Transcript

32 © 2007, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses Volume 11 Issue 1

in infl uencing the ability of nurses to apply

research evidence to their practices.

To begin, let’s focus on using a research

implementation framework. One of the more

popular research implementation frameworks

used in nursing is the Promoting Action on

Research Implementation in Health Services

(PARIHS) framework, which was developed by

Kitson and colleagues in the United King-

dom (Kitson, Harvey, & McCormack, 1998;

Rycroft-Malone, 2004; Rycroft-Malone et al.,

2002). Their framework, created from collective

experience gained from research, quality im-

provement and practice development projects,

suggests that successful use or implementation

of research into clinical practice is a function of

three elements: evidence, context and facilita-

tion. These three elements, each with their own

Putting Evidence Into PracticeDoes the Workplace Really Matter?

Shannon Scott-Findlay, RN, PhDErna Snelgrove-Clarke, RN, PhD(c)Mandi Newton, RN, PhD

sSince the inception of the “Evidence & Out-

comes” column, we’ve tackled a host of issues

related to putting research into practice, rang-

ing from the frank questions of “Is there a place

for research in my clinical practice?” and “What

are the benefi ts to research-based practice?” to

the dilemmas of using evidence that doesn’t

“fi t” with clinical expertise, and the challenges

of using clinical practice guidelines. In this

article, we discuss the role of the workplace

February | March 2007 Nursing for Women’s Health 33

subelements, are thought to have a synergistic

relationship, with each positioned on a high-to-

low continuum. According to the framework,

for implementation of research to be success-

ful, there must be clarity about the nature of

the evidence (“high” evidence), the quality of

the practice environment (“high” context) and

how evidence is “assisted” into practice (“high”

facilitation). The assumption underpinning

the framework is that if each subelement is

deemed to be high, then implementation is

more likely to be successful. For example,

under the element “evidence,” there are three

components—research, clinical experience and

patient preferences. Evidence is deemed to be

high if knowledge from randomized controlled

trials, systematic reviews and evidence-based

guidelines are used and if there are high levels

of consensus and partnerships between patients

and health care professionals in determining

treatment plans.

Keeping this framework in mind, the issues

discussed in previous “Evidence & Outcomes”

columns have focused exclusively on the state

of the evidence, whether that be the benefi ts

of putting research into practice, how to use

clinical practice guidelines (a form of evidence)

and the implementation of research evidence

when clinical experience, practical wisdom

and research evidence are incongruent. In this

article, we’ll shift focus and begin to untangle

some of the challenges of a second element of

the framework: Context.

The Workplace As ContextTraditionally, the onus to integrate research

fi ndings into everyday practice has been placed

on individual practitioners. This is consistent

with the era of personal and professional re-

sponsibility. This onus contributes to an inad-

equate understanding of the infl uence organiza-

tional context has on practitioners’ research use

behaviors. In addition, lack of understanding

regarding the infl uence of context in research

use is one of the greatest barriers to using

research in clinical practice. Specifi cally, the

context in which nurses work shapes a broad

host of patient and organizational outcomes,

including nursing retention, sick time and qual-

ity of care. Therefore, it stands to reason that

nurses’ ability to read and use research in their

practice is shaped by their work environment.

The appeal of the PARIHS framework is that

it emphasizes that to put research into clinical

practice, we need to look at more than simply

identifying high-quality research.

Research utilization scholars have con-

sistently identifi ed the organizational envi-

ronment, or context, as an important factor

infl uencing research use and health care

professionals’ behaviors (Brett, 1987, 1989;

Crane, 1989; Stetler, 2003). However, they

haven’t examined the infl uence of context in

great detail. This is likely due to the complexity

of organizational context. Context is the overall

environment or setting in which practice takes

place (Kitson et al., 1998; McCormack et al.,

2002). Organizational context is a broad term

for the practice environment. It has three

subelements that contribute to an organiza-

tion’s complex nature: culture, leadership and

evaluation (Kitson et al.; McCormack et al.,

2002) (see Box 1). In the PARIHS framework, a

high context would be characterized as valuing

Box 1.

Elements That Constitute a Practice Environment (Context)

Culture is expressed in terms of accepted patterns of physical, cognitive, affective and social behaviors of the individuals who work in the organization.

Leadership refers to leaders’ approaches to managing conflict and relationships, building teams, implementing solutions and responding to everyday work situations to achieve one or more particular goals.

Evaluation is both part of the research process that generates evidence on which to base practice and is part of the feedback process that demonstrates whether or not changes in practice are appropriate.

Shannon Scott-Findlay,

RN, PhD, is a postdoctoral

fellow in the Department

of Pediatrics, Faculty of

Medicine and Dentistry at

the University of Alberta,

Edmonton, Canada.

Erna Snelgrove-Clarke,

RN, PhD(c), is an assistant

professor in the Faculty

of Nursing, Dalhousie

University in Halifax,

Canada.

Mandi Newton, RN, PhD,

is a postdoctoral fellow in

the Faculty of Nursing at

the University of Alberta in

Edmonton, Canada.

DOI: 10.1111/j.1751-486X.2007.00115.x

34 Nursing for Women’s Health Volume 11 Issue 1

continuing education and patient-centered

care, as well as having clear leadership, effec-

tive teamwork and measures to evaluate work

processes and other aspects of the environment.

To illustrate, culture is expressed in terms of

accepted patterns of physical, cognitive, affec-

tive and social behaviors of the individuals who

work in the organization. Leadership occurs

within the organization’s context and refers to

leaders’ approaches to managing confl ict and

relationships, building teams, implementing

solutions and responding to everyday work

situations to achieve one or more particular

goals (Cummings, Mallidou, & Scott-Find-

lay, 2005). Finally, evaluation is both part of

the research process that generates evidence

on which to base practice and is part of the

feedback process that demonstrates whether or

not changes in practice are appropriate. In the

PARIHS framework, evaluation is acknowl-

edged to include multiple methods and sources

of feedback. Therefore, considering the element

of context in this framework, research uptake is

more likely to occur when there is a high con-

text—that is, when there are receptive cultures,

strong leadership and appropriate evaluative

systems.

Infl uences of the WorkplaceOther conceptual work demonstrates how the

culture of a nursing work environment, in par-

ticular, can affect how research is or is not used

by nurses in their day-to-day work. Scott-Find-

lay and Golden-Biddle (2005) argue that there

are at least three different ways in which culture

infl uences the research-use behaviors of prac-

titioners (see Box 2). First, the organizational

approach to work infl uences how practitioners

do or don’t use research in their practice. In

much of nurses’ work, the researchers found a

strong organizational preference for “doing”

and looking busy—that is, doing tasks is valued

over developing relationships with patients and

refl ecting on one’s practice; looking busy is val-

ued over sitting and a fast pace is valued over a

slower pace. Using research in clinical practice,

Successful use or

implementation of

research into clinical

practice is a function

of three elements:

evidence, context

and facilitation.

Box 2.

Three Ways the Workplace Can Infl uence Research Use

1. The organizational approach to work influences how practitioners do or don’t use research in their practice. For example, in a culture where “doing” tasks and appearing “busy” are valued, nurses may be less likely to take the time to read research and consider how to apply it to their practices.

2. The organization’s culture influences what types of knowledge are perceived as important or rel-evant, and which health care professionals (e.g., doctors, nurses) think it’s acceptable to use research for guiding practice decisions. For exam-ple, in a culture where discussing research find-ings on rounds is considered acceptable, nurses may be more likely to want to apply research to their practice.

3. The structuring and organization of nurses’ work shapes how they use or do not use research. For example, in a culture where interaction and col-laboration with colleagues is limited or is not fos-tered, nurses may be less likely to read research and apply it to their practice.

February | March 2007 Nursing for Women’s Health 35

however, requires opportunities and time for

nurses to refl ect on their clinical practices and

to keep abreast of research relevant for their

practices.

Second, the researchers found that cul-

ture infl uences what types of knowledge are

perceived as important or relevant, and which

health care professionals (e.g., doctors, nurses)

think it’s acceptable to use research for guiding

practice decisions. Refl ect on your own practice

environment for a moment. For instance, what

type of knowledge (e.g., research, experiential)

is valued in patient rounds? Is research knowl-

edge even considered in this space?

Finally, the researchers found that the struc-

turing and organization of nurses’ work shapes

how they use or do not use research. Again, if

nurses’ work is oriented toward “doing” tasks,

less time and space will be allocated for forums

for interacting and collaborating with col-

leagues on using research in practice.

The Role of LeadersSo, does the workplace matter in the pursuit of

research-based practice? We think it does and

we’re convinced that most nurses would agree

that their work setting shapes the decisions they

make at work (e.g., the infl uence of institu-

tional priorities and values) and how they’re

able to carry out their work (e.g., through the

accessibility of resources). There are organi-

zational or institutional reasons why nurses

do or don’t use research in their practices. We

feel that leadership, as part of organizational

context, has an important role in creating

organizational contexts that are conducive to

research-based practice. As Cummings et al.

(2005) suggest, “Research use does not happen

in a vacuum without resources, without being

sanctioned within the organizational culture,

without being convenient when multiple priori-

ties face the practitioner, and without having

some perceived benefi t” (p.7). Leaders can be

critical in developing workplace environments

where research use is expected, where resources

are allocated to facilitate research use and where

time and space are set aside for nurses to have

the opportunity to participate in activities to

use research. While much responsibility for

making research-based practice a reality in

today’s health care institutions remains at the

bureaucratic level (management-level decision

makers), leaders at the hospital unit level where

nurses work have a signifi cant role. The work-

place does matter! NWH

In the next “Evidence & Outcomes” column, we’ll

focus on strategies nursing leaders can use to cre-

ate work environments that foster research use.

ReferencesBrett, J. (1987). Use of nursing practice research

fi ndings. Nursing Research, 36(6), 344–349.

Brett, J. (1989). Organizational integrative mecha-nisms and adoption of innovations by nurses. Nursing Research, 38(2), 105–110.

Crane, J. (1989). Factors associated with the use of research-based knowledge in nursing. Unpub-lished dissertation, University of Michigan.

Cummings, G., Mallidou, A., & Scott-Findlay, S. (2004). Does the workplace infl uence nurses’ use of research? Journal of Wound, Ostomy and Continence Nursing, 31(3), 106–107.

Kitson, A., Harvey, G., & McCormack, B. (1998). Approaches to implementing research in prac-tice. Quality in Health Care, 7, 149–159.

McCormack, B., Kitson, A., Harvey, G., Rycroft-Malone, J., Titchen, A., & Seers, K. (2002). Getting evidence into practice: The meaning of ‘context.’ Journal of Advanced Nursing, 38(1), 94–104.

Rycroft-Malone, J. (2004). The PARIHS frame-work—A framework for guiding the implemen-tation of evidence-based practice. Journal of Nursing Care Quality, 19(4), 297–304.

Rycroft-Malone, J., Kitson, A., Harvey, G., McCormack, B., Seers, K., Titchen, A., et al. (2002). Ingredients for change: Revisiting a conceptual framework. Quality and Safety in Health Care, 11(2), 174–180.

Scott-Findlay, S., & Golden-Biddle, K. (2005). Un-derstanding how organizational culture shapes research use. Journal of Nursing Administration, 7/8, 356–362.

Stetler, C. (2003). Role of the organization in translating research into evidence-based practice. Outcomes Management, 7(3), 97–105.

Lack of under-

standing regarding

the influence of

context in research

use is one of the

greatest barriers to

using research in

clinical practice.


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