an
Clinical
Leader
EDNS *
* Nursing Director-Research
NUM *
* Casual Research
Assistants
*Clinician Leader
FacilitationResearch
Education
Practice Development
Nursing *Director -Division
* Professor of Nursing
Nurse Educator *(Division)
* Nurse Educator (Central)
* Clinician Leader
* PD Coordinator
* Nursing Director-
Education
Clinical
Leader
EDNS *
* Nursing Director-Research
NUM *
* Casual Research
Assistants
*Clinician Leader
FacilitationResearch
Education
Practice Development
Nursing *Director -Division
* Professor of Nursing
Nurse Educator *(Division)
* Nurse Educator (Central)
* Clinician Leader
* PD Coordinator
* Nursing Director-
Education
77
evidence-based framework in practice is a lack of confidence in skills (Miller and
Messenger 1978; Funk, Champagne et al 1991; Kajermo, Nordstrom et al 1998;
Retsas 2000; Parahoo 2001; Bryar, Closs et al 2003). Although, several resources
for evidence-based practice are provided by the study hospital and the health
department, such as on-site medical library, intranet access to library databases and
full-text research articles, and intranet access to other tertiary and government
databases, it was evident in early discussions with clinicians that few nurses were
aware of the available resources or had practical experience using the available
resources. Clinician skill development also has the potential to enhance sustainability
of engagement with evidence-based practice and research within the unit because it
is envisioned that the mentorees will take on a leadership role in project development
and they will teach the knowledge and skills they learned to other nurses in the unit,
thus making the unit as a whole less dependent on the services of outside experts, a
significant factor in the resource-conscience health care environment.
3.6.6 Clinical Practice Governance Committee
Clinical governance is a system through which organisations are held responsible
for continuously improving the quality of their services and upholding high
standards of care by creating a culture and climate in which excellence in clinical
care will thrive (United Kingdom DOH, 1998; Scally and Donaldson, 1998).
Governance ensures that an organisation does what it should and avoids what is
unacceptable (Carver 1990, cited in Office of Safety and Quality in Health Care
(Health Care Division) 2007).
Governance encompasses self-regulation, self-sufficiency, independence and
autonomy, the latter of which Fay (1987) explicitly explicates as a key concept in
the theory of critical social science. A clinical practice governance committee with
decision-making power near or at the executive level of the organisation serves as
an advocate for nurses through assistance in circumventing the organisational
barriers to evidence-based practice and research utilisation.
78
3.7 Conclusion
Practice Development is about enabling nurses to transform the world in which they
work through a facilitated process of critical reflection and action. One of the
endpoints or outcomes of contemporary Practice Development is emancipatory
change, thus situating it in a critical social science framework seems appropriate.
Critical social science aims to explain and critique a social world in such a way that
the understanding or enlightenment of the social world becomes the catalyst for
empowerment which results in an emancipatory transformation or change.
A critical social science theoretical framework requires nurses to be reminded of the
therapeutic nature of nursing; the influence nursing has on patient outcomes and the
impact of evidence-based nursing care on patient outcomes. The research design and
intervention for this study was developed with principles of critical social science in
mind, with respect to the problem of concern, namely developing nursing practice
through decreasing perceived barriers to nurses' engagement with research and
evidence-based practice.
This chapter described the theoretical underpinnings of contemporary Practice
Development and presented a case for the use of critical social science as a
framework for development of an intervention aimed at creating a culture of inquiry
and evidence-based practice in nursing. The intervention, a facilitated programme
based on a Practice Development methodology involving informed commitment to
the process of developing practice, development of a shared vision and agenda for
change, provision of skilled facilitation, education and skill development in research
and evidence-based practice and a process for clinical practice governance, was
described and justified with support from the research literature.
The next chapter will detail the methodology and methods used to answer the
research questions. Influence of the theoretical model for Practice Development,
with its underpinnings in critical social science, will be made evident in the
description of the outcomes (dependent variables), the measurement of the outcomes
(data collection instrument), the sample selection and the recruitment procedures.
79
CHAPTER 4. METHODOLOGY AND METHODS
4.1 Introduction
As discussed in Chapter 3, critical social science has been promoted as the theoretical
framework for contemporary Practice Development, a process of moving through
phases of enlightenment, empowerment and emancipation in order to effect a change in
the culture and context of care. The purpose of this study was to address the gaps in the
literature on the effectiveness of a Practice Development approach on changing the
culture and context of care. Traditionally, 'organisational culture' and 'cultural change'
have been explored and described using qualitative methodologies. An important
element of this research is the departure from traditional methods of inquiry.
This study is innovative in its attempt to identify, quantify and measure variables
associated with a culture that is conducive to nurses' engagement with research and
evidence-based practice. A model for change using a Practice Development
methodology was evaluated for its effectiveness in changing the culture and context of
care. A non-randomised, longitudinal quasi-experimental approach was chosen to
answer the research questions. This chapter presents a discussion and justification of the
methodological approaches used to answer the research questions. The research design
and sampling methods will be explained, the intervention and outcome measures
detailed and the study procedure outlined. Validity and reliability as well as the plan for
data analysis will also be discussed, as will an examination of the ethical considerations.
4.2 Objectives
The objectives of this study were twofold:
1. to develop and implement an evidence-based strategic model of Practice
Development for nurses in a major teaching hospital in Australia; and
2. to design and test an evaluation strategy to measure the effectiveness of the
model in changing the culture and context of care.
80
4.3 Research Questions
The research questions are the source of derivation for the study hypotheses. The key
questions for this research were:
4. Is there a relationship between nurses' perceptions of the culture and context
of care and nurses' perceptions of research and evidence-based practice?
5. Is there a relationship between engagement in a facilitated process of
Practice Development and change in nurses' perceptions of the culture and
context of care?
6. Is there a relationship between engagement in a facilitated process of
Practice Development and change in nurses' perceptions of research and
evidence-based practice?
4.4 Scientific Hypotheses
In testing the intervention, six hypotheses were proposed. The hypotheses were
expressed and tested as two-tailed hypotheses, as it was important to statistically detect
any difference, irrespective of direction. Minimum meaningful differences for each
outcome variable will be defined at the point of describing each measurement.
Given the emerging theoretical and empirical support for an organisational culture of
evidence-based practice, the first hypothesis was:
H1 There is a relationship between nurses' perceptions of the culture and context of
care (as defined by perceptions of autonomy and control over practice,
workplace empowerment, and constructive team dynamics) and nurses'
perceptions of evidence-based practice (as defined by perceptions of barriers to
evidence-based practice and skills in evidence-based practice).
The remaining hypotheses are related to the outcome measures:
H02-06 Among nurses working in an acute tertiary facility, there is no difference
between nurses working in units with a 12-month facilitated programme of
Practice Development and nurses working in units without a 12-month
81
facilitated programme of Practice Development in change in nurses' perceptions
of:
H02 autonomy and control over practice,
H03 workplace empowerment,
H04 constructive team dynamics,
H05 barriers to evidence-based practice, and/or
H06 skills in evidence-based practice.
4.5 Research Design
A longitudinal, pre-test/post-test, with non-equivalent control group design, was used to
quantitatively measure the culture and context of care before, during and after
implementation of a Practice Development programme (the intervention) and is
presented in Figure 4.1. Designs that follow individuals or groups over time are aptly
suitable for obtaining data required for the measurement of programme effects and
identification of factors contributing to differential patterns of change across groups
(O'Connell and Mc Coach 2004) – a notion supported by several researchers in a range
of disciplines. The time line for the study was dictated by imperatives from the
organisation and thus total time was fixed at 12 months. Data were collected at baseline
(T0), 6 months (T1) and 12 months (T2), with the aim of exploring short and longer term
changes over time.
XE
I Y1E Y2E
XC
Y1C Y2C
E = experimental group I = intervention/treatment applied
C = control group Y1 = post test measurement (6 months)
X = pre test measurement Y2 = post test measurement (12 months)
FIGURE 4.1 NON EQUIVALENT CONTROL GROUP DESIGN
82
Conventionally, the gold standard of experimental research is a randomised, controlled
design because randomisation strengthens the internal validity of the design and the
findings. However, a randomised controlled design is not always appropriate or feasible
in clinical practice when evaluating the effectiveness of complex programme
interventions on change in situations where contextual factors cannot be controlled and
the nature of the intervention does not lend itself to standardisation. In addition, when a
theoretical framework such as critical social science (which predicates itself on enabling
and empowerment of individuals in social groups) guides the research design, random
assignment to groups is antithetical. Clinicians were the determiners of if and when
Practice Development would be implemented on their units instead of a Practice
Development programme being imposed upon them by their Nursing Unit Manager
(NUM), or higher level of authority.
This process of negotiation, consensus and ownership are consistent with the tenets of
Practice Development (Murray 1999; Hinchcliffe 2000). In this situation, a quasi-
experimental methodology, in which the researcher does not have complete control over
allocation of states of the independent variable but complete control over the timing of
the independent variable (Field and Hole 2003), is appropriate. This supports earlier
recommendations from researchers that studies in clinical environments where
maintaining control is problematic and sample attrition is high, should use quasi-
experimental designs; and additionally, that the use of pre-test measures and analysis of
reasons for sample attrition may increase the power to detect differences between groups
and enable a more confident interpretation of the results (Griffiths and Wilson-Barrett
1998).
The design of the study enables the researcher to not only describe the characteristics of
a set of cases but also to make inferences about associations between phenomena by
comparing various characteristics of the cases (deVaus 1995). The purpose of the study
was to evaluate the impact of a facilitated Practice Development programme (that is,
independent variable) on a cohort of nurses (that is, cases) in terms of specific
characteristics of the culture and context of care delivery (represented by outcome or
83
dependent variables). Characteristics of the nurses in the cohort (represented by
demographic variables) were also identified in order to explore associations between
demographic characteristics and perceptions of the culture and context of care.
4.6 Variable Definitions
4.6.1 Independent Variable
As this was a quasi-experimental study, the main explanatory or independent variable
was the dichotomous categorical variable representing the intervention, that is
involvement in a 12 month strategic facilitated Practice Development programme.
4.6.2 Dependent Variable
Attitudinal data, namely nurse perceptions of the context and culture of care were
calculated as subscale scores derived from responses drawn from the data collection
instrument. The five outcome or dependent variables in this study, based on the themes
derived from the literature synthesis (see Figure 2.3, p. 50) were measured using
existing validated instruments, albeit with some minor adaptations. Original instrument
scales were maintained in most cases, thus the range of possible scores differed for each
subscale as indicated in Section 4.7.9. All of the dependent variables, which were
derived from scaled scores were treated as continuous and were summarised as means
and standard deviations.
Data were collected at three time points: T0 (baseline pre-programme implementation),
T1 (6 months post-programme implementation), and T2 (12 months post-programme
implementation); resulting in one to three measurements per participating nurse within
each unit. Data were collected at multiple time points to identify short and longer term
changes over time.
4.6.3 Descriptive Variables
Demographic characteristics were drawn from the data collection instrument. The
following data were collected at the start of the study and at each data collection time
point:
84
age (continuous; in years)
sex (categorical; male, female)
initial nursing education (categorical; hospital, university)
highest nursing qualification (categorical; hospital diploma/certificate,
Graduate/Post Graduate Certificate, Graduate/Post Graduate Diploma, Master, PhD,
other)
years post registration nursing experience (categorical; less than 2 years, 2-5 years,
6-10 years, 11-15 years)
primary nursing role (categorical; clinical, management, education, research, other)
employment status (categorical; full time, part time)
4.7 Methods
4.7.1 Participants and Setting
The study setting was a 942 bed tertiary referral teaching hospital within a health service
district employing more than 2000 Registered Nurses, Midwives and Enrolled Nurses.
The hospital is located in the second largest state in Australia, Queensland, and services
an estimated population of 550,000, with the majority of clients living within 15
kilometres (Queensland Government/Queensland Health 2006). Nursing Directors
assume responsibility for nursing services in the following clinical specialties: medicine,
oncology, inpatient and ambulatory perioperative services, mental health, critical care,
maternity and gynaecology services, neonatology, and disability and community care
services.
The study hospital was typical of acute tertiary hospital settings in Australia. As shown
in Table 4.1, the representativeness of the study setting was determined by comparing
characteristics of the hospital with acute tertiary hospitals, generally, in Australia, and,
specifically, in Queensland. In the 2004 Australian Institute of Health and Welfare
(AIHW) report, Australian Hospital Statistics 2002–03 (AIHW 2004a), principal referral
hospitals in large major cities averaged 454 beds (2.5 beds per 1000 population) with an
average length of stay of 3.8 days (6.5 days excluding same day separations).
85
In 2002-2003, Queensland's large public hospitals, of which the study hospital is one of
nine, averaged 414 beds (also 2.5 beds per 1000 population), with an average length of
stay of 3.5 days (5.8 days excluding same day separations) (AIHW 2004b). The study
hospital was also similar to other acute tertiary hospitals in Australia and in Queensland
based on four key hospital outcome indicators, namely cost of case mix-adjusted
separations (an indicator of efficiency), waiting times for elective surgery (an indicator
of access), emergency room waiting times7 (an indicator of responsiveness) and hospital
separations with an adverse event (an indicator of safety).
4.7.2 Target Population
The target population was registered nurses working in clinical units in acute tertiary
hospitals in Australia. The Registered Nurse workforce at the study hospital was similar
on demographic variables, namely age and sex, to Registered Nurses working in
principal referral hospitals in Australia and Queensland. In 2004, the average age of
registered nurses Australia-wide was 43 years and in Queensland the average age of
registered nurses was 44 years (AIHW 2004). In the same year, the registered nurse
workforce was comprised of 9% male nurses Australia-wide and 9% in Queensland
(AIHW 2004).
The study hospital's similarity was supported with pilot study8 data whereby the
average age of registered nurses was 41 years (SD 11; 95% CI 39-43); however, the
registered nurse workforce at the study hospital was comprised of 15% male. Although
this pilot study data reflects survey responders, these statistics provide evidence that the
study hospital can appropriately be used as a representative subset of the target
population for this study.
7 Emergency room waiting times are categorised as: Category 1 (resuscitation), Category 2 (emergency), Category 3 (urgent), Category 4 (semi-urgent) and Category 5 (non-urgent) as per AIHW report (2004). 8 The pilot study will be discussed in detail in Chapter 5.
86
TABLE 4.1 COMPARISON OF THE STUDY HOSPITAL WITH AUSTRALIAN AND QUEENSLAND PRINCIPAL REFERRAL HOSPITALS ON FOUR KEY HOSPITAL INDICATORS
Australia Queensland Study Hospital Hospital Indicators
Principal referral hospitals
Principal referral hospitals
Principal referral hospital
2002‐2003 Cost per case‐mix adjusted separations
$3178 ($3326†)
$2977 ($3007†)
$3,583
Waiting times for elective surgery (at 50th percentile)
2002‐03 26 days†
2003‐04 28 days
2002‐03 20 days†
2003‐04 22 days
2002‐03 specific data for study
hospital not
available
2003‐04 23 days
2002‐2003 Emergency room waiting times (percentage receiving care within required time)
All categories† Cat 1 ‐ 99% Cat 2 ‐ 75% Cat 3 ‐ 61% Cat 4 ‐ 61% Cat 5 ‐ 85%
All categories† Cat 1 ‐ 99% Cat 2 ‐ 73% Cat 3 ‐ 55% Cat 4 ‐ 55% Cat 5 ‐ 80%
All categories Cat 1 ‐100% Cat 2 ‐ 83% Cat 3 ‐ 63% Cat 4 ‐ 74% Cat 5 ‐ 96%
2002‐2003 Hospital separations with an adverse event9
Public Hospitals 5.1/100
All Queensland Public Hospitals
5.0/100 Queensland
Principal Referral Hospitals 6.4/100
5.4/100
Sources: AIHW (2004). Australian Hospital Statistics 2002–03; Queensland Health (2006). An Investment in Health. Queensland public hospitals performance report 2005‐06; Queensland Health (2005).Queensland Hospital Admitted Patient Data Collection, 2002‐2003; Queensland Health (2006). Report from the Measured Quality Service to the District Manager Royal Brisbane & Women's Health Service District. † Data for principal referral and women's and children's specialist hospitals, combined.
9 Data is for total adverse events related to drugs, medications, biological substances, medical or surgical care, procedures resulting in reactions or complications, and other external causes as per AIHW report (2004).
87
4.7.3 Inclusion and Exclusion Criteria
Inclusion criteria for the study were clinical units or teams within the Divisions of
Medicine, Surgery and Perioperative Services, Cancer Services, Critical Care Services
and Women's and Newborn Services in which:
• there were three or more registered nurses in the clinical team;
• the team had responsibility for direct client care;
• the team's service was delivered from a geographically stable location within the
health service district; and
• the team's clients were typically admitted for at least one overnight stay.
Clinical units or teams were excluded if their service delivery was any of the following:
• predominantly ambulatory (for example, outpatient clinics, operating theatres);
• located within the dental hospital or satellite dental clinics, the satellite mental
health clinics, or the satellite renal dialysis clinics; and/or units in remote
locations from main hospital campus; and/or
• considered part of an administrative unit (for example, research and/or staff
development unit, nurse pool or nurse bank department).
Exclusion criteria were based on feasibility, scope of study and limits on sustained
direct client care due to high patient turnover. The four units that participated in the
original demonstration project were also excluded to eliminate bias from prior
knowledge of working within a model of Practice Development. From a total of 106
units in the hospital health service district, the eligible sampling frame for the study was
determined to be 43 units, from which a sample of eight clinical units or teams was
selected to participate in the study. A breakdown of the sampling frame is presented in
Table 4.2 (p. 89).
4.7.4 Sample
4.7.4.1. Sampling strategy
From the 43 eligible units, a purposive sample of eight clinical units or teams was
selected to participate in the main study. The process of sample selection was
88
underpinned by the theoretical framework, specifically the concepts relating to
empowerment, collective autonomy, commitment and ownership in order to maintain
motivation as discussed in Section 3.6 (p.70) and Section 4.7.7 (p.92). Eight was
deemed feasible within the scope of this study by the Executive Director of Nursing
Services and the Director of the Centre for Clinical Nursing.
Clinical units or clinical teams were selected using a convenience sampling method for
reasons previously discussed in Section 4.5 (p. 81). A mailing list of employed staff was
generated and supplied by the Human Resources department at the start of each data
collection period. Four of the clinical units elected to be involved in the implementation
of a Practice Development programme. NUMs and nursing staff in the four control
groups expressed that timing for participation in the Practice Development programme
was not suitable for a number of reasons. These four control units agreed to maintain
existing processes of practice and practice review and to act as controls for the study. A
survey questionnaire was mailed out to all nurses working in the eight study units at the
time of each survey10.
4.7.4.2. Sample size calculation
Power is the probability that anticipated minimum effects obtain statistical significance
(Tabachnick and Fidell 2007). Although, the sample size in this study was limited by
scope and feasibility, a prospective power analysis was performed based on limited
published data in order to estimate the required sample size to detect an index of
confidence.
10 This was the same process used in the pilot study.
89
TABLE 4.2 B
REA
KDOW
N O
F SA
MPLING FRAME FO
R STU
DY
Se
rvice Divisions [n
] TO
TAL N=106
Exclus
ion
Criteria
Rea
sons In
eligible fo
r Stud
y Units
Eligible
for Stud
y
Units in
Main
Stud
y
Units
Eligible
for Pilot
Prev
ious
Dem
o Pro
ject
Uni
t
Less
than 3
RNs in
team
No
direct
patien
t ca
re
Pro
vide
same
day
service
Mob
ile
or
satellite
loca
tion
Med
ical (M
ED) [29]
1 6
2 3
4 13
5 8
Surg
ical (S
UR) [
22]
1 1
1 10
‐ 9
2 7
Men
tal H
ealth (M
HS) [15]
‐ 1
‐ ‐
7 7
‐ 7
Can
cer (C
AN) [
11]
1 1
1 2
1 5
1 4
Critica
l Car
e (C
RI) [8
] ‐
‐ ‐
2 1
5 ‐
5 W
omen & Children (W
&C) [
11]
1 1
1 4
‐ 4
‐ 4
Com
mun
ity (C
OM) [
1]
‐ ‐
‐ ‐
1 0
‐ 0
Adm
inistration (A
DM) [
5]
‐ ‐
5 ‐
‐ 0
‐ 0
Den
tal S
ervice (D
EN) [
2]
‐ ‐
‐ ‐
2 0
‐ 0
Satellite Dialysis Clinic (S
DC) [
1]
‐ ‐
‐ ‐
1 0
‐ 0
Disab
ility [D
IS] [1]
‐ ‐
‐ ‐
1 0
‐ 0
ELIG
IBLE
43
8 35
INEL
IGIB
LE
4 10
10
21
18
63
‐ 71
90
A review of the Practice Development literature identified no published studies
investigating pre and post implementation of a Practice Development programme that
met the original inclusion criteria for the literature review; thus, there were no reported
statistical effects. However, the characteristics used to describe the culture and context
of care incorporate some characteristics studied in the magnet hospital research. In a
study measuring organisational traits of hospitals, Aiken and Patrician (2000) found the
Nursing Work Index-Revised (NWI-R) instrument was reliable in differentiating
between magnet and non-magnet hospitals on organisational attributes. For instance,
mean scores for the 'autonomy' subscales were 17.0 (SD 2.34) for magnet hospitals and
14.2 (SD 4.20) for non-magnet hospitals. Likewise, mean scores on the 'control'
subscale were 22.7 (SD 3.11) and 17.4 (SD 4.20) for magnet and non-magnet hospitals,
respectively. But without a change score for each group, it is difficult to estimate the
percentage in change between the two groups.
Based on the above estimates, with a type I error of 5% (0.05, two-tailed) and a type II
error of 20% (0.80 power), a retrospective power calculation (Battistutta 2007)
confirmed a sample size of 36 participants in each group was adequate to reject the null
hypotheses to be tested, which proposed no difference in perceptions between nurses
involved in a facilitated Practice Development programme and nurses not involved a
facilitated Practice Development programme. However, this calculation does not allow
for the possibility of a unit clustering design effect. Since there was no benchmark of a
clinically acceptable difference in past similar studies; therefore, 10% difference was
accepted in this study as being clinically significant.
The eight clinical units or teams selected for the study differed on variables that were
beyond the control of the researcher, such as type of clients serviced, bed capacity and
acuity, staff age, experience and skill mix, manager leadership style, and already
established relationships with other health professionals. Pre-implementation data were
collected on as many variables as possible for both the experimental (also known as the
intervention) group and the control group at baseline to identify similarities and
differences. In order to obtain data for comparison of the study sample with the hospital
91
population, a baseline survey was distributed to all 2016 nurses working in the 106 units
based on a current employee list generated and supplied by the Human Resources
department in November 2004.
4.7.5 Recruitment
Prior to recruitment of clinical units, support for the study and support to approach the
unit nursing staff was obtained from the Executive Director of Nursing Services, the
divisional Nursing Director and the unit Nurse Unit Manager. This occurred in order to
establish part of the basis of the infrastructure for nursing practice development, which
was support from senior nursing staff. Next, all clinical nurses on the clinical units or
teams approached were given verbal and written information about the project by the
researcher or a member of the research team either during their regular unit meetings or
at dedicated in-services arranged by the Nurse Unit Manager. At these information
sessions, nurses were provided with information about the structure, process and
products of Practice Development and the research study and all clinician questions
were answered.
The nursing staff were then encouraged to communicate with each other their
perceptions of the advantages and disadvantages of Practice Development and to decide
as a team whether they wanted firstly, to engage in the Practice Development
programme at this time, and secondly, to be involved in an evaluative study of the
Practice Development programme in the hospital. As mentioned previously, this process
of negotiation, consensus and ownership are consistent with the tenets of Practice
Development (Murray 1999; Hinchcliffe 2000). Once a group decision was made, it was
communicated to the researcher either by direct contact or through the NUM.
4.7.6 Intervention
The experimental group was exposed to a facilitated Practice Development programme,
a multi-component complex intervention being evaluated in a complex social
environment. The components of the Practice Development programme in this study
included the following:
staff commitment and organisational support;
92
skilled facilitation by credible change agents;
development of shared values, vision, mission and agenda for change;
infrastructure, including operational support, dedicated time and space, and
information technology (IT)/internet access;
evidence-based practice skill development and research mentoring; and
formal processes for autonomy and clinical practice governance.
Standardising each component of a complex intervention is not possible. However, with
complex interventions the focus is not on standardising the components but on
standardising the function of the components (Hawe, Shiell et al 2004), thus allowing
the adaptation of the form of each component to suit the context of the environment. A
brief operational description of each component of the Practice Development
Programme is presented in Table 4.3 (p. 94).
4.7.7 Study Protocol - Experimental Group
This section will provide details about the processes and procedures for practice review
and change associated with each of the six components of the Practice Development
Programme and will be followed by Table 4.4, an outline of the timetable for
implementation of the programme over a 12 month period.
4.7.7.1. Component 1: Staff Commitment and Organisational Support
Prior to implementation of the Practice Development framework, an information session
was held with the Directors of Nursing (DON), followed by information sessions with
Nursing Unit Managers (NUM), who were nominated to attend the information sessions
by their respective DON. Reasons for nominations ranged from a perceived need by the
DON that the unit needed a vehicle for motivation and team building and or that the unit
needed a vehicle for advancing the momentum for embracing practice inquiry and
change that was already present in the unit. NUMs were provided with written literature
and verbal information on Practice Development, including a brief history of its
historical and theoretical evolution to present day, examples of outcomes from Practice
93
Development activities both in Australia and overseas, and a description of the
components of the model to be implemented in the hospital.
The meetings were facilitated by members of the research team, with the study
researcher following up with NUMs individually to clarify any points of discussion.
Written information was presented to each NUM in the form of a "Practice
Development Toolkit" compiled by the study researcher. The NUMs were encouraged to
ask questions in a safe, non-threatening forum. At the end of the forum, an appeal was
made to NUMs to support implementation of the Practice Development programme and
participation in the study project and also with permission to approach their staff to
provide the same information and appeal for participation. Permission was sought from
the NUMs, not because it was officially needed, although the health care system still
worked within a hierarchical framework, but because permission indirectly gave some
indication that the NUM would support the implementation of Practice Development if
the nursing staff on their unit decided to participate.
The next step was to conduct information meetings with the nursing teams. Several
information meetings, organised by the researcher and facilitated by the researcher
and/or co-researcher were held in each unit in order to present the information to as
many staff employed on the unit as possible. The same format for the information
sessions described above was repeated for each unit. Several meetings were held in each
unit in order to present the information to as many staff employed on the unit as
possible. The staff nurses were encouraged to discuss Practice Development with each
other in order to achieve a consensus in the choice to accept or decline the invitation to
(1) participate in the Practice Development programme, and (2) to participate in the
Practice Development study. The nursing team was given the choice of consent and
were assured that a rejection of the invitation to participate in either would not impact
negatively on their ability to access the research and evidence-based practice resources
that currently existed in the hospital. They were also assured that they, as a team, could
refuse to participate in the program, regardless of the desires of the NUM.
94
TABLE 4.3 O
PER
ATI
ONAL DES
CRIP
TIONS OF COMPONEN
TS O
F ST
RATE
GIC P
RACTI
CE DEV
ELOPM
ENT PROGRAMME
COMPO
NEN
T BRIE
F OPE
RATI
ONAL DES
CRIP
TION O
F COMPONEN
T FU
NCTI
ON
COMMIT
MEN
T Th
e Re
search Team disseminated Practice Develop
men
t information to nursing staff at all levels prior to im
plem
entation
. Nursing
team m
embe
rs in atten
danc
e at each inform
ation session were en
courag
ed to discu
ss th
e inform
ation with th
eir co
lleag
ues.
Inform
ation sessions w
ere sche
duled un
til a
ll staff ind
icated th
ey had eno
ugh inform
ation to m
ake an in
form
ed te
am decision
rega
rding pa
rticipation in th
e Practice D
evelop
men
t program
me an
d/or study
. Implem
entation occurred on
ly after com
mitm
ent to
the prog
ramme an
d/or study by the nu
rse un
it m
anag
er and th
e team of n
ursing staff was con
firmed
.
SKILLE
D
FACILIT
ATI
ON
Intern
al fa
cilitators (for example, nurse m
embe
r of th
e clinical te
am, later title
d Practice D
evelop
men
t Portfolio H
olde
rs) o
r local
nurse ed
ucator) a
nd externa
l facilitators (for example, exp
erienc
ed N
urse Researche
r an
d/or N
urse Edu
cator with he
alth service‐
wide respon
sibilities) w
ere iden
tifie
d for each unit in the interven
tion group
. All Nurse Edu
cators (d
epartm
ent a
nd lo
cal)
participating in th
e prog
ramme were specially tr
aine
d in Practice Develop
men
t con
cepts an
d proc
esses in a one‐day exp
eriential
worksho
p co
nduc
ted by an expe
rien
ced facilitator. A
t least one fa
cilitator w
orking w
ith each in
terven
tion un
it atten
ded a on
e‐week intens
ive Practice D
evelop
men
t training prog
ramme an
d Internationa
l Practice Develop
men
t Con
ferenc
e. All facilitators
invo
lved in th
e prog
ramme met in w
eekly focu
s grou
ps to de‐brief a
nd reflect on their ne
w role as Practice Develop
men
t facilitators.
SHARED
VALU
ES
Initial w
eekly Practice D
evelop
men
t meetin
gs in
volved fa
cilitated discu
ssions fo
cused on obtaining con
sens
us of sha
red team
values, v
ision an
d mission of the unit, as w
ell a
s a prioritised ag
enda fo
r de
veloping practice an
d ch
ange
. The
se m
eeting
s co
ntinue
d un
til the staff accepted th
e fin
al m
ission statemen
t and prioritised age
nda for practice develop
men
t.
INFR
AST
RUCTU
RE
Supp
ortive in
frastruc
ture w
as con
firmed and estab
lishe
d in th
e form of d
edicated spa
ce w
ithin the un
it perim
eter w
ith
compu
ter/intern
et access for p
ractice de
velopm
ent w
ork an
d ne
gotiation of ded
icated practice de
velopm
ent tim
e for staff, which
was built into th
e work roster. Interna
l facilitators w
ere expe
cted to assist s
taff in neg
otiating time with N
urse U
nit M
anag
er.
Routine Practice D
evelop
men
t team m
eetin
gs con
tinu
ed, a
t least fo
rtnigh
tly but freq
uenc
y varied w
ith th
e ne
eds of th
e team
and
the na
ture of the practice de
velopm
ent a
ctivity be
ing un
dertak
en. P
ractice Develop
men
t Cluster m
eeting
s were he
ld m
onthly.
TRAIN
ING
Training in
clud
ed edu
cation
, skill de
velopm
ent a
nd m
entoring in evide
nce‐ba
sed practice and th
e research process. A
t least one
staff m
embe
r from
each interven
tion unit w
as released from
clin
ical respo
nsibilities to atten
d the 1‐da
y 'in
trod
uction to evide
nce
practice program
me' and
/or the 12‐w
eek 'evide
nce‐ba
sed practice m
entor prog
ramme'. S
taff were assisted to neg
otiate rostered
time off for tr
aining purpo
ses an
d expe
cted to disseminate learning to th
eir respective te
ams.
GOVER
NANCE
A Clin
ical Practice Gov
erna
nce Com
mittee with influ
ence at the execu
tive le
vel o
f hospital a
dministration was estab
lishe
d. The
Gov
erna
nce Com
mittee maintaine
d a da
taba
se of a
ll practice develop
men
t and research activity and m
onitored progress of
activities. M
embe
rship was com
prised of E
xecu
tive D
irector of N
ursing
, Nursing D
irector‐Re
search
, Clin
ical Cha
ir in N
ursing
, Nurse Researche
r, all internal and externa
l facilitators, a
nd at least one staff mem
ber from
each of th
e interven
tion units.
95
4.7.7.2. Component 2: Skilled Facilitation
Prior to implementation of the Practice Development model, selected 'change agents',
namely, Nurse Educators at the central (n=7) and divisional interface (n=5), the Nurse
Researcher, the Research Nursing Director, the Education Nursing Director and the
Director of the Practice Development and Research Unit, attended a one day
experiential workshop on facilitation within a Practice Development framework (see
Appendix 8, Volume 2, p.82 for an outline of the workshop agenda). Details of the
workshop from preparation to evaluation have been described elsewhere (McAlister and
Osborne 2004). Divisional Nurse Educators and the Nurse Researcher were selected
change agents and were also supported by the facility (for example, financial support
and paid time away from the workplace) to attend an international Practice
Development conference and week-long Practice Development summer school
facilitated by internationally known experts in the field . An additional support for the
'new' Practice Development Facilitators was weekly focus group meetings to discuss
their experiences and share ideas they experimented with while actioning their new role.
The purpose of the focus group was to identify the development needs of traditional
nurse educators in their new role as Practice Development Facilitators.
4.7.7.3. Component 3: Development of Shared Values and Vision
Development of a shared, prioritized, within-team agenda for change is important for
collective action toward practice change. Increased and sustainable practice change can
then be seen as an indicator of cultural change - a change in the way nurses 'view' and
'do' their practice. The values clarification exercise, using some tools adapted from
Manley (1997, 1999) (see Appendix 9, Volume 2, p.85) and some tools purposely
designed for the study by the study researcher, was conducted in a series of initial
Practice Development meetings facilitated by the study researcher and/or the co-
researcher. These meetings were specifically for the purpose of identifying shared
values related to the ultimate purpose of the unit and recognising dissonance between
where the team says they want to be (vision) and where they actually are (reality).
96
The team was also facilitated to identify inhibitors that were blocking access to the
vision and enablers that would assist them in achieving their purpose and vision (see
Appendix 9, Volume 2, p.85). Ground rules (see Appendix 10, Volume 2, p.88) that
encouraged participative safety were established in the first meeting by those present
and team members were encouraged to speak freely. All ideas and comments were
written verbatim on butcher's paper, and then with group engagement, themed or
categorised and presented back to team members for verification. In addition, the same
details were recorded in a team communication book so that team members not able to
attend a meeting could be kept informed of the progress at each meeting. These initial
Practice Development meetings culminated in the development of a mission statement
(see Appendix 11, Volume 2, p.89), for the unit that was comprised of five key
components:
the mission of the unit,
the vision of the unit,
guiding principles to realize that mission and vision,
the purpose of the unit, and
how the purpose was to be achieved.
The mission statement was then framed and posted on the unit in a prominent place in
view of all visitors to the unit. By making the shared mission statement explicit and
visible, the team was continually reminded of their commitment.
4.7.7.4. Component 4: Infrastructure, including Time and Space
Dedicated time and space for development work was regarded as necessary
infrastructure to support clinicians at the local level to engage in evidence-based practice
and research. The study facility is well-resourced with computers in every nurses'
station, however the nurse's station is typically a busy hub of activity and the computers
are in frequent use. Thus, the function of these areas was not conducive to the purpose
of the Practice Development program, which was to provide nurses with the time and
space for critical reflection on practice and evidence searching.
97
The NUM was assisted to find, negotiate and acquire a suitable space and outfit the
space with a computer with internet access. The study researcher assisted this process by
either making the initial contact with senior management or following up on contacts
made by the NUM to acquire a dedicated space. When the dedicated Practice
Development room was identified and set up, the study researcher organised a formal
event attended by the Executive Director of Nursing (EDNS), who commemorated the
Practice Development room with a sign identifying the room as a dedicated 'Practice
Development Room' and 'cut the ribbon' to officially 'open' the resource. After the
opening ceremony, a celebration with light refreshments and photo opportunities,
attended by the EDNS, DON, NUM, Practice Development facilitators, Practice
Development portfolio holder and unit staff nurses followed, giving the staff the
opportunity to discuss their practice development plans with senior management.
4.7.7.5. Component 5: EBP and Research Training
Although, several excellent resources for evidence-based practice were provided by the
hospital and the health department, such as on-site medical library, intranet access to
library databases and full-text research articles, and intranet access to other tertiary and
government databases, few nurses were aware of the available resources or had practical
experience using the available resources (Webster, 2004, personal communication). In
addition, the medical library provided short training courses on searching and retrieval
of database information. However, in order for the skills learned in the short course to
be sustainable, they must be supplemented with relevant, practical applications and
extended 'hands on' engagement with the process. The 12-week Evidence-based
Practice Mentorship Program was designed to mentor nursing staff through the process
of using an evidence-based framework to answer clinical nursing questions while
providing practical experience in using available resources.
A participant was selected for the program in consultation with their line supervisor
(Nurse Unit Manager) and the Nursing Director. Before attending the program,
participants were required to collaborate with staff in their work area to identify clinical
questions around which there was variation in practice. The participant then used the
98
clinical questions from practice to work through a structured 12-week program (see
Appendix 12, Volume 2, p.92). At the end of the first six-weeks, participants were
expected to have used their newly acquired or refined skills in evidence-based practice
to create a one-page summary clinical practice guideline which included
recommendations for practice and identified areas for further research. Participants also
created a poster for presentation at a scientific meeting or conference and a copy for
display on the unit. The second six weeks could be spent in two ways: (1) the participant
could explore a second clinical question or (2) if there was insufficient evidence to
adequately answer the clinical question explored in the first six weeks, participants
would be guided through the process of developing a research proposal designed to
answer the original question, and writing applications for ethics approval and funding. If
the proposal was successful, the nurse would be mentored through the research process.
Anticipated benefits of entering into a research and evidence-based practice mentoring
partnership were numerous. Nurses mentored in research built on the knowledge from
the Evidence-based Practice Mentorship Program. They gained knowledge and
developed skills in other aspects of the research process such ethical responsibilities,
recruiting and consenting participants, collecting and managing data, and analysing and
discussing results. Research mentorees were also encouraged to actively participate in
the dissemination of findings at local, national and international conferences and by
contributing to publications. This provided the mentoree, and their unit, with exposure
and visibility in the nursing and healthcare community, thus moving the unit closer to
their vision of being recognised as leaders in their clinical areas. Other pragmatic
benefits suggested in the literature included more efficient distribution of multiple tasks,
taking into account each person's strengths and skills and their increased learning about
aspects of the research process; thus making the project easier to conduct (Morrison-
Beedy, Aronowitz, Dyne, et al 2001; Hayes 2000).
Research mentoring also has the potential to enhance sustainability of engagement with
evidence-based practice and research within the unit because it was envisioned that the
mentorees would take on a leadership role in project development and they would teach
99
the knowledge and skills they learned to other nurses in the unit, thus making the unit as
a whole less dependent on the services of outside experts, a significant factor in the
resource-conscience health care environment.
4.7.7.6. Component 6: Clinical Practice Governance
Effective clinical governance requires structures and processes that integrate financial
control, service performance, and clinical quality in ways that will engage clinicians at
all levels and across all disciplines in order to generate service improvements (Scally
and Donaldson 1998). In order to establish and maintain an evidence-based practice and
research culture formal processes of clinical governance were established to maintain
robust monitoring of research and evidence-based activity. Areas that required diligent
monitoring included the rigour of the research, the adherence to ethical standards, the
transparency in decision-making processes regarding implementation of findings,
maintaining sustainable, systematic practice changes, and dissemination of findings
locally, nationally and internationally, if applicable.
A clinical practice governance committee was established to monitor the progress of
Practice Development activities, intervene where needed to progress projects that stalled
in the face of organisational barriers, and link clinicians with similar interests across the
hospital. Members represented all service divisions and all nursing levels, including the
EDNS and the Clinical Chair in Nursing. Terms of reference (see Appendix 13, Volume
2, p.93) were developed and accepted by the committee at the first meeting and the
committee met monthly and maintained a database of practice development activity and
progress.
4.7.8 Study Protocol - Control Group
NUMs of the four control groups committed to maintain existing processes of practice
and practice review and committed their units to act as controls for the study.
Traditional processes used a more hierarchical 'top-down' approach, whereby plans for
practice change were initiated by the DON of the service or the NUM on the unit. These
plans were usually preceded by practice audits conducted by the Quality and Safety
100
Department, indicating outcomes less than the identified or benchmarked key
performance indicators (KPIs). Thus, the data collection was done externally to the unit,
the decision of what to do in light of the data was made by management and the practice
changes were imposed on the unit staff. The Quality and Safety Department would re-
audit the clinical practice for changes in the KPIs.
Anecdotally, nursing staff on the units indicated that they did not receive audit feedback
from the Quality and Safety Unit on their practice, nor on the changed practice, but
feedback to the NUM was provided in the form of the comparing previous KPIs with re-
audited KPIs. This resulted in feedback about lack of improvement in KPIs. Each unit
also had a Level 2 Clinical Nurse in the role of Research Portfolio Holder, whose
responsibility was to implement the imposed practice changes and initiate projects on
the NUMs (or his/her) own personal research agenda.
4.7.9 Outcomes
In this study, the primary outcome indicators used to demonstrate effectiveness of a
facilitated programme of Practice Development were mapped to each hypothesis. The
outcomes were described in terms of minimal clinically meaningful change between
intervention and control groups. Outcomes were measured using measurement
instruments previously validated in the literature, albeit modified for this study11. The
primary outcomes (that is, dependent variables) for this study, all measured on a
continuous scale, included:
BARRIERS TO RESEARCH AND EVIDENCE-BASED PRACTICE
(BARRIERS), defined as nurse-related or organisational-related barriers to
engagement in evidence-based practice and practice innovation. This variable was
measured using a modification of the BARRIERS Scale (Funk, Champagne,
Wiese, and Tornquist 1991a, 1991b; Funk, Tornquist, and Champagne 1995); with
possible scores ranging from 2-8.
11Instrument modifications and evidence of validity in Australian population will be discussed in detail in Section 4.9
Survey Instrument Design (p.103). Permissions to use existing instruments from instrument authors can be viewed in Appendix 23, Volume 2, p.141.
101
SKILLS IN EVIDENCE-BASED PRACTICE (SKILLS), defined as
competence in use of identified components of the evidence-based process, namely
formulating a clinical question, searching for evidence, appraising and
synthesising evidence, implementing best evidence and evaluating evidence in
practice. This variable was measured using a scale specifically developed for use
in this study; with possible scores ranging from 1-5.
AUTONOMY AND CONTROL OVER PRACTICE (AUTONOMY), defined
as perceptions of autonomy in patient care decisions, control over the practice
environment, organisational support and collaborative relationships with medical
professionals. This variable was measured using a modification of the Nursing
Work Index-Revised scale (Aiken, Havens, and Sloane 2000; Aiken and Patrician
2000; Aiken, Sloane, Lake, Sochalski, and Weber 1999; Aiken, Sloane, and
Sochalski 1998); with possible scores ranging from 4-20.
WORKPLACE EMPOWERMENT (EMPOWERMENT), defined as
perceptions of access to organisational knowledge, support, resources and
opportunities, and formal and informal power. This variable was measured using a
modification of the Conditions of Work Effectiveness-II scale (Laschinger,
Almost, and Tuer-Hodes 2003; Laschinger, Finegan, Shamian, and Casier 2000;
Laschinger and Havens 1996; Laschinger, Sabiston, and Kutszcher 1997); with
possible scores ranging from 6-30.
CONSTRUCTIVE TEAM DYNAMICS (TEAM) defined as perceptions of
shared team vision, participative safety, evaluation of work excellence, orientation
and support for innovation in the practice environment. This variable was
measured using a modified Team Climate Inventory scale (Anderson and West
1998; Kivimaki and Elovainio 1999) (Anderson and West 1998; Kivimaki and
Elovainio 1999); with possible scores ranging from 4-20.
102
TABLE 4.4 P
ROPOSE
D P
RACTI
CE DEV
ELOPM
ENT PROGRAMME TI
MET
ABLE
Wee
k
Activities
Time Com
mitmen
t Fo
cus
Evalua
tion
Goa
l
Wee
ks
1‐4
Initial facilitated PD
team m
eeting
s Value
s clarificatio
n Se
t up de
dicated PD
space with IT access
Neg
otiate PD time
Develop priority list
Se
t up PD te
am
commun
ication
strategy and network
1 h
our pe
r week f 4
– 6
weeks
Value
s clarification
; unit
shared vision an
d mission
; W
here and how
does th
eir p
ractice
relate to th
eir
profession
al
autono
my?
W
here doe
s cu
rren
t practice fit
and no
t fit w
ith
shared vision?
Ba
selin
e Ev
alua
tion ‐
Staff P
D Survey
Pr
ioritis
ed age
nda
develope
d an
d accepted
by te
am
Mission statemen
t posted
on unit
PD ro
om fitted w
ith IT
and internet access
Com
mun
ication bo
ok in
use
E N L I G H T E N M E N T
Develop
ing
awaren
ess of
gap be
tween
ideal p
ractice
and reality of
practic
e
Wee
ks
4‐6
PD Team m
eetin
gs
PD Project m
eetin
gs
PD Cluster m
eetin
gs
Gov
erna
nce meetin
gs
PD In
itiatives
EB
P Tr
aining
Re
search M
entoring
1 ho
ur per w
eek
As de
term
ined by
clinical te
ams an
d project r
equiremen
ts
1 h
r per m
onth
1 h
r per m
onth
as neede
d 1 d
ay per w
eek (12 wks)
on going
Prioritising
initiativ
es as pe
r;
research and
developm
ent
agen
da
Organ
ising project
team
s Organ
ising off line
roster
PD Portfolio H
olde
r iden
tific
ation an
d training
Te
am m
embe
rs rostered
to atten
d EB
P men
tor
prog
ram or on
e‐da
y EBP
worksho
p
E M P O W E R M E N T
Initiatin
g creative
rostering
solution
s
Iden
tifying
learning
need
s an
d pu
rsuing
oppo
rtun
ities
Note = Th
e proc
ess of m
oving from
enlighten
men
t throu
gh empo
wermen
t to em
ancipa
tion was not necessarily a line
ar
proc
ess, but one th
at w
as con
tinua
lly cha
nging an
d evolving
.
103Wee
k
Activities
Time Com
mitmen
t Fo
cus
Evalua
tion
Goa
l
Wee
ks
6‐26
PD Team m
eetin
gs
PD Project m
eetin
gs
PD Cluster m
eetin
gs
Gov
erna
nce meetin
gs
PD In
itiatives
EB
P Tr
aining
Re
search M
entoring
Dissemination
1 ho
ur per fo
rtnigh
t As de
term
ined
1 h
r per m
onth
1 h
r per m
onth
as neede
d 1 d
ay per w
eek (12 wks)
on going
as neede
d
Re
view priority list
Project p
lann
ing
and de
velopm
ent
Project
Implem
entation
Data co
llection
and eviden
ce
gathering
Project e
valuating
Com
mun
ication of
prog
ress
6 Mon
th Evaluation ‐Staff
PD Survey
Cha
nge in culture and
context o
f care
Cha
nge in perceptions of
EBP
Activity Re
ports
maintaine
d
E M P O W E R M E N T
Mission
statem
ent
posted
Dev
elop
men
t ag
enda
conf
irmed
1st p
roject
team
or
gani
sed
1st p
roject
unde
rway
EBP tr
aini
ng
Wee
ks
27‐52
co
ntinue
d as abo
ve
co
ntinue
d as abo
ve
co
ntinue
d as
abov
e, plus
Presentation of
finding
s locally and
nation
ally
Writin
g fund
ing
prop
osals
12 M
onth Evaluation ‐
Staff P
D Survey
Activity Re
ports
maintaine
d
E M A N C
I
P
A
T
I O N
Ong
oing
evalua
tion
and feed
back
Tea
m
prog
ressin
g ow
n sh
ared
rese
arch
agen
da
Sustaine
d pr
actice
chan
ges
-L
ON
G T
ER
M G
OA
LS
-
CH
AN
GE
IN
TH
E C
UL
TU
RE
AN
D C
ON
TE
XT
OF
CA
RE
S
US
TA
IN
AB
LE
EF
FE
CT
IV
E P
RA
CT
IC
E C
HA
NG
ES
104
4.8 Instrument Development, Implementation and Evaluation
4.8.1 Background
Designing an appropriate instrument presents a number of conceptual and technical
challenges which must be considered in the pursuit of two main goals: optimising
response and avoiding measurement error. Some issues to consider included
identifying the full extent of concepts of interest to unit staff and the organisation;
describing these concepts in terms of directly or indirectly measurable outcomes; and
choosing indicator items or variables that corresponded to these outcomes.
This chapter begins with a comprehensive and explanatory description of the survey
instrument development process and the survey implementation plan, followed by a
discussion of findings from the pilot study and implications of the pilot study
findings for the main study. The chapter will end with a discussion of the ethical
considerations of conducting the research.
4.8.2 Aim and Objectives
Report of pilot studies in the nursing literature are generally reports of 'mini' studies
with the purpose of answering the research questions, but on a smaller scale. The
main purpose of a pilot study should be to assess the design, operational aspects and
readiness for the planned full study (Gardner, Gardner et al 2003) but under the exact
protocol of the main study. These parameters were tested previously in a
demonstration pilot project12 prior to the commencement of the current study.
Therefore, the specific objectives of this pilot study were: (1) estimation of response
rate from the survey implementation plan; (2) analysis of validity of the instrument;
and (3) analysis of the reproducibility and reliability of the instrument. The next
section will present the results of the pilot testing of the survey instrument and
survey implementation plan. Both the instrument and the survey implementation
plan were piloted among a random sample of units in the hospital that were excluded
12 A demonstration study was conducted by this researcher (as co-researcher) to test the design, operational
aspects and readiness for a full planned study prior to commencement of the pilot of this study. Recommendations were reported in an unpublished report (see Appendix 24, Volume 2, p.146) to the hospital executive and will not be reported in this document. The objectives of the pilot study described in this section are specifically in relation to the development of the measurement instrument and operational issues related to distribution and response.
105
from the main study sampling frame, then revised accordingly prior to data
collection at baseline.
4.9 Survey Instrument Design
4.9.1 Background
Designing a successful survey instrument presents a number of challenges which
must be considered in the pursuit of two main goals: optimising response and
avoiding measurement error. Challenges for designing an instrument to measure the
culture and context of care, aligned with the theoretical underpinnings of Practice
Development, and addressing the lack of a single empirically tested instrument,
include identifying the full extent of concepts of interest to unit staff and the
organisation; describing these concepts in terms of directly or indirectly measurable
outcomes; and choosing indicator items or variables that correspond to these
outcomes. The following section will provide a comprehensive description of the
processes involved in designing the survey instrument, from selecting appropriate
measurement scales to assessment of instrument validity and reliability.
4.9.2 Measuring Perceptions of Barriers to Evidence-based Practice
Sandra Funk and colleagues (1991) suggested that the only way to find out about
nurses’ perceptions of barriers to research utilisation was to ask nurses and, thus,
they developed the BARRIERS scale, the most documented frequently used
instrument described in the literature to measure nurses' perceptions of barriers to
research utilisation (Funk, et al 1991a).
The theoretical framework guiding instrument development was based on Roger's
Diffusion of Innovations Model (Rogers 1983). An innovation is any object, idea or
practice that an individual perceives as new and diffusion is the process by which the
innovation is communicated or spread to others (Rogers 1995). According to Rogers
(1995), four main factors determine the rate of diffusion or adoption of an
innovation:
the innovation as perceived by the adopters (that is, relative advantage,
compatibility, complexity, trialability, observability),
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the communication channels (that is, how the message about the innovation
gets transmitted),
the time to adoption (that is, the time it takes for the 'adopters' to first become
aware of the innovation, to decide to accept the innovation, and to adopt the
innovation); and
the social system in which the innovation must be diffused (that is, the social
system is a set of interrelated units engaged in collaborative problem-solving
to accomplish common goals and the rate of diffusion is dependent on such
elements as group norms, characteristics of opinion leaders, presence of
change agents, individual vs. organisational decision-making, and
consequences of the innovation).
The original 28-item Barriers to Research Utilisation scale (Funk, Champagne et al
1991a; Funk, Champagne et al 1991b) is made up of four subscales, measuring the
constructs of barriers to research utilisation related to the nurse or adopter of change
(8 items), barriers related to the setting or organisation (8 items), barriers related to
the innovation or research itself (6 items) and barriers related to the presentation and
accessibility of the research (6 items). All original subscales used a 4-point Likert
scale (and a 'no opinion' choice that was coded as missing); and items were summed
and averaged to yield subscale scores ranging from 1 to 4.
Factor analysis of the original BARRIERS instrument resulted in a four factor
structure: Factor 1- nurse barriers, Factor 2- organisation barriers, Factor 3- research
itself barriers, and Factor 4- communication of research barriers (Funk 1991). From
the original Barriers Scale, only the first two subscales were used for this study:
barriers related to the nurse (8 out of 8 items used) and barriers related to the
setting (7 out of 8 items used). This was done because items under these two
subscales have persisted throughout the literature on the top ten list of barriers to
research utilisation. Internal reliability of these two original factors were acceptable
at the conventionally accepted alpha level (Funk, 1991a) (e.g. Cronbach's alpha
ranged from 0.72 to 0.80). The BARRIERS scale has repeatedly demonstrated high
reliability scores in subsequent use (for example see Walsh 1997a; Walsh 1997b;
Walsh 1997c; Nilsson et al 1998; Bryar 2003; Kajermo 1998; Parahoo 2001; Retsas
2000; Hutchinson 2004; McCleary 2003). Cronbach alpha coefficient for the
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Perception of Barriers to Research and Evidence-based Practice was 0.94 overall
and for the nurse barrier subscale and the organisational barrier subscales, 0.90 and
0.83, respectively.
One original item 'administration will not allow implementation' was revised into
two separate items, 'senior management will not allow implementing of changes in
practice' and 'nurse managers will not allow implementing changes in practice'. This
change was done to reflect the terminology of the local context13 , as the original
Barriers Scale was developed within a US context. In addition, one item, 'the nurse
feels results are not generalisable to own setting', was omitted from the study
instrument.
Item wording changes occurred in 14 of the 15 original items. In nine items, wording
was changed from 'the nurse…' to 'nurses…' to encourage the reflection of situation
for team vs. individual. Also, wording in nine items was changed to suit the local
context and the language of evidence-based practice was incorporated into six items.
For example, the item 'physicians will not cooperate with implementation' was
changed to 'doctors will not cooperate with implementation of changes in practice'.
Items in the original Barriers Scale were rated on a scale of 1 to 4 (1 = 'barrier to no
extent', 2 = 'barrier to a little extent', 3 = 'barrier to a moderate extent' and 4 =
'barrier to a great extent') with an additional choice of 'no opinion'. In the study
instrument, items were rated on a 5-point Likert scale (1 = 'strongly agree' 2 =
'agree', 3 = 'neither agree nor disagree', 4 = 'disagree', 5 ='strongly disagree'),
retaining a sixth option of 'no opinion', which was coded as missing.
The change in the response choices occurred as a result of reported confusion by face
validity reviewers and the content validity reviewers as how to respond to questions
because of the double negative implicating a negative statement followed by a
negative response, particularly in the case of choosing response item 1 ('to no
extent') and also because even though respondents agreed with the statement (for
example, that it reflected the situation in their work environment) they were not sure
13 Following pilot study, 'nurse managers' was changed to 'middle management' to further clarify this
item as relating to nurses in charge of units (for example, nurse unit managers, clinical nurse consultants).
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it was a barrier to evidence-based practice or innovation14. In addition, one
limitation of using a 4-point Likert scale is that forcing a choice may distort the
responses of individuals who truly do not care or who truly have no opinion. One of
the limitations of a 5-point Likert scale is the potential for neutral bias, whereby
responses tend to be biased toward the centre since most people choose the neutral
response as the best place to respond when they would prefer not to have to choose,
don't care or have no opinion. However, some would see it as a strength if people
truly do not have a directional opinion. Adding a sixth choice of 'no opinion' to the
traditional 5-point scale may improve the validity of the questionnaire and reduce the
neutral bias that occurs with an answer in the middle. The sixth response choice
allowed respondents to report being neutral on an issue (that is, 'neither agree nor
disagree' placed at position three in a 5-point scale) but also allowed for having no
opinion at all (that is, 'no opinion').
These changes15, based on the review of the literature, and face and content validity
assessment, resulted in a 16-item Perception of Barriers to Research and Evidence-
based Practice scale (Section 1) with eight items measuring barriers related to the
nurse and eight items measuring barriers related to the organisation. All items used a
5-point Likert scale. Item scores for subscales were summed and averaged to yield
mean subscale scores (range 1-5). A mean BARRIERS scale score was then
calculated by summing the two subscale scores. Thus, the full range of potential
scale scores for the Perceptions of Barriers to Evidence-based Practice was 2 to
10.16 17
14 Following the pilot study, comments from reviewers indicated they were still confused about how
to respond. Thus, original response items were re-implemented but formatting of response items and directions to complete survey section was amended to make reading the item and responding to it less confusing. It is important to note here that, the 5-point Likert scale with added sixth option of 'no opinion' format was retained for the other subscales in the instrument to avoid neutral bias.
15 See Appendix 22, Volume 2, p.122 for an item by item list of changes and rationales for changes. 16 As mentioned earlier, the original response items were re-implemented resulting in a 4-point Likert
response scale (range 1-4) and the full range of Barriers scores changed to 2-8. 17 For all scales, scaled scores were calculated as follows: for a scale composed of 4-5 items, a scale score was
only calculated if 3 items were answered; for a scale composed of 6-8 items, a scale score was only calculated if 4-5 were answered; for a scale score composed of 9 or more items, a scale score was only calculated if 6-8 items were answered.
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4.9.3 Measuring Perceptions of Skills in Evidence-based Practice
Barriers that nurses reported in the literature that related to research included lack of
awareness of research, research statistical analyses not understandable, research
reports not readily available, conflicting research reports, relevant research not
compiled in one place and nurse not capable of evaluating the quality of the research
(Funk, Champagne et al 1991). These issues can all be addressed in the evidence-
based practice process and it is engagement in the evidence-based practice process
and movement toward a research culture that is the focus of this study. None of the
previously validated scales specifically addressed nurses' perceptions of competence
in skills in the evidence-based practice process.
Therefore, at the end of Section 1, four items were added to assess nurses’ perception
of confidence in skills in evidence-based practice. Thus, the four added items were
designed to identify nurses' perceptions of their confidence in using the skills in
every step of the evidence-based practice process, namely competence in turning
problems into questions, finding evidence to support practice, evaluating the quality
of research and implementing and evaluating practice change. Inherent in these
evidence-based practice skills are skills in finding, reading, understanding,
appraising and synthesising research findings, as well as implementing and
evaluating the integration of those findings into clinical practice. Response choices
were on a 5-point Likert scale (1 = 'strongly agree' 2 = 'agree', 3 = 'neither agree nor
disagree', 4 = 'disagree', 5 ='strongly disagree') and included an additional sixth
response choice of 'no opinion', which was coded as missing.
This resulted in a 4-item Perception of Confidence in Skills in Evidence-based
Practice scale18. All items used a 5-point Likert scale. Item scores were summed
18 Following the pilot study, item wording and response choices were changed to obtain information on perceptions of competence in EBP skills instead of confidence to better reflect the focus of the barriers to research utilisation literature. Also following the pilot study, the item 'I feel confident with my skills in implementing and evaluating changes in practice' was separated into two items to clearly represent two distinct 'steps' in the EBP process, implementation and evaluation. This resulted in a 5-item Skills in EBP subscale for the main study. Also, following the pilot study, response choices were changed to reflect Patricia Benner's (Benner 1984) 5-point 'novice to expert' scale, retaining the sixth option of 'no opinion'. This was done so that the response choices reflected perceived competence. In the acquisition and development of a skill, a learner passes through the five levels of proficiency which is reflected in three general aspects of skill, namely (1) movement from reliance on abstract principles to the use of past concrete experience as paradigms, (2) change in the learner's perceptions by seeing the situation less and less as a compilation of equally relevant components, and
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and averaged to yield a mean scale score (range 1-5). Thus, the full range of
potential scores for the Perceptions of Confidence in Skills in Evidence-based
Practice scale was 1 to 5.
4.9.4 Measuring Perceptions of Control and Autonomy over Practice
One instrument described in the literature to measure nurses' perceptions of a
autonomy and control over practice is the Nursing Work Index-Revised (NWI-R)
scale (Aiken and Patrician, 2000b). The NWI-R was adapted from the original
'magnet hospital' tool, the Nursing Work Index (NWI) (Kramer and Schmalenberg,
2003a) developed to measure individual nurses' job satisfaction and perception of
quality of care. The NWI-R was adapted to not measure individual nurse traits but to
measure aspects of organisational traits of a professional nursing practice
environment (Aiken and Patrician, 2000b). Subscales were conceptually derived to
measure autonomy, control over the work environment, and relationships with
doctors, all of which are organisational attributes described in the literature as being
indicative of an environment supportive of nursing practice (Aiken and Patrician,
2000b).
Content validity was first established with the NWI through the instrument's
development from magnet hospital characteristics, an extensive review of the
literature on job satisfaction and work value instruments, and a critique of the
instrument by three of the four magnet hospital researchers (Kramer and
Schmalenberg, 2003a). In addition, criterion-related validity of the NWI-R was
correlated with different organisational forms that have been associated with better
outcomes, for example dedicated AIDS units and magnet hospitals (Aiken et al.,
1994; Aiken et al., 1996). In application, the NWI-R subscales were stable over time
for specific institutions and when used by different investigators, and demonstrated
high internal reliability scores (Cronbach's alpha for the entire NWI-R was 0.96 and
ranged from 0.84-0.91 for each subscale) (Aiken and Patrician, 2000b).
more and more as a complete whole in which only certain parts are relevant or more relevant than others, and (3) passage from detached observation to involved performer who no longer stands outside the situation but is now engaged in the situation (Benner 1984). See Appendix 20, Volume 2, p.120 for an item by item list of changes and rationales for changes.
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From the original 57-item Revised Nursing Work Index-Revised (NWI-R) (Aiken
and Patrician 2000a,b), a modification on the original 65-item Nursing Work Index
(Kramer and Hafner 1989), 17 items were extracted reflecting four subscales to form
Section 3 of the study instrument. The four subscales were control over practice
environment (10 items), autonomy (5 items), nurse-doctor relationships (2 items),
and organisational support (11 items).19 These four subscales were conceptually
derived from the NWI-R (by the authors) to measure those organisational attributes
reported in the literature as characteristic of organisations supportive of professional
nursing practice (Aiken and Patrician 2000).
Response choices were changed from the original NWI-R instrument 4-point Likert
scale to all items measured on a 5-point Likert scale ranging from '1' (strongly agree'
to '5' (strongly disagree), and including an additional sixth response choice for 'no
opinion that was coded as missing. This was done because the 'middle response'
choice does not necessarily represent a neutral position and excluding it may produce
invalid results (McColl, Jacoby et al 2001). Also, presenting respondents with the
opportunity to have no opinion may avoid erroneous representativeness (McColl,
Jacoby et al 2001). Some item wording was changed to make the context specifically
nursing (for example, 'staff' was changed to 'nurses', 'my discipline' was changed to
'nursing'). The item 'my nurse manager is a capable leader and manager' in the
original NWI-R was broken into two items 'my nurse manager is a capable leader'
and 'my nurse manager is a capable manager'. This was done in response to
comments from expert reviewers during content validity assessment suggesting that
characteristics of capable leaders and capable managers could be distinct and this is
supported in the leadership literature.
Rewording also occurred in the original item 'collaboration (joint practice) between
nurses and physicians' being changed to 'there is collaboration in decision making
regarding patient care practices between nurses and doctors' to clarify the item to
specifically relate to decision-making. Two items were added: 'there is enough time
and opportunity to question and change practice' and 'the work of nursing is valued
in this unit'. These items reflect themes in the barriers to evidence-based practice and 19 Some items were coded into one or more of the subscales, thus number of coded items (n=28) does not equal
number of items in the scale (n=17).
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nursing and practice development literature. All item changes20, 21 were based on
review of the literature and face and content validity assessment.
The result was a 17-item Perception of Control and Autonomy over Practice
subscale (Section 3) with five items measuring autonomy, ten items measuring
control over practice environment, eleven items measuring organisational support
and two items measuring nurse-doctor relationships. All items used a 5-point Likert
scale. Item scores for subscales were summed and averaged to yield mean subscale
scores (range 1-5). An AUTONOMY scale score was then calculated by summing the
four subscales. A mean AUTONOMY scale score was then calculated by summing
the subscale scores. Thus, the full range of potential scores for the Perception of
Control and Autonomy over Practice scale was 4 to 20.
4.9.5 Measuring Perceptions of Workplace Empowerment
Professional practice environments are achieved by empowering nurses through
increased opportunities for autonomy, accountability and control over practice
(Zelauskas and Howes, 1992) and are maintained by good interdisciplinary working
relationships (Grindel et al., 1996; Hoffart and Woods, 1996). According to Kanter's
Theory of Organisational Structures, empowered work environments are those in
which employees feel that they have access to information, support, resources, and
opportunity (Laschinger et al., 2003). Employees who feel empowered are more
likely to contribute effectively to the goals of the organisation. This theory has been
tested and supported in several studies (Laschinger et al., 2003; Laschinger et al.,
1997). If one of the goals of the organisation is to become a research culture, then
the staff must feel empowered in their work environment to strive to achieve that
goal.
One instrument described in the literature to measure nurses' perceptions of
workplace empowerment is the Conditions of Work Effectiveness Questionnaire II 20 The reader is referred to Appendix 22, Volume 2, p.122 for a complete detailed item-by item list of
modifications to all existing instruments used in the design of the study instrument, including rationale for any changes.
21 Following the pilot study other wording changes were made to reflect the Australian context in response to comments from respondents on the pilot questionnaire. For example, 'supervisor' was changed to 'nurse manager' and 'physicians' was changed to 'doctor'.
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(CWEQ-II) (Laschinger et al., 2003; Laschinger et al., 1997), a modified version of
the Conditions of Work Effectiveness Questionnaire described in a doctoral thesis by
Chandler (1986, cited in Wilson and Laschinger 1994). The CWEQ and subsequent
CWEQ-II are based on Kanter's theory (Kanter 1993; Laschinger et al 2003; Almost
et al 2003). The CWEQ-II has consistently demonstrated high reliability with
Cronbach's alpha scores ranging from 0.64-0.92 (Klavovich, 1996; Laschinger et al.,
1997; Laschinger et al., 2000; Laschinger et al., 2003; Sarmiento et al., 2004).
Laschinger et al (2003) also demonstrated high interrelationships between the CWE-
II and the NWI-R with Pearson significant correlations ranging from 0.81-0.85
(Laschinger et al., 2003).
The original 19-item Conditions of Work Effectiveness Questionnaire-II, also
underpinned by Kanter's theory (Kanter 1993; Laschinger, Almost et al 2003), is
comprised of three instruments: (1) a validated 12-item shortened version of the
original 35-item Conditions of Work Effectiveness Questionnaire (Laschinger,
Almost et al 2003), made up of four subscales that measure the constructs of
perceptions of access to information (three items), access to resources (three items),
access to support (three items) and access to opportunity (three items); (2) the Job
Activities Scale (JAS)-II , a three-item measure of perceptions of formal power; and
(3) the Organizational Relationships Scale (ORS)-II, a four-item measure of
perceptions of informal power. All original instruments used a 5-point Likert scale.
Item scores for subscales were summed and averaged to yield mean subscale scores
(range 1-5). An empowerment score was then calculated by summing the six
subscales. Thus, the full range of potential scores for the original CWEQ-II was 6 to
30. In addition, Laschinger et al (2003) included a two-item measure of
empowerment, The Global Empowerment Scale, to validate the CWEQ-II.
From the CWEQ-II, 18 items from the six subscales were used. One item from the
original CWEQ-II, 'the current state of the hospital', was omitted because of
comments from the experts reviewing for content validity which implied confusion
and lack of context about meaning or reference to 'state of the hospital'. Five new
items were added. Two of the new added items in the access to resources subscale
were related to constructs of barriers to research and evidence-based practice (for
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example, 'time to read research' and 'time to implement research findings'). These
items were added to aid with data checking as similar items were presented in the
barriers to evidence-based practice subscale.
Two of the new added items added to the access to opportunities subscale were
related to the construct of constructive team dynamics (for example, 'exchanging
favours with peers') and the construct of barriers to evidence-based practice (for
example, 'training programmes for learning new things') and both were used in the
original CWEQ (Laschinger, 1996; 1997; 2003). The former item was added to
measure the degree to which nurses in the team actively pursue exchanging favours
with each other. The latter item was included to address the specific issue of one of
the barriers to evidence-based practice identified in the literature, that is, lack of
skills and knowledge, relating this to whether nurses initiated this exchange of
favours with each other to ‘create’ time for skill and knowledge development.
The last added item was also from the original CWEQ (for example, 'the relationship
of the work of your unit to the hospital') and was added to the access to information
subscale. This item was used in the original CWEQ (Laschinger, 1996; 1997; 2003)
and included in this survey to address specific issue of perceptions of where the
team's work fits in with hospital's agenda.
Six of the seven items comprising the original power and informal power subscales
were grouped with the access to opportunity subscale items and one item ('rewards
for innovation on the job') was grouped with the access to support subscale items,
although they were still coded and scored under their respective, original subscales
of formal and informal power. Response choices on the original CWEQ-II varied in
wording of response choices (for example, 'none' or 'no knowledge' on one end of a
Likert scale and 'a lot' or 'know a lot' on the other end of the scale) and the format of
the responses was a numerical scale in which only the endpoints and the middle
value were labelled.
For the study instrument, response choices were changed from a 5-point likert scale
in which not all response categories were labelled (for example, 1 = 'none', 2 (no
label), 3 = 'some', 4 (no label), and 5 = 'a lot') to a 5-point Likert scale in which all
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response choices were labelled (for example, 1 = 'very good', 2 = 'good', 3 = 'fair', 4
= 'poor' and 5 = 'very poor'), and included an additional sixth response choice of 'no
opinion', which was coded as missing. The reason for this change is that although the
empirical evidence on which is more effective in increasing survey response -
labelling all response categories or just the endpoints - is inconclusive, labelling all
response choices may act as a check on leniency errors (McColl et al 2001). In
addition, labelling all response categories makes the questionnaire look more
consistent. Wording changes in three items occurred to reflect the local Australian
context. For example, 'physician' was changed to 'doctor', 'top management' was
changed to 'senior management', and 'supervisor' was changed to 'manager'.
Item changes22, based on review of the literature, and face and content validity
assessment, resulted in a 23-item Perceptions of Workplace Empowerment scale
(Section 2) with three items measuring perceptions to information, five items
measuring perceptions of access to resources, three items measuring perceptions of
access to support, four items measuring perceptions of access to opportunity, three
items measuring perceptions of formal power and five items measuring perceptions
of informal power. All items used a 5-point Likert scale. Item scores for subscales
were summed and averaged to yield mean subscale scores (range 1-5). A mean
EMPOWERMENT scale score was then calculated by summing the six subscales.
Thus, the full range of potential scores for the Perceptions of Workplace
Empowerment scale was 6 to 30.
4.9.6 Measuring Perceptions of Constructive Team Dynamics
The theory guiding development of the CWEQ-II (that is, Kanter's Theory) has also
been used in developing instruments to measure teamwork in teams (Anderson and
West 1998). This commonality serves to connect the construct of work place
empowerment with that of constructive team dynamics. Thus, in keeping with
Anderson and West’s definition of a team, in this study, a team is defined as the
group to which a nurse is assigned, with whom the nurse identifies and who the
nurse interacts with regularly in order to perform work-related tasks (Anderson and 22 The reader is referred to Appendix 22, Volume 2, p.122 for a complete detailed item-by item list of
modifications to all existing instruments used in the design of the study instrument, including rationale for any changes.
116
West 1998). Work based teams in an acute hospital setting are typically identified
geographically, as in a ward/unit or clinic. Team climate is defined as a team’s
shared perceptions of organisational policies, practices and procedures (Anderson
and West 1998) and is made up of shared vision and objectives, a participative
environment, a commitment to excellence in task performance and support for
innovation (Bower et al 2003). Vision is the idea of a valued outcome that represents
a motivating force at work (Anderson and West (1998). Participative safety is the
idea that involvement in decision-making is motivated and reinforced while
occurring in a non-threatening environment (Anderson and West (1998). Task
orientation is a shared concern with excellence in task performance in relation to the
shared vision (Anderson and West (1998). Support for innovation is the expectation,
approval and practical support for introducing new and improved ways of doing
things (Anderson and West 1998).
One instrument described in the literature to measure perception of constructive team
dynamics is the Team Climate Inventory (TCI) (Anderson and West 1998).
Extensive research into both climate and innovation by the authors informed the
development of a four factor model of work group innovation; the four factors being
team objective, participation, task orientation and support for innovation (West and
Anderson 1996). The TCI has been validated extensively by the authors who have
reported acceptable levels of internal reliability with Cronbach alpha scores ranging
from 0.84-0.93 (Anderson and West, 1998; Loewen and Loo, 2004). The scales have
also demonstrated substantial interrelationships with Pearson correlations ranging
from 0.34-0.62 (Anderson and West 1998) and 0.54-0.88 (Loewen and Loo 2004).
Kivimaki and Elovainio (1999) also found high reliability with a shortened version
of the instrument (Cronbach's alpha ranged from 0.82-0.86). The TCI has been used
to prepare for creating practice development wards by identifying if the necessary
level of team work was present in the unit before embarking on practice
development (Walsh and Walsh 1998). The TCI has also been used most recently to
assess improvement in teamwork in mental health settings (O'Sullivan, et al 2009).
From the 19-item shortened Team Climate Inventory (West, personal
correspondence, 2004), a modified and shortened version of the original Team
Climate Inventory (Anderson and West 1998), all 19 items were used from four
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subscales to form the Perceptions of Constructive Team Dynamics scale (Section 4)
of the study instrument. The four subscales measure the four constructs of: team
objectives (four items), participation (six items), task orientation (five items), and
support for innovation (five items). A new item was added to the task orientation
subscale, 'team members help each other create time for research and development
work'. As 'time' has been consistently reported in the literature as a barrier to
engagement in research and evidence-based practice, this item was added to measure
the degree to which nurses in the team actively pursue creation of time for
development work through negotiation with other members of the team. Response
choices in the original 19-item shortened Team Climate Inventory varied between
subscales.
Wording changes occurred in the four original team objectives items and the four
original task orientation items. These items were changed to declarative statements
and respondents asked were asked their level of agreement. This was done because
subtle changes in question wording within one instrument may cause shifts in
response patterns and can bias results (McColl, Jacoby et al 2001). Items in the
participation and the support for innovation subscales were rated on a 5-point Likert
scale ranging from 'strongly disagree' to 'strongly agree'. In the study instrument,
the response choices for these two scales were changed to 1 = 'strongly agree' 2 =
'agree', 3 = 'neither agree nor disagree', 4 = 'disagree', 5 ='strongly disagree', and
included a sixth option of 'no opinion', which was coded as missing.
The order of the response choices was changed for consistency across the
questionnaire.23 In the original instrument, items in the team objectives subscale
were rated on a 7-point Likert scale ranging from 'not at all' at one end to 'somewhat'
at the midpoint to 'completely' at the far end. Items in the task orientation subscale
were also rated on a 7-point Likert scale ranging from 'to a very little extent' at one
end to 'to some extent' at the midpoint to 'to a very great extent' at the far end. In the
study instrument, the response choices for these subscales were changed to the same
23 Note: All items for workplace empowerment, control and autonomy over practice environment and
constructive team dynamics subscales were recoded prior to analysis so that larger values represented greater agreement with items. Items in the barriers subscale were recoded so that larger values represented greater perception of item as a barrier.
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5-point Likert scale as for the participation and the support for innovation scales.
The above mentioned changes24, based on review of the literature, and face and
content validity assessment, resulted in a 20-item Perceptions of Constructive Team
Dynamics subscale (Section 3) with four items measuring shared vision, six items
measuring participative safety, five items measuring commitment to excellence in
team performance, and five items measuring support for innovation. All subscales
used a 5-point Likert scale. Item scores for subscales were averaged to yield mean
subscale scores (range 1-5). A TEAM scale score was then calculated by summing
the four subscales. A mean TEAM scale score was then calculated by summing the
four subscales. Thus, the full range of potential scores for the Perceptions of
Constructive Team Dynamics scale is 4 to 20.
4.9.7 Validity
Instrument validity is measured and documented on new instruments and established
instruments used on new populations. Validity is the degree to which an instrument
actually measures up to the concepts it is intending to measure (Polit and Beck
2004). Several types of validity were measured in this study instrument, including
face validity, content validity, construct validity, and criterion validity. The
processes of each will be described in detail.
Face validity is concerned with whether, on an informal, superficial review of items
by non-expert reviewers, the questionnaire is measuring what it is supposed to
measure. Face validity was assessed by an experienced university academic in
literature and textual criticism and by an administrative assistant working in a
hospital setting with no direct patient contact. Although face validity is the least
scientific measure of validity (Litwin 1995), it was deemed important to have the
instrument reviewed first by non-nursing reviewers to increase the likelihood of
identification of any obvious item ambiguities, inconsistencies and/or problem areas
from persons not familiar with the intimate jargon of contemporary nursing.
24 The reader is referred to Appendix 22, Volume 2, p.122 for a complete detailed item-by item list of
modifications to all existing instruments used in the design of the study instrument, including rationale for any changes.
119
Content validity is concerned with how appropriate the choice of items appears to
reviewers with knowledge and expertise in the topic area and examines the extent to
which the instrument covers all major aspects relevant to the constructs being
measured (Litwin 1995; Polit and Beck 2004). Content validity comes from
engagement with the relevant literature, content experts, and a sample representative
of the population under study.
Six Registered Nurses, each with greater than ten years clinical experience,
considered experts in their nursing specialties, and with expertise in nursing
research, nursing education, evidence-based practice and/or Practice Development
processes were invited to review the instrument and the instrument was revised
accordingly. These reviewers were chosen for their capacity to be reflective of the
profession yet considerate of the level and perspectives of the unit staff that would be
completing the surveys during the study period. They were stakeholders with a
vested interest in recruitment and retention of the nursing workforce and hospital
outcome indicators of quality patient care. Their nursing roles included clinician,
researcher, educator, unit level manager, research department head and nursing
professor. An additional non-nurse reviewer considered an expert in public health
research and statistical methods was consulted.25
Construct validity is concerned with how meaningful the instrument is when in
practical use. In drafting survey questions, theoretical assumptions are always made
about how concepts are related to one another; these assumptions should be tested.
Construct validity examines whether the results obtained using the questionnaire
confirm expected statistical relationships (Litwin 1995), the expectations being
derived from underlying theory guiding the methodology (McColl et al 2001), in this
case Practice Development methodology.
There are two forms of construct validity: convergent validity, which tests that two
or more instruments that are supposed to measure the same construct are positively
25 After the initial validity checks, the instrument was piloted on six randomly selected units from the sampling frame (one from each of six nursing divisions) not selected to participate in the main study and comments related to content validity issues were addressed, and the instrument revised accordingly, prior to the main survey.
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correlated (Schneider, Whitehead, Elliot et al 2007); and divergent validity, which
measures the differentiation from one construct to another that may be potentially
equivalent (Schneider, Whitehead, Elliot et al 2007). Construct validity is basically a
measure of how well the instrument performs in a variety of populations and settings
over a number of years. However, construct validity is often only determined after
years of experience with a survey instrument (Litwin 1995). Since the instrument
developed for this study is technically a new hybrid instrument and relationships
between all subscales has not yet been established, it is not possible to assess
construct validity at this time. However, assessment of construct validity is an issue
worth pursuing in subsequent research.
Criterion validity is concerned with how well one instrument measures up against
another one known to be valid that can provide criteria against which to benchmark.
Criterion validity can be broken down into concurrent validity and predictive validity
(Litwin 1995) but can be supported with one dataset as a starting point. Concurrent
validity requires that the instrument be judged against some other instrument that is
an acknowledged 'gold standard' and is relevant, well known and accepted as being
good measures of the variables of interest (Litwin 1995).
Although the study instrument was designed by combining subscales from relevant,
valid and reliable scales found in the literature, none of these instruments had been
heralded as 'gold standards'. For example, the BARRIERS scale is the most
frequently-used scale to measure perceptions of barriers to research utilisation.
However, there are reports of obtaining different factor analysis results when
instruments were used with different populations (for example, see Retsas 2000;
Retsas and Nolan 1999). In addition, no published literature to date was identified in
which all the subscales used together in one study instrument were previously used
together; although there are studies investigating the correlation between some
subscales. For example Laschinger and colleagues (Laschinger and Havens 1996;
Laschinger, Sabiston et al 1997; Laschinger, Almost et al 2003) have explored
correlations between subscales of the NWI-R and the CWEQ-II and found them to
be moderately to highly correlated. For this reason, concurrent validity of the
instrument was not assessed in this study. Predictive validity is concerned with the
ability of the instrument to forecast expected events, behaviours, attitudes or
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outcomes (Litwin 1995). Predictive validity is calculated as a correlation coefficient
and explores the degree of correlation between the measure of the construct of
interest and some future measure or outcome of the same construct (Schneider,
Whitehead, Elliot, et al 2007). Due to the scope of this study and feasibility in
undertaking additional measurement strategies, predictive validity was not assessed
in this study.
4.9.8 Reliability
Instrument reliability is a measure of how reproducible the instrument's data are or
the stability with which the constructs are 'captured' in terms of content. Reliability is
the consistency of measure. It reflects that adequate items asked about capture
perspectives on the construct in order to obtain a stable, overall response/scale score.
It is the amount of random error in the measurement technique. One commonly used
measure of reliability is internal consistency reliability which is applied to groups of
items thought to measure different aspects of the same construct or how well the
items measure the same issue (Litwin 1995; Polit and Beck 2004).
Internal consistency reliability of the instrument was undertaken using Cronbach's
coefficient alpha of the individual subscales and a global culture of inquiry subscale.
Item-total correlations were computed for instrument items measuring the culture
and context of care (that is, 80 items from the 98-item questionnaire). Alpha scores
for subscales in the study instrument were compared with alpha scores previously
reported in the literature for their respective subscales not only because of the
changes that occurred to some items following the literature review and validity
testing but also because the majority of subscales had not been tested previously on a
population of Australian Registered Nurses. For well-developed instruments the
lowest acceptable reliability coefficient is usually .80; although for a new instrument,
.70 is considered acceptable (Nunnally 1978; Champion and Leach 1989; Peterson
1994)26.
4.10 Survey Implementation Plan 26 These parameters for acceptable internal consistency were postulated by Nunally in 1978 and have
been accepted internationally as the norm since published. The parameters were confirmed in a meta-analysis of Cronbach's coefficient alphas of 1030 samples consisting of over 300,000 individuals by Peterson in 1994.
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4.10.1 Background
Survey results are only as good as the amount of bias or error that can be eliminated
from the survey design. But despite the quality of the survey design, results may still
be affected by the number of useable surveys returned, that is, the survey response
rate. Although response rates for mail-out surveys have been estimated at 25-30%
(Polit and Beck 2004), a well administered mail-out survey can yield similar, if not
much higher, response rates at a much lower cost than face-to-face or telephone
surveys (deVaus 1995), particularly in homogeneous populations (deVaus 1995;
Dillman 2002).
Another advantage of mail-out surveys over telephone or face-to-face is the
decreased chance for bias in responses, particularly on controversial question items
in which respondents may feel inclined to answer in a way they perceive is socially
acceptable when speaking directly with an interviewer. de Vaus points out that 'even
the best-trained interviewers can affect the way respondents answer questions'
(deVaus, 1995, p110). Following the decision to use a mail-out survey, a survey
implementation plan based on Dillman's Tailored Design Method (Dillman, 2000)
was developed to maximise response rates.
4.10.2 Dillman's Tailored Design Method
In the late 1970s, a time when mail surveys were considered less than desirable
because of the relatively lower response rates as well as other flaws, compared to
telephone and face-to-face approaches, Don Dillman described a survey
implementation plan that incorporated a system of interconnected actions for
conducting high quality mail surveys and improving the potential for obtaining
acceptable response rates and decreasing non response bias (Dillman 2000).
Total Design Method is based on the theory of social exchange that says that the
behaviour or actions of individuals are motivated by the return these behaviours are
expected to bring from others (Dillman 2000; 2002). Key principles of social
exchange theory are to increase perceived rewards for responding, decrease
perceived costs and create respondent trust in beneficial outcomes from the survey
(Dillman 2000).
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Total Design Method emphasised the importance of both instrument design and
layout as well as survey implementation (Dillman 2000). Since the 1970s, advances
in technology and theory, better understanding of survey requirements, improved
social science knowledge base, and ever expanding research evidence on survey
response behaviours have precluded the use of a one size fits all model and sparked
the evolution of the Total Design Method into the Tailored Design Method (Dillman
2000), a method which has incorporated a broader consideration of the causes of
survey error and determinants of response behaviour.
According to Dillman (2000), the following five components have been confirmed in
the literature and are required to achieve a high response rate:
(1) user-friendly questionnaire design;
(2) four contacts by first class mail, including pre-notification and follow up
contacts, plus an additional 'special' contact;
(3) personalisation of correspondence;
(4) return envelopes with real first class stamps; and
(5) token prepaid financial incentives.
The specific purpose of using personalised contact, a return envelope and an
incentive is to create trust and influence the respondent's expectations of rewards and
costs. In a systematic review of 68 randomised, controlled trials and quasi-
experimental studies, McColl et al (2001) critically reviewed the survey literature,
which supported the strategies recommended by Dillman (2000). A more recent
systematic review of 372 eligible trials that evaluated 98 strategies for increasing
response rate to postal surveys also supported Dillman's recommendations (Edwards
et al 2003).
Both reviews recommended several strategies to increase response rate and reduce
survey error based on the best available evidence (McColl et al 2001; Edwards et al
2003). Thus, Dillman's Tailored Design Method and other evidence-based strategies
were incorporated into the survey implementation plan and protocol in this study.
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4.10.3 Protocol for Survey Implementation Plan
Although the protocol of survey implementation in this study was based on
Dillman's (2000) five essential components, modifications to the strategies were
necessary. The modifications will be described in this section.
4.10.3.1. User-friendly questionnaire design
The objectives of questionnaire design are to reduce non-response and to reduce
measurement error. Small improvements in response have been demonstrated,
particularly in respondents who were deemed least likely to respond (Dillman,
Sinclair and Clark 1990; 1993 in Dillman 2001) and poor questionnaire layout can
cause questions to be overlooked or answered with a biased response (Dillman 2000;
2002). The following principles have been demonstrated to reduce non-response and
measurement error and were incorporated into the development of the questionnaire
for this study: clear and easy to understand questions, interesting, relevant and salient
questions, questionnaire item order that is salient to the respondents, questionnaire
layout in accordance with visual principles of design for comprehension and easy
response, and length of questionnaire (Dillman 2000; 2002, McColl et al 2001,
Edwards et al 2003).
Thus, the survey was formatted in booklet form instead of individual sheets stapled
in the corner. It was printed on white paper in black ink in 12 point Times New
Roman font. The front cover contained a black and white picture of nurses looking at
information on a computer. Information about the purpose of the study, contact
details of the researchers, independent contact for complaints, and instructions that
answering questions was optional, were provided on the first page. An estimated
time to complete the questionnaire was also provided.
Each section of the questionnaire (and sections within sections) was prefaced with
brief instructions for completing the relevant section. A section containing
demographic questions was placed last on the questionnaire and sensitive-nature
questions were avoided. Only the subscales from previously validated instruments
that were relevant to the theoretical framework underpinning Practice Development
were used, thus making the survey shorter than it would have been if each of the four
125
instruments were used in its entirety (see Appendix 16, Volume 2, p.104 for a copy
of the final survey instrument).
4.10.3.2. Five contacts with participants
Multiple points of contact with participants improves response rate (McColl et al
2001, Dillman 2000; 2002). In a meta-analysis of 39 trials (60,220 participants),
response rate odds increased by half when participants were pre-notified (McColl et
al 2001). Similar results were found in another meta-analysis of 17 trials (18,904
participants), response rate odds increased by the same amount when follow-up
contact was used (Edwards et al 2003).
Dillman (2001) recommended four contact points, including pre-notification and
follow up contacts, plus an additional 'special' contact, which was in a different
format from the other contacts, for example, a telephone call. The intention was that
each of the contacts was different because stimuli that are different from previous
ones are usually more powerful than repetition of a previously used technique
(Dillman, 2001). In this study, it was not feasible to contact every member of the
sample by telephone for the 5th contact. Thus, each contact was differentiated in the
nature of the cover letter and the characteristics of the outer packaging (
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Table 4.5; see also Appendices 17-21 , Volume 2, p.117-121).
4.10.3.3. Personalisation of correspondence
A mail merge programme was used to generate mailing labels for individuals in the
sample. The mail-out envelopes and letters were addressed to individuals and
distributed to each nurse through processes currently in place in the facility for
distribution of mass mail-outs.
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TABLE 4.5 DISTRIBUTION PROTOCOL FOR SURVEY IMPLEMENTATION
Time Description of Mailed Out Materials
Week ‐2 1st contact
package contents: pre‐survey notice letter on white paper
outer packaging: white size 10 business envelope
recipient: entire sample
Week 0 2nd contact
package contents: cover letter on white paper, questionnaire, pre‐addressed return envelope, incentive
outer packaging: A5 size manilla envelope
recipient: entire sample
Week 2 3rd contact
package contents: reminder/thank you note on blue paper
outer packaging: white size 6 3/4 envelope
recipient: entire sample
Week 4 4th contact
package contents: follow up letter on white paper, questionnaire, pre‐addressed return envelope
outer packaging: A4 size manilla envelope
recipient: non‐responders
Week 6 5th contact
package contents: follow up letter on white paper, questionnaire, pre‐addressed return envelope
outer packaging: A4 size white envelope
recipient: non‐responders
Dillman (2000, 2002) recommends personalisation of covering letters to 'show
regard for the respondent' (p.152) so each letter contained a personal salutation (for
example, Dear Mr Doe). Each cover letter was written to effect a different response
from the respondent. The pre-survey notice letter was designed to indicate briefly
that a questionnaire would arrive within two weeks, that the person's response would
be greatly appreciated but that no immediate response was necessary (see Appendix
17, Volume 2, p.117). The questionnaire was then distributed with a detailed cover
letter explaining the purpose of the request, asked for a response, and noted why a
128
response was important (see Appendix 18, Volume 2, p.118). The thank
you/reminder postcard was designed to express appreciation for responding to those
who have already responded and in anticipation of those yet to respond (see
Appendix 19, Volume 2, p.119). A replacement questionnaire was sent with a cover
letter indicating that the person had not responded, a powerful form of implicit
personalisation (Dillman 2000, 2002), and urging them to do so (see Appendix 20,
Volume 2, p.120). The final contact was a second replacement questionnaire
distributed with a final cover letter designed to appear 'special' to the respondents
and implicitly expressing the importance of the response to the researcher by the
increased expense of a 5th mail-out to the recipient (see Appendix 21, Volume 2,
p.121). The 5th 'contact' was delivered in an A4 white envelope, to distinguish it from
the A4 manilla envelope that is typically identified with internal mail delivery.
4.10.3.4. Pre-addressed return envelopes
Dillman (2000) recommended return envelopes with real first class stamps. Each
mailed questionnaire was packaged with a return envelope pre-addressed to 'The
Researcher-PD Study". McColl et al 2001 reviewed several previous reviews on the
impact of postage rates (for example, first class vs. second class) and type (for
example, hand stamped vs. franked or reply-paid envelopes) and found the findings
equivocal in increasing response rate. However, since the survey was via an in-
house mail distribution process, stamps were not required on the return envelopes.
Although a meta-analysis of postal survey response rate found no evidence to
suggest that the characteristics of the posting envelope increased response rate
(Edwards et al 2003), the contacts in this study were clearly differentiated from each
other in this way. This component of the implementation plan also differed from
Dillman (2000) in the use of first class postage, which was not required because
survey distribution was conducted using the internal mailing system currently in use
in the facility.
4.10.3.5. Token prepaid incentives
Dillman (2000) recommended prepaid financial incentives. Higher response rates
have been achieved when an incentive was included with the questionnaire (McColl
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2001, Dillman 2000; 2002). In this study, it was not feasible nor considered
appropriate by the ethics committee to use a financial incentive.
In a meta-analysis of 72 studies, Edwards et al (2003) found that a non-monetary
incentive increased the odds of response by over one-tenth. Thus, the first
questionnaire sent was packaged with a non-financial incentive. The incentive used
in the pilot study was a package containing one gourmet coffee bag and one gourmet
tea bag.27 Participants were presented with the incentive and encouraged to keep and
use the incentive whether or not they chose to participate in the study. After
designing and testing the validity and reliability of the study instrument, and
formulating the survey implementation strategy, a pilot study was conducted.
4.11 Statistical Methods
Data were analysed using a per-protocol (PP) analysis and a modified intent-to-treat
(MITT) analysis. In PP analysis, only those patients who completed the trial as
planned are included in the analysis. In MITT analysis, all nurses are analysed as
part of the group to which they were originally assigned. However, in order to
provide a more accurate assessment of the study results (Lang and Secic 2006),
nurses found not to have met the eligibility criteria were excluded.
4.11.1 Data Preparation
Several strategies were employed for verification and screening. A data code book
outlining the coding protocol, and including all valid values involved in the coding
process, was developed to ensure data entry was consistent between different data
enterers28. A code was designated for every question, for every survey entered and
for every nurse participant. Missing responses were coded as '9'. Coded data were
entered, verified and cleaned.
27 In response to comments from the first survey suggesting appreciation of a different, simpler incentive, the
incentive packaged in the second and third surveys at 6 and 12 months was a chocolate Freddo® frog. 28 The data code book and database, containing data labels and data values, were set up by the researcher. Data
were entered by the researcher and the research assistant. Once all data was entered, the researcher maintained sole responsibility for data management, verification, screening and analysis.
130
In preparation for analysis, item scores in subscales were reverse-coded so that
higher scores indicated a greater agreement with the item.29 A data base was set up in
SPSS by the study researcher containing the codes and labels. Data obtained from
paper questionnaires were directly entered into an SPSS data file by the study
researcher and analysed using Statistical Package for the Social Sciences (SPSS) v15
and v16 (SPSS Inc. 2006; SPSS Inc. 2007).
Although double data entry is the most commonly used procedure to ensure that
incorrect data is not entered (King and Lashley 2000), the value or gains in data
quality may not justify the cost of performing the procedure (Day, Fayers et al 1994;
King and Lashley 2000; Kleinman 2001). Therefore, data verification was achieved
in this study by a "visual record verification check" procedure using a continuous
sampling plan as described by King and Lashley (2000, p.95). In the procedure, the
first ten records of the random-ordered data set were proofread or checked against
their original survey forms and then every tenth record after that. If an incorrect
record was found then the record was corrected and the verification check returned
to 100% checking of data records until ten successive correct records were found.
The procedure continued until a 10% random selection of the data records was
checked as per King and Lashley's (2000) procedure. A schematic of the procedure
is shown in Figure 4.2. Errors found and corrected were randomly distributed and
did not display a systematic pattern.
29 After the pilot study, response choices in the barriers to EBP subscale reverted to modified versions of the
original Barriers Scale where choices ranged from 1 = 'this is a barrier to no extent' to 4 =' this is a barrier to a great extent'. Thus, recoding of these items in the main study was not required. The higher the score, the greater the item was a barrier to research and EBP. See Appendix 22, Volume 2, p.122 for a more detailed rationale.
131
FIGURE 4.2 SCHEMATIC OF PROCEDURE FOR VISUAL RECORD VERIFICATION CHECK USING A CONTINUOUS SAMPLING PLAN (ADAPTED FROM DODGE 1947 (CITED IN KING
AND LASHLEY 2000)
Consistency checks were conducted to check that baseline demographic data existed
for all cases with follow up data (that is, data at each data collection point). Internal
data consistency was done, as suggested by Polit and Beck (2004), by checking
whether data from different variables were compatible. For example, if data were
internally consistent each case's response on question Q66 ('Nurses do not have time
to read research at work') would be compatible with their response on question Q27
('Time available to read research'). Similarly, responses for each case should be
compatible on question Q65 ('Nurses do not feel they have enough authority to
change patient care practices') and question Q4 ('Nursing controls its own practice
in this unit'). As another example, if the respondent entered a code of '1' on Q81
('Years of post registration experience') indicating 'less than two years' and there
was an entry of '1' on Q82 ('Initial nursing education') indicating 'hospital trained',
then one of those two fields would have contained an error because nursing
Start
Visually check 10 successive
Randomly sample 10% of data
Correct the incorrect data
Data errors found in a record
No data errors found in a record
Data errors found in a record
No data errors found in a record
132
education has been situated in the university sector in Australia for well over twenty
years. After verification, the next step in data preparation was data screening.
Tabachnick and Fidell (2007) recommend a practical checklist for screening data
prior to the main analysis which includes:
• inspection of univariate descriptive statistics for accuracy of input,
• evaluation and dealing with amount and distribution of missing data,
• identifying and dealing with non normal variables and univariate outliers
• checking pairwise plots for nonlinearity and homogeneity of variance,
• identifying and dealing with multivariate outliers,
• evaluating variables for multicollinearity and singularity.
4.11.1.1. Accuracy of input
Data were inspected for duplicate file numbers and duplicate survey identification
numbers and true duplicates were removed. In order to inspect univariate descriptive
statistics for accuracy of input, a frequency table was generated for all variables. The
median, minimum and maximum values (for categorical variables), and means and
standard deviations (for continuous variables), were checked for plausibility. This
included checking for out-of range or invalid values (that is, wild codes) by
comparing data with the code book ranges for each variable. Anomalies were
checked against the original paper questionnaire and corrected, when necessary.
4.11.1.2. Amount and distribution of missing data
Missing data is a problem in data analysis and the seriousness of it depends upon the
pattern of missing data (Tabachnick and Fidell 2007). If a small amount (5% to 20%
or less) of data points are randomly missing from a large data set, problems are less
serious (Little and Rubin 2002; Tabachnick and Fidell 2007). Variables missing
completely at random (MCAR) or missing at random (MAR) would be the ideal;
however variables where missing data are related to the dependent variables cannot
be ignored (Tabachnick and Fidell 2007).
Following data verification, cleaning and screening, and prior to analysis, the five
dependent variables and seven descriptive variables (that is, demographic variables)
were examined for missing values and fit between their distributions and the
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assumptions of multivariate analysis. The variables were examined separately for the
275 surveys in the intervention group and the 214 surveys in the control group for
each survey period.
At T0, two dependent and one descriptive variable had missing values on more than
5% of the cases for the study group and three dependent variables but no descriptive
variables had missing values on more than 5% of the cases for the control group. The
missing values in both groups were found to be MCAR (Little MCAR's test: χ2
=26.15, df=50, sig=0.998 for study group; χ2 =58.28, df=46, sig=0.129 for control
group). On examination of separate variance t-tests to see if missingness was related
to any other variable, most variables had values missing that supported MAR due to
a p value > 0.05. However, the dependent variable EMPOWERMENT had 8%
missing values in the study group and missingness was related to the descriptive
variable age (t=4.2, df =8.4, p=0.003). In addition, the dependent variable TEAM had
8 % missing values in the study group and was related to the dependent variable
BARRIERS (t=-3.5, df=5.5, p=0.015).
At T1, all five dependent variables and one descriptive variable, had missing values
on more than 5% of the cases for the study group and four dependent variables and
no descriptive variables had missing values on more than 5% of the cases for the
control group. None of the values were completely MAR (Little MCAR's test: χ2
=81.67, df=62, sig=0.048 for study group; χ2 =67.89, df=46, sig=0.020 for the
control group). On examination of separate variance t-tests to see if missingness was
related to any other variable, most variables had values that could be inferred as
MAR due to a p value > 0.05. However, the descriptive variable nurse qualification
had 5.2% missing values in the study group and missingness was related to the
dependent variable TEAM (t=3.5, df =4.6, p=0.020). In addition, the dependent
variable BARRIERS had 19 % missing values and was related to the descriptive
variable age (t=-4.4, df=25.1, p=0.000).
At T2, three dependent and one descriptive variable had missing values on more than
5% of the cases for the study group and two dependent variables but no descriptive
variables had missing values on more than 5% of the cases for the control group. The
missing values in both groups were found to be MCAR (Little MCAR's test: χ2
134
=61.98, df=58, sig=0.336 for study group; χ2 =35.39, df=36, sig=0.497). On
examination of separate variance t-tests none of the variables had missingness
related to any other variable.
All dependent variables displaying greater than 5% missing values that were MCAR
or MAR were retained as they were critical to the research question and no missing
values were imputed. Age and nursing qualification were also retained as descriptive
variables to be examined later as potential confounders or effect modifiers.
4.11.1.3. Non normal variables and univariate outliers
Inspection of univariate descriptive statistics and graphical representation of the
continuous variables were conducted to identify two components of normality,
skewness (related to the symmetry of the distribution) and kurtosis (related to
peakedness of a distribution) and found to be normally distributed. All dependent
variables fit within the following guidelines indicating adequate normality for
assessing normality: mean within 10% of the median, a standard deviation (SD) less
than half the mean, minimum and maximum approximated by the mean ± 3 SD, and
skewness and kurtosis both within +3 and – 3 (Battistutta 2004)
Data were assessed for univariate outliers (cases with an extreme value on one
variable) that may have had an affect on the distribution. Outliers were sought
separately within each group by inspection of univariate descriptive statistics and
graphical representations of the variables (for example, histograms, boxplots). One
nurse in the study group and one nurse in the control group were considered
potentially significant univariate outliers because they demonstrated an absolute
value z-score greater than 3.29 (p< 0.001, two-tailed test) on one or more dependent
variables in all surveys in which they participated (Tabachnick and Fidell 2007).
However they were not deleted from the analysis in order to capture the real and
possible extreme views or characteristics in the sample. Eight other nurses in the
study group and five other nurses in the control group were considered potential
univariate outliers because they demonstrated an absolute value z-score greater than
2.58 (p<0.01, two-tailed test) in one or more of the surveys in which they
participated (Tabachnick and Fidell 2007). Again, these cases were deemed to be a
legitimate part of the sample and, thus, were not deleted. As Tabachnick and Fidell
135
(2007) suggest, when potential univariate outliers were identified a decision was
made about whether transformations were acceptable to improve the normality of
distributions and reduce the impact of the univariate outliers by pulling them closer
to the middle of the distribution. In this study log transformations did not bring the
outliers closer to the middle of the distribution.
4.11.1.4. Nonlinearity and heteroscedasticity
The assumption of linearity is that there is a straight line relationship (that is, linear)
between two variables (Tabachnick and Fidell 2007). Pairwise linearity for all pairs
considered in analysis was checked using within-group scatterplots and found to be
mostly satisfactory and is presented in Figure 4.3.
Because the main analysis was on grouped data, the assumption of homogeneity of
variances instead of heteroscedasticity, which is assumed for ungrouped data, had to
be met. An assumption of homogeneity of variances assumes that the variance of one
BARRIERS SKILLS EMPOWER AUTOCONTROL TEAM
BARRIERS
SKILLS EMPOWER AUTO/ CONTROL
TEAM
FIGURE 4.3 SCATTER PLOT OF CORRELATIONS BETWEEN OUTCOME VARIABLES FOR EXPERIMENTAL AND CONTROL GROUPS AT BASELINE
136
variable (for example, continuous dependent variable) is relatively similar at all
levels of another variable, for example, discrete grouping variable (Field 2005;
Tabachnick and Fidell 2007). Where means were being compared across groups, the
variance of the continuous variables within groups were calculated and compared for
similarity. Perceptions of AUTONOMY, EMPOWERMENT and TEAM were all
positively linearly related to each other and all negatively linearly related to
perception of BARRIERS. However, perception of SKILLS did not appear to be
linearly related to any of the other dependent variables. There were no violations to
the assumption of homogeneity of variances based on the means as evidenced by non
significant Levene test statistics for all dependent variables.
4.11.1.5. Multivariate outliers
Multivariate outliers are cases with unusual combinations of scores on two or more
variables. Multivariate outliers were identified by Mahalanobis distance, which
Tabachnick and Fidell (2007) have defined as the distance of a case from the point
created at the intersection of all the variables (that is, centroid). Cases were
considered multivariate outliers if they were located some distance from the cluster
of other points and have a Mahalanobis Distance greater than χ2(df 5) = 20.15 (p<
0.001)30. By using Mahalanobis distance with p<0.001, derived from leverage
scores, no cases were identified as multivariate outliers in their own groups.
4.11.1.6. Multicollinearity and singularity
Multicollinearity and singularity are problems with the correlation matrix where
either variables are too highly correlated (that is, multicollinearity) or variables are
redundant (that is, singularity). A correlation matrix is simply a matrix where each
row and each column represents a different variable and the value where the row and
column intersects is the correlation between the two variables. The correlations
between dependent variables discussed in Section 4.11.1.4, was considered to be a
suggestion of multicollinearity; thus, the need for consideration of multivariate
dependent variable analyses or analyses that accounted for correlated data. However,
when the dependent variables were correlated in the groups no variables
30 Mahalanobis Distance calculation formula extrapolated from Tabachnick and Fidell (2007), Table C4. Critical
values of Chi Square (χ2).
137
demonstrated high correlation, that is, greater than .90 (Tabachnick and Fidell 2007);
suggesting a stable correlation.
4.11.2 Influence of Research Design on Analytical Approach
Although analysing ordinal data using an ordinal strategy is usually adopted by
measurement purists (Kim 1975), several seminal studies have demonstrated that
assuming equal interval of rankings of ordinal scale data, as is the case when using
parametric strategies to analyse ordinal data, produces only minor and non-
systematic errors in the correlations (Lavobitz 1967; Lavobitz 1970; Kim 1975). In
addition, Kim (1975) argued that "parametric strategies are more compatible with the
successive refinement of our measurement and theories and with the interplay
between substantive theory and measurement" (p.294).
Researchers continue to use ordinal-scaled dependent variables in analyses typically
described as requiring interval data on a regular basis (Harwell and Gatti 2001). In
the published literature on the variables of interest in the current study, although
ordinal data was analysed using non parametric statistics to obtain rankings in the
barriers literature; parametric statistics to obtain means and standard deviations to
describe relationships between scale variables was used in all other analyses. In light
of the seminal studies mentioned above, and the desire to compare findings from this
study with findings in the literature, parametric statistics were used in bivariate and
multivariate modelling in this study.
4.11.2.1. Bivariate Analysis
Practice Development is about team culture and thus, the purpose of this study is to
measure differences in organisational traits within and between teams or units in the
hospital. In order to study organisational traits, individual nurse survey data must be
aggregated to the unit level (Aiken and Patrician 2000) and likewise, in this study,
the nursing unit is the unit of analysis, although the influences can be at both
individual nurse and unit level. An organizational trait is reliably measured when the
variability in evaluations between nurses in a unit is small relative to the variability
in the average evaluations across the units (Aiken and Patrician 2000). Bivariate
analyses were conducted in the pilot study to compare responders and non
138
responders on such demographic variables as sex, nursing role, and work area; and to
compare those who completed the study with those lost to follow up due to attrition
or opting not to respond.
Since this was a non-randomised controlled trial, bivariate analyses were conducted
in the main study to establish representativeness of the eligible study sample to the
eligible hospital population, as well as to establish baseline similarity between the
intervention group and the control group, on categorical (that is, sex, initial nursing
education, nursing level, years post registration nursing experience, primary role,
team relationship, employment status, and work area) and continuous (that is, age)
demographic variables; and on the five continuous outcome variables (that is,
perceptions of BARRIERS, SKILLS, EMPOWERMENT, AUTONOMY and TEAM).
Categorical variables were summarised as frequency counts and percentages;
normally distributed continuous variables were summarised as means (standard
deviations) and non normally distributed continuous variables were summarised as
medians (minimum and maximum). Chi square tests were used to summarise and
describe associations between demographic data and outcome variables. Statistics
were computed and quantitative and qualitative assessment of differences will be
discussed in Chapter 5.
4.11.2.2. Confounding variables
As this study was non-randomised, there was potential for confounding variables to
have an effect on the association between the intervention and the outcome variables.
Confounding is the mixing of effects and it occurs when the nuisance variable is
independently correlated to the independent variable, the Practice Development
intervention, and the dependent or outcome variables. No confounding variables
were identified in the available literature on evaluation of Nursing/Practice
Development Units and/or programmes. However, Walsh and Walsh (1998) suggest
that team climate may have a relationship to readiness to engage in developing
practice. In addition, group differences identified in bivariate analyses were
considered and explored for confounding.
139
4.11.2.3. Effect Modification
The potentially confounding variables above have, by definition, the potential to be
effect modifying. Effect modification occurs when the relationship (that is, effect) is
different in one subgroup compared to another. The main research question asks if
engagement with Practice Development has an effect on perceptions of the culture
and context of care. Perceptions of the culture and context of care are imbedded in
the subculture of the unit or team. Thus, the unit has the potential to strengthen the
effect of the Practice Development intervention in one unit than another. Therefore,
testing for both confounding and effect modification was conducted for descriptive
variables identified in bivariate analysis.
4.11.2.4. Multivariate Analysis
Multivariate statistics are appropriate for revealing complex interrelationships among
several variables and are designed to avoid inflated error rates that can occur when
each dependent variable is analysed separately, particularly when they are correlated
with each other (Tabachnick and Fidell 2007). In addition, multivariate statistics
also match the multivariate design of repeated measures in longitudinal studies.
Generalized estimating equations (GEE) modelling, introduced by Liang and Zeger
(1986), was used to formally consider all hypotheses regarding the independent
variables and controlling for other variables in the model (Miller 2005).
GEE was used to estimate change in mean perceptions of the culture and context of
care (that is, BARRIERS, SKILLS, EMPOWERMENT, AUTONOMY, and TEAM)
GEE does not depend on the assumptions of independence of data or normally
distributed data, and are not limited by incomplete data sets (Miller 2005). Typically,
in longitudinal study designs whereby measurements are repeatedly taken on the
same subject, correlation between repeated measurements for one individual is
expected. The same is expected in clustered or multilevel study designs whereby
correlations are expected for individuals belonging to the same cluster. For example,
perceptions of the practice environment of nurses working on a unit would be
expected to correlate with other nurses working on the same unit.
140
Conventional statistical methods that assume independence of observations are, thus,
inadequate for analysing longitudinal responses with repeated measurements and
multilevel data (Li, Maddalozzo, Harmer, et al 1998; Ghisletta and Spini 2004). GEE
modelling, an extension of generalized linear models (Liang and Zeger 1986;
Ghisletta and Spini 2004), accounts for dependence among observations. In GEE,
cases (surveys) are assumed to be dependent within subjects (nurse participant) and
independent between subjects (intervention versus control group) (SPSS Inc. 2008).
Another advantage of GEE models over other general linear models (GLM) for
repeated longitudinal data is that analysis is not dependent on balanced data, that is,
an individual providing responses at all measurement time points (Burton, Gurrin
and Sly 1998). The model permitted change over time (main effect) to be considered
and then, with an interaction of time by group, permitted the consideration of
whether or not time had an impact on intervention. This design also permits
accounting for clustering of nurse surveys by nurse and nurses by group in estimates
of precision and takes into account potential confounders and/or effect modifiers..
4.11.3 Significance Level Applied to Analyses
Statistical significance provides information about whether a relationship exists
beyond chance variation while effect size provides information about the strength of
the relationship, a more clinically significant result (Cohen, Cohen et al 2003), which
is interpreted importance with or without statistical significance.
Statistical significance was accepted at the conventional value of p < 0.05, that is the
probability that the observed result would occur less than or equal to 5% of the time
in replicated studies if the null hypothesis were true. As discussed earlier, due to the
lack of published reports on effect size or clinical significance in pre/post
implementation of a Nursing or Practice Development Unit or programme, clinical
significance for this study was accepted for each outcome if there was at least a 10%
change in nurses' perceptions of BARRIERS, SKILLS, EMPOWERMENT,
AUTONOMY or TEAM.
141
4.12 Pilot Study
4.12.1 Background
Report of pilot studies in the nursing literature are generally reports of 'mini' studies
with the same objectives and research outcomes as the planned full research study
with the purpose of answering the research questions, but on a smaller scale. The
main purpose of a pilot study is to assess the design, operational aspects and
readiness for the planned full study (Gardner, Gardner et al 2003) but under the exact
protocol of the main study. Having met these goals in the demonstration trial prior to
this study31, the main purpose of this pilot study was to assess the measurement
instrument tool and issues related to survey distribution and survey response.
The specific objectives of this pilot study were: (1) estimation of response rate from
the survey implementation plan; (2) analysis of validity of the instrument; and (3)
analysis of the reproducibility and reliability of the instrument. This section will
present the results of the pilot testing of the survey instrument and survey
implementation plan, which were both piloted among a random sample of units in
the hospital. These units were later excluded from the main study sampling frame.
The pilot study setting and target population were the same as for the main study32.
Recruitment and follow up for the pilot study was conducted over three months,
September to November in 2004. The first contact letter was mailed out early
September and the fifth contact letter with 2nd replacement questionnaire was
mailed out in late October.
The sampling frame was similar to that of the main study. From a total of 106 units
in the hospital health service district, the eligible sampling frame was determined to
be 43 units, minus the eight units selected to participate in the main study, resulting 31 A demonstration study was conducted by this researcher (as co-researcher) to test the design, operational
aspects and readiness for a full planned study prior to commencement of the pilot of this study. Recommendations were reported in an unpublished report (see Appendix 24, Volume 2, p.146) to the hospital executive and will not be reported in this document. The objectives of the pilot study described in this section are specifically in relation to the development of the measurement instrument and operational issues related to distribution and response.
32 See Section 4.7 (p.83) for a full description of study setting, population, inclusion and exclusion criteria, sample and sampling strategy.
142
in pilot sampling frame of 35 units. A stratified sample by service division of one
unit from each division (for example, Medical, Surgical, Women's and Newborn
Services, Cancer Services, Mental Health and Critical Care) was randomly selected
using a table of computer-generated random numbers. A survey questionnaire was
mailed out to all nurses working in the six units randomly selected for the pilot study
(n=143), based on a current employee list generated and supplied by the Human
Resources department, and using the same processes as planned for the main study
(Section 4.7.4, p. 87).
4.12.2 Pilot Study Results
4.12.2.1. Participant Flow and Estimation of Response Rate
From an eligible sample of 137 registered nurses, 102 surveys were returned33. An
overall response rate of 74% was achieved using the five-contact survey
implementation plan designed for this study (Figure 4.4). Of the 102 eligible
responders, 49% responded after the 2nd contact and were considered early
responders; 51% responded after the 3rd, 4th, or 5th contact and were considered late
respondents. The fifth contact produced a greater response rate than the fourth as
shown in Figure 4.5.
33 Data reflects consideration that from an eligible sample of 138 nurses, two surveys were returned incomplete
as respondents 'opted not to respond' (lost to follow up); one survey was returned incomplete as respondent was not involved in direct patient care (ineligible).
143
FIGURE 4.4 PILOT STUDY PARTICIPANT FLOW
‐Ineligible (n=1) no direct patient care (n=1)
Additional Responders after Contact 5 (2nd follow up Q; 3rd Q) n=20
Additional Responders after Contact 4 (1st follow up Q; 2nd Q) n=7
Analysis
Follow
up
Asses
sed for Eligibility
Enro
lmen
t
Employed registered nurses on pilot wards
N=143
Eligible Sample N=138
Analysed (n=104) N=102/137
74%
Lost to follow up (n=33) Did not return survey
(n=33) Note: pilot survey administered once only
Ineligible (n=5) leave (n=3) resigned (n=1) unknown location (n=1)
Responders after Contact 2 (1st Q) n=50
Contact 1 (pre notice) No responses expected
Additional Responders after Contact 3 (reminder/thank you) n=28
+Lost to follow up (n=2) opted not to respond (n=2)
144
74%
62%57%
37%
n=17
n=7n=28
n=50
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Contact 1 Contact 2 Contact 3 Contact 4 Contact 5
Contact Point
Percen
tage of E
ligible Sa
mple (n
=137)
0
20
40
60
80
100
120
Num
ber of Eligible Res
pond
ents (n
=102
)
Cumulative Percentage of Total Sample
Total Number of Returned Surveys
FIGURE 4.5 CUMULATIVE RESPONSE FOR PILOT STUDY SURVEY
4.12.2.2. Baseline Data
The pilot sample was comprised mostly of females (85/100; 85%) with a median age
of 41 years (min 23, max 64). As far as self-identified nursing role, most of the
registered nurses were working in a clinical position compared to a managerial,
education or research position. For example, 93% (96/101) were Level 1 or Level 2
clinical nurses, with only 3% (3/101) in management position and 3% (3/101) in
education or research positions. Just under half of the nurses in the pilot sample had
greater than 15 years experience (45%; 46/102); and just over half were employed
full time (53%; 53/102). As per Table 4.6, while almost two-thirds of the nurses in
the pilot sample received their initial nursing training in the hospital, almost one-
third held a Bachelor's degree or higher. Almost half the respondents indicated they
had recent formal training in research or evidence-based practice and believed they
were currently involved in practice development.
145
TABLE 4.6 NURSING, RESEARCH AND EBP EDUCATION OF PILOT SAMPLE AT BASELINE
Formal Education/Training
Pilot N=104 n (%)
Initial nursing education (n=102)
Hospital 59 (58%)
University 43 (42%)
Nursing qualifications (n=92)
Bachelor's degree 45 (49%)
Higher degree (graduate certificate/ diploma, Masters degree, PhD)
35 (38%)
Other 12 (13)
Last time attended evidence‐based practice/research training (n=98)
< 6 months ago 25 (26%)
6‐12 months ago 21 (21%)
12‐24 months ago 13 (13%)
> 2 years ago 39 (40%)
Currently involved in PD (n=98)
Yes 48 (49%)
No 18 (18%)
Don't know 32 (18%)
Because the sampling frame was an employee list generated and supplied by the
Human Resource department, there was limited demographic information on which
to compare groups as not even de-identified summary data of age and gender was
accessible. In trying to ascertain possible reasons why participants did or did not
respond, non-responders were compared to responders on the limited demographic
variables available. It is appropriate to discuss the differences between responders
and non-responders in terms of meaningful differences. When comparing responders
on sex, proportionately more males responded to the survey than females. In
comparing responders and non-responders on nursing staff positions, a lesser
proportion of registered nurses, typically more junior level nurses, returned their
survey when compared with more senior level nurses (Table 4.7).
146
TABLE 4.7 DEMOGRAPHIC CHARACTERISTICS OF RESPONDERS VERSUS NON‐RESPONDERS
Demographic Characteristics
Non‐responders 33/137 (24%)
n (%)
Responders 104/137 (76%)
n (%)
Sex
Female n=114 28 (25%) 86 (75%)
Male n=18 2 (11%) 16 (90%)
Position
Registered Nurse n=105 32/105 (31%) 73 (70%)
Clinical Nurse n=25 1/25 (4%) 24 (96%)
CNC/NUM n=5 ‐ 5 (100%)
Educator n=0 ‐ ‐
Researcher n=2 ‐ 2 (100%)
Two-thirds of male responders did not return surveys before the 3rd contact (that is,
late responder) but there was little difference among females in those returning
surveys prior to a third contact (that is, early responder) and after. Additionally,
there was similarity between early and late responders in terms of nursing position;
nearly half and half (Table 4.8).
TABLE 4.8 DEMOGRAPHIC CHARACTERISTICS OF EARLY VERSUS LATE RESPONDERS
Early Responders (n=50/104)
Late Responders (n=54/104)
Sex
Female 45/85 (52%) 40/85 (48%)
Male 5/15 (33%) 10/15 (67%)
Nursing Position
Clinical 36/73 (50%) 37/73 (50%)
Clinical Nurse 10/24 (42%) 14/24 (58%)
CNC/NUM 3 (60%) 2 (40%)
Researcher/Educator 1 (50%) 1 (50%)
147
4.12.2.3. Instrument validity
Modifications were made to the instrument following pilot testing.34 Regarding
questions related to the Barriers to Research and Evidence-based Practice scale,
prior to instrument review by experts for content validity assessment, response
choices for the Barriers subscales were changed from their original response choices
to a more recognisable 5-point Likert scale (for example, 'strongly agree' to 'strongly
disagree'), and including a sixth response of 'no opinion' that was coded as missing.
Following pilot study, however, evidence in the form of comments implied
respondents had difficulty in not only differentiating responding to an item and
responding to an item as a barrier but also in navigating through the double-negative
statements created. Therefore, response choices were changed back to those in the
original Barriers subscales. This would also allow better comparisons with
previously reported data, in which the original response choices were used. The
original response choices were amended to address the issue of the double-negative
statements and improve clarity for respondents. For example, following the
instructions 'for each item, circle the number of the response that best represents our
view', Item 1 originally read 'senior management will not allow implementation of
research findings in practice' with response choices of 'to no extent', ' to a little
extent', ' to a moderate extent', ' to a great extent', and 'no opinion'.
De Vellis (2003) points out that it is important that respondents are able to
differentiate between expressing their strength of agreement or disagreement and
expressing the strength of the attribute being measured. Thus, for clarity, the
instructions remained the same and the items remained the same but the response
choices were slightly amended to read 'this is not a barrier', 'this is a barrier to a
little extent', 'this is a barrier to a moderate extent', 'this is a barrier to a great
extent', and 'no opinion'.
Another change following the pilot study was that 'nurse managers' was changed to
'middle management' to further clarify this item as relating to nurses in charge of 34 The reader is referred to Appendix 22, Volume 2, p.122 for a complete detailed item-by item list of
modifications to all existing instruments used in the design of the study instrument, including rationale for any changes.
148
units (for example, NUMs, Clinical Nurse Consultants). Another change that
occurred after piloting the instrument was that in the Barriers subscale, the item
'nurses do not have time to read research', was changed to 'nurses do not have time
to read research at work'. This was changed in response to comments from
respondents such as '…do you mean at all or while we are at work?' Another change
is that in two items, the words 'will not allow' was changed to 'will not support' in
keeping with the discourse of the Practice Development literature regarding support
needed for practice development initiatives to be successful.
One last change in relation to the Barriers subscale was that the item 'nurses see little
benefit for themselves in changing practice' was changed back to the original item,
'nurses see little benefit for self' because the changed item was too similar in wording
to another item and to possibly identify personal impacts on nurse.
Regarding the questions relating to SKILLS, following the pilot study, item wording
and response choices were changed to obtain information on perceptions of
competence in evidence-based practice skills instead of confidence to better reflect
the focus of the barriers to research utilisation literature. Also, the item 'I feel
confident with my skills in implementing and evaluating changes in practice' was
separated into two items to clearly represent two distinct 'steps' in the evidence-
based practice process, implementation and evaluation.
Additionally, response choices were changed to reflect Patricia Benner's (Benner
1984, p.13-34) five levels of proficiency in skill acquisition, thus resulting in a 5-
point 'novice to expert' scale, and retaining the sixth option of 'no opinion'. This was
done so that the response choices reflected perceived competence in the acquisition
and development of evidence-based practice knowledge and skills as a learner passes
through the five levels of proficiency, which is reflected in three general aspects,
namely (1) movement from reliance on abstract principles to the use of past concrete
experience as paradigms, (2) change in the learner's perceptions by seeing the
situation less and less as a compilation of equally relevant components, and more
and more as a complete whole in which only certain parts are relevant, and (3)
passage from detached observation to involved performer who no longer stands
149
outside the situation but is now engaged in the situation (Benner 1984, p13-34).
These changes resulted in a 5-item SKILLS subscale for the main study.
For the section regarding EMPOWERMENT, the item 'rewards for innovation on the
job' was removed from the other items on the support subscale to be near items
related to the formal power subscale, as per the original CWEQ-II. Because where
items are located in relation to other items may affect the response they attract from
participants.
No changes were made to any items on the TEAM subscale following piloting of the
instrument. For the section regarding AUTONOMY, wording changes were made to
reflect the Australian context in response to comments from respondents on the pilot
questionnaire. For example, 'supervisor' was changed to 'nurse manager' and
'physicians' was changed to 'doctor'. The survey questionnaire was assessed for
validity during the processes of instrument development and piloting of the
instrument.
4.12.2.4. Instrument Reliability
Despite item wording changes as explained above, instrument items were assessed in
the subscales of origin in the original instruments from which they were
extrapolated. The instrument subscales of perception of BARRIERS, SKILLS,
EMPOWERMENT, AUTONOMY and TEAM demonstrated internal reliability
coefficients of 0.89, 0.87, 0.94, 0.91, and 0.97 respectively, all within acceptable
estimates of 0.70 for a new instrument (basic research) and 0.80 for an established
instrument (applied research)35. Cronbach's alpha coefficients were calculated for
each subset of items already grouped together as subscales within their original
respective instruments so that comparisons could be made with previously reported
reliability data (see Section 1.1 for a description of measurement instruments) and
ranged from 0.67 to 0.96 (Table 4.9). Cronbach's coefficient alpha was also
calculated for a global culture of inquiry scale (perceptions of AUTONOMY +
35 These parameters for acceptable internal consistency were postulated by Nunally in 1978 and have been accepted internationally as the norm since published (Nunnally 1978). The parameters were confirmed in a meta-analysis of Cronbach coefficient alphas of 1030 samples consisting of over 300,000 individuals by Peterson in 1994.
150
EMPOWERMENT + TEAM) and this scale also demonstrated acceptable internal
reliability with an alpha of 0.97 (n=60, CI = 0.96-0.98).
TABLE 4.9 INTERNAL CONSISTENCY RELIABILITY SCORES (CRONBACH'S ALPHA)
SUB SCALES
n (N=102)
α 95% CI
SUBSCALE 1: WORK EMPOWERMENT (23 items)
72 0.94 0.92‐0.96
Access to information (3 items) 88 0.88 0.83‐0.92
Access to resources (5 items) 93 0.89 0.85‐0.92
Access to support (3 items) 98 0.91 0.88‐0.94
Access to opportunity (4 items) 98 0.83 0.77‐0.88
Informal power (5 items) 89 0.81 0.74‐0.87
Formal power (3 items) 92 0.67 0.53‐0.77
SUBSCALE 2: CONTROL AND AUTONOMY (17 items) (Note: some items factor under more than one subscale)
72 0.91 0.88‐0.94
Autonomy (5 items) 88 0.75 0.65‐0.82
Control over practice environment (10 items) 77 0.88 0.83‐0.92
Relationship with doctors (2 items) 96 0.77 0.66‐0.85
Organisational support (12 items) 78 0.89 0.85‐0.92
SUBSCALE 3: TEAM COLLEGIALITY (20 items)
81 0.97 0.96‐0.98
Team vision (4 items) 81 0.94 0.91‐0.96
Participative safety (6 items) 93 0.95 0.94‐0.97
Commitment to performance excellence (5 items) 88 0.89 0.85‐0.92
Support for innovation (5 items) 90 0.95 0.93‐0.96
SUBSCALE 4: BARRIERS TO EBP (16 items)
89 0.89 0.85‐0.92
Nurse‐related barriers (8 items) 91 0.81 0.74‐0.82
Organisational‐related barriers (8 items) 96 0.84 0.79‐0.897
SUBSCALE 5: SKILLS IN EBP (4 items) 96 0.87 0.82‐0.91
151
4.13 Ethical Considerations
This study was conducted in accordance with the National Statement on Ethical
Conduct in Research Involving Humans (National Health and Medical Research
Council (NHMRC 1999). Both the University and the Hospital Human Research
Ethics Committees approved this study (see Appendix 14, Volume 2, p.95).
4.13.1 Consent and Information to Participants
During the recruitment process as described in Section 4.7.5 (p. 91), all clinical
nurses on the clinical units or teams approached by the researchers were given verbal
and written information (see Appendix 15, Volume 2, p.98) about Practice
Development and the research study either during their regular unit meetings or at
dedicated in-services arranged by the NUM. Descriptions of these information
sessions were previously discussed in Section 4.7.5 (p. 91).
Participants were advised that completing and returning the survey questionnaires
indicated that they understood the information provided and consented to participate
in the research study. Participants were advised that they could withdraw from the
study at any time and that withdrawal from the study would not jeopardise their
relationship with the hospital. Thus, individual staff team members retained the right
to choose to participate in the surveys. Each data collection questionnaire was
prefaced with the participant information in an abbreviated form. Participants were
provided with contact details of the secretariats of the human research ethics
committees at both the study facility and the researchers' tertiary institution, in the
event that participants had any complaints about any aspect of the research study, the
way in which it was conducted or any questions about their rights as research
participants.
4.13.2 Risks to Participants
This study was considered 'negligible risk' research according to the NHMRC ethical
statement (NHMRC et al 2007, p.16). Negligible risk research is research in which
the foreseeable risk to participants is no more than an inconvenience, such as
completing a questionnaire, participating in a survey or giving up time to participate
152
in research (NHRMC et al 2007, p. 16). Each unit was assessed to determine if the
registered nurses were involved in any other surveys being conducted.
4.13.3 Confidentiality
Data management was in accordance with the NHMRC guidelines on human ethics
(NHMRC, 1999; NHMRC et al 2007), and the University and Hospital Human
Research Ethics Committees. Research data were coded for identification purposes,
however any information obtained in connection with the study and that could
identify a participant remained confidential. Questionnaires were mailed directly to
participants and completed questionnaires were returned directly to the study
investigator via return envelopes self-addressed to the researcher.
Documents with names (for example, current employee lists supplied by Human
Resources Department) were maintained separately from questionnaires and only
unique identifying survey numbers and participant ID numbers, generated
specifically for this study, were entered into the database. Mailing lists, data
collection sheets and completed surveys were store separately, and will continue to
be stored, in locked cabinets for seven years after the last publication arising from
this study in the study facility's research department locked archive storage.
All computer data were, and is still, password protected and accessible only by the
researchers. After the requisite period of seven years, the researcher will be notified
and all paper data sheets will be shredded and deposited into confidential waste
receptacles and computer files will be deleted as per Hospital protocols. Any data
used in publications was and will be aggregated and anonymous. Identifiable data, if
and when required, will only be disclosed with permission of the participants, except
as required by law.
153
4.14 Conclusion
This chapter presented a detailed account of the methodology and methods used in
the Pilot Phase of the study, specifically focusing on results of survey response and
instrument validity and reliability. The survey instrument was piloted on a stratified
sample of six randomly selected units and the response rate following a 5-contact
survey implementation plan resulted in a response rate of 74%, considered high for a
mail-out survey. The instrument was found to be both a valid and reliable measure of
the constructs that comprise a 'culture of inquiry'. In light of respectable validity,
reliability and response rate, the survey was deemed appropriate, with minimal
changes, for distribution in the main study as per final protocol. The next chapter
will present a detailed account of the results from the analysis of data collected.
154
CHAPTER 5. STUDY RESULTS
5.1 Introduction
The purpose of this chapter is to present study results, analyses of findings and
patterns relevant to the research questions and hypotheses. Recruitment and follow
up for the main study was conducted over fourteen months, November 2004 to
December 2005. Data were collected from the study sample at three time points:
baseline (T0), 6 months (T1) and twelve months (T2). The first data collection survey
was conducted between November and December 2004; the second data collection
survey between April and May 2005; and the final data collection survey between
November and December 2005. Due to fluctuation in the number of nurses
employed and the number of nurses returning useable surveys across data collection
time points, response rates and study attrition rates differed over time.
5.1.1 Response Rate
From the sample nurses employed in the eight study units at baseline, 165/226
nurses returned useable surveys, resulting in a response rate of 73%. In addition,
174/241 (72%) nurses and 150/225 (67%) nurses returned surveys at 6 months and
twelve months, respectively. When explored by group, there was a trend for a lower
response rate by the control group. However, the overall response rate over the
twelve-month data collection period averaged 71%.
5.1.2 Study Attrition
A total of 265 nurses completed 489 surveys. Study attrition was defined by the
number of nurses who left the study during an identified period of time divided by
the number of nurses participating in the study at the end of that identified period of
time, expressed as a percentage. Seventy-two participants were employed on their
respective units at all of the three data collection periods and completed three
surveys; an overall study attrition rate of 28% over the twelve month study period.
However, the attrition rate was slightly greater from baseline to six months (34%)
and from six months to twelve months (31%).
155
FIGURE 5.1 MAIN STUDY PARTICIPANT FLOW AND ATTRITION
Eligible RNs Employed: 107
CONTROL INTERVENTION
Total Included in Analysis Nurses (51%): 134/265 [T0=73; T1=78; T2=63]
Surveys over Time (44%):
214 / 489
Total Included in Analysis Nurses (49%): 131/265 [T0=92; T1=96; T2=87]
Surveys over Time (56%):
275 / 489
Analysis
12 m
onth
s
(3rd Sur
vey)
6 mon
ths
(2nd Sur
vey)
1st Survey Respondents (68%): 73
Eligible RNs Employed: 119
1st Survey Respondents (77%): 92
Eligible RNs Employed: 125
New 2nd Survey (67%): +27
Same 1st & 2nd Survey: +69
Lost to 2nd Survey: ‐23
Eligible RNs Employed: 116
New 2nd Survey (77%): +38
Same 1st & 2nd Survey: +40
Lost to 2nd Survey: ‐33
Eligible RNs Employed: 103
New 3rd Survey (71%): +20
Same 1st & 2nd & 3rd Survey: +26
Continued 2nd & 3rd Survey: +13
Returned 1st & 3rd Survey: +4
Lost to 3rd Survey: ‐14
Eligible RNs Employed: 122
New 3rd Survey (61%): +15
Same 1st & 2nd & 3rd Survey: +49
Continued 2nd & 3rd Survey: +19
Returned 1st & 3rd Survey: +4
Lost to 3rd Survey: ‐20
156
When comparisons were made between groups, the attrition rate at six months was
lower for the intervention group (25% lost to follow up) then the control group (45%
lost to follow up) and the trend persisted at twelve months, with the intervention
group losing 29% to follow up and the control group losing 35% to follow up
(Figure 5.1). Thus, 43% (112/265) of the nurses in the study completed only one
questionnaire; 28% (73/265) completed at least two questionnaires; and 28%
(75/265) completed all three questionnaires during the study period.
5.2 Baseline data
5.2.1 Demographic Characteristics of Study Sample at Baseline
Descriptive information was derived at baseline to compare demographic
characteristics and nursing background of nurses in the intervention and control
groups. As shown in Table 5.1, in general, the groups were similar at baseline,
although there were exceptions. For instance, both groups were composed of mostly
female nurses in clinical roles, and, on average, just over a one to one ratio of full
time to part time employees. However, nurses in the intervention group were, on
average, older yet less experienced then those in the control group. For example, in
the intervention group, 46% of staff had five or less years nursing experience
compared to 37% in the same category in the control group. In contrast, the control
group consisted of approximately two-thirds of nurses with five or more years
nursing experience compared to one-half in the intervention group. The control
group also had a greater percentage (7%) of nurses working in research roles
compared to the intervention group (0%).
157
TABLE 5.1 DEMOGRAPHIC AND NURSING BACKGROUND OF STUDY SAMPLE AT BASELINE
5.2.2 Education and Training Characteristics of Study Sample at Baseline
Descriptive information, obtained at baseline, to compare education and training of
the intervention and control groups is presented in Table 5.2. By and large, a greater
percentage of nurses in the intervention group obtained their first nursing
qualification through the university system compared to nurses in the control group;
69% and 62%, respectively. This trend of university education begins to even out
post initial nursing qualification as almost 85% of the nurses in each group reported
completing a university degree, with a higher percentage of nurses in the control
group completing postgraduate level qualifications.
Demographic Characteristics
Control (n=73)
Intervention (n=92)
Age (years) n 44 41
Median (min, max) 33 (22‐50) 35 (22‐62)
Mean (SD) 34 (7.91) 38 (11.35)
Sex Female n (%) 66/73 (90) 78/92 (85)
Years nursing experience n (%)
Less than 2 years 9/72 (13) 23/91 (25)
2‐5 years 17/72 (24) 19/91 (21)
6‐10 years 20/72 (28) 26/91 (29)
11‐15 years 10/72 (14) 7/91 (8)
Greater than 15 years 16/72 (22) 16/91 (18)
Current role n (%)
Clinical (RN, CN) 62/72 (86) 87/91 (96)
Management (NUM, CNC, MN) 4/72 (6) 3/91 (3)
Education 0 1/91 (1)
Research 5/72 (7) 0
Other 1/72 (1) 0
Employment status n (%)
Full time 36/71 (51) 51/91 (56)
158
Approximately two-thirds of the nurses in the intervention group had recent formal
research or evidence-based practice training in the past twelve months, compared to
just under two-fifths in the control group. Twice as many nurses in the intervention
group than the control group considered themselves to be currently involved in
practice development. This was expected as the units in the experimental arm of the
trial had extensive access to knowledge from the research team about Practice
Development and participation in the study. Conversely, nurses in the control units
were notified of their involvement in the study through their NUM; reflected in
almost half of those nurses not knowing whether they were involved in Practice
Development.
TABLE 5.2 NURSING, RESEARCH AND EBP EDUCATION AND/OR TRAINING
Formal Education/Training
Control (n=73)
Intervention (n=92)
Initial nursing education n (%)
Hospital trained 27/72 (38) 28/91 (31)
University trained 45/72 (62) 63/91 (69)
Highest nursing qualification n (%)
Hospital certificate/diploma 9/71 (13) 14/96 (15)
Bachelor's degree (undergraduate) 52/71 (73) 68/96 (75)
Higher degree (postgraduate) 9/71 (12) 8/96 (8)
Other 1/71 (1) 1/96 (1)
Last formal EBP/research training n (%)
Never 1/69 (1) 0
Less than 6 months ago 27/69 (39) 54/84 (64)
Within past 6‐12 months 11/69 (16) 11/84 (13)
Within past 12‐24 months 8/69 (12) 10/84 (12)
More than 2 years ago 22/69 (32) 9/84 (11)
Currently involved in practice development n (%)
Yes 23/70 (33) 58/85 (68)
No 13/70 (19) 7/85 (8)
Don't know 34/70 (49) 20/85 (24)
159
5.2.3 Perceptions of the Culture and Context of Care and the Culture of Evidence-based Practice at Baseline
As presented in Table 5.3, on average, nurses’ perceptions of the culture and context
of care at baseline were similar between the two groups. For example, the difference
between the two groups’ AUTONOMY, EMPOWERMENT and TEAM scores
averaged 2%, with the intervention group generally averaging more positive scores
than the control group on AUTONOMY and EMPOWERMENT scores. One
explanation for the difference in these two scores at baseline may lay in the nature of
leadership and management in the intervention units, generally, the NUMs of the
intervention units initially committed their support to be involved in the process. On
the other hand, the control group generally averaging higher scores on SKILLS and
TEAM scores. One explanation for this difference in the SKILLS score may be the
higher percentage of research nurses in the control group, as it would be expected
that nurses working in a research capacity would have more highly developed
competence and confidence in accessing and appraising the literature, and
implementing and interpreting results.
Greater differences between the two groups were demonstrated in perceptions of
research and evidence-based practice. Although, nurses in the control group were
more positive about their skills in research and evidence-based practice, their higher
mean BARRIERS score36 indicated they perceived there to be more barriers to
research and evidence-based practice than the intervention group nurses.
36 Each BARRIERS item score was marked on a 5 point scale ranging from 1= 'this is not a barrier' to 4 = 'this is
a barrier to a great extent' (with 5= 'no opinion'). Thus, a higher score represents a greater perception of barriers.
160
TABLE 5.3 BASELINE DESCRIPTIVE STATISTICS FOR NURSES’ PERCEPTIONS OF THE CULTURE AND CONTEXT OF CARE BY GROUP
5.3 The Culture and Context of Care
5.3.1 Relationship between Attributes of the Culture and Context of Care
Relationships depicted in scatter plots as discussed in Section 4.11.1.3 (p.133) were
confirmed by bivariate correlations analysis, as presented in Table 5.4, using
Spearman rho correlation coefficient, a non-parametric test statistic. Correlation
analyses, usually based on paired data, identify and describe relationships between
variables. Two variables are considered to be correlated when a change in one is
likely to be accompanied by a change in the other. Spearman's rank-order
correlation coefficient, rho (ρ), was used to assess the relationship between nurses’
perceptions of the different indicators of the culture and context of care. These
relationships are presented in Table 5.4. Assumptions of the test were met.
As hypothesised, the different outcome indicators of the culture and context of care,
nurses’ perceptions of AUTONOMY, EMPOWERMENT and TEAM, were all
moderately to highly positively correlated with each other in both the intervention
group and the control group, with Spearman’s rho coefficients greater than 0.4 (p<
.05). Visual inspection of the patterns of correlation indicated that associations were
generally higher for the intervention group than for the control group. It is plausible
Control (N=73) Intervention (N=92)
PERCEPTIONS (range)
MEAN (SD) 95% CI MEAN (SD) 95% CI Absolute Difference (95% CI)
% Diff.*
BARRIERS (2‐8)
4.98 (.93) 4.75‐5.21 4.67 (1.01) 4.45‐4.89 .31 (‐.54 to .65)
6%
SKILLS (1‐5)
2.63 (.99) 2.40‐2.87 2.43 (.88) 2.24‐2.63 .20 (‐.54 to .63)
8%
AUTONOMY (4‐20)
13.64 (1.91) 13.17‐14.11 14.07 (2.21) 13.59‐14.54 .43 (‐.24 to 1.30)
3%
EMPOWERMENT (6‐30)
21.57 (4.2) 20.57‐22.58 22.12 (3.76) 21.28‐22.96 .55 (‐.15 to 1.25)
3%
TEAM (4‐20)
14.10 (2.27) 13.56‐14.65 14.07 (2.58) 13.50‐14.64 .03 (‐.77 to 2.01)
<1%
* % Diff. = difference in score between intervention relevant to control
161
that the higher correlation for nurses in the intervention was due to sampling error
given the non randomised nature of group allocation.
5.3.2 Relationship between Skills in Evidence-based Practice and Barriers to Evidence-based Practice
As shown in Table 5.4, there was only a very weak correlation between perception of
SKILLS in evidence-based practice and perception of BARRIERS to research and
evidence-based practice, in both the intervention group and the control group, with
Spearman’s rho coefficients of .03 and .14, respectively. The difference between the
two groups was in the direction of the correlation, negative in the intervention group
and positive in the control group.
5.3.3 Relationship between the Culture and Context of Care and Research and Evidence-based Practice
Correlation analysis revealed that nurses’ perceptions of AUTONOMY,
EMPOWERMENT, and TEAM were all moderately and inversely correlated with
their perceptions of BARRIERS. In general, perceptions of SKILLS did not correlate
with any of the other outcome indicators except AUTONOMY, and then only in the
intervention group. As shown in Table 5.4, for example, correlation coefficients for
SKILLS with the other attributes were all under .20, except in the case of the
intervention group, where the correlation between SKILLS and AUTONOMY was
positively yet weakly correlated (ρ = .29, p = .01).
It was important to establish whether a relationship existed between the attributes of
the culture and context of care and these findings support the acceptance of H1 in
most instances. The only exception was related to SKILLS in research and evidence-
based practice. This finding is worth exploring in future because the research
literature has consistently identified perception of skills in research and evidence-
based practice as one of the top ten barriers to research utilisation. As such, it would
be expected that SKILLS and BARRIERS would be inversely related, which was not
demonstrated in this study.
162 TA
BLE 5.4 C
ORREL
ATI
ONS BET
WEE
N O
UTC
OME VARIA
BLE
S BY GROUPS AT BASE
LINE
INTE
RVEN
TION G
ROUP
CONTR
OL GROUP
(using Spe
arman
's Rho cor
relation coe
fficient
)
BARR
IERS
SKILLS
EM
POWER
.
AUTO
NOMY
TEAM
BARRIE
RS
Correlation Coe
fficien
t
.14
‐.34*
* ‐.38*
* ‐.2
8*
Sign
ificanc
e. (2‐tailed)
.26
.01
.00
.03
n
65
63
61
61
SKILLS
Correlation Coe
fficien
t ‐.0
3
.13
.17
‐.01
Sign
ificanc
e (2‐tailed)
.80
.30
.19
.91
n 7
8
67
64
66
EMPOW
ER.
Correlation Coe
fficien
t ‐.3
6**
.06
.56*
* .48*
*
Sign
ificanc
e (2‐tailed)
.00
.60
.00
.00
n 75
78
64
65
AUTO
NOMY
Correlation Coe
fficien
t ‐.36*
* .29*
* .63*
*
.5
3**
Sign
ificanc
e (2‐tailed)
.00
.01
.00
.00
n 82
81
78
62
TEAM
Correlation Coe
fficien
t ‐.33
**
.16
.65*
* .72
**
Sign
ificanc
e (2‐tailed)
.00
.16
.00
.00
n 77
76
73
78
*Correlation signific
ant a
t the 0.05 level (2‐taile
d). **Correlation signific
ant a
t the 0.01 level (2‐tailed).
163
5.4 Practice Development and Change in the Culture and Context of Care
The assumptions for univariate, bivariate and multivariate analyses were met.
Outcome indicator variables, that is, perceptions of the culture and context of care,
were modelled separately. As presented in Table 5.5, absolute percentage change in
nurses' perceptions of the culture and context of care over time (surveys) and
between groups (PD versus non PD) is evident, ranging from 8% to less than 1%.
The exception to this is that there was no change in perception of SKILLS for the
intervention group between baseline and six months (mean difference (SD) =.00
(.72); 95% CI = -.1.49 to .58).
Generally, perception scores for AUTONOMY, EMPOWERMENT and TEAM
increased from baseline to six months in both the nurses engaging with the Practice
Development model for practice review and change and those nurses maintaining
routine processes for practice review and change with, a greater change over time in
the intervention group (average 3%) compared to the control group (average 2%).
Similarly, for both groups the perceptions of BARRIERS decreased, indicating that
both groups perceived there to be less barriers to research and evidence-based
practice at six months. When assessing differences in perceptions from baseline to
twelve months, similar to the previous trend, average change scores for the nurses
involved with Practice Development were higher (4%) than those in the non Practice
Development group (2%).
As presented in Table 5.6, GEE modelling demonstrated that even when
demographic and background characteristics, such as age and qualification were
accounted for, change in perception of BARRIERS for nurses engaged in a Practice
Development methodology for practice review and change, over time, was not
statistically significant at 12 months. Furthermore, according to the level of clinical
significance set at the start of the study, although change in perceptions is obvious,
clinical significance of the change could not be established. This pattern of statistical
significance was repeated in separate GEE models for perceptions AUTONOMY
(Wald χ2 = 1.27 (df 1); p = .26), EMPOWERMENT (Wald χ2 = .03 (df 1); p = .86)
and TEAM (Wald χ2 = .00 (df 1); p = .96).
164
TABLE 5.5 MEANS AND STANDARD DEVIATIONS OF CHANGE DIFFERENCES IN THE PERCEPTIONS OF THE CULTURE AND CONTEXT OF CARE ACROSS TIME AND BY GROUP
Perceptions Control Intervention
Time
Mean (SD) Clinical effect (95% CI)
Mean (SD) Clinical effect (95% CI)
BARRIERS T0 4.98 (.93) ‐ 4.67 (1.01) ‐
T1 4.64 (1.40) ‐ 4.46 (1.18) ‐
T2 4.70 (1.32) ‐ 4.31 (1.28) ‐
∆ 0‐6 mths ∆T0‐T1 ‐.34 (1.50) ‐.91 to .63 [7% ] ‐.21 (.97) ‐.43 to .39 [4% ]
∆ 6‐12mths ∆T1‐T2 .06 (.70) ‐.58 to .15 [1% ] ‐.15 (1.11) ‐.41 to .53 [3% ]
∆ 0‐12 mths ∆T0‐T2 ‐.28 (1.42) ‐1.08 to .37 [6% ] ‐.36 (1.25) ‐.49 to .57 [8% ]
SKILLS T0 2.63 (.99) ‐ 2.43 (.88) ‐
T1 2.67 (.94) ‐ 2.43 (.90) ‐
T2 2.56 (.86) ‐ 2.56 (.85) ‐
∆ 0‐6 mths ∆T0‐T1 .04 (.64) ‐.44 to .22 [2% ] .00 (.72) ‐1.49 to .58 [no ∆]
∆ 6‐12 mths ∆T1‐T2 ‐.11 (.73) ‐.25 to .50 [4% ] .13 (.58) ‐.94 to .44 [5% ]
∆ 0‐12 mths ∆T0‐T2 ‐.07 (.83) ‐.41 to .44 [3% ] .13 (.81) ‐1.39 to ‐.01 [5% ]
AUTONOMY T0 13.64 (1.91) ‐ 14.07 (2.21) ‐
T1 14.21 (1.9) ‐ 14.54 (2.23) ‐
T2 14.15 (2.02) ‐ 14.38 (2.11) ‐
∆ 0‐6 mths ∆T0‐T1 .57 (.91) ‐.10 to .37 [4% ] .47 (2.45) ‐1.49 to .58 [3% ]
∆ 6‐12 mths ∆T1‐T2 ‐.06 (1.40) ‐.52 to .92 [< 1% ] ‐.16 (.64) ‐.94 to .44 [1% ]
∆ 0‐12 mths ∆T0‐T2 .51 (1.26) ‐.54 to .75 [4% ] .31 (1.63) ‐1.52 to .33 [2% ]
EMPOWER. T0 21.57 (4.2) ‐ 22.12 (3.76) ‐
T1 22.15 (4.21) ‐ 22.65 (3.95) ‐
T2 21.66 (4.03) ‐ 21.22 (4.30) ‐
∆ 0‐6 mths ∆T0‐T1 .58 (2.54) ‐.48 to 2.13 [3% ] .53 (3.99) ‐2.99 to .38 [2% ]
∆ 6‐12 mths ∆T1‐T2 ‐.49 (3.04) ‐.1.8 to 1.33 [2% ] ‐1.43 (1.61) .22 to 1.87 [6% ]
∆ 0‐12 mth ∆T0‐T2 .09 (3.24) ‐.1.07 to 2.26 [< 1% ] ‐.90 (3.47) ‐1.72 to 1.21 [4% ]
TEAM T0 14.10 (2.27) ‐ 14.07 (2.58) ‐
T1 14.15 (2.41) ‐ 14.77 (1.96) ‐
T2 14.20 (2.45) ‐ 14.12 (2.34) ‐
∆ 0‐6 mths ∆T0‐T1 .05 (1.37) ‐.47 to .94 [< 1% ] .70 (2.12) ‐2.0 to ‐.21 [5% ]
∆ 6‐12 mths ∆T1‐T2 .05 (1.90) ‐1.08 to .86 [< 1% ] ‐.65 (.96) ‐.11 to .92 [4% ]
∆ 0‐12 mths ∆T0‐T2 .10 (2.02) ‐.41 to .44 [1% ] .05 (2.19) ‐1.52 to .33 [< 1% ]
Note: This table emphasises the estimated effect and its 95% confidence interval, which are more clinically meaningful than P values; ∆=change
165
TABLE 5.6 P
ARAMET
ER EST
IMATE
S AND EST
IMATE
D STA
NDARD ERRORS FO
R PER
CEP
TION O
F BARRIE
RS
WIT
H U
NST
RUCTU
RED
CORREL
ATI
ON M
ATR
IX (G
EE M
ODEL)
Param
eter
Estimate ( β
) Em
pirica
l (SE
) Lo
wer 95% CI
Upp
er 95%
CI
Wald χ
2 (df
) p
Intercep
t 4.583
.10
4.39
4.78
2.193.58 (1)
.00*
Non PD (c
ontrol)
.20
.15
‐.09
.48
1.85 (1)
.17
Intercep
t 6.24
.29
5.67
6.80
465.54 (1)
.00*
Non PD (c
ontrol)
.11
.18
‐.24
.46
.38
.54
Qua
lifica
tion
Hos
pital q
ualifica
tion
(0.00)
‐1.11
.41
‐1.92
‐.31
7.36
.01
Ba
chelor's de
gree
‐1.2
.29
‐1.80
‐.67
18.30
.00
Grad/ Postgrad. Certificate
‐.883
.41
‐1.70
‐.08
4.59
.03
Grad/ Postgrad. D
iploma
‐.20
.38
‐.94
.55
.26
.61
Master's deg
ree
‐.45
.38
‐1.20
.31
1.36
.243
Age Ran
ge
Gen X (1.00)
‐.90
.29
‐1.47
‐.33
9.63
.00
Gen Y
‐.53
.15
‐.82
‐.24
12.60
.00
Ba
by Boo
mer
‐.25
.23
‐.71
.20
1.21
.27
Ove
rall Tes
t Res
ults ‐ ‐W
ald χ
2 = .38 (d
f1); p=.54
Notes: S
E = stan
dard error; ^
Wald χ
2 with Bon
ferron
i Correction; *p<
.01, N
S p> or = .05
166
5.5 Additional Analyses
5.5.1 Representativeness of Study Sample to Hospital Population
Descriptive information was derived at baseline to compare demographic and
background data of the hospital population and the study sample and is presented in
Table 5.7 and Table 5.8. The two groups were generally found to be similarly
matched on most characteristics, although some differences were noted, as shown in
Table 5.7. Nurses in the study sample, as a group, were similar to nurses in the
hospital population for age, sex, education, nursing experience, nurse position and
employment status. For example, the composition of both cohorts included mostly
female nurses, with a median age of 34, working full time in a clinical role. The
exception to this was that nurses in the study sample were, in general, less
experienced as a group than those in the hospital population; with 42% of the study
sample having five or less years experience compared to 31% of the hospital
population cohort.
As presented in Table 5.8, a greater percentage of nurses in the study sample (66%)
compared to the hospital population (57%) were initially university trained;
however, post initial training, the difference in tertiary training begins to become
more similar. For example, 80% of nurses in the hospital cohort have tertiary
qualifications compared to 85% of nurses in the study sample; albeit, the percentage
of nurses in the hospital population with post graduate qualifications was double the
percentage of study sample nurses in the same category. Similarly, a greater
percentage of nurses in the study sample indicated more recent formal evidence-
based practice or research training compared to the hospital population, 53% versus
43%, respectively.
5.5.2 Stability of Study Cohort over Time
Descriptive information was also captured to compare demographic and background
data of the study cohort at baseline, six months and twelve months in order to
establish stability of unit characteristics as based on characteristics of the staff.
167
TABLE 5.7 C
OMPARISON O
F DEM
OGRAPH
IC CHARACTE
RISTI
CS AND N
URSING BACKGROUND O
F ACUTE CARE NURSE
S
Dem
ograph
ic In
form
ation
Pop
ulation
(N=6
02)
Stud
y
Sample
(N=165
)
Con
trol
(n=7
3)
In
terven
tion
(n=9
2)
Sample
Bas
elin
e n=
165
Sample
6 mon
ths
n=174
Sample
12 m
onth
s n=150
Age
Age n
575
92
44
41
92
116
139
Med
ian (m
in, m
ax)
34 (2
1, 65
) 34 (2
2, 62)
33 (2
2‐50
) 35 (2
2‐62
) 34 (2
2, 62)
33 (2
1‐63
) 33 (2
1‐62
)
Mea
n (S
D)
37 (10.37)
36 (10.00
) 34 (7
.91)
38 (1
1.35)
36 (10.00
) 35 (10.11)
35 (10.16)
Sex
Female n (%
) 50
9/60
2 (85)
144/165 (87)
66/73 (90)
78/92 (85)
144/165 (87)
151/174 (87)
125/145 (86)
Years nursing experience
n (%)
Less th
an 2 yea
rs
73/597 (12)
32/163 (2
0)
9/72 (1
3)
23/91 (
25)
32/163 (2
0)
34/171 (2
0)
41/145 (2
8)
2‐5 ye
ars
114/597 (19)
36/163 (2
2)
17/72 (24)
19/91 (
21)
36/163 (2
2)
37/171 (2
2)
32/145 (2
2)
6‐10 yea
rs
149/59
7 (25)
46/163 (2
9)
20/72 (28)
26/91 (
29)
46/163 (2
9)
53/171 (3
1)
34/145 (2
3)
11‐15 ye
ars
85/597 (14)
17/163 (10)
10/72 (14)
7/91 (8
) 17/163 (10)
17/171 (18)
13/145 (9
)
Greater th
an 15 yea
rs
176/59
7 (30)
32/163 (2
0)
16/72 (22)
16/91 (
18)
32/163 (2
0)
30/171 (18)
25/145 (17)
Current role n (%)
Clinica
l 56
0/60
0 (93)
149/163 (91)
62/72 (86)
87/91 (
96)
149/163 (91)
165/174 (95)
136/145 (94)
Man
agem
ent
19/600 (3
) 7/163 (4)
4/72 (6
) 3/91 (3
) 7/163 (4)
4/174 (2)
6/145 (4)
Educ
ation
4/60
0 (1)
1/163 (1)
0
1/91 (1
) 1/163 (1)
1/174 (1)
1/145 (1)
Res
earch
13/600 (2
) 5/163 (3)
5/72 (7
) 0
5/163 (3)
3/174 (2)
2/145 (1)
Oth
er
4/60
0 (1)
1/163 (1)
1/72 (1
) 0
1/163 (1)
0 0
Wor
k stat
us
n (%
) Fu
ll time
323/60
0 (54)
87/162 (5
4)
36/71 (
51)
51/91 (
56)
87/162 (5
4)
92/173 (5
3)
80/146 (5
6)
168
TABLE 5.8 C
OMPARISON O
F NURSING, R
ESEA
RCH AND EBP
EDUCATI
ON O
F ACUTE CARE NURSE
S AT BASE
LINE
Dem
ograph
ic In
form
ation
Pop
ulation
(N=6
02)
Stud
y
Sample
(N=165
)
Con
trol
(n=7
3)
In
terven
tion
(n=9
2)
Sample
Bas
elin
e n=
165
Sample
6 mon
ths
n=174
Sample
12 m
onth
s n=150
Initial
Nur
sing
Educ
ation
Hos
pital T
rained
255/59
9 (43)
55/159 (3
4)
27/72 (38)
28/91 (31)
55/159 (3
4)
54/172 (3
1)
48/145 (3
3)
Unive
rsity Tr
ained
344/59
9 (57)
108/159 (66)
45/72 (62)
63/91 (69
) 108/159 (66)
118/172 (6
9)
971/145 (67)
La
st For
mal
EBP/
Res
earch
Training
Nev
er
0 0/153 (1)
1/69 (1)
0 0/153 (1)
29/173 (17)
25/145 (17)
Less th
an 6 m
onth
s ag
o 252/58
7 (43)
81/153 (5
3)
27/69 (39)
54/84 (64)
81/153 (5
3)
70/173 (4
0)
59/145 (4
1)
Within pa
st 6‐12 mon
ths
109/58
7 (19)
22/153 (14)
11/69 (16)
11/84 (13)
22/153 (14)
32/173 (18)
27/145 (19)
Within pa
st 12‐24 mon
ths
81/587 (14)
18/153 (12)
8/69 (12)
10/84 (12)
18/153 (12)
16/173 (9
) 15/145 (10)
Mor
e th
an 2 yea
rs ago
145/58
7 (25)
31/153 (2
0)
22/69 (32)
9/84 (11)
31/153 (2
0)
26/173 (15)
19/145 (13)
Highe
st
Nur
sing
Qualifica
tion
Hos
pital
116/588 (2
0)
23/162 (14)
9/71 (13)
14/96 (15)
23/162 (14)
22/167 (13)
17/145 (12)
Bac
helor’s de
gree
339/58
8 (58)
120/162 (74)
52/71 (73)
68/96 (75)
120/162 (74)
126/167 (75)
111/145 (7
7)
Highe
r de
gree
139/58
8 (22)
17/162 (11)
9/71 (12)
8/96 (8
) 17/162 (11)
19/167 (11)
15/145 (10)
Oth
er
3/58
8 (1)
2/162 (1)
1/71 (1)
1/96 (1)
2/162 (1)
0 2/145 (1)
Cur
rent
ly
Invo
lved in
PD
Yes
244/59
1 (41)
81/155 (5
2)
23/70 (33)
58/85 (68)
81/155 (5
2)
98/170 (5
8)
88/141 (6
2)
No
119/591 (2
0)
20/155 (13)
13/70 (19)
7/85 (8
) 20
/155 (13)
21/170 (12)
11/141 (8)
Don
’t Kno
w
228/59
1 (39
) 54
/155 (3
5)
34/70 (49)
20/85 (24)
54/155 (3
5)
51/170 (3
0)
42/148 (2
8)
169
The study cohort was similar over time for age and sex; education and nursing
experience; and nursing role and employment status; and RN to EN ratio, as
presented in Table 5.7 and Table 5.8.
Comparison of perceptions of the culture and context of care of the study sample and
the hospital population are presented in Table 5.9. By and large, mean perception
scores for the hospital population and the study sample were similar, with the
exception of perceptions of EMPOWERMENT. For instance, absolute differences
between the two cohorts on most perceptions averaged 1%, while the absolute
difference between the two groups on EMPOWERMENT scores was 14%.
TABLE 5.9 COMPARISON OF NURSES' PERCEPTIONS OF CULTURE AND CONTEXT OF CARE BETWEEN HOSPITAL POPULATION AND STUDY SAMPLE
5.5.3 Characteristics of Study Units
Table 5.10 presents data on service type, size, activity and acuity, as well as staff
characteristics of the clinical units selected for the study. The study units differed on
variables that were beyond the control of the researcher, such as type of clients
serviced, bed capacity and acuity, staff age, experience and skill mix, manager
leadership style, and already established relationships with other health
professionals. Pre-implementation data were, therefore, collected at baseline on as
many variables as possible for both groups in order to identify similarities and
differences.
Nurses' Perceptions
Hospital Population (n=602)
Study Sample (n=159)
Range Mean (SD) 95% CI Mean (SD) 95% CI
BARRIERS 2‐8 4.83 (1.00) 4.75 to 4.91 4.83 (0.95) 4.66 to 4.99
SKILLS 1‐5 2.61 (0.92) 2.53 to 2.69 2.53 (0.93) 2.37 to 2.69
AUTONOMY 4‐20 13.77 (2.45) 13.56 to 13.97 13.87 (2.10) 13.50 to 14.23
EMPOWERMENT 6‐30 18.41 (3.82) 18.09 to 18.73 21.93 (3.84) 21.26 to 22.60
TEAM 4‐20 13.90 (2.87) 13.66 to 14.14 13.99 (2.47) 13.55 to 14.42
170
TABLE 5.10 C
HARACTE
RISTI
CS OF ST
UDY UNIT
S (200
4‐20
05)
Cha
racter
istics
Interven
tion U
nits
Con
trol U
nits
Unit 1
(n=2
7)
Unit 2
(n=2
2)
Unit 3
(n=18)
Unit 4
(n=2
5)
Unit 5
(n=2
2)
Unit 6
(n=2
1)
Unit 7
(n=12)
Unit 8
(n=18)
Spec
ialty se
rvice
Med
ical
Surgical
Surgical
Med
ical
Gyn
aeco
logy
Med
ical
Med
ical
Med
ical
Num
ber of bed
s (staffed
) 20
30
15
30
26
20
30
20
Sepa
ration
s (n
umbe
r pe
r ye
ar)
552
1158
1365
933
2150
552
1071
804
Ave
rage LOS (d
ays)
11.54
6.48
9.10
9.28
3.53
11.19
7.56
3.54
Acu
ity (h
ospital inde
x)
2.76
2.82
4.56
2.30
1.65
2.57
2.30
1.56
EN/R
N Skill m
ix (%
RN staff)
99%
92%
95%
88%
100%
85
%
89%
88%
RN m
edian ag
e in yea
rs
(minim
um, m
axim
um)
35
(21,5
9)
31.5
(21,5
7)
31
(21,6
1)
33
(21,5
4)
33.5
(22,57)
35
(22,47
) 29
(23,49
) 28
(21‐43
)
Staff initially ho
spital‐
trained n (%
) 9/23 (3
9)
5/22 (2
3)
4/18 (2
2)
8/24 (3
3)
10/22 (46)
8/21(38)
2/12(17)
7/16(44)
Staff w
ith tertiary nur
sing
qualifications n (%
) 18/27 (8
2)
19/22 (86)
16/18 (89)
21/24 (88)
19/21 (90
) 11/
15 (9
0)
11/12 (9
2)
11/15 (7
3)
>5 yea
rs nur
sing
expe
rien
ce n (%
) 17/24 (71)
11/22 (5
0)
9/18 (5
0)
9/24 (3
7.5)
15/22 (68)
16/21 (76
) 5/12 (4
2)
10/16 (62)
Employ
men
t statu
s (% FTE
) 13/24 (54)
11/22 (5
0)
8/18 (4
5)
19/24 (79)
8/21 (3
8)
11/21 (5
2)
7/12 (5
8)
10/16 (62)
Source: R
oyal Brisban
e And W
omen
's Hospital H
ealth In
form
ation Se
rvices;
RN = Reg
istered Nurse; E
N = Enrolled Nurse; L
OS = leng
th of h
ospital stay; FTE = fu
ll time eq
uivalent
171
5.6 Conclusion
In the context of this study, there was no statistically significant difference in
perceptions of the culture and context of care or in perceptions of barriers to research
and evidence-based practice over time, between clinical units involved in a 12-month
facilitated Practice Development programme and clinical units that maintained
existing processes for practice review and change. In addition, although small
differences in changes in perceptions were evident, these differences did not meet
the established threshold value to be accepted as clinically significant, that is, 10%
change, set for this study. These findings will be discussed further in the next
chapter.
172
CHAPTER 6. DISCUSSION
6.1 Introduction
There is a large and diverse body of literature on Nursing and Practice Development
spanning almost five decades - a testament to the ever-changing ambitions, tenets, aims,
structures, processes and outcomes that nursing leaders and scholars in the field have
nurtured in order to develop nurses and nursing; and, more importantly, to achieve better
patient outcomes. Although Nursing and Practice Development processes and
programmes have continually evolved in the midst of changes in society and healthcare,
key attributes of a culture of inquiry and evidence-based practice, with the potential to
sustain practice developments, persisted. This research traced the chronological and
theoretical evolution of Nursing and Practice Development and revealed, through a
critical analysis of the literature and synthesis of findings from past evaluations, key
attributes. There was, however, an identified gap in the literature regarding effectiveness
of Practice Development as a methodology for achieving change in the culture and
context of care.
An assumption, supported in the literature, is held that nursing engagement in the
research and evidence-based practice agenda leads to increased effectiveness in patient
care outcomes. Therefore, it was important to establish first whether attributes of the
culture and context of care were related to perceptions of engagement with research and
evidence-based practice and second whether a Practice Development intervention was
effective in changing those attributes.
This study explored the historical and philosophical development of Practice
Development and investigated the effectiveness of using Practice Development
processes and methodology for achieving change in the culture and context of care, with
the aim of specifically changing nurses' perceptions of barriers to research and evidence-
based practice. Thus, this study is significant to improving patient care outcomes as well
173
as advancing the discipline of nursing through increasing nurses' engagement in research
utilisation in practice.
What this study has found is that attributes of the culture and context of care are related
to nurses' perceptions of barriers to research and evidence-based practice. However, the
findings did not provide evidence of effectiveness of using Practice Development as a
process-model for changing the culture and context of care, specifically in relation to
nurses' perceptions of barriers to research and evidence-based practice. This chapter will
explore the study findings and their implication for developing nursing practice.
6.2 Perceptions of the Culture and Context of Care
Hypothesis 1 (H1) posits that there is a relationship between perceptions of the identified
attributes of an effective culture and context of care (as defined by autonomy and
control, workplace empowerment, constructive team dynamics) and perceptions of
engagement with research and evidence-based practice (as defined by barriers to
research and evidence-based practice). This study found perceptions of autonomy and
control, workplace empowerment and constructive team dynamics are positively and
moderately to highly correlated with each other.
6.2.1 Perceptions of Autonomy and Control in the Practice Environment
Over time, the notion of nursing autonomy and control in the practice environment has
been investigated by several researchers in a variety of practice climates (Holl 1996;
Ballou 1998; Wade 1999; Finn 2001; Kramer and Schmalenberg 2003a; Kramer and
Schmalenberg 2003b; Laschinger, Almost, and Tuer-Hodes 2003; Mrayyan 2004).
Moreover, autonomy and control over decision-making in the practice environment has
been a steadfast attribute in the history of Nursing and Practice Development. For
example, at the nurse-led, inpatient Loeb Center, Lydia Hall emphasised autonomous
functioning and contribution of the professional nurse to patient outcomes (Marriner-
Tomey 2006) and stressed the need for valuing and engendering the therapeutic nature
of nursing rather than the bureaucratic-dominated, task-oriented model of care (Pontin
174
1999). Pearson carried this theme through in the first nursing-led units in the UK, where
he encouraged nurses to challenge their assumptions about nursing (Johns 1991).
The King's Fund Centre NDUs supported a climate where "each person's contribution
[was] valued and an opening, questioning, supportive approach [was] fostered" (1989, p.
2, cited in Turner-Shaw and Bosanquet 1993). Turner-Shaw and Bosanquet (1993), in
their evaluation of the early King's Fund Centre NDUs, concluded that NDUs should be
free from organisational constraints. They also concluded that nurses in NDUs needed
the freedom to control their own work; that the NDU leaders must have control of the
NDU budget and dedicated time for development work, including support for flexible
rostering (Turner-Shaw and Bosanquet 1993). Similarly, following the evaluation of the
Leed's NDU programme, Gerrish (Gerrish, Clayton et al 1999) recommended that
NDUs should have an identified leader with authority for practice in the unit and
successful NDUs enabled clinicians to not only develop their full potential but also
function autonomously.
With the Practice Development ideology promoted by the Manley/McCormack/ Garbett
School of thought, came the desire to situate Practice Development methodology within
a critical social science framework. Critical social science is interested in the idea of
"collective autonomy" whereby a group, after considered and rationale reflection,
determines the policies and practices it will follow and acts in accordance with them
(Fay 1987).
Degree of autonomy, authority, control over practice and participative decision-making
can be connected to an organisational culture that supports nurses to be collaborative
partners in the delivery of efficient, effective, patient-centred healthcare services.
Moreover, organisational support for change has been highlighted as an important
component for the establishment and 'success' of Nursing and Practice Development
Units. This includes management support and infrastructure to support change.
175
Lack of organisational support has been identified repeatedly in the literature as one of
the most-cited barriers to engagement with research and evidence-based practice. NDUs
were reported as thriving best within a supportive organisation (Turner-Shaw and
Bosanquet 1993). In a subsequent King's Fund Centre NDU evaluation, Pearson found
the most-cited barriers to NDU establishment were the availability of resources and
funding and lack of support from managers and senior nurses (Pearson 1997). This was
supported in an evaluation of the Leed's NDU programme, whereby Gerrish (Gerrish,
Clayton et al 1999) concluded that major factors that influenced 'success' of the Practice
Development Units were autonomous functioning, financial resources and the nature of
support from managers, medical staff and educational institutions. Kitson and Currie
(1996) recommended the need for more supervision, preparation, training and
infrastructure support for nurses engaged in practice development work and a shift in the
organisational culture toward practice development as a core activity.
In addition to management support, support from other health professionals, particularly
the dominant medical hierarchy, has also been recommended as a critical component in
a professional nurse practice environment and lack of support from other health
professionals has been identified as a key organisational barrier to engagement with
evidence-based practice. The demise of many early NDUs has been linked to lack of
cooperation and support from medical colleagues (Malby 1996) and lack of involving
other health professionals as stakeholders during the planning phases of establishing
NDUs (Wright 1998; Gerrish, Clayton et al., 1999; Gerrish 2001). The main aim of the
Institute of Leeds Practice Development Units (PDUs) was to bring all clinical
professions together to achieve collaborative, patient-focused goals through
collaborative practice. Collaborative nurse-doctor relationships are associated with
doctors that facilitate exchange of important clinical information (Aiken and Sloane
1997).
In the Magnet Hospital research literature, there are suggestions that an environment
that supports nursing excellence is a key factor not only in attracting and retaining
highly qualified nurses, but also in promoting positive patient care outcomes (McClure,
176
Poulin et al 1983). Among the key characteristics of a model of professional nursing
practice at the 'magnet hospitals' studied is a nurse executive who is a formal member of
the highest decision-making body in the organization; nurses at the clinical interface
who have responsibility for organising care and staffing appropriate to patient needs;
administrative structures of governance that are supportive of nurses' decisions about
care; and good communication between nurses and physicians (McClure, Poulin et al
1983).
Patient, nurse and organisational outcomes are affected by the environment in which
care is delivered (Aiken and Patrician 2000). Subsequent research has highlighted other
important characteristics of a professional nursing practice environment, such as
visibility and staff support of hospital nurse leaders; autonomy and control within
clinical practice, the status of nurses within the organisation; collaboration across levels
and disciplines; and characteristics related to the organisational culture, such as
participative management, support of professional development, and workplace
empowerment (Scott, Sochalski et al 1999; Kramer and Schmalenberg 2003a; Kramer
and Schmalenberg 2003b).
The findings from this study support these views. Autonomy and decision-making are
important considerations when establishing a culture of evidence-based practice and
inquiry. This study provides empirical evidence of the moderate and inverse relationship
between nurses' perceptions of autonomy and control in the practice environment and
their perceptions of barriers to evidence-based practice.
6.2.2 Perceptions of Workplace Empowerment
Just as autonomy and control has been a persistent theme in the Nursing and Practice
Development evolution in developing a culture of inquiry, so has the notion of enabling
and empowerment. Empowerment has been a cornerstone in The Loeb Center, which
was aiming for a culture where professional nursing practice was valued for its
therapeutic contribution to patient outcomes. Lydia Hall's vision for the Loeb Center
was to develop and draw attention to the importance of the therapeutic nurse-patient
177
relationship, which would empower nurses to practice professional nursing that focused
on patient needs and empower patients to be active decision-makers in their care.
The movement of 'New Nursing' in the UK in the early 1990s focused on, among other
things, empowerment of nurses and change management (Wright 1995). The early
NDUs under the auspices of Alan Pearson and Steve Wright encouraged, supported and
enabled nurses to challenge their assumptions about nursing and empowered them to
change the way they think about nursing. This opened the way for nurse-led initiatives
and innovations in nursing practice, nursing roles and nursing models of care. Likewise,
the King's Fund Centre NDUs supported a safe climate of collegiality whereby team
members were encouraged to question practice and in which each person's input was
appreciated (The King's Fund Centre 1989, cited in Turner-Shaw and Bosanquet 1993).
In fact, the King's Fund Centre's definition of a Nursing Development Unit ended with a
strong statement about enabling nurses to develop not only professionally, but
personally as well.
It was important to not only empower nurses, but to include other disciplines and middle
managers in early planning stages to avoid dissent and discord (Turner-Shaw and
Bosanquet 1993). Gerrish (1999, 2000), in her pluralistic evaluation of the University of
Leeds NDU programme confirmed that PDUs and NDUs were mostly influenced by
those who held power at the operational level, namely nurse managers and medical
officers. Employees who feel empowered are more likely to contribute effectively to the
goals of the organisation. This theory has been tested and supported in several studies in
relation to significant organisational outcomes such as organisational commitment, job
autonomy, participation in organisation decision-making, and perceived control of
nursing practice (Wilson and Laschinger 1994; Laschinger and Havens 1996;
Laschinger, Sabiston et al 1997; Laschinger, Almost et al 2003). If the organisation is to
become a research and evidence-based practice culture, then the staff must feel
empowered in their work environment to strive to achieve that goal.
178
Following a commissioned review of nursing practice development activities in Oxford,
Kitson and colleagues (Kitson, Ahmed et. al., 1996) developed a conceptual theory upon
which an operational framework for research implementation was based. The aim of the
framework was to enable nurses to ground practice development work by first
describing practice using a systematic, evidence-based approach, then developing and
evaluating practice in order to empower nurses to change the way they practice nursing.
The concept of empowerment became indisputably linked to nursing and practice
development with the pursuit for theoretical underpinnings for Practice Development
spearheaded by Manley, McCormack and Garbett. This pursuit resulted in the
proclamation of critical social science, a theory based on enlightenment, empowerment
and emancipation, as the explanatory key to understanding and undertaking Practice
Development. Thus, the theory holds that empowerment, the ability to make goal-
directed decisions and implement actions to meet desired goals, is associated with the
ability of the group to come together, as Fay (1987) posits, as a collective autonomy; in
other words - a team.
The findings from this study also support the notion that empowerment is a key attribute
of a practice climate working involved in developing nursing practice and working
toward a culture of evidence-based inquiry. The moderate and inverse correlation
between empowerment and barriers to evidence-based practice identified in this study
provides evidence of the relationship between the two.
6.2.3 Perceptions of Constructive Team Dynamics
Related to the notions of autonomy and control, as well workplace empowerment,
teamwork and an organisational culture that supports teams has been asserted as one of
the essential components of successful nursing and practice development and change
(Black 1993; Salvage and Wright 1995; Walsh and Walsh 1998). A sense of
constructive team dynamics is evident in a group that focuses on a shared vision,
participative safety, task orientation and support for innovation (Anderson and West
1998; Kivimaki and Elovainio 1999; Bower, Campbell et al 2003). Anderson and West
179
(1998) theorised that innovations often resulted from team activities undertaken by
groups which were exemplified by these four characteristics of climate. This is relevant
to the findings of this study in that this study provides empirical evidence of the inter
relatedness of constructive team dynamics with workplace empowerment and autonomy
and control in the practice environment.
Vision is the idea of a valued outcome that represents a motivating force at work
(Anderson and West 1990) and shared vision is shared, clear and realistic vision and
objectives (Anderson and West 1998). Team work is the deliberate activity aimed at
achieving agreement of effort in the pursuit of shared vision, objectives and goals
(Zimmerman, Shortell et al 1993) and is a team's shared perceptions of organisational
policies, practices and procedures (Anderson and West 1998). At the Loeb Center,
Lydia Hall sought to draw together a team of professional nurses that shared a vision for
a primary nursing model of care and commitment to the establishment and sustainability
of a nurse-initiated, therapeutic nursing unit. Turner-Shaw and Bosanquet (1993), in the
first published evaluation of the early King's Fund Centre NDUs, found that shared
agreement by team members of the purpose, aims and objectives of the unit was
necessary for Nursing Development Units to flourish.
The concept of reflecting on the current status of the professional practice environment
and development of shared philosophies and models of care to guide practice in the
environment were implicit in the work of the early Burford, Oxford and Tameside
NDUs as well as the King's Fund Centre NDUs. However, the concept became more
formalised with the introduction of published NDU criteria by the Centre for the
Development of Nursing Policy and Practice at the University of Leeds that explicitly
mandated that NDUs and PDUs had to make evident a recognised conceptual and
operational framework for organising and developing best practice in the unit.
The concept of shared values became more entrenched in the language of nursing and
practice development with the evolution toward the acceptance of Manley, McCormack
and Garbett's promotion of critical social science as the theoretical underpinning to
180
understand and engage in Practice Development work. With its critical social science
premise of a collective autonomy being necessary for change, identification of a mutual
set of shared values and beliefs is necessary for a group or team to develop and advance
- a notion that continued to be supported in the establishment of Clinical Practice
Development on the NSW Central Coast.
Participative safety is interaction between team members in a participative and non-
threatening environment (Anderson and West 1998). A practice environment that is
receptive, amenable and supportive of an open exchange of ideas can set the stage for
the establishment of a climate of collaboration and teamwork. Turner-Shaw and
Bosanquet (1993) recommended that the nursing and practice development environment
should stimulate openness, honesty and effective communication. Following an
evaluation of the University of Leeds NDU programme, eight criteria or measures of
'success' were identified and included, among other things, effective team working and
enabling practitioners to develop their full potential (Gerrish, 1999, 2001). Greenwood
and Kearns (1996) reported delivery of more culturally-sensitive care, improved team
work and more participatory decision-making as positive outcomes of engagement in
practice development.
In exploring ways to assess teams' readiness for practice development, Walsh and Walsh
(1998) identified several factors contributing towards teamwork, such as good morale
and open channels of communication, effective conflict resolution strategies, a feeling
that each individual will be supported by the team, feeling safe to suggest new ideas, a
sense of working together, an inclusive approach to change, and sharing common goals.
This sense of safety to participate in decision-making can facilitate rather than inhibit
the pursuit for practice excellence. Task orientation is a commitment to excellence in
task performance and willingness to monitor that task performance (Anderson and West
1998). A commitment to excellence and evaluation of outcomes that attest to the
achievement of nursing initiatives, innovations and best practice was highlighted in the
accomplishments of Lydia Hall, Alan Pearson, and Stephen Wright, and evidenced in
publications both in the professional and public press.
181
In a retrospective evaluation of the Tameside NDU, Black (1993) reported high
motivation in the NDUs to develop nursing skills in order to provide high quality care
and higher morale than nurses in other surveys. In their original evaluation report of the
first four King's Fund Centre NDUs, despite no discussion of the findings or their
meaning, Turner-Shaw and Bosanquet concluded with the recommendation that health
care organisations wanting to provide effective, high quality care to patients should
consider establishing NDUs (Turner-Shaw and Bosanquet 1993). NDUs were expected
to monitor the quality of care, take requisite follow-up action, and evaluate the effects of
the work of the unit on patients and staff (The King's Fund Centre, 1989). Descriptive
accounts of reflective practice and values clarification exercises as well as retrospective
evaluations of the continuing work of NDUs proliferated in the 1990s and well into the
21st century.
In their evaluation of a model of Practice Development in an aged care unit,
McCormack and Wright (1999) reported more continuity of care, improved standards of
documentation, better understanding of a team nursing model of care, better
improvements in skill-mix, more clarity about professional accountability, and a more
positive attitude toward patient involvement in care. This notion of striving for
excellence and professional accountability continued as an important goal for Practice
Development Units in Australia. This was evidenced in reports of practice changes in a
Sydney CDU(N) that were more effective and culturally-sensitive (Greenwood and
Kearns 1996) and in the strategic plan for practice development for NSW Central Coast
which set up a program that could identify progress and recognise achievements
(FitzGerald and Solman 2003).
Support for innovation is not only the cooperation to support, develop and apply
innovative ideas but also the expectation of approval and practical support for
introducing new and improved ways of doing things (Anderson and West 1998). In the
evolution of nursing and practice development, The Loeb Center, was the foremost
leader in changing the direction of nursing and nursing care, a direction followed and
182
refined by Alan Pearson. In 1981, Burford was designated as a Nursing Development
Unit whose purpose was to "explore and pilot new approaches to practical delivery of
nursing care" (p5). Turner-Shaw and Bosanquet (1993) recommended that the nursing
and practice development environment should engender a willingness to change.
The mantle was taken up by The King's Fund Centre NDUs which aimed to provide
dynamic and evolving environments that welcomed new ideas and encouraged
systematic inquiry into nursing care processes while simultaneously promoting the role
of NDUs as models, leaders, role setters, and test beds (Redfern et al 1998; Sally
Redfern et al 1997). The theme of innovation and change was echoed and expanded in
the measures of success identified following an evaluation of the Leed's NDU
programme, in which adopting strategic approaches to change and disseminating
innovative practice was just as important as engaging in innovative practice (Gerrish,
1999; 2001).
The growing influence of the evidence-based practice movement was becoming evident.
There was a shifting in the nature and focus of practice development activity and a drift
in the literature toward differentiating practice development activities, audit activities
and research activities. Redfern and colleagues published several reports on evaluating
research, audit and networking activities in the King's Fund Centre NDUs as well as
evaluations of the implementation of evidence-based changes in South Thames NDUs,
with measurable clinical indicators as outcomes (Redfern 2002; Redfern and Christian
2003; Redfern, Christian, Murrells, and Norman 2000; Redfern, Christian, and Norman
2003; Redfern et al 1998; Redfern et al 1997).
Kitson and Currie (1996) prefaced their review of clinical practice development and
research activities in the Oxford Regional Health Authority by first defining the two
terms. Following the review, the PARiHS framework for research implementation was
designed with the aim of integrating research, development and practice (Kitson, 2002;
Kitson, Ahmed, Harvey, Seers, and Thompson 1996; Kitson, Harvey, and McCormack
1998; Kitson, Harvey and McCormack 1998; Rycroft-Malone 2004; Rycroft-Malone et
183
al 2002b; Rycroft-Malone et al 2004; Rycroft-Malone et al 2002a). Despite the changes
occurring at this time, innovations and change in practice for improved patient-centred
care remained the ultimate goal of practice development work - a goal Manley,
McCormack and Garbett proposed as being best achieved through facilitation of
reflective, creative thinking and emancipatory action.
Greenwood and colleagues (Greenwood 1999; 2000; Greenwood and Gray 1998;
Greenwood and Kearns 1996) reported that Australian CDU(N)s in Sydney continued to
concentrate on the agenda of consumer-focused and research-based care achieved
through an opening and questioning approach to care and a better appreciation of the
complex nature of nursing care. And again, on the NSW Central Coast, Fitzgerald and
colleagues (FitzGerald and Solman 2003) categorised their practice development
activities into those that used critical reflection, facilitation, values clarification and
team building to investigate specific clinical problems using an evidence-based
approach; those that focused on collaborative projects conducted in a research
framework; and those that were those associated with a funded research programme
based on strong collaborative partnerships. This categorisation allowed for clarification
and definition of activities while at the same time recognising the importance of each as
a legitimate means to an end, that of responsive, innovative practice change.
The literature on nursing and practice development identified individual, organisational
and multidisciplinary support for research and evidence-based practice, control and
autonomy over the practice environment, workplace empowerment, and constructive
team dynamics as frequently recurring themes. The effectiveness of the interaction of
these components (within the context of team) in achieving, maintaining and sustaining
a culture that supports innovation and change, that is, a culture of inquiry, is yet to be
explored.
6.2.4 Barriers to Research and Evidence-based Practice
This study found that attributes of a dynamic and effective culture and context of care
are inversely related to perceptions of barriers to engagement with research and
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evidence-based practice. This has implications in that the more sense of empowerment,
autonomy, control over practice, and team continuity nurses perceive, the less barriers
nurses perceive there are to engagement with research and evidence-based practice. This
finding is important because it provides empirical evidence of the relationship between
various key outcome indicators of the culture and context of care and their relationship
with perception of barriers to engagement in the evidence-based practice agenda.
Evidence-based practice is about using best available evidence to guide practice and
about pursuing innovation and change for better patient outcomes. Health services
executives and managers must first be able to identify if their organisation is ready to
support and enable change.
This study's timely synthesis of the Practice Development literature from 1960-2004, a
period when the movement was steadily gaining momentum, uncovered key attributes
that consistently permeated the discourse around developing nursing practice: (1)
autonomy in patient care decisions and control over the practice environment; (2) a
sense of feeling empowered in the workplace and having access to resources and
support; (3) feeling part of a team that is moving in the same direction, with a common
purpose and vision, as well as a team in which nurses feel safe to participate, safe to
monitor and evaluate practice and safe to challenge the status quo and initiate change in
innovation. These key attributes are all related to each other and all are inversely related
to perceptions of barriers to research and evidence-practice.
Engagement with research, be it use of existing research to guide practice or initiation of
nurse-initiated research, has consistently been one of the key attributes of the Nursing
and Practice Development movement. The early NDUs at Burford, Oxford and
Tameside were recognised for establishing a teaching and research programme (Johns
1991; Pearson 1992), aspiring to close the theory-practice gap by engagement in
research (Ersser 1988) and instrumental in developing the nurse consultant role through
collaborative links with the university sector, respectively.
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Similarly, the Royal College of Nursing Institute introduced structure around the theme
of engagement with research by developing a framework to integrate research
development and practice (Kitson, Ahmed et al 1996; Rycroft-Malone 2004). And,
although there was a trend toward focusing on processes of change and action with the
Manley/McCormack/Garbett school of thought, in their definition of Practice
Development, they still maintained the word 'effectiveness', a word inherent in evidence-
based practice. The theme of research engagement carried over into nursing and practice
development in Australia. CDU(N)s concentrated on, among other things, research-
based nursing practice (Greenwood 1999) and the NSW Central Coast Health's strategic
plan supported evidence-based practice and research engagement across three levels of
Clinical Practice Development (FitzGerald and Solman 2003).
The evidence-based practice movement stimulated awareness and use of research in
guiding clinical decision making in practice. Clinicians recognise the role of research
when it provides valid, realistic answers in practical situations (Clarke and Proctor 1998,
1999). Although a relationship between research evidence and effective practice is
acknowledged, the nature of that link is confusing. Clarke and Proctor (1999) suggested
that the emphasis of practice is the therapeutic impact of intervention and the emphasis
of research is the using of research findings or the doing of research. Practice
Development Units were seen as a way to ensure that delivery of care that was evidence-
based and clinically effective (Rycroft-Malone, Harvey et al 2002b).
The advent of evidence-based practice has created a new found discourse and re-
connection with the research utilisation literature. But translation of research into
practice has only ever been about practice improvement or development of practice.
Tolson (1999) argues that practice innovation and research, implementing research-
based changes in practice, and involving consumers in the evaluation of those changes
reflects practice development. The evidence-based practice paradigm positions nurses to
exert more influence on practice and practice change because of the advantage of its
focus on the systematic process of search, retrieval, implementation and evaluation of
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sound empirical evidence to support practice change - a process that has the potential to
counter opinion-based practice.
By and large, the study findings discussed thus far support Hypothesis 1 and answers the
first research question: Is there a relationship between nurses' perceptions of the culture
and context of care and nurses' perceptions of research and evidence-based practice?
This relationship has been established in this study.
6.3 Practice Development and Change in the Culture and Context of Care
Hypotheses 2-6 (H02-06) posit that among nurses working in an acute tertiary facility,
there is no difference in change in nurses' perceptions of the culture and context of care,
namely perceptions of autonomy and control over practice (H02), workplace
empowerment (H03), constructive team dynamics (H04), barriers to evidence-based
practice(H05), and/or skills in evidence-based practice (H06), between nurses working in
units with a twelve-month facilitated programme of Practice Development and nurses
working in units without a twelve-month facilitated programme of Practice
Development. The Practice Development intervention in this study was well-defined and
rigorous. It was developed in line with the principles of evidence-based practice in that
the intervention was researched for authenticity of outcome measures reflecting the
culture and context of care as well as both the outcome measures and the components of
the intervention connecting together and epitomising the tenets of Practice Development
methodology. It was supported by a clearly articulated education plan. This study found
no statistically significant effect of change in nurses’ perceptions of the culture and
context of care between nurses engaged in a Practice Development methodology and
nurses not. Although differences in change of perceptions between the two groups from
baseline to twelve months were noted, the change percentage or clinical differences
ranged from 1% to 3% and did not meet the level of clinical significance set at the start
of the study.
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There is a significant body of research on barriers to research and evidence-based
practice and a significant body of descriptive literature on using a Practice Development
methodology to change the culture and context of care as demonstrated in the literature
review. However, prior to the commencement of this study, there had been no
substantial research investigating the effectiveness of strategies for decreasing barriers
or challenging the assumption of effectiveness of using Practice Development processes
to decrease barriers. More recent studies continue to support the need for this type of
empirical work, that is evaluating frameworks for practice for effectiveness in
translating and implementing research into practice to ensure our practices are evidence-
based, that is, patient-centred, cost effective and targeted to improve clinical outcomes
for our patients (Greenhalgh et al 2004; Newhouse et al 2007; Kitson, Rycroft-Malone,
Harvey, et.al 2008; Estabrooks, Winther and Derksen 2004). Not only is the call for
more empirical research in nursing on implementation of evidence-based practice and
organisational attributes that impact on research utilisation supported in scholarly
publications by nursing scholars, but also in documents developed by other nurse
leaders to inform health care policy at a local, national and international level (Duffield,
et. al. 2007; Picone, et. al. 2000). Organisations that are seeking to improve nursing
practice require evidence-based information about effective strategies to removing the
barriers to engagement in the research and evidence-based practice agenda. This study
provides evidence to inform organisational decisions in this regard.
This research provides the evidence necessary for nurse executives and nurse leaders
who are establishing programmes for developing practice in nursing and facilitating a
change in the way nurses think about their practice. In an analysis of Practice
Development processes using an action research-type methodology, Clarke and
Wilcockson (2001) concluded that there were two levels of thinking among clinicians -
those whose thinking is located within existing structures and systems of care delivery
and those whose thinking can see beyond those existing structures and systems.
Clinicians thinking at the first level use the limitations of the existing system as excuses
for not developing practice and cannot see the potential of developing practice (Clark
and Wilcockson 2001); they are, generally, negative and pessimistic. In contrast,
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clinicians thinking at the second level can see the potential of developing practice and
are able to think laterally to identify innovative strategies for achieving that potential
and meeting identified needs (Clarke and Wilcockson 2001); they are, generally,
positive and optimistic. The philosophy guiding development of practice in this study
was based on considered combination on key features taken from all schools of thought
over the years and thus the Practice Development programme was aimed at supporting
nurses to critically examine their practice using an evidence-based approach in order to
bring about patient-centred, efficient and effective practice change through research
utilisation. In this regard, it is important to examine any trends in this direction.
Although past scholars recognised that methodological limitations and lack of
measurement criteria weakened the findings of past evaluations of Nursing and Practice
Development, no research before the commencement of this study actually challenged
past insights and processes of evaluation. Furthermore, this study makes evident in its
review of the theoretical and chronological development of Nursing and Practice
Development that the changed directions of developing nursing practice occurred in
response to political, societal and personal theories and philosophies not in response to
empirical evidence of effectiveness. Before this study, no research challenged the
relationship between the process of developing nursing practice and the espoused
outcomes.
In this study, after twelve months, for the nurses' involved in the Practice Development
programme, there was an 8% decrease in nurses' perception of barriers to research and
evidence-based practice compared to a 2% decrease in perceptions of barriers for those
nurses in the control units. Although 8% does not reach the arbitrary level of clinical
significance established for this study, it is worth considering on its own. More research
following up these nurses for another twelve months is required to see if the trend
continues.
In both the study group and the control group, there was a slight increase in perceptions
of empowerment after six months, but then these perceptions decreased to below
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baseline by twelve months. Reasons for these findings may lie in initial feelings of
empowerment by all the nurses because participation in the study was determined by
their staff consensus decision. The nurses may have perceived some degree of access to
knowledge about the organisation, resources, positive feedback about their work,
opportunities, and feelings of formal and informal power in the initial stages of the
study, but these feelings of empowerment were not sustainable over twelve months.
More research following up whether the access was only perceived to be reduced or was
actually reduced by the organisation is required. As both groups felt less empowered at
the end of the twelve months, indicates that the latter may be true.
Nurses in both the intervention group and the control group had improved perceptions
about skills in evidence-based practice, although the change difference in the skills score
at 12 months was higher for the control group. Similarly, nurses in both groups had
improved perceptions about a sense of constructive team dynamics, although the change
difference in the team score at 12 months was higher for the intervention group.
An improved awareness of the resources already available in the facility to gain skills,
such as the well-resourced on-site medical library with full access to on line journals,
the research and evidence-based practice training series facilitated by the medical
librarians, availability of a nursing liaison librarian, and the twelve-week structured and
practical evidence-based practice mentor programme facilitated by the Centre for
Clinical Nursing (http://www.health.qld.gov.au/rbwh/research/ clinical_ nursing.asp).
Nurses involved in the Practice Development programme demonstrated more improved
perceptions about autonomy and control over practice then those nurses in the control
group. This may be due to the Practice Development information sessions presented to
those nurses, in which these issues were discussed in great detail. Discussions in
Practice Development meetings with the nurses in the study group focused on re-
claiming responsibility for their nursing practice and the fact that evidence for
continuing or changing practice is stronger than opinion. The nurses involved in
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developing practice tended to pursue clinical projects that they avoided in the past
because of their conditioned thinking 'the doctor won't let us change it anyway'.
Based on findings from this study, the null hypotheses (H 0.2-6), that there is no
difference between the two groups in change in their perceptions of the culture and
context of care, must be accepted. Is there a relationship between nurses' perceptions of
the culture and context of care and nurses' perceptions of research and evidence-based
practice? The study findings are do not support this. Is there a relationship between
engagement in a facilitated process of Practice Development and change in nurses'
perceptions of research and evidence-based practice? Again, the study findings do not
support this.
6.4 From Practice Development to Developing Practice
Ambiguity in concept and definition of Practice Development is inherent in the
literature and, although different, evidence-based practice is inherent in the widely
accepted definition of Practice Development by McCormack et al (1999). What makes
the process of evidence-based practice and the process of Practice Development
different is that evidence-based practice aims to improve patient outcomes through
activities directed at the implementation of best available evidence into practice, one
practice at a time; while Practice Development aims to improve patient outcomes
through activities directed at changing the way practitioners think about the way they
practice, thus changing the ethos or culture of professional practice in a given practice
context. However, programs aimed at changing the culture and context of nursing
practice need to be re-directed away from the focus on theory-driven models of inquiry
to a focus on pragmatic strategies for developing nursing practice so that it is an active
involvement of the clinician rather than a passive agenda for the organisation - in other
words, a move away from practice development and a move toward developing practice.
Developing practice is about ownership and the clinicians themselves should own the
domains and parameters of practice. There is an imperative now, a result of the
influence of the evidence-based practice agenda to shift away from accepting
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unsupported theoretically-driven models to ensure sustainability of practice
developments and to work with clinicians to develop strategies that suit their context.
Clinicians thinking at the first level are expert, implicit and intuitive thinkers (Clarke
and Wilcoxson 2001; Boreham 1994) and can prioritise time and focus on important
activities to advance toward goals (Covey 1989) and thus achieve results in development
work. Limitations in thinking are reflected in decreased capacity for critical inquiry
(Clarke and Wilcockson 2001). For instance, establishment of nursing-led units (NLUs)
may have differed from NDUs because of an arising out of a pragmatic need, for
example, bed shortages, and not necessarily out of a conscious intention to develop
innovative nursing practice (Wiles, Postle, Steiner et al 2001; Wiles et al 2003)
Recognition and understanding of the multidisciplinary nature of healthcare cannot be
overlooked; however, not at the expense of denying the unique and important
contribution of any one discipline. Nursing must be valued for its therapeutic capacity
and nurses must be supported to practise therapeutic nursing. Therapeutic nursing care
should be evidence-based and nurses cannot afford to lose sight of the impact on patient
outcomes of effective therapeutic nursing interventions.
6.5 Measuring the Culture and Context of Care
It is difficult to assess if the culture of a unit has changed when there are no baseline
measures against which to compare. One of the issues expressed by past and current
scholars of Nursing and Practice Development as a process-model for change is the
difficulty in evaluating its impact or effectiveness. Several strategies and approaches for
evaluating the effectiveness of Nursing and Practice Development on staff and patient
outcomes included randomised controlled trials (Pearson, Punton, and Durant 1992;
Griffiths and Evans 1995), controlled and uncontrolled before and after studies
(McCormack and Wright 1999; Keatinge, Scarfe, Bellchambers et al 2000), quasi-
experimental designs using equivalent control groups (Hall 1975); retrospective
evaluations guided by pluralistic evaluation methodology (Gerrish 1999; 2001) or case
study methodology (Black 1993), modified action research (Pearson, Durant, and
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Punton 1989; Pearson, Punton, and Durand 1992), or an inductive Practice Development
design (McCormack and Wright 1999); most with varying degrees of methodological
limitations restricting acceptance of findings and conclusions. Several scholars
concluded that more rigour was needed in designing evaluation strategies (Draper 1996;
Salvage 1989; 1990; Vaughan 1998). In addition, the location-specific context of past
research and evaluation strategies used to assess the impact of nursing and practice
developments is not conducive to reproducibility and benchmarking.
What this study has added to the scholarship of developing nursing practice is a set of
defined and correlated outcomes that can be used to measure the culture and context of
care of the work environment in which a unit or team practices. This, then, can be used
as a starting point for baseline measurements prior to implementing an intervention.
Change in the culture and context of care can then be measured from this starting point.
Units or teams can assess the quality of the extent to which they have an effective
culture and context of care and determine if they are moving forward. Standardised
measurement criteria will enable benchmarking. Furthermore, replication studies using
standardised measurement criteria would make possible validation of the tool on
different populations of nurses which, in turn, can enable refinement.
In a systematic review on the diffusion of innovation in service organisations,
Greenhalgh et al (2004) concluded that organisational leaders must achieve a receptive
context for change, that is, the kind of culture and climate that supports and enables
change in general. In order to do this, organisational leaders need to take steps to
prepare for readiness for innovation and change and determine strategies for supporting
and enhancing the process of change (Greenhalgh et al 2004). The finding of this study
is of benefit to organisations trying to identify if their organisation is ready and receptive
for change; that is, is their context ready to support and enable critical inquiry,
innovation and change. The finding from this study will enable executives and nurse
leaders to prepare for readiness by first evaluating the culture and context of care in their
organisation using an instrument designed to capture nurses’ perceptions of key
outcome indicators consistently identified as indicative of a culture of inquiry and
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evidence-based practice. These same outcome indicators can then be evaluated for
change following any intervention aimed at practice change. In addition, the
representativeness of the study cohort to the general hospital population suggests this
finding can be generalised to other acute care nursing units.
Most studies on Nursing Development Units, and later, Practice Development Units, and
most recently Practice Development as an intervention to enhance the uptake of
evidence-based practice, research utilisation, innovation and practice change were
approached predominantly from a pragmatic perspective. However, the limited
politically and academically-driven research identified and attempted to establish a
theoretical driver in an effort to perhaps standardise processes or approaches to
developing nursing practice. However, this approach provided little empirical evidence
of confirmation of the effectiveness of a theoretically-driven model for innovation,
sustainability of innovations, or change in the culture and context of care.
The significant contributions of this research are:
new knowledge about the relationships between perceptions of attributes of an
effective culture and context of care and perceptions of barriers to research and
evidence-based practice;
validation and confirmation of a standardised, comprehensive instrument to measure
the culture and context of care in a nursing unit;
empirical evidence that a politically and theoretically-driven model of innovation has
little effect on change in the culture and context of care over a twelve month period;
and
generation of data with the potential to establish benchmarks in measuring changes in
nurses' perceptions of the culture and context of care, which can be researched further
for its predictive ability in identifying those teams which are ready to embrace the
continuing challenge of developing nursing practice.
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6.6 Strengths and Limitations
This research has identified that nurse autonomy and control over the practice
environment, workplace empowerment and constructive team dynamics are attributes
that have consistently been associated with an effective culture and context of care, that
is, a culture of inquiry and evidence-based practice. The research has also designed and
validated a survey instrument, constructed from existing instruments, to measure change
in the culture and context of care. The survey instrument underwent face and content
validity and was pilot tested to establish validity and reliability. The survey was
administered three times over a 12-month period using an evidence-based
implementation strategy to a sample of 265 nurses working in an acute care
environment. The survey was used to measure the effectiveness of a rigorously designed
evidence-based intervention based on Practice Development methodology designed
specifically to effect change in the culture and context of care. However, as with all
research, there are limitations to the interpretation of these results that must be
acknowledged when attempting to generalise the findings to a wider context. The
following is a discussion of the strengths and limitations of the study.
There are identified limitations in this study related to the research design. While the
gold standard of experimental research is a randomised controlled design, there are
situations in clinical practice where this is not feasible. In this study, a convenience
sampling strategy was used. Clinicians were the determiners of if and when Practice
Development would be implemented on their units instead of a Practice Development
program being imposed upon them by their Nursing Unit Manager (NUM), or higher
level of authority. This process of negotiation, consensus and ownership are consistent
with the tenets of Practice Development (Murray 1999; Hinchcliffe 2000). In this way,
it was anticipated that sustainability of Practice Development processes and
sustainability of practice changes and innovations as a result of the Practice
Development process would be enhanced because of clinician commitment, teamwork,
'ownership' and control in the early stages of implementation. In so doing, it was not
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feasible to randomly select the 'experimental' groups as the experimental groups were
self-selecting.
Another limitation is related to non randomised sampling, which has the potential to
introduce bias into study results. In such cases, matching samples is an acceptable
alternative where randomisation is not possible. However, there are difficulties in
matching clinical units or teams for comparison, a limitation that has been previously
reported in earlier evaluative studies on Nursing and Practice Development (Bond 1998;
Clifford and Murray 2001). In this study, it was difficult to match the clinical units or
teams because of the sampling strategy employed. The clinical units or teams selected
for the study differed on many variables that were beyond the control of the researcher,
such as management and leadership style of manager, type of clients serviced, staffing
skill mix and already established relationships with other health professionals. In a
recently commissioned report on the state of the workforce and work environment in
New South Wales, Duffield et al (2007) confirmed the considerable variation across
units at the nursing ward level. Thus, pre-implementation data were collected on both
the experimental and the control units at baseline and across time to identify similarities
and differences on demographics and other measures of interest under study in order to
account for this variability in any statistical models.
Change in sample membership may also introduce bias into study results. In this study
change in the sample membership over time occurred due to recruitment and retention
of nursing staff within the hospital, commencement and termination of leave, and staff
transfer and promotion within the hospital during the twelve month period of data
collection. However, one of the study aims was to measure sustainability of change over
time at the clinical unit level. deVaus (1995) suggests the best way of finding out about
a group of people was to survey every person in the group. Therefore, all nurse
clinicians employed in the eight sample units at the time of a survey were invited to
participate in the survey. Thus, individual nurse responses were aggregated into a
clinical unit group response. Hence, stability of the sample membership was a less
critical requirement in this study. The study aimed to identify a change in the practice
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culture or environment of a nursing clinical unit, an organisational trait, not an
individual nurses' trait. Follow up of nurses who were no longer working in a particular
clinical unit was not warranted. Nor did it matter that there were data for some nurses at
subsequent time points that were not available previously. Individual scores at any one
time point were used to generate an aggregate clinical unit score as the unit of measure.
Other identified limitations of this study are in relation to the use of survey methods; for
instance, the inability to compare compliance rates of responders with non-responders,
which can have an affect on bias of the sample. Survey findings are only as good as the
amount of error avoided and the useable surveys returned. The degree of bias from non-
response error depends on the percentage of non-responders, the degree to which they
differ systematically from responders and the degree to which variables identified as
clinically or statistically significant relate to the study aims (Barclay et al 2002). There
was limited significant difference between responders and non-responders in the pilot
survey. Previous findings are inconsistent in this regard as context and motivation are
survey specific. Although there are statistical tests for minimising the affect of bias, the
difficulty lies in not being able to identify what the bias is and to what extent it occurs
(deVaus 1995). One way to make adjustments for this bias is to compare characteristics
of the sample with those of the sampling frame. Since the researcher did not have direct
access to characteristics of the sampling frame, it was not possible to determine how
closely the characteristics of the sample reflected the sampling frame. Baseline data
were collected on the hospital population, used as a surrogate comparison, to establish
representativeness of the study sample.
Non response error can also be the result of a low response rate, another potential
limitation using survey methods. Non response reduces effective sample size and power
and can introduce bias (Armstrong,White et al 1995). Obtaining an acceptable response
rate to mail-out surveys is difficult with a population that is constantly bombarded with
surveys as a matter of routine. Keeping in mind that the average return rate for mail out
questionnaires ranges from 25 to 30% (Polit and Beck 2004), an evidence-based survey
implementation strategy was piloted prior to data collection in the main study. The
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effectiveness of this strategy was evident in the return rate greater than 70%. Adapting
Dillman's Tailored Design Method to fit the population and resources yielded a
respectable response rate of 76% on pilot testing. This response rate was nearly matched
in the main study with an overall response rate of 71%.
A survey implementation plan is as important as the survey design when trying to
reduce non-response. The approach to survey design used in this research raises
questions about such issues as time constraints, resources and imposition on staff. The
approach reported here was time consuming and required additional resources.
Ultimately, investigators need to establish if the increase in response rate is worth the
effort and cost of multiple contacts.
Another limitation when using surveys to collect data on attitudes, opinions or
behaviours, is the potential for overestimation of compliance via self-report method.
Previous studies utilising observation and self reporting mechanisms found that by
comparing self-reported behaviours with observed behaviours, healthcare workers tend
to overestimate (Henry, Campbell, Collier et al 1994). In addition, with self-reported
data, there is the potential for social desirability (de Vaus 2005) considerations whereby
participants answer questions by giving acceptable rather than true opinions so that they
are seen favourably by the researcher. Future studies may need to use a combination of
self-reporting instruments with prospective observation using ethnographic methods to
improve estimates as well as to collect valuable qualitative as well as quantitative data.
One further potential limitation of the study was related to the validity of the findings
and potential for generalisability to other contexts and settings. The validity of the study
can be separated into two components: internal validity and external validity. Internal
validity refers to the validity of inferences drawn as they relate to actual study
participants (Rotham 1998), that is, the extent to which it was possible to make an
inference that the Practice Development program truly influenced the perceptions of
practice culture and engagement in critical inquiry, evidence-based practice and
research. The external validity (or generalisability) refers to the validity of inferences
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drawn as they relate to nurses on clinical units outside of the study population (Rotham
1998). The generalisability of a study depends on the study population being
representative of the target population.
To address the issue of generalisability, data on nurse and hospital characteristics were
collected at baseline at the national, state and local level to ascertain the
representativeness of the sample to the target population of nurses working in principal
referral hospitals in Australia and Queensland. It was also possible to characterise
participants and non-participants on some demographic characteristics, namely sex,
primary role, nursing level and work area to determine any differences.
6.7 Conclusion
Developing nursing practice is encouraging, supporting and enabling clinicians to
interrogate practice, focusing on three key areas: patient-centredness, nurse competency
and health outcomes. It involves a disciplined process of interrogating practice, realising
gaps between what is valued and what is reality in practice, and changing practice to
narrow that gap. The quality and safety agenda makes evidence-based practice an
imperative. In this contemporary health care environment, with its advancing technology
and research, its ageing registered nurse workforce, its ever-changing skill-mix of the
workforce, and its constant budgetary constraints, changing to and embracing practices
that have been demonstrated to be efficient and effective is vital. This imperative holds
true as well for the processes used to effect practice change – that is, those processes
must be evidence-based.
Although, clinicians, educators and researchers continue to publish prolifically on the
structure, process and outcomes of developing practice, there has been little variation in
the nature of the publications. Between 2004, when data collection for this study began,
and 2009, a literature search using the same strategy as for the original search identified
another approximately 1400 publications, narrowed to almost 400 possible empirical or
evaluative research studies and, of these, approximately 175 related to research
utilisation or evidence-based practice. Adding the final search terms related to culture
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change, the final search identified less than 25 publications. Although the rate of
publications in the past five years almost equals that of the past 40 years, and the quality
of the publications has developed, there are still few studies investigating the
effectiveness of practice development processes on changing the culture and context of
care.
In 2004, Pearson, Laschinger, Porritt et al (2004) defined a health work environment as
one characterised by, among other things, positive inter-staff relationships, autonomous
practice and control over practice and work role, participation in decision-making,
strong clinical leadership, opportunities for professional development, nurse job and role
satisfaction, positive perceptions of the work environment, patient satisfaction and
decrease in complication rates and mortality, and delivery of observable high quality
care. Pearson et al 2004)’s definition of a healthy work environment corroborates that of
an effective culture and context of care as defined in this study as by nurses’ perceptions
of autonomy and control, workplace empowerment, constructive team dynamics.
Pearson and colleagues subsequently published a series of comprehensive systematic
reviews of evidence on factors that foster a healthy work environment, such as staffing
and workload (Pearson, Pallas, Thomson et al 2006), nursing leadership (Pearson,
Laschinger, Porritt et al 2004), nursing team composition (Pearson, Porritt, Doran et al
2006a) and professional practice of the nurse (Pearson, Porritt, Doran et al 2006b). The
evidence in these systematic reviews were synthesised into narrative summaries. In a
systematic review of 48 experimental, qualitative and textual papers, a combination of
leadership styles and characteristics was found to contribute to the development and
sustainability of a healthy work environment (Pearson, Laschinger, Porritt et al 2004). A
second review of 22 included experimental, quasi experimental, qualitative and
descriptive studies found that accountability, commitment, enthusiasm and motivation
are team characteristics associated with creating a health work environment; and social
support from supervisors and colleagues increased satisfaction levels among nurses
(Pearson, Porritt, Doran et al 2006a). In a third review of 19 included quantitative,
descriptive and qualitative studies, there was evidence to suggest that professional
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practice has a positive impact on the work environment in terms of nurses’ role
satisfaction and patient outcomes; however, the evidence is ambiguous in many areas
and thus more research in recommended (Pearson, Porritt, Doran et al 2006b). Finally in
a fourth review of 40 papers, including one systematic review, one cohort study and 38
correlational descriptive studies, there was evidence to suggest strong correlations
between patient characteristics and work environments; and workload and staffing on
the quality of patient outcomes, staff outcomes and organisation outcomes (Pearson,
Pallas, Thomson et al 2006). The empirical findings from this study demonstrate that
perceptions of autonomy and control, workplace empowerment and constructive team
dynamics are positively and moderately to highly correlated with each other. Thus; the
findings from the more recent narrative syntheses of the available evidence; provide
theoretical depth to the study findings and have highlighted the lack of development of
empirical studies on the culture and context of care and measuring the effect of
evidence-based interventions aimed at changing culture.
McCormack and colleagues published a series of papers describing the methodology
and findings from a realist synthesis of evidence relating to practice development
(McCormack, Wright, Dewar et al 2007) and found there to be consistency between
approaches used in developing practice, ranging from ‘active learning’ or ‘reflective
learning’ strategies (McCormack et al 2007). They conclude that although the dominant
approach is action learning there is little evidence on the effectiveness of action learning
and little evidence on the direct relationship between approaches to developing practice
and practice development outcomes achieved, with the most common outcome reported
being ‘increased confidence’ among participants (McCormack et al 2007). McCormack
et al (2007) also concede that although a variety of change strategies are reported in the
literature, current literature does not allow for direct measurement of practice
development outcomes arising from specific interventions and there is a lack of clarity
in study methodologies. This study found no statistically significant change, in 12
months, in nurses’ perceptions of the culture and context of care between nurses
engaged in an approach to practice based on Practice Development processes and those
engaged in routine processes for practice inquiry. These findings, coupled with the
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findings of the more recent realist synthesis of the practice development literature
suggest that there remains a lack of evidence on the effectiveness of a Practice
Development methodology.
What this chapter has highlighted is that the imperative for developing practice by
demonstrating the effectiveness of nursing and clinical practice on patient and staff
outcomes and the effectiveness of theoretically based-processes on changing the culture
and context of care remains.
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CHAPTER 7. CONCLUSIONS AND RECOMMENDATIONS
7.1 Introduction
This study was originally planned to be conducted over a three-year period as it was
recognised at the start of project development that change in perceptions and behaviour
takes time. The Practice Development programme was evaluated after 12 - months due
to not only time-limiting imperatives imposed by the organisation but also an outcomes-
focused agenda, also dictated by the organisation.
Over the course of the amended time frame, the purpose and objectives of the study
were met, namely to develop, implement and evaluate the effectiveness of a structured
programme of nursing Practice Development for nurses working in a major tertiary
referral hospital in Queensland, Australia. The development of a model for nursing
practice development and an appropriate evaluation strategy will lend support to future
comparison studies and benchmarking in nursing practice development programmes
worldwide.
The focus of this study was on the process using a conceptualised Practice Development
framework, hypothesising that practice change could only be sustainable if we changed
the way nurses 'think and do' nursing. Nursing is a practical profession, and essentially
an outcome-focused profession, that is tangible outcomes related to 'product' not
intangible outcomes related to 'process'.
When a model of change using the tenets of Practice Development is introduced to
nurses, criticisms come in the form of 'we do care about the patient' and 'we are trying to
do the best for our patients'. Perhaps its timely for nurse academics and nurse theorists
to appreciate the fact that clinicians in general are experts in their craft, have the
knowledge and skills to practice safely and competently, have the insight to not
perpetuate practices that are harmful or unsafe, and, have the compassion to consider the
203
patient in the health care equation. Perhaps the nursing profession can be advanced one
clinical project at a time, taking process into consideration, but not clouding the focus of
the anticipated outcome of best patient care.
7.2 Conclusions
It is important to recognise the distinction between Practice Development processes and
the activity of developing practice. The end result of the Practice Development process
is heralded to be transformation in the way nurses perceive themselves in relation to
healthcare decision making and patient care outcomes. Nurses' routine and continual
critical interrogation of practice, challenging practices, using existing evidence and
creating new knowledge are the end result of developing practice.
This study was designed to detect changes in nurses' perceptions in the culture and
context of care as well as the relationship between those perceptions and perceptions of
barriers to evidence-based practice under less than optimal intervention research
conditions, such as lack of random selection or allocation, differences between the
control and intervention groups at baseline, potential unreliability of self-report
measures, and research attrition. Statistical methods cannot overcome all of these design
issues, but statistical methods that reflect the organisation of the data will offer the most
useful information as we continue in the pursuit of empirical evidence of best practice in
developing nurses and nursing practice and best practice in the analysis of change in the
culture and context of care. In pragmatic clinical research investigating interventions for
change, however, clinical significance is more of a ‘marker’ of effectiveness; statistical
significance being supplemental in supporting clinically significant findings. This study
found no clinically or statistically significant findings that engaging in a Practice
Development methodology for developing practice was related to change in nurses’
perceptions of the culture and context of care.
The findings of this research are informed by and have contributed to the work of those
who have gone before and set the scene for the next stage in the evolutionary agenda of
204
developing practice. These findings, thus, have implications for the future of the
progress of developing practice in nursing.
7.3 Recommendations for Practice
This study is innovative in its attempt to identify, quantify and measure variables
associated with a culture that is conducive to nurses' engagement with research and
evidence-based practice and to test a methodology for effecting change in that culture.
On the basis of the findings of this research, and bearing in mind the strengths and
limitations of the study, a number of recommendations can be made.
Finding 1: Perceptions of autonomy and control in the professional practice
environment, workplace empowerment, and constructive team dynamics, that is,
outcome measures of the culture and context of care, are correlated to each other and
inversely correlated to barriers to research and evidence-based practice.
Recommendation 1: I recommend that organisational leaders interested in
creating a culture of inquiry, assess readiness to engage with the research and
evidence-based practice agenda by measuring perceptions of barriers to
research and evidence-based practice, autonomy and control, workplace
empowerment and constructive team dynamics before embarking on the arduous
journey of practice review and practice change.
Finding 2: Evidence for the effectiveness of a theoretically-driven, process-driven
model of Practice Development for practice review and change, in changing the culture
and context of care, is inconclusive.
Recommendation 2: I recommend that the evolution of Nursing and Practice
Development continue on now by acknowledging the past work of scholars in the
field on process yet moving forward toward an outcome-focus agenda of
developing practice; and that innovations that take form are investigated for
205
effectiveness before committing time and resources into implementation
strategies.
Finding 3: A set of defined and correlated outcome measures can be used to measure
the culture and context of care; and to measure change in the culture and context of care
following interventions aimed at developing a culture of inquiry and evidence-based
practice.
Recommendation 3: I recommend that individual nursing units continually
monitor and evaluate their practice climate for excellence in patient-centred
care and effective practices by regularly measuring the practice environment for
change in perceptions, continually auditing clinical practice processes and
outcomes, and ascertain the relationship between the two.
7.4 Recommendations for Further Research
Further research is needed on effective strategies for creating a culture of inquiry and
evidence-based practice in the Australian context. Moreover, follow up empirical work
is needed to estimate engagement with research and evidence-based practice through
quantification of research and evidence-based practice project activity.
Follow up studies on the outcome of research and evidence-based practice activity, that
is, the impact of practice change on patient clinical outcomes in order to clarify and
strengthen the link between research and evidence-based practice and clinical outcomes
is warranted.
More empirical research, for example randomised controlled trials, investigating the
effectiveness of different strategies in encouraging and supporting nurse engagement in
the research and evidence-based practice agenda is also warranted. In addition, multi
method studies may provide clearer understanding of the nature of the interrelatedness
of not only attributes of an effective culture of inquiry but also management and
leadership styles of clinical managers and skill mix of staff.
206
In keeping with the practical and outcome-oriented nature of nursing, comparative
studies are needed on the impact and sustainability of practice change resulting from
project-oriented activity compared to process-oriented activity.
7.5 Closing Comments
The purpose of this research has been to address the gaps in the nursing and practice
development literature regarding effectiveness of a facilitated Practice Development
methodology in changing the culture and context of care. This has been achieved by
firstly, identifying attributes of an effective culture and context of care; secondly, by
constructing and validating a comprehensive instrument to measure change in these
attributes; thirdly, by providing empirical evidence of the relationship of the identified
attributes to each other and to barriers to engagement with the research and evidence-
based practice agenda; and fourthly, by determining that effectiveness of a Practice
Development methodology in changing the culture and context of care is inconclusive.
Advances in healthcare practice and medical technology continue to move forward at a
rapid pace; propelled by modernisation, innovative developments, and breakthrough
research discoveries. This research is noteworthy in its contribution to advancing the
discipline of nursing by providing evidence of the degree to which attributes of the
culture and context of care, namely autonomy and control, workplace empowerment and
constructive team dynamics, can be connected to engagement with research and
evidence-based practice.
The acknowledgement, acquiescence and acceptance of the evidence-based practice
movement, despite pockets of 'resistance', have facilitated the advances in healthcare by
promoting a culture in which research-supported and evidence-based practice are
requisites for optimum, effective patient outcomes. However, nursing is running not
only to catch up but also to keep up. Nursing research, particularly clinical nursing
research, is still a relative newcomer, not only in producing research but in using
research. Nursing is still coming to terms with evidence-based practice, of particular
interest in the nursing discourse is the 'what is evidence in nursing?' debate.
207
Furthermore, a recent analysis of the research utilisation literature in nursing concluded
that although there has been an increase in productivity in research utilisation articles,
more empirical work is needed in the field (Estabrooks, Winther and Derksen 2007).
Contemporary scholars confirm this need (Eccles, Armstrong, Baker et al 2009;
Estabrooks 2003). Also, nursing is still willing to accept and implement ideas and
theories without fully investigating their effectiveness.
This research is needed because it has boldly taken a stand to stop, look and listen:
STOP uncritical reliance and mass uptake of theory-driven practice without evidence of
its effectiveness in practice. LOOK at and rigorously evaluate the effectiveness of the
practical application of the theory in practice. LISTEN to the evidence of effectiveness
before making decisions of organisation-wide program implementation.
The results from this Australian research are important and timely in exploring and
opening the door for a critical dialogue about untested theory-driven practice in this age
of evidence-based practice. The nursing research agenda is aimed at decreasing the
‘research-practice- gap. It is timely now to add another item on the agenda – decreasing
the ‘research - rhetoric’ gap.
208
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