INTRODUCTION
"The time has come the walrus said to talk of many things, of sailing ships and sealing wax and cabbages and kings". Indeed the time has come - and its a time of reform - not just a tinkering around the edges - but of rule breaking; not just reducing/main taining costs but of reengineering - doing more with less; not just developing new technologies but of their creative use. Albert Einstein's wisdom is as relevant today as it was decades ago "The significant problems we face cannot be solved at the same l evel of thinking we were at when we created them."
The clues that it is a time for calling in the chits include: - evidence-based practice is "in" - ritual and intuition are "out" - inappropriate/ineffective diagnostic and therapeutic interventions are not being tolerated - evidence-based tools for decision-making in practice (e.g. CPGs, Care Maps, Critical Paths) are proliferating and being made widely accessible (e.g. on-line, internet) - accountability for outcomes is demanded of each and every health care profession - the "lone ranger" practitioner is neither effective nor tolerated - "collaborative" practice is taking on many shapes and sizes - consumer participation in decision making is not an option - the medical model (paradigm) has been replaced (by many if not most) by the consumer model (paradigm) - In this era of shared responsibility and cost-consciousness, patient preferences are a k ey element of health care decisions and should be considered in the development of practaice guidelines.
How come it is taking us so long to recognize these clues - to reconceptualize our world of professional nursing - to clearly demonstrate how nursing care makes a difference - how health care resources and therapeutic nursing interventions are effectively and efficiently utilized to improve the health status of clients of our health care system? Clearly, there is a need to improve the research and evidence bases of our practice. This is the Nightingale Legacy - Research and Practice. In Nightingale's view , nursing should be a search for truth. She held that the ability to collect accurate information and make correct observations is essential. "If you cannot get the habit of observation one way or other, you had better give up being a nurse, for it is not your calling, however kind and anxious you might be"(1)
However, promoting and implementing research-based practice is not a simple task; nor is it solely reliant upon nurses in clinical practice. There are forces affecting the advancement of research-based practice within both the health care and nursing systems.
I know Dr. Ritchie is going to address this as well, so I am going to focus more on some "how come" questions related to research-based nursing practice and discuss two interrelated processes which must be attended to if the "how come" questions are to be turned into "why not" questions - or "just do it" approaches. And I am going to address this with particular emphasis on research utilization.
HOW COME?
How come there is a gap between knowledge generation and application? Is it that research is not seen to be relevant to practice? If so, how come we aren't getting the relevant research done? Are we not asking the right or relevant questions? We know nurs es have questions - consider those generated through the provincial Agency Challenge and agency dinosaur and sacred cow challenges. There are relevant questions. So - How come they are not being explored? Are researchers not listening to those questions? And even if they are to some extent - How come clinicians are not more engaged in answering those questions? Furthermore sometimes there are answers to the practice relevant questions. How come we're not using the research?
Example: Internet - IM Injection Sites
In the clinical arena the challenges of promoting research-based practice require a different view of our world - they require us to create a new future. How we shape our future will depend to great extent on how we perceive the clues I mentioned earlier - do we see them as threats? or opportunities? do we see this as a loss? or a gain?
I believe it is time to turn our nursing system upside
down:
From one that is currently-
We know that neither the mere existence or dissemination of knowledge nor enforced behavior change ensure that attitudes, values and behaviors will change(3). Using research findings in nursing practice can be thought of as adoption of an innovation - a com plex process which involves several stages.
Rogers'(4) (1983) theory of diffusion of innovations with its four successive stages is a good place to start. The first stage - knowledge - occurs as nurses become aware of the innovation. Next, in the persuasion stage, they form a favorable or unfavorable attitude toward the innovation. Thirdly, nurses make decisions to adopt or reject the innovation, at least on a trial basis. If a new practice is mandated without practitioners moving through these appropriate stages, it is unlikely that the innovation w ill be implemented consistently or as intended. Consistent application with evaluation occurs in the fourth confirmation stage - if progress has been successful through the previous stages.
A number of researchers have found that the source for new knowledge influences the rate at which individuals pass through the first stage. Print-media and interpersonal contacts (research-oriented conferences and inservice programs and role models) are m ost influential in solving clinical problems and adopting innovations (Brett(5), Coyle and Sokop(6), Means(7), Salasin and Cedar(8), Stinson and Mueller(9)). Although educational programs are suggested as important methods of research dissemination, few studies hav e examined the extent to which research findings are incorporated into nursing curricula.
In 1995, Barta(10) reported on a study that investigated pediatric nurse educators' inclusion of evidence-based pain management techniques in the curriculum. Practices most highly diffused among pediatric nurse educators were use of pain scales, providing s ensory information and teaching self-comforting strategies. However, only the use of pain scales was in the "include always" range. The least diffused innovation in this sample was the use of TENS (transcutaneous electrical nerve stimulation). It's intere sting to note that at the 1992 International Pediatric Nursing Conference at Child Health 2000, Dr. Leora Kutner11 spoke about desirability (in fact predicted) that physical methods to ease pain would become more commonplace - including therapeutic touch, massage and TENS - and that this would reflect the growing appreciation of the research that shows that pain can be shifted by means other than pharmacological. However, sadly in a 1994 report from Alberta, Williams'12 study of nurse educators in that pr ovince we learn that there is a significant lack of fundamental know-how about the pharmacological management of acute pain - that little time is spent on pain management in nursing curricula and that content is often spontaneous rather than planned. In Barta's study the educators chose nursing journals, nursing texts and Cumulated Index of Nursing Literature, as most useful sources of information for updating instruction of baccalaureate degree students. One has to seriously question the currency of tex ts and their appropriateness as a source of update!
Factors influencing nurses in the persuasion stage are agency policy, procedure manuals, and the opinions of other professionals. Rather than actual agency policy about research-based nursing practice, Brett(13) found that it was perceived policy that influ enced innovation adoption behavior among her sample of hospital nurses. In the last two innovation adoption stages, the most common barriers identified by clinicians were organizational barriers. Nurses' perception that they lack authority and support of administration to change nursing practice inhibits innovation adoption.
Romano's (14) identified five attributes of the innovation, as perceived by potential users, that affect the rate of its adoption. Innovations which have an obvious advantage to the patient/client; are compatible with nurses' values and experiences; are rela tively simple to understand and implement; can be tested and evaluated; and demonstrate results are likely to be adopted relatively quickly - with nurses passing through each of the four stages quickly and without much angst. However, problems are sure to arise when at least one of these attributes differ and when attention is not paid to assisting nurses move through the four stages in a logical and timely fashion.
PCA Example
In 1991 members of the RNABC Nursing Research Committee Network questioned why their staff nurses were not using the Patient Controlled Analgesia approach, including the pump, as intended and supported by research. Subsequently an 11 site research study w as carried out by 13 nurse-investigators. The purpose of the study was to determine nurses' learning needs to bring about effective and efficient implementation of a PCA approach within the complexity of decision-making about pain management. We used Rogers'(15) innovation adoption framework, paying special attention to two of the five attributes of PCA (the innovation) not previously investigated - compatibility of PCA with nurses' existing values and experiences and complexity of the approach.
We found that nurses' beliefs related to PCA changed in varying degrees depending upon the accumulation of positive or negative forces in their agencies. Positive forces included planned implementation, education/clinical experience and positive outcomes for most patients, even the chemically dependent. Nurse-involvement in patient selection for PCA was another positive force, as was the ease of pump use and safety features. The timing of learning and clinical application of new information and skills was as important as the availability of knowledgeable peer supported clinical experience. The positive forces enhanced nurses' ability to adopt a new perception of the PCA approach and supported them in the transformation of their pain management beliefs.
Negative forces were opposite of the positive forces and included increased workload during early phases of PCA implementation. These negative forces inhibited the implementation of PCA and changes in pain management beliefs.
Our findings support the need to systematically address five issues when embarking on the innovation adoption process:
Why not change this how come into a "just do it"? What resources/processes are there to assist moving through the innovation adoption process? One is a research utilization framework.
A research utilization framework can facilitate the research adoption process and the resolution of some of the above mentioned issues. The four best-known frameworks are the Western Interstate Commission for Higher Education in Nursing, also called WICHEN(16); the Conduct and Utilization of Research in Nursing or CURN(17), NCAST(18) and Stetler/Marram(19). WICHEN and CURN frameworks are both based on the concepts of diffusion of innovation and planned change; NCAST focusses solely on diffusion of innovations; and the refined Stetler/Marram framework is an interactive, staged model.
Based on the work of Stetler (20) and the expressed needs of nurses and
health care agencies in British Columbia, a decision-making model for
utilization of research findings in practice was developed and published
in the workbook Nursing Research: From Ques tion to Funding(21).
Application of this framework requires partnerships among nurses with
clinical expertise, research experience, and administrative
responsibilities. Each of the four phases requires particular nurses to be
involved, decisions to be made,
and resources to be accessed. The framework can be modified by individual agencies, thus making it relevant to both staff needs and the organizational structure.
The Vancouver Health Department Nursing Research Committee - a sub-committee of their Nursing Council - decided that their focus would be on assisting staff nurses in research utilization. Based on the work of RNABC an agency-specific research utilization
framework was developed and a supporting manual written. During this process the committee members critiqued the RNABC model, identified their agency's needs and resources, articulated their agency's culture, philosophy, and mission statement, and consul
ted with Nursing Council and the Quality Improvement Program. The result - a widely accepted framework and manual that are user-friendly and "owned" by each of the health units in the department.
How well a given framework will serve a situation or agency depends on the framework's efficacy, the type of problem, and the congruence of the framework's theoretical based with nurses' decision making22. As well, the framework must fit with the organiza
tion's structure, philosophy of nursing practice, and available resources.
SUMMARY
Each stage of the innovation adoption process is critical to appropriate implementation of research-based nursing practice. Change is rarely easy, but can be facilitated by addressing known organizational and individual factors and using a research utiliz
ation framework.
Other individuals and organizations have tackled the "how comes" head on - and turned them into "why nots" - "why not do it?" or "just do it". The "why nots" have included:
Putting our efforts into mobilizing a supportive environment for quality nursing care - care that uses research findings appropriately - can have far reaching effects in promoting the health of children and their families - that's what we are all about.