Nursing and Health Sciences

(2002),

4

, 89–95

Research Article

Blackwell Science, LtdOxford, UKNHSNursing and Health Sciences1441-07452002 Blackwell Science Asia Pty Ltd

43

111Utilization of research evidence

H. Edwards et al.

10.1046/j.1441-0745.2002.00111.x

Research Article8995BEES SGML

Correspondence address: Dr Helen Chapman, School of Nursing,Queensland University of Technology, Kelvin Grove Campus, LockedBag No. 2, Red Hill, Qld 4059, Australia. Email: h.chapman@qut.edu.auReceived 29 October 2001; revised 14 February 2002; accepted 14March 2002.

Utilization of research evidence by nurses

Helen Edwards,

RN

,

P

h

D

, Helen Chapman,

RN

,

E

d

D

and Leigh M. Davis,

RN

,

BN

(

H

ons)

,

P

h

D

candidate

School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia

Abstract

This paper challenges the hegemony (the mindset prevailing within education and health-careenvironments) that produces and maintains the problems associated with nurses using researchevidence in their practise. The challenge is organized around the construct of change. The envis-aged changes concern what nurses think and do in relation to nursing research. The position heldin the present paper is that the use of research evidence by nurses in their practise will remain achallenge until changes occur to the ways that nurses understand, value and initiate research. Itis argued that changing the ways that nurses understand, value and initiate research requires anideological shift: a re-education from one set of beliefs, perceptions, values and practises toanother. The paper concludes with some suggestions for transforming the hegemonic influencesof nurse education systems and the health-care organizations in which nurses work.

Key words

change, hegemony, ideological shift, research utilization.

INTRODUCTION

The term ‘evidence-based practise’ is becoming abuzz word within nursing. The need for qualitypatient outcomes and cost-effective care has made itessential that nurses base their practise on researchevidence. The notion that research-based knowledgeis necessary to improve clinical practise is not new.Ever since Florence Nightingale used research evi-dence to bring about vital changes in the delivery ofhealth care (Roberts & Taylor, 1998), research hasbeen increasingly recognized as an essential basis fornursing knowledge and practise development. Today,nursing research constitutes an extensive body of lit-erature that will indubitably continue to flourish asthe nursing profession responds to current demandsfor evidence-based practise, a practise underpinnedby research utilization. However, despite an increasein research output, utilization of research evidence bynurses in clinical settings remains a challenge.

PREVAILING RESEARCH CULTURE

A research culture develops in tandem with researchparticipation, research dissemination and utilizationof research evidence. These pursuits demand suchcapabilities as knowledge justification and verifica-tion, critical inquiry and investigation, and scholarlywriting, interpretation and discourse. Academic nurseeducation has positioned nurses to not only acquirethese capabilities but also to develop a positiveresearch culture in the sense that across all areas ofnursing, ‘research is perceived favorably and usedpro-actively by the majority of practitioners’ (Le May

et al.

, 1998). However, there is evidence to suggestthat research activities, such as participation, dissemi-nation, and utilization of research evidence, are stillnot perceived favorably or used proactively by themajority of nurses.

Recent Australian reports and reviews on variousaspects of nursing education provide examples of thismarginalization and devaluing of research activities.One purpose of an early review (Reid, 1994) was torecommend measures for improving the effectivenessof nurse education. In a chapter dealing with aca-demic staff and research, six recommendations weremade that focused on staff development, researchfunding, and scholarships to encourage and developresearchers in nursing. A very recent report notesthat there is no evidence of implementation of the

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vast majority of these recommendations (Johnson &Preston, 2001).

Another example from Australia of research inac-tivity by nurses is provided by a 1996 research study.Although 91% of nurse respondents agreed that nurs-ing research was necessary to improve clinical prac-tise, only 30% had conducted research and, perhapsof more import in the light of current demands forevidence-based practise, only 15% regularly readresearch (Wright

et al

., 1996). Results of a UK study(McSherry, 1997) demonstrated that although 92.5%of the nurse participants were in agreement withresearch-based practises, 62.5% had a poor under-standing of the research process.

Furthermore, it has been determined that clinicianstend to construe nurse researchers as ‘ivory tower’academics who generally pursue theoretical ratherthan practise goals with subsequent research findingsthat are not applicable to practise issues (Hicks &Hennessy, 1997; Clarke & Proctor, 1999; Le May

et al.

, 1998; Upton, 1999). While opinion about theposition of research activity within professional prac-tise ranges from being an essential and necessarycomponent of practise to being exclusively theresponsibility of outsiders (Clarke & Proctor, 1999),generally nurse clinicians view research as separate topractise (Burrows & McLeish, 1995).

Research evidence also suggests that when nursesdo participate in research they tend not to submittheir work for publication. One study revealed thatonly 58% of the participants wrote up their researchand of these, only 10% submitted for publication withonly 9% being successful (Hicks, 1995). Researchknowledge, as with any other form of knowledge, isarguably of little consequence if it is not reported andused. For nursing research this argument can beextended to infer that research knowledge is of littlevalue if it is not used to improve patient care(LoBiondo-Wood & Haber, 1998). This extendedargument assumes further significance in light of theclaim by Hicks (1995) that there is a shortfall in boththe quantity and quality of published research withthe capacity to alter practise.

From these research findings it can be deduced thatnurses generally hold negative attitudes towardsresearch; that the majority of clinical nurses perceiveresearch to be something apart from their practiseand, in the research they do read, find little to informtheir practise. Such deductions have important impli-cations for the utilization of research evidence bynurses in clinical settings.

The position held in the present paper is that theuse of research evidence by nurses in their practisewill remain a challenge until changes occur to the

ways that nurses understand, value and initiateresearch. It is argued that changing the ways thatnurses understand, value and initiate research willrequire an ideological shift: a re-education from oneset of beliefs, perceptions, values and practises toanother. Essentially, the present paper is coming froma position that contests the hegemony—the mindset—prevailing within nurse education systems and health-care organizations that produces and maintains theproblem.

AN IDEOLOGICAL SHIFT

Hegemony may best be thought of as:

. . . an ongoing ideological control which is takenfor granted by social members. Hegemony can besaid to occur when certain groups have unequalpower over other groups, and benefit from thisinequality, and this situation is presented as rightand normal, historically defined (Foster, 1986).

Within nurse education systems and the health-careorganizations in which nurses work the effects of the‘ongoing ideological control that is taken for granted’is so pervasive that its influence may not even be rec-ognized. ‘Ideology, as a set of beliefs and practises,influences every aspect of our experience and the waywe make sense of that experience’ (Lovat & Smith,1995). Hegemony is the process through which theknowledge and messages associated with the world-view of the dominant group are imposed and willinglyaccepted; a circumstance not unusual in environmentsthat are hierarchical.

Either consciously or, more often, unconsciously,the selection of knowledge, and the representa-tions of this . . . present a particular view ofevents, actions and relations. In so doing, theinterests of some . . . are protected and enhancedat the expense of others. (Lovat & Smith, 1995).

Changing the ways that nurses understand, valueand initiate research will thus require an ideologicalshift: a re-education from one set of beliefs, percep-tions, values and practises to another.

The envisaged changes are about what nurses thinkand do in relation to nursing research. From the per-spective taken in the present paper, the changes areinextricably connected with individual nurses andtheir personal constructs: how they make sense of,and view, their world. Although the changes areessentially cognitive, structural change will also berequired because changing entrenched and traditional

Utilization of research evidence 91

practises requires ‘more than a change in beliefs, itrequires a change in the structures which have signifi-cantly conditioned and shaped those beliefs’ (Smith,1993).

Two structures responsible for conditioning andshaping beliefs about research are nurse educationsystems and the health-care organizations withinwhich nurses work. However, this argument is circu-lar and somewhat paradoxical in the sense that struc-tural change is dependent on individual changebecause ‘organizations learn only through individualswho learn’ (Senge, 1990), or as Fullan (1993) argues,systems do not change by themselves; people changesystems. Thus, it is the hegemony—the mindset—prevailing within nurse education systems and health-care organizations that produces and maintains theproblem, which becomes the major barrier to change.

All of this strongly implies that, to be successful,any change strategy aimed at enhancing the use ofresearch evidence must incorporate the subjectiverealities of nurse clinicians. It also implies that thebarriers to change in the ways that nurses understand,value and initiate research can effectively bebreached through a change in individual mindset.While it is increasingly acknowledged that researchutilization is an organizational issue as much as it isan issue for the individual practitioner (Muir Gray,1997; Roberts & Taylor, 1998), organizational changecomes only after change in the mindsets that aremaintaining the status quo. The envisaged changeswill be difficult and not without conflict; nor will theyoccur overnight. However, unless nurse leaders advo-cate change in the ways that nurses understand, valueand initiate research, use of research evidence byclinical nurses is likely to remain problematic.

INFLUENCE OF SYSTEMS AND ORGANIZATIONS

Nurses acquire the knowledge, skills and competen-cies they need to begin to practise nursing duringtheir basic undergraduate education; it is then thatthey begin to understand the real world of nursing. Itis through education that they become aware of what‘learning and understanding in the discipline consistsof’ (Ramsden, 1992). For example, contemporarynursing deems it essential that students acquire ‘thebroad knowledge base and analytical ability to makeinformed decisions about care and its managementsoundly based on research rather than merely customand practise’ (Jinks, 1991). Thus, during initial nurseeducation, students are introduced to the fundamen-tal concepts and skills of evidence-based practise.

As students they are introduced to criticalapproaches to problem identification and decision-making, to information search and retrieval skills, toresearch processes and methodologies, and to criticalapproaches to the reading and evaluation of researchevidence. Furthermore, justification of performancebased on conceptual, theoretical or research evidenceis intrinsic to the nature of academic work. Assign-ments, for example, must be based on evidence fromthe literature and, during clinical practicums, studentsmust base clinical decision-making and specific nurs-ing interventions on relevant theory or research evi-dence. The inclusion of content of this nature withinformal curricula is not up for question. However,unintended curricula may be delivering other mes-sages, not only in formal classroom contexts but alsoin other environments in which teaching and learningtakes place.

The hidden curriculum

The unintended curriculum is hidden and not explic-itly intended (Print, 1993; Glatthorn, 1999). Part ofthe hidden curriculum consists of the values and atti-tudes transmitted by those with whom we come incontact. Consider for example the effect registerednurses, doctors and other health professionals have onstudents during clinical practicums. The values andattitudes transmitted in the ‘real’ world of nursing—the workplace—tend to have a stronger influence thanthe official curriculum or intentional learning trans-mitted in the classroom. Therefore, many of the val-ues, attitudes and beliefs that are internalized duringclassroom learning tend to be modified or changed inkeeping with those of the work setting. This modifica-tion is often necessary in order for the student toescape the unpleasant feelings associated with cogni-tive dissonance, a state that unfortunately is likely toarise whenever orientating to a new clinical area.

This is not to imply that internalizing establishednursing culture is not a desired goal for nurses.Rather, the transmission of important aspects of cul-ture is a primary function of education. A culturetends to be self-perpetuating: it defines ‘the way wedo things around here’ (Simonsen, 1997). It is by‘internalizing the definitions, assumptions, and arbi-trary typifications taken for granted and communi-cated by significant others’ that we become socializedinto a culture (Mezirow, 1991). However, when learn-ing the way we do things around here—that is, whenbeing socialized into a culture—it is important thatthe capacity to think critically and to distance oneselfin order to make judgments has been developed orelse mere socialization occurs.

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Without the capacity to think critically and to dis-tance oneself in order to make judgments the atten-dant danger when entering a new culture is thatexisting practises and beliefs will be seen as unchal-lengeable and unchangeable. For example, nurse clini-cians work in environments that are generallybureaucratic and which promote consistency and con-formity to routine with an emphasis on completingtasks rather than on considerations of best practise(Roberts & Taylor, 1998). Within such environments,where economic conservatism and emphasis on strat-egies for reducing health care expenditure predomi-nates—where cost-effectiveness and outcomes are thedriving forces—there may be many existing practisesand beliefs deserving challenge and question. Forinstance, if ‘the way we do things around here’ is notto value research, and the capacity to evaluate the sit-uation critically (to challenge existing practises andbeliefs and uncover underlying assumptions) is notdeveloped in the newcomer, it is likely that socializa-tion into ‘the way we do things around here’ willquickly occur.

Much of the pervasive power of a hidden curricu-lum comes from the fact that it is hidden; that it isusually not recognized, much less discussed or chal-lenged. Despite what is written in formal curricula, itis clear that hidden curricula also influence what clini-cians (first as students and then as registered nurses)learn and understand in order to practise nursing.However, within any environment much of the powerof hidden curricula would be dissipated if questionswere raised not only about what is being done, butalso about why it is being done, how it is being done,and how it could be improved. If these sorts of ques-tions formed the basis for open and honest debate byall stakeholders, then ‘the way we do things aroundhere’ is likely to be founded on critical and contem-porary thinking and the existing state of affairsactively chosen, not just passively tolerated.

The hegemonic influence of nurse education sys-tems and workplace environments does not stop withhow nurses learn and understand about fundamentalnursing concepts and skills such as research and evi-dence-based practise. It also impacts on the meaningthat nurses attach to the term ‘research’, and howthey value and approach research.

Meaning of ‘research’

Humans are born with the inherent need to exploretheir environment (Reio & Wiswell, 2000) or to deter-mine the who, what, why, how, or when of some phe-nomena, and since time immemorial, humans haveengaged in inquiry to find answers. Today there are

many different theories of knowledge and interpreta-tive frameworks to guide those who engage in inquir-ies in order to investigate and understand the world.However, most, if not all, of the methodologies canbe subsumed under one or other of two paradigmsthat essentially represent polar views: the quantitativeresearch paradigm (also known as the positivist tradi-tion) or the qualitative research paradigm (alsoknown as the naturalistic tradition). The differentunderstanding between these two paradigms largelydepends on how we see our world; how our beliefs,values, and attitudes influence our perspective.

Regardless of perspective, ‘research’ is generallyunderstood in terms of the positivist tradition, a tradi-tion that in many ways remains unchallenged. Forexample, the metaphors and the terminology mostoften used when research is discussed generally relateto positivism (Clarke & Proctor, 1999; Donmoyer,1999). We commonly see aspects of the research pro-cess in terms of ‘data’, ‘analysis’, and ‘subjects’. We‘write up’ the ‘findings’; we ‘discover’ the ‘truth’ and‘prove’ ‘hypotheses’. The hegemony or dominance ofpositivist terminology and metaphors is further shownin the very notion of ‘discovery’. Discovery is gener-ally understood in terms of finding something ‘outthere’ that is waiting to be found, rather than in termsof something that has been developed or constructed.The use of terms and metaphors relating to the posi-tivist tradition has become so entrenched that they areaccepted as right and normal and non-problematic.They have become omnipotent in research discoursesto the point that ‘other’ is seen as non-compliant withthe requirements of ‘good research’ (Clarke &Proctor, 1999).

The intention has not been to enter the exhausted(and exhausting) debate about the merits of differentresearch orientations, but rather to illuminate the nar-row way that research is traditionally understood, andthe hegemony that has maintained the status quo. Allparadigms are legitimate modes of inquiry and oneparadigm need not be valued over another. Nurseeducation and workplace environments have aresponsibility to ensure that a broad understanding ofthe term 'research' is encouraged. They also have aresponsibility to ensure that not only different para-digms, but also different value-perspectives related toresearch activity, are equally supported and valued.

Valuing research activity

The attitudes and values of those around us also influ-ence the way research is understood and valued.Although the values and attitudes of those in theworkplace may have a stronger influence on learners

Utilization of research evidence 93

than the official curriculum, it is to be expected thatnot only what is written in unit outlines (especiallycontent and assessment methods) but also the valuesand attitudes of teachers will influence studentlearning.

Hidden agendas or biases may unknowingly surfaceand influence education content. Certainly it is notuncommon for the taught curriculum to vary substan-tially from the written curriculum because teacherstend to give greater attention to student interests; towhat they are comfortable with; to what has workedin the past; or to what they believe students need toknow (Glatthorn, 1999). For example, in light ofcurrent demands for evidence-based practise and thelow percentage of nurses in Australia undertakingresearch studies, nurse educators may give greaterattention to research methodologies and processesthan how to read and evaluate published research.Also, an awareness of the political need to providehard quantifiable data in terms of outcomes (Pearson,1991) may promote educators to give priority toquantitative research methodologies over otherapproaches.

If content is excluded because of hidden agendas orpersonal biases, or because a particular belief orvalue-perspective is privileged over another, therecan be serious consequences in terms of the develop-ment of a nursing research culture. However, aresearch culture is dependent not only on those whoengage in research, but also on those who engagewith research. That is to say, the development of aresearch culture relies not only on those with thecapacity to do original research, study a serious intel-lectual problem, and disseminate findings. It alsorelies on those with the capacity to use their knowl-edge of research processes to analyze and critique thework of others, to make connections between the dif-ferent sources of knowledge, and use that knowledgeto improve patient care. Thus, although nurses may beexpected to engage with research as an integral partof evidence-based practise, it is unrealistic to expectall nurses to engage in research. Indubitably thebeliefs, values, and attitudes of others influence notonly how nurses see and understand the world ofnursing but also how they value and engage inresearch activity. The beliefs, values, and attitudes ofothers also influence what components of the nursingrole are valued and accepted.

For example, while it is apparent that nursing as aprofessional body views research as an integral com-ponent of the nursing role, that this is the view heldby nurses as individuals is not as obvious. The conten-tion is that either engaging in or with research may beperceived as only an ascribed role, a mere abstraction

and unrelated to the reality of the workplace. Thusthe role is neither acknowledged nor activelyaccepted, much less pursued by nurses in clinicalenvironments. The reality is that, in order to providequality managed patient care, the role of a clinicalnurse in the 21st century encompasses much morethan direct clinical care. Although ‘clinician’ may bethe primary role for most nurses in clinical settings,fulfillment of other roles such as researcher, advocate,and teacher are necessary for the provision of holisticand quality care.

Nurse education has a responsibility to ensure thatnurses are able to understand, engage in, and valueall components of the nursing role. Workplace envi-ronments have an equal responsibility to ensure thatthe necessary support and resources are available forclinical nurses to engage in any activity or role neces-sary for the provision of quality care. However, theresponsibilities of nurse education and workplaceenvironments do not stop there. Because of theirpower to influence what is understood, valued andimplemented in nursing practise, education and theworkplace environments have a responsibility to pre-pare and encourage nurses to initiate research that isdriven by the sorts of questions that will provideanswers and evidence on which to base practise.

Initiating or approaching research

It is through nursing research that important knowl-edge about phenomena of interest to nurses and theirclients is generated, and the researcher generallyworks within a paradigm that is consistent with his orher world view (Polit & Hungler, 1999). While selec-tion of the guiding paradigm (and thus the methodicalapproach) is an early step in any project (Polit &Hungler, 1999), it is the research problem that mostfittingly drives the study. Investigations are carriedout because answers are wanted and a particularmethodology is selected because it is the best way tostudy or find an answer to the question. Thus, asMacGuire (1991) argues, it is the purpose of theresearch—the nature of the question posed—thatdetermines the most appropriate approach for investi-gation. The nature of the question posed derives fromthe context in which the answer—the evidence—isneeded.

As claimed earlier, nursing research knowledge isof little value if it is not used to improve patient care,and clinicians tend to ignore research that they do notconsider relevant to their current context of care(Brink & Wood, 1994). It follows that the most valuedand valuable research questions will be those gener-ated by context and discipline-specific questions such

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as ‘What do I want to know about my practise?’‘What sort of evidence do I need?’ ‘Why does thistreatment work and not the other?’ ‘Why is it hap-pening like this?’ ‘How do patients experience this?’‘How can the situation be improved?’. These sorts ofquestions generate research problems and questionsthat are relevant to nursing practise. Because clini-cians want, and need, answers that are clear, practical,and applicable to the clinical situation (Brink &Wood, 1994), it is important that the question drivesthe study, not preference for a particular guidingparadigm.

However, the research problem and question (thepurpose of the research) are frequently subordinatedto methodological approach not only because theselected paradigm is preferred by the researcher butalso because of other influences, such as publicationaccess and funding allocations. For example, in thedrive to promote nursing research some professionaljournals have given priority to the quantitativeapproach in order to enhance their academic status,and this in turn advantages research guided by thepositivist paradigm in terms of publication access. Inparallel, academic research in universities has becomea major factor in funding allocations. In America, anestimated 75% of National Institutes of Health fund-ing has been awarded to research-intensive universi-ties (Baldwin & Nail, 2000). Nurse education has notescaped this funding requirement, which operates at acorporate and individual level, because those depart-ments or individuals that do not produce research canhandicap the final rating of a university or depart-ment (Hicks & Hennessy, 1997). This has led to asymbiotic relationship between professional nursingjournals and university schools of nursing, which hashelped to make quantitative studies the gold standardfor evidence-based care. Researchers have been givena clear message that experimental research is themethodology favored by professional bodies espe-cially in the academic community. However, the posi-tivist paradigm is not always the best guide toinvestigating a question.

While the purpose of an investigation is clearly notalways to determine cause and effect or to confirm ahypothesis, it is certainly vital that health researcherscontinue to investigate causation and treatment of ill-ness and disease for purposes of health restoration.However, research is also needed to address the chal-lenges associated with day-to-day care and, arguably,nurse researchers are best placed to do this. Tradi-tionally, the constructs ‘nursing’ and ‘care’ have beenclosely associated and, while nurses are obviously notthe only health professionals who care, they are theonly group to claim human caring per se as their cen-

tral concern (Pearson, 1991). Nursing’s ethos of carebased on a holistic model, together with its contem-porary professional orientation rather than task ori-entation, challenges nurse researchers to not onlyvigorously pursue research that addresses the caringaspects of health-care provision, but also to utilize arange of methodological approaches in doing so. Therecognition and acceptance of a variety of approachesto research as legitimate paths to knowledge is neces-sary because much of nursing care is too complex andunique to be studied from any one stance (Pearson,1991). It is essential that education and workplaceenvironments influence and encourage nurses to learnand understand research, to value the activities ofresearch, and to select the research methodologybased on the research question.

CONCLUSION

The purpose of the present paper was to challengethe hegemony (the mindset prevailing within educa-tion and health care environments) that produces andmaintains the challenges associated with nurses usingresearch evidence in their practise. The challenge wasorganized around the construct of change and criticalanalysis and synthesis of relevant literature. Theenvisaged changes concerned what nurses think anddo in relation to nursing research. It was argued thatchanging the ways that nurses understand, value andinitiate research will require a shift—a re-education—from one set of beliefs, perceptions, values and prac-tises to another. Specifically, it was argued that use ofresearch evidence by nurses in their practise willremain a challenge until changes occur to the waysthat nurses understand, value and initiate research. Inthe belief that critique without evocation for improve-ment is merely censure, some suggestions for trans-forming the influences of education and workplaceenvironments are offered. These suggestions arebroad and evolved during the process of advancingand articulating the central argument of this paper.

Suggestions include the following.• Ensure that ‘the way we do things around here’

is underpinned by critical and contemporary thinkingabout all aspects of nursing practise: engage in openand honest debate; share knowledge, values andopinions; challenge and possibly change problematicvalues and beliefs; be mindful of personal agendasand biases.

• Broaden understandings of the term research,and recognize that each approach is a legitimatemode of inquiry.

• Avoid stereotypical constructs that polarize andisolate research activities.

Utilization of research evidence 95

• Celebrate not contest differences inmethodological approaches and understandings ofreality.

• Value different beliefs and value-perspectivesabout research.The suggestions are not sequential, nor prioritized.They are not intended to be inclusive but rather toserve as catalysts for reflection and the generation offurther questions and challenges to the hegemonyprevailing within nurse education systems and health-care organizations that produces and maintains barri-ers to the utilization of research evidence in nursingpractise

.

Perhaps most importantly, the suggestionsare applicable to all nurses regardless of primary roleor level of experience.

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