Evidence-Based Practice and Research Utilization Activities Among Rural Nurses

Clinical Scholarship

Evidence-Based Practice and Research UtilizationActivities Among Rural NursesRosaline A. Olade

Purpose: To identify the extent to which rural nurses utilize evidence-based practice guidelinesfrom scientific research in their practice; to describe both previous and current researchutilization activities in which they have participated, and to identify the specific barriersthey face in their practice settings.

Design and Methods: Data for this descriptive study were collected through questionnaireswith open-ended questions focused on (a) current utilization of nursing research findings,(b) previous involvement in nursing research activities, and (c) participation in medicalresearch activities. The participants were 106 nurses from various practice areas in sixrural counties of a southwestern state in the United States.

Findings: Results revealed that only 20.8% of the participants stated they were currentlyinvolved in research utilization, and they were mostly nurses with bachelor’s degrees. Thetwo most common areas of current research utilization were pain management and pressureulcer prevention and management. Barriers to research utilization, such as rural isolationand lack of nursing research consultants, were identified.

Conclusions: The types of research utilization activities identified by these nurses indicatehow much the facilities in which these nurses work in the rural areas are striving with theutilization of available scientific evidence. Rural nurses face unique barriers related to sit-uational and geographic factors, with implications for nursing administrators, researchers,and educators.

JOURNAL OF NURSING SCHOLARSHIP, 2004; 36:3, 220-225. C©2004 SIGMA THETA TAU INTERNATIONAL.

[Key words: rural nurses, research utilization, research activities, evidence-based practice]

* * *

D espite increased focus on evidence-based practice inrecent years, information is lacking about utiliza-tion of research findings for evidence-based practice

(EBP) among nurses in rural areas. Many studies on researchutilization in the past have been conducted in urban settings.The farther one ventures away from large urban medical cen-ters, the less one hears about research utilization activitiesfor EBP in nursing. If nursing is to be truly an evidence-basedprofession, improving utilization of research findings in clin-ical practice not only must remain within urban-based largehospitals but also must be part of nursing practice in anygeographic location. The study reported in this paper wasfocused on research utilization activities of licensed nursesand the specific barriers these nurses faced in rural areas.

Background

The gap between conducting research and translatingit into nursing practice has existed for at least the lastquarter of a century (Abdellah, 1970; Lindeman, 1975).

However, in the last decade, the disparity between conduct-ing research and integrating it into practice has becomean international nursing concern. This situation led theInternational Council of Nurses (ICN) to form the TaskForce on Nursing Research in 1990 to deliberate a world-wide priority agenda on nursing research (InternationalCouncil of Nurses, 1990). Although nurse researchers havecontinued to conduct clinically relevant nursing researchstudies, the gap between research and practice remains (Beroet al., 1998; Bostrom & Wise, 1994; Chulay, 1997; Hewison& Wildman, 1996; Mulhall, 1997). In a national studyfocused on the state of research utilization in nursing, Omery

Rosaline A. Olade, RN, PhD, FWACN, Gamma Pi , Associate Professor,University of Nebraska Medical Center, College of Nursing, Omaha, NE.Correspondence to Dr. Olade, University of Nebraska Medical Center, Col-lege of Nursing, 985330 Nebraska Medical Center, Omaha, NE 68198-5330.E-mail: [email protected]

Accepted for publication February 3, 2004.

220 Third Quarter 2004 Journal of Nursing Scholarship

Research Utilization among Rural Nurses

and Williams (1999) concluded that the way nurses are edu-cated was a barrier, especially at the staff nurse level, wherenursing research is not included in the curriculum.

In the last few years several editorials in nursing jour-nals in the United States, Canada, the United Kingdom, andAustralia have called for EBP among nurses (Bliss-Holtz,1999; Pearson, 1997; Simpson, 1996). The creation of cen-ters to gather and disseminate evidence reports, such as thePractice Guideline Clearinghouse at the Agency for Health-care Research and Quality (AHRQ) in the United States, theCochcrane Collaborative Library in Europe, and the JoannaBriggs Institute for evidence-based practice in Australia, in-dicate the priority on EBP guidelines.

Trends in Research Utilization for Evidence-Based PracticeResearch utilization, which is the translation of research

findings in practice, is a concept that has been emphasizedin nursing since the early 1970s. Nursing leaders such asAbdellah (1970) and Lindeman (1975) called for using sci-entific evidence from research to improve the quality of carein nursing practice. By the mid-1970s, two research uti-lization projects had been launched. The Division of Nurs-ing launched the 6-year WICHEN project (Western Inter-state Commission for Higher Education in Nursing) andthe 5-year CURN project (Conduct and Utilization of Re-search in Nursing) was launched by a state nursing orga-nization. Those projects formed a solid foundation for re-search utilization models in the US (White, Leske, & Pearcy,1995). In the early 1990s, the American Association of Crit-ical Care Nurses (AACN) launched the Thunder project.That study was focused on use of intravenous nonheparinflush solutions and generated scientific evidence for cost-effective nursing practice (American Association of CriticalCare Nurses, 1993). Efforts at developing more relevant re-search utilization models to enhance the use of scientific andother sources of evidence have continued (Camiah, 1997;Olade, 2002; Stetler, 2001; Titler et al., 2001). As notedby Estabrooks (1999), the terms research utilization andEBP have often been used interchangeably, even though theyare not synonymous. Research utilization refers only to us-ing findings from research studies; EBP is a more generalterm for many sources of evidence. Stetler, Brunell, Giu-liano, Morsi, Prince, and Newell-Stokes (1998) emphasizedthat EBP encompasses more than research utilization. Theynoted that practice could be based on (a) evidence from vari-ous sources such as performance data obtained from qualityimprovement initiatives, (b) consensus recommendations ofrecognized experts, and (c) affirmed experiences, in additionto scientific research findings. However, the evidence pro-vided through research is still the most scientifically based.As Bliss-Holtz (1999) noted in an editorial: “Whereas re-search utilization is one of the several ways by which onecan come to evidence-based practice, nursing leaders shouldwork on mapping out each of the other avenues of evidence,at least as clearly as the routes to research utilization hadbeen charted” (p. 4).

Motivations for Research UtilizationEfforts have been made over the years to identify barriers

as well as facilitators, in regard to research utilization amongpracticing nurses (Funk, Tornquist, & Champagne, 1995).These barriers have included lack of time, lack of staff, lackof access to research information, lack of research knowl-edge among nurses without university education, lack of ad-ministrative support, and lack of authority to change prac-tice (Estabrooks, 1999; Hatcher & Tranmer, 1997; Kajermoet al., 2000; Le May, Mulhull, & Alexander, 1998; Olade,2003; Parahoo, 2000; Tsai, 2000). Factors that facilitate re-search utilization in practice include administrative commit-ment and support, knowledge of research process, favorableresearch attitude, affiliation with a university, and financialresources (Estabrooks, 1999; Kajermo et al., 2000; Olade,2001; Pettengill, Gillies, & Clark, 1994; Rizzutto, Bostrom,Suter, & Chenitz, 1994; Rodgers, 2000; Tsai, 2000). Ac-cording to Crane (1995), closer ties between academic andservice institutions enhance research utilization. Tsai (2000)noted that the university affiliation and high level of ed-ucation among nurses might have accounted for the highnumber of nurses (64%) who reported involvement in re-search activities in their institutions. Rodgers (2000) noted,however, that most studies to assess research activities havehad experimental designs or close-ended questionnaires, andalso qualitative studies are important.

More efforts are needed to enable all nurses, includingthose in rural areas, to use the available scientific evidencefor evidence-based nursing care. Thus, this study was con-ducted with these objectives: (a) identify the extent to whichnurses utilized research in their practice in rural areas; (b)describe both previous and current research utilization ac-tivities in which nurses have participated; and (c) identifynurses’ perceived needs for future research in their practicesettings in these rural areas.

Rogers’ theory of innovation diffusion, indicating a time-ordered sequence of stages through which individuals passas they adopt new ideas, practices, or behaviors, was the the-oretical framework for this study. Rogers (1983) describedfive stages of the diffusion process: (a) knowledge, (b) per-suasion, (c) decision, (d) confirmation, and (e) implementa-tion. The adoption process includes these five stages whenincorporating innovation into daily activities. Diffusion ofinnovation occurs when nurses eventually apply researchfindings in clinical practice. Rogers indicated that both theadopter’s individual characteristics and practice setting char-acteristics, such as bureaucratic structure and system norms,influence the rate and extent of diffusion. Nurses in rural ar-eas, in addition to their personal characteristics, may havepractice setting characteristics that are unique to their geo-graphic locations that may affect research utilization. Thecritical stage in which the innovative action takes place isthe implementation stage, when research findings becomeutilized. How rural practice settings have affected the extentof research utilization among these nurses is an importanttopic for study.

Journal of Nursing Scholarship Third Quarter 2004 221


Methods

This descriptive study was focused on research utilizationactivities among rural nurses (N=106) in various practice ar-eas in a southwestern state of the United States. Responsesto a questionnaire containing open-ended questions allowedus to assess the specific research utilization activities amongnurses. The questionnaire was designed by the investigatorand was verified for content validity by two doctoral nurses,two RNs, and a sociologist. The questions pertained to (a)current utilization of nursing research findings, (b) previousinvolvement in nursing research activities, and (c) partici-pation in medical research activities. After approval by theinstitutional review board, the questionnaires with cover let-ters were distributed randomly to many practice settings inthe six surrounding rural counties through graduate studentswho came from those counties. Nurses were encouraged topick up the questionnaires from their units. Participationwas voluntary and confidentiality of information was main-tained through anonymity. Completed questionnaires weresent directly by participants to the investigator in a pread-dressed envelope attached to each questionnaire.

Content analysis of the data was performed for open-ended questions (Bogdan & Bilken, 1982). A common cod-ing frame that categorizes responses was designed, withmain categories and subcategories constructed for eachquestion. Responses were tabulated manually to form astructured data matrix of rows and columns. Frequencieswere generated for the responses to each research activ-ity identified. Reliability and validity checks were under-taken by having two nursing researchers and a sociologistread through the transcripts to verify the categories. Fre-quencies of the demographic characteristics were performedusing SPSS.

Findings

Of the 120 questionnaires distributed, 106 were returnedfor a response rate of 88.3%. Participants’ ages ranged from21 to over 50, with 18% less than 30 years old. About 32%of the participants had bachelor’s degrees, 50% were staffnurses, and over 73% had more than 5 years of experience.Nurses practicing in hospital settings constituted 64.2% ofthe sample.

Because less than half of the participants had universityeducation, data were further examined to determine wherenurses first learned about nursing research. Over 26% ofthe participants reported that they heard about nursing re-search in their associate degree programs. However, theiraccompanying comments revealed that they did not learnthe research process in any specific course. Twelve percentsaid they first learned about research during practice, but11% of the participants said they did not have any researchknowledge.

Extent of Involvement in Research UtilizationRespondents said they had participated more in research

utilization in the past than they did at the time of study. Al-

though 44 (41.5%) of the participants reported participat-ing in nursing research utilization in the past, only 20.8%(n=22) were currently involved in research utilization. Ofthose 22 nurses, 14 had BSN degrees. The remaining par-ticipants gave various reasons for not currently utilizing re-search in their clinical practice. These nurses commentedabout the isolation from nurse researchers, or from anynurse with experience in research utilization that could beviewed as a role model. They emphasized that having some-one around with research ability and experience to guidethem would boost their ability to utilize research findings.However, 42% of the participants reported that they hadnever participated in research utilization in their entire nurs-ing career.

Research Utilization Activities for Evidence-Based NursingParticipants were asked to disclose the research findings

implemented in the past as well as those they were currentlyusing in their practice. These research activities were thencategorized as (a) clinical patient-focused interventions and(b) nonclinical interventions, as presented in Tables 1 and 2.

Current research utilization activities. The two most com-mon areas of current research utilization were pain man-agement and pressure ulcer prevention and management, asshown in Table 1. In the area of pain management, thesenurses mentioned the use of the research findings on EMLAcream, general pain, and chest-pain management protocols.The use of the Braden scale and various wound managementprocedures were some of the measures mentioned regardingpressure ulcer research utilization. Patient education wasanother area in which these nurses utilized research find-ings, specifically for childbirth education, self-breast exam-ination, and relaxation techniques. Participants emphasizedtheir use of findings on nonheparin saline flushes for costeffectiveness, and said it was the one research utilization ac-tivity strongly supported by nursing administrators in theirfacilities.

Past research utilization activities. Participants reportedmore types of utilization activities in this section, as shownin Table 2. However, half of them pertained to the use ofnonheparin saline flushes and pain management protocols.

Table 1. Current Nursing Utilization Activities (n=22)

n

Clinical patient-focused interventionsPain management 5Pressure ulcer prevention and management 4Patient teaching 3Intravenous saline flush 3Emergency room service 1

Nonclinical interventionsNursing education 1Management policy 1Occupational health 1No specific activity listed 5



Table 2. Past Nursing Utilization Activities (n=44)

n

Clinical patient-focused interventionsIntravenous saline flush 16Pain management 6Use of restraints 4Wound management 4Alzheimer care 4Positioning patients 2Breastfeeding and discharge instructions 2Bathing newborn 2AIDS prevention and long-term care 2Dressing for operating room 2Emergency room triage 2Infection control 2Blood pressure procedure 2Clinical pathway for surgery patients 2

Nonclinical interventionsAssertiveness and delegation studies 2Role of research nurse in clinical trials 2Improving clinical follow-up in national registry 2

In addition to these listings, many of these nurses includedcomments such as: “What we do is the result of some kindof research.” “Most of the findings that I have used, I foundexperimentally works.” “Our nursing policies are research-based and are updated yearly with current literature.”

One of the participants, a nurse practitioner, commented:

My entire practice is based on nursing research. I started workingin 1968. . . . I think of Florence Nightingale and her research. Allaspects of nursing can be traced to research. Some may not realizethis, but I can justify anything I do by one of the multiple nursingtheorists. I found that involving nurses in actual projects assiststhem to see that others have addressed the same problems and thatresearch is important and can be fun.

Participation in Medical Research ActivitiesData collection for medical research was the most com-

mon research activity reported by these participants. Ap-proximately 65% of them had participated in this activ-ity. The list was too numerous to display here. Over 75%of the research activities involved clinical drug trials. Thenurses involved in these medically related research activitieswrote eloquently about their involvement and how physi-cians have integrated some of the findings in their practicesettings. Other comments included: “I assist in the data col-lection for investigational clinical drug studies, I am cur-rently trying to apply what I learned from medical researchto nursing practice.” “The GUSTO trials changed nurses’triage and times for acute MI (myocardial infarction) pa-tients in ER (emergency) settings.” “The results of publishedresearch are utilized in updating the acceptable OR (oper-ating room) standards where I work. Changes regardingOR attire, traffic, fingernails, sterilization, and expiration

dates.” “I worked with [a] physician during nutritional sup-port research. We integrated many aspects into practice andmade many changes in policies.”

Their comments indicated that many were not able to dis-tinguish between nursing and medical research; some of thefindings listed as medical research were actually findingsfrom nursing studies.

Future Research Utilization for Evidence-Based PracticeWhen participants were asked if they would be interested

in utilizing nursing research in their practice in the futureif given the opportunity and support, 76.4% of them re-sponded affirmatively. One participant who said “No,” ex-plained, “I do not have the time to do my job the way Iwas trained. It would not be fair to include research as amandatory part of my job.” When asked to identify areas oftheir practice in which they would like to see more nursingresearch applied in their practice settings, they identified sev-eral topics for research. These topics were then categorizedas six main themes: (a) nursing outcomes, (b) psychosocial,(c) staffing and quality of care, (d) health care cost analy-sis, (e) policy and procedure, and (f) nursing education andresearch. These types were further subdivided as patient-centered and non-patient-centered activities, as shown inTables 3 and 4.

Barriers to participation in research utilization that wereidentified included lack of time because of poor staffing,

Table 3. Perceived Needs for Patient-Centered Research

Nursing outcomes• “To measure the effectiveness of implemented programs to decrease

emergency room visits and admissions to hospital”• “How interactions affect behavior and motivational compliance”• “Pain relief and IV start with regards to the pediatric patient”• “Occurrence or reoccurrence of infection in patients”• “Outcome studies and nursing interventions”• “Patient outcomes—do patients that participate in a clinical drug trials

receive better nursing care?”

Psychosocial• “Applications of holistic health”• “Improved organization to increase RN-patient interaction time”• “Psychiatric and nursing care for psychiatric patients with medical

problems”• “Oncology and rehabilitation care in elderly geriatric patients, using

respect to see them as reliable human beings”• “Ways to improve communication among all disciplines for better patient

care”• “How to measure if the patient was truly informed during the informed

consent process”• “Children with mothers on illicit drugs—how they fare with school,

health, behavior, etc.”

Staffing and quality of care• “Risk of decreased RN-to-patient ratio”• “Quality of care related to level of nursing staff”



Table 4. Perceived Needs for Non-Patient-CenteredResearch

Health care and cost analysis• “Recovery speed in pediatric patients hospitalized vs. receiving home

health care”• “Home health cost vs. benefit, patient healing faster at home”• “Time saved using computer narcotic distribution system”• “Follow up on patient’s medications and their effectiveness”

Policy and procedure• “Critical paths”• “Enforcing visiting hours in CCU”• “Time management, cost effectiveness in order to establish protocols for

care in certain conditions”

Nursing education and research• “Nursing research related to learning needs of nursing students”• “Multimedia learning in nursing”• “Greater understanding of how staff nurses view their role in clinical

research”

lack of research knowledge, lack of interest of nursing ad-ministrators, lack of financial resources and organizationalsupport, isolation from nurse researchers, lack of researchconsultants, and lack of experienced nurses to serve as rolemodels for research utilization. Participants commented:“The only research we hear of around here comes from thedoctors and pharmacists,” and “Common sense tells me thatthe findings in medical research are used daily, but I have notdirectly taken part in any research.”

Discussion

In this study, only 20.8% of the participants were cur-rently involved in research utilization. This number is rela-tively low compared to other studies conducted in the US,Canada, China, and Europe (Estabrooks, 1999; Omery &Williams, 1999; Parahoo, 1998; Retsas & Nolan, 1999;Rizzutto, 1994; Tsai, 2000; Walczak, McGuire, Haisfield,& Beezley, 1994). Comments of some participants that theywere not sure that nurses do research indicate the need formore nurses practicing in rural areas to be educated aboutusing scientific evidence in practice. In addition, some be-lieved that physicians had conducted the research that hasbeen integrated into nursing practice. This finding has notbeen commonly reported from other studies, and it might berelated to the isolation of these nurses in rural areas awayfrom university or urban medical centers where many largenursing research studies are conducted.

Nurses with BSN degrees in this study were a large pro-portion of those involved in current research utilization ac-tivities. Some of these BSNs commented on the lack of expe-rienced nurses with research backgrounds with whom theycould consult. They believed that having such role mod-els or consultants would enhance the use of research in

their practice settings. The issue of isolation and lack ofrole models appeared in almost all their comments, andseemed to be more pronounced in this study of rural nursesthan has been reported from any previous study (Nilsson,Nordstrom, Krusebrant, & Bjorvell, 1998; Parahoo, 2000;Pettengill et al., 1994; Retsas et al., 1999). The reasons givenby nurse leaders in this study for not currently participatingin research utilization were “no time” and “no budget forresearch.” According to Omery & Williams (1999), unlessnursing leaders believe in research utilization and promotea culture to support those activities, research utilization willfail to become a value in nursing.

The types of research utilization activities identified bythese nurses in rural areas indicate some important areas ofpractice, including pain management, pressure ulcer preven-tion and management, patient teaching, intravenous salineflush, and use of restraints. Many participants emphasizedhow cost-effective the nonheparin saline flush was, and howadministrators actively supported the utilization of this sci-entific evidence in their facilities. The effect of regulations byJCAHO to integrate best practices in these areas is obviousin the identified research utilization activities. Still disheart-ening, however, was that less than 21% of the participants inthis study were involved in utilizing available scientific evi-dence in their practice, a proportion considerably lower thanin studies conducted in urban settings (Estabrooks, 1999;Kajermo et al., 2000; Pettengill et al., 1994; Rizzutto et al.,1994; Rodgers, 2000; Tsai, 2000). The negative comment ofone of the nurses, that research utilization was part of herjob, shows that the value of research in nursing is not a real-ity for some nurses. Research to those nurses remains morean academic exercise than a way to practice innovation.

Education has been one of the reported facilitators of re-search utilization. The fact that most of those involved inthe research utilization activities had BSN degrees is con-sistent with previous studies that education is important inresearch utilization in practice settings (Brown, 1997; Funket al., 1995; Kajermo et al., 2000; Parahoo, 2000; Pentengillet al., 1994; Rizzutto et al., 1994; Rodgers, 2000). It alsois consistent with Rogers’ (1983) model that the knowledgestage is a prerequisite for the implementation stage in utiliz-ing innovations. Those who were involved in research uti-lization activities showed a feeling of achievement in the waythey discussed their research activities, and over 75% of theparticipants showed desire for future utilization of researchfindings in their practices.

Conclusions and Implications

The findings of this study add to the existing knowledgeof research utilization by nurses in rural areas. Strategies areneeded to help nurses in rural areas to integrate evidence-based guidelines in their practice. The quality improvement(QI) committee in each health organization could facilitatethe use of scientific findings by documenting the degreeof adherence to EBP guidelines that were integrated into



practice in their own organizations. Such a requirementcould help build a culture in which research is valued, sothat EBP becomes the norm among nurses and nurse lead-ers, regardless of the geographic locations of their healthfacilities.

To increase research utilization in rural areas, the valueof research utilization should be emphasized in all levels ofnursing education. Collaborative efforts are needed amongnursing administrators, researchers, and educators in neigh-boring urban areas, making use of available advanced tech-nology in distance education. Nursing administrators candemonstrate that research utilization is a valued aspect ofEBP by including money for research in their budgets. Wherepossible, an experienced research coordinator should be onsite to consult with nurses to initiate research utilization ac-tivities and enhance EBP. When a small rural hospital couldnot afford this, it could pool resources with other area fa-cilities to hire a research consultant whose time would beshared among the rural facilities. Short consultative visits inaddition to supportive consultation through various long-distance learning media could help reduce the research iso-lation of nurses in rural settings.

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Evidence-Based Practice and Research Utilization Activities Among Rural Nurses