Putting Evidence Into Practice: Does the Workplace Really Matter?

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  • 32 2007, AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses Volume 11 Issue 1

    in in uencing the ability of nurses to apply

    research evidence to their practices.

    To begin, lets 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, weve 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 bene ts to research-based practice? to

    the dilemmas of using evidence that doesnt

    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 Womens 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

    componentsresearch, 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 bene 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, well 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

    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 in uence organiza-

    tional context has on practitioners research use

    behaviors. In addition, lack of understanding

    regarding the in uence of context in research

    use is one of the greatest barriers to using

    research in clinical practice. Speci 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 identi ed the organizational envi-

    ronment, or context, as an important factor

    in uencing research use and health care

    professionals behaviors (Brett, 1987, 1989;

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

    havent examined the in 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-

    tions 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 Womens 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 organizations context and refers to

    leaders approaches to managing con 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-

    textthat is, when there are receptive cultures,

    strong leadership and appropriate evaluative

    systems.

    In 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

    in uences the research-use behaviors of prac-

    titioners (see Box 2). First, the organizational

    approach to work in uences how practitioners

    do or dont use research in their practice. In

    much of nurses work, the researchers found a

    strong organizational preference for doing

    and looking busythat is, doing tasks is valued

    over developing relationships with patients and

    re ecting on ones 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 In uence Research Use

    1. The organizational approach to work influences how practitioners do or dont 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 organizations culture influences what types of knowledge are perceived as important or rel-evant, and which health care professionals (e.g., doctors, nurses) think its 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 Womens Health 35

    however, requires opportunities and time for

    nurses to re ect on their clinical practices and

    to keep abreast of research relevant for their

    practices.

    Second, the researchers found that cul-

    ture in uences what types of knowledge are

    perceived as important or relevant, and which

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

    think its acceptable to use research for guiding

    practice decisions. Re 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

    were convinced that most nurses would agree

    that their work setting shapes the decisions they

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

    tional priorities and values) and how theyre

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

    accessibility of resources). There are organi-

    zational or institutional reasons why nurses

    do or dont 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 bene 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

    todays health care institutions remains at the

    bureaucratic level (management-level decision

    makers), leaders at the hospital unit level where

    nurses work have a signi cant role. The work-

    place does matter! NWH

    In the next Evidence & Outcomes column, well

    focus on strategies nursing leaders can use to cre-

    ate work environments that foster research use.

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

    ndings. Nursing Research, 36(6), 344349.

    Brett, J. (1989). Organizational integrative mecha-nisms and adoption of innovations by nurses. Nursing Research, 38(2), 105110.

    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 in uence nurses use of research? Journal of Wound, Ostomy and Continence Nursing, 31(3), 106107.

    Kitson, A., Harvey, G., & McCormack, B. (1998). Approaches to implementing research in prac-tice. Quality in Health Care, 7, 149159.

    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), 94104.

    Rycroft-Malone, J. (2004). The PARIHS frame-workA framework for guiding the implemen-tation of evidence-based practice. Journal of Nursing Care Quality, 19(4), 297304.

    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), 174180.

    Scott-Findlay, S., & Golden-Biddle, K. (2005). Un-derstanding how organizational culture shapes research use. Journal of Nursing Administration, 7/8, 356362.

    Stetler, C. (2003). Role of the organization in translating research into evidence-based practice. Outcomes Management, 7(3), 97105.

    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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