Nursing practice study of aus and nz

International Journal of Nursing Practice 2001; 7: 392–405

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R E S E A R C H PA P E R

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Approaches used to implement research findings into nursing practice: Report of a study tour to Australia and New Zealand Alison L Kitson RN, BSc(Hons), PhD, FRCN Professor and Director, RCN Institute, Royal College of Nursing, London Accepted for publication September 2000 Kitson AL. International Journal of Nursing Practice 2001; 7: 392–405 Approaches used to implement research findings into nursing practice: Report of a study tour to Australia and New Zealand The focus of the study tour to several research and nursing units in Australia and New Zealand (NZ) was to investigate what has influenced the way nurses implement research into practice.The key areas examined were strategic policy influences, activities within leading academic units and responses in practice areas.The main themes to emerge were that the strategies developed by health policy makers in Australia and New Zealand have been profoundly influenced by the global clinical effectiveness and evidence-based practice movements. Nursing needs to position itself firmly in the centre of such developments and leading nursing initiatives need to be mainstreamed into the wider evidence-based movement. While activity around clinical/practice guideline development moves on, more work needs to be done to understand how best to actually implement research in practice. Issues of organizational context, ownership, practice, culture and identifying local champions are emerging as key challenges for the next stage of implementation. Much can be learnt from ongoing dialogue.

Key words: evidence-based practice, research implementation, research utilization.

INTRODUCTION

also tried to get perspectives from policy, academic and practice levels.

The purpose of the study tour to Australia and New Zealand was to investigate what has influenced the way nurses implement research into practice. More specifically, the study aimed to: (i) identify and document the most effective methods being used to help nurses get research findings into practice; (ii) observe how these methods were being implemented; and (iii) get the views of staff responsible for implementation. The study tour

Four main trends have emerged in the research on research utilization. These are issues about terminology, clarification and refinement of the theoretical underpinnings, testing of theories, and emerging consensus about what seems to work.

Correspondence:Alison L Kitson, Professor and Director, RCN Institute, Royal College of Nursing, 20 Cavendish Square, London,W1G 0RN United Kingdom. Email: alison.kitson@rcn.org.uk

The most widespread term used to describe the uptake and use of research in practice is research utilization.

Crane describes the research utilization process as

PREVIOUS RESEARCH IN THE AREA

Terminology

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Table 1 Descriptions of research diffusion, dissemination and implementation Diffusion

Dissemination

Implementation

Key characteristics

Passive concept, not targeted, haphazard, unplanned, uncontrolled.

More active, more aggressive flow of information from source, targeting/tailoring to an audience.

More than increasing awareness, highlighting implications of message for specific practice/ audience.

Communication channels

Recipients likely to be open to seeking out message, academic, specialist journals.

Use of secondary sources, meta-analyses, summaries, overviews, guidelines, seminal journals and press coverage settings.

Use message promoted locally by key individuals as well as organizations and behavioural tools sensitive to opportunites and constraints in key settings.

Success criteria

Highly motivated individuals, incentives, rewards high, know where to find information.

Targeting of message to key recipients, relevance to practice, incentives and sanctions linked to update.

Use of numerous communication routes, many methods, personal encounter with local/ outside expert.

Adapted from Lomas 1993 2

being directed towards the transfer of specific researchbased knowledge into practice.1 Such a process incorporates the systematic use of the identification and synthesis of multiple research studies, the transformation of the research base into a clinical protocol that specifies (nursing) actions to meet specific care problems, and the implementation and evaluation of nursing actions with service organizations through the use of planned change processes.

From a different perspective, Lomas has provided descriptions of related terms such as research dissemination, diffusion (active and passive) and implementation (Table 1).2 None of the definitions offered fully embrace the assessment, development, implementation and evaluation of the research into practice as defined by Crane; however, utilization as a term seems to be overtaken by research implementation or, more simply, research-based practice. Figure 1 summarizes the emerging stages describing research implementation.

Theoretical underpinnings There are four main thematical positions that have influenced notions about research implementation. These are

the classic model, the social interaction and diffusion model, the problem-solving model and the linkage model.

Classic research, development and diffusion model This has been variously described in the early literature.3,4 They describe it as the classic scientific model that has guided most national and federal investments in basic research.The underlying assumptions are straightforward.

Teams of expert scientists develop basic knowledge, which may need to be applied in the real world. It is consequently developed into a commodity that is disseminated to potential users.

Social interaction and diffusion model This model introduced a more social interactive approach to the uptake and use of new knowledge.5 The model differentiates between the ‘innovation development’ and the ‘innovation decision’ processes. Innovations were defined

by Rogers as ideas, practice or objects that are perceived as new to the individual.

This model shares the same starting point for knowledge generation as the classic model, that is, knowledge is generated by external experts and given to potential

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Evaluation methods in 6 system to review performance against agreed, explicit targets.

Accountability process.

1

Implementation processes developed to ensure 5 optimum penetration of new information into context. Four essential areas: (i) nature of message (ii) characteristics of individual (iii) nature of context (iv) nature of change management strategy

Topic identification (e.g. national priorities, local problem identification)

2 Location and assessment of quality of existing research evidence (e.g. systematic reviews, critical appraisal skills)

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4 Transmission of information (dissemination or diffusion) involves both the content and means by which new information is communicated

Synthesis of existing research and development of guidelines (e.g. clinical guideline development practice protocols)

Research utilization emphasizes 1, 2, 3; less detail about 4, 5 and 6 Research implementation emphasizes 4, 5 and assumes processes 1–3 Evidence-based practice emphasizes 1, 2, 3 & assumes understanding of 4–6 Research dissemination concentrates on transmission of information (step 4) Research diffusion concentrates on transmission of information (step 4) Figure 1. Six stages in the research utilization/research implementation/evidence-based practice cycle. Stage 1 beings where a topic for research utilization is identified, either through a process of priority setting or local problem identification. At Stage 2, systematic reviews are undertaken to establish the evidence base for the intervention. Stage 3 involves the synthesis of existing research. Stage 4 is a transmission of the information. Stage 5 is implementation and Stage 6 involves evaluation of its effectiveness.The descriptions at the bottom of the figure reflect how the different terms emphasize different stages in the cycle.

users. It focuses on the nature of the message and what type of messengers communicate it most effectively.

Problem-solving model The first systematic and comprehensive model of knowledge use and change in social systems was put forward

by Lewin.6 This was one of the first models to represent a user-oriented approach to knowledge generation and research use.

Five steps were identified, starting with a need (sensed and articulated by the user or users) that is translated into a problem statement with possible diagnoses of potential solutions. Review of existing knowledge and research follows problem identification and is related to finding a

solution. External knowledge that is appropriate to resolving the problem is adapted to meet the user’s need.

The research (innovation) is then adopted and implemented, followed by an evaluation of its ability to satisfy the original need.

In contrast to the other two approaches, the problemsolving model is user initiated and controlled, and can be described as a self-applied innovation.

Linkage model The final model described in the early literature aimed to bring the other three models together into a single perspective.3 It argued that a central component of understanding research utilization was understanding the

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characteristics of user (practice) systems with the characteristics of the research (knowledge generating) systems.

It was argued for a user-owned problem identification process that was supported by but not taken over by the ‘knowledge generation’ system (i.e. a university or research organization). Having established the relationship, systems are set up that transmit the needs for new knowledge from the user system to the research system.

Ways of developing, retrieving or adapting the necessary knowledge are found and the two partners then work together to transform and disseminate new knowledge, skills and products back to the users.

Testing the theories and emerging trends Lomas’ and Haynes’ study of Caesarean section rates in one province in Canada represents a classic model interpretation of research implementation.7 Research knowledge was translated into guidelines, which were then given to key opinion leaders in a number of practice areas.

The variant on the classic research uptake model was to recommend that the diffusion and implementation stages could be augmented by identification of local opinion leaders and the provision of educational events followed by audit and feedback. Findings from this and similar studies had the effect of perpetuating the view that research utilization proceeds in a predictable linear way.8 Other medical studies have also assumed that distinct interventions such as educational outreach visits and guideline development can be utilized and tested as discrete interventions.9,10 However, recent systematic reviews have confirmed that wider organizational factors need to be taken into consideration.11–13 Some of the earliest studies in research utilization were based on Rogers’ diffusion of innovations theory.14 Horsley et al. led the Conduct and Utilisation of Research in Nursing Project (CURN), which was supported by the Michigan Nurses Association over a 5-year period.15 Using the Linkage Model, the CURN project facilitated organizational change required for effective research utilization.

In addition, research-based clinical protocols were developed together with the development and testing of the most effective change management strategies.

Nursing projects that have used the problem-solving model or a variant of it (most usually emphasizing the need for the innovation to be led by practitioners rather than researchers) are the Iowa model and Stetler’s model of research utilization.16,17 Classically, both of these

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nursing models start out by identifying problem identification as the first step in the research utilization process, which invariably covers review and critique of the literature, assessment of quality and appropriateness of the research evidence, a decision to implement, the implementation plan and the evaluation. Stetler was one of the first researchers to argue for the development of the role of the Clinical Nurse Specialist (CNS) as a key promoter of research-based practice.

A final trend in the North American literature can be identified in the more recent nursing frameworks to emerge, for example, the Horn model, that adopt a more organizational change/quality improvement perspective.18 Trends in the development of research utilization models in Canada and the UK have taken a different slant.

The Ottawa model of research use seems to be based on a classical model design with elements of diffusion of innovations built in.19 In contrast, Estabrooks argues that what is needed is a more thorough analysis of major areas of inquiry into the determinants of research utilization before effective models can be developed.20 She suggests that more focus needs to be given to the scientific, historical and philosophical foundations, policies and type of interventions to increase research utilization and outcomes.

In the UK, two major trends have emerged that have influenced the way nurses have conceptualized research implementation/utilization. The earlier influences embraced a problem-solving (action research) approach that is typically characterized by the practice development movement.21–23 Here practitioners were helped to identify aspects of care where they were supported in introducing new (either evidence-based or experiential) practices.

At the same time as this movement was developing, there was a parallel movement within the classic approach. This was promoted through the increased interest in evidence-based medicine (health care). Several intervention studies such as the Promoting Action on Clinical Effectiveness (PACE), and FACTS Framework for Appropriate Care Throughout Sheffield (FACTS) projects attempted to document the success factors that promoted effective research utilization.24,25 Like the systematic reviews, these studies have reinforced the multifaceted nature of effective research implementation and the importance of considering multiple strategies simultaneously (Effective Health Care Bulletin 1999).13,26

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What is not evident from the literature is the relative weighting or importance of several of these variables, and particularly, the interplay between the evidence, the characteristics of the context or environment into which the evidence is to be introduced, the mechanisms used to introduce the new information (change strategies, individual opinion leaders etc.) and the characteristics (skills, knowledge, attitude, position and status) of the individuals involved.

FRAMEWORK OF ANALYSIS From the literature, four key questions can be used to guide assessments of the quality and effectiveness of research utilization/implementation activities.

1. Who generates the new knowledge, research and innovation, and how is its quality guaranteed?

2. What is the organizational culture like into which the innovation is being introduced?

3. How do you get people in the system to be interested in (or to own) the innovation?

4. How do you introduce the change and actually make it happen?

From this overview of the theoretical perspectives, it is apparent that research utilization is a complex interactive process. The purpose of the study tour to Australia and New Zealand was to evaluate which of the main theoretical perspectives were influencing ideas in nursing in these countries.

METHOD The study tour was undertaken during October and November 1999. Three sorts of organizations were visited: (i) those responsible for developing health/ research policy; (ii) nursing academic units; and (iii) clinical practice areas. Criteria used to select the areas visited included being research active in the area, active in policy development, identified by international/ national community to be an opinion leader in the area of research implementation (either clinical, political, academic, policy) or published in an international journal on the subject of research implementation.

Table 2 summarizes the organizations and individuals visited during the study tour according to policy, academic or clinical focus. In Australia, Victoria, New South Wales and South Australia were visited, and in New Zealand, visits were made to Auckland and Wellington.

Contact with individuals visited had been arranged before the visit and typically involved a 1–2 h interview,

or in some cases (particularly in the clinical areas), up to half a day visiting the area and talking to the staff.

An unstructured interview approach was used, beginning with questions about the history and development of the work on research implementation to more detailed discussions about specific issues of challenges. While the academic and clinical visits focused on nursing developments, it was clear that significant developments were being encouraged to happen within medical and broader health-care areas.These were not followed up due to time constraints.

RESULTS The findings from the visits are summarized in Table 3.

A short outline of the key trends are presented using the main headings of policy/strategic influences, nursing academic units and practice areas.

Policy/strategic influences The strongest policy or strategic influence identified in both countries was the impact of the evidence-based health-care movement. The pattern was the identification of academic units to begin work on systematic reviews, guideline development and training in critical appraisal skills (Melbourne, Victoria; Auckland, New Zealand).

Most of these centres had links with the UK Cochrane Collaborating Centre and therefore had adopted the similar approach to refinement of research evidence.

In New South Wales, the head of the Australian Centre for Effective Health Care recognized the importance of the evidence-based movement but saw it as part of a wider strategy of quality improvement and clinical effectiveness.

The strategy was to get external support to set up projects on the grounds that this would involve clinicians changing practice for themselves, and involved the exploration of Berwick’s approach, called the Breakthrough series, or a similar package.

This more organic, developmental approach was not detected so strongly in either South Australia or New Zealand. In New Zealand, the government had set up a project to attempt to describe the limits and extent of core medical services and to set quality standards.28 Several guideline groups were established and worked throughout the 1990s on a range of clinical areas. Most recently, the Effective Practice Initiative Centre was established at Auckland University with the primary purpose of implementing the guidelines.

Strategy/policy

Victoria

New South Wales

South Australia

New Zealand

Manager, Effectiveness Unit, Quality Branch, Department of Human Services

Australian Centre for Effective Healthcare, Sydney University

Royal Adelaide Hospital

Head, Effective Practice Institute, University of Auckland

New South Wales College of Nursing, Sydney

Nursing Academic Units

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Table 2 People and places visited during study tour

Chief Nurse Advisor, Ministry of Health, Wellington

Victoria Centre for Nursing Practice Research, School of Postgraduate Studies, University of Melbourne

Centre for Evidence-based Paediatric Practice, New Children’s Hospital, New South Wales

Department Director, Joanna Briggs Institute, Department of Clinical Nursing, Adelaide University

University of Auckland

LaTrobe University, School of Nursing, Melbourne

Australian Catholic University/St Vincent’s Hospital

Flinders Medical Centre, Adelaide

Auckland Institue of Technology Massey University, Auckland Victoria University, Wellington

Practice Areas

Director of Nursing, Cabrini Hospital, Melbourne

New Children’s Hospital, Sydney

Flinders Medical Centre, Adelaide

New Zealand Centre for Evidencebased Nursing, Auckland

St Vincent’s Hospital, Sydney

Royal Adelaide Hospital

Director of Nursing, Wellington Hospital

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Strategy/Policy

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Table 3 Summary of main influences used to implement research evidence into practice New South Wales

South Australia

New Zealand

Clinical effectiveness agenda.

Guideline development.

Evidence-based medicine.

Critical appraisal skills.

Systematic reviews.

Quality improvement.

Care pathways.

Clinical effectiveness agenda Using guideline development. and EBM as one element of wide strategy.

Using quality improvement models to give practitioners experience in changing practice.

Clinical effectiveness agendas Guideline development led to innovation in nursing and setting up of Joanna Briggs Institute (JBI) at Adelaide University.

Partnership set-up, JBI focus.

Clinical effectiveness/healthcare rationing Development of care guidelines led to taking up evidencebased medicine movement.

Funding via public health departments.

Multidisciplinary perspective.

Funding via clinical effectiveness/public health

Evidence-based nursing.

Systematic reviews.

Set up effective practice initiative.

Multidisciplinary perspective

Guideline developments.

Modelled on Cochrane collaboration but outside main EBM developments.

Network of partners between JBI, Adelaide University and other academic and practice centres.

Methods developed for: guideline identification; systematic reviews;

Development of guidelines funding to public health Multidisciplinary Developed collaborations with New Zealand initiative and with JBI. Evidence-based nursing embracing guideline development, review etc. emerging awareness of need for implementation strategies

Evidence of change in practice and systems to promote local ownership of topic identification, guideline development.

Partnership with JBI. Not clear what impact it has had.

Flinders University using quality assurance/pathways to change practice.

Outside of Auckland, not a lot of awareness of EBP initiative.

Number of initiatives are extensions of quality improvement.

Few strategies for introducing change but growing awareness of the need.

Nursing academic units

UNIVERSITY OF MELBOURNE Variant of evidence-based approach.

Development of parallel system.

Nursing not fully integrated into strategic approach.

Keen to set up secondments/train clinicians in appraisal skills.

AUSTRALIAN CATHOLIC UNIVERSITY Working on a problem-based, inductive model, helping individuals Evidence-based Practice Centre at New Children’s Hospital

Practice areas

CABRINI HOSPITAL Keen to develop a range of academic and clinical links.

Using care pathways, shared governance agenda as way into changing culture of organization.

NEW CHILDREN’S HOSPITAL Variant on EBP appraoach. EB Nursing Unit set up. Devised way of promoting ownership of guidelines, restructured nursing practice committee.

Developing training programme.

Keen to link with multidisciplinary team locally and internationally.

Not formally linked to JBI.

EBP, evidence-based practice; EB, evidence-based health care; EBM, evidence-based medicine.

A.L. Kitson

Vicoria

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Nurses have been involved in each of the strategic developments described above, very much in the role of members of expert guideline groups or as users of some of the services (systematic review information, critical appraisal skills workshop).Two exceptions to this were the Evidence-based Nursing Initiative at Melbourne University School of Postgraduate Nursing and the Joanna Briggs Institute for Evidence-based Nursing and Midwifery (JBIEBNM) at Adelaide University. In Melbourne, additional funding had been secured from the health department to fund this initiative. Its primary objective was to develop evidence-based practice skills in nursing. The JBIEBNM started in 1995 when the Director of Nursing of the Royal Adelaide Hospital recruited an external consultant to devise a plan to improve clinical nursing practice and link it to a strong research culture. The Department of Clinical Nursing was subsequently set up at Adelaide University with the JBIEBNM being established as an Australian evidence-based practice centre.

Support was given by the Royal College of Nursing, Australia, and funding was secured with grants from state governments and contributions from associate members (local hospitals) across Australia, New Zealand and Hong Kong.

The trends that emerged from the interviews undertaken suggest that a dominant driver of change has been the clinical effectiveness agenda. Clinical effectiveness has been more narrowly defined by some policy makers to focus on the development of evidence-based practice systems (typically located in public health departments, linking to the Cochrane Collaboration, undertaking systematic reviews, guideline development and running workshops on critical appraisal skills).

Other approaches have focused on integrating evidence-based practice within a broader framework, particularly acknowledging the need for clinicians to be actively involved from the start in thinking about changing or improving practice. Techniques used to support this policy initiative were based on international quality improvement programmes or on research implementation strategies emerging from guideline development and subsequent implementation.27–29 While it was clear that nursing was not excluded from these initiatives, it was evident that they were not in a leading policy position. Exceptions were the developments in Melbourne and Adelaide, which were, however, perceived to be outside the mainstream policy process by some.

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Academic units A total of seven academic centres were visited across Australia and New Zealand (Tables 2, 3). The units ranged in size, focus and level of contact with clinical areas. They also ranged in their investment in and knowledge of research implementation.

Consistent with the strategic influences, the majority of academic units were linking improvements in research uptake in practice to the wider evidence-based practice movement. Three phases or stages of development were identified: (i) units that had become involved with the JBIEBNM initiative; (ii) those that had chosen a model of evidence-based practice/clinical effectiveness outside the JBIEBNM activity; and (iii) those units that were pursuing a more problem-based inductive approach to improving practice.

Joanna Briggs Institute for Evidence Based Nursing and Midwifery (JBIEBNM) Initiative The JBIEBNM initiative marked the beginning of the evidence-based nursing movement in Australia. The JBIEBNM network was set up to include collaborating partners in other parts of Australia, New Zealand and South-East Asia. It has had a significant impact on raising awareness about evidence-based practice.

The centres in Adelaide and Auckland followed a similar approach to knowledge generation and testing before implementation. This effectively was topic selection through discussion with key stakeholders (clinical nurses within hospitals in membership of JBIEBNM), undertaking a systematic review of the literature, transformation of the evidence into a practice guideline, and publication and dissemination of the guideline.

Both centres had completed a number of guidelines and had given them to clinicians without knowing exactly what approaches to use about how they were going to be implemented. Staff in both Adelaide and Auckland recognized that this was the next stage where they had to concentrate their efforts. Some teaching was now being undertaken around critical appraisal skills, research awareness workshops and change management skills.

Discussions were beginning at the Royal Adelaide Hospital around using quality improvement and broader clinical effectiveness approaches to begin to involve clinicians in research-based practice. This was seen as a hospital-wide initiative involving both nursing staff for JBIEBNM and key clinical leaders.

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The commitment and expertise of the staff in both units was noticeable. They were excited by the opportunities the work provided and were keen to develop their activity to the point where they could demonstrate changes in practice. Additional services that the JBIEBNM network provided were review of hospital policies and procedures and providing an evidence base (where available) to underpin practice. Both units had contacts with colleagues internationally and worked together to identify further clinical topics for practice guideline development.

A whole series of practice guidelines have been developed and a dissemination and implementation strategy is being devised.

Other models of evidence-based practice The work of Professor Sue Nagy and colleagues in the Evidence Based Nursing Unit at the New Children’s Hospital, Sydney, offers another approach. Based more explicitly on methodologies for systematic reviews and critical appraisal skills from the Cochrane Collaboration, the team has worked hard to raise awareness throughout the hospital by running workshops and undertaking systematic reviews. One has been completed (i.v. administration) and another one is underway.

The team encouraged the establishment of the nursing practice group whose job was to review the policies and procedures of the organization and then to agree about topics for systematic reviews. Attendance at the critical appraisal skills workshop is encouraged for all clinical nurse specialists (CNS) (equivalent of senior sisters in the UK), and staff attend as part of their professional development. The team have not yet considered how they are going to implement the guidelines but have identified two key groups, the ward educators and clinical nurse consultants (CNCs), who could be instrumental in promoting acceptance.

At Melbourne University, Professor Judith Parker and colleagues have secured funding directly from the Health Department to establish the Victorian Centre for Nursing Practice Research. This unit is also part of the JBIEBNM network. Their approach has been to identify a number of joint appointments/clinical research fellowships and train them in evidence-based practice methods. The expectation is that once trained, these individuals will be able to go back into their local environment and start to implement what they have learned.

Problem-based, inductive approach to improving practice Other approaches to increasing the use of research or creating more awareness of the need for research in clinical practice were described by clinical chairs at the Australian Catholic University in Sydney, La Trobe University in Melbourne, Massey University, Palmerston North and Victoria University in Wellington, New Zealand.

Common trends revolved around working with clinicians to help them undertake small-scale pieces of research that would inform their practice. Issues raised in adopting this strategy included dedicated time, educating fund suppliers, setting realistic time-frames and objectives, and not underestimating the resistance from clinicians themselves about the value of such activity.

Individuals in this group were less confident about the impact of guidelines and evidence-based practice on the quality of nursing care. Some were developing strategies to demonstrate how their approaches would show improvements, using indicators such as research awareness, research use, undertaking small-scale clinical research and presentation and publication of studies.Their view was that guidelines alone would not be sufficient to create the culture change required to enable nurses to base their practice on research.

Practice areas A total of six practice areas were visited. Three of these were linked to the academic units that had been visited (New Children’s Hospital in Sydney, Royal Adelaide Hospital and Auckland Healthcare); and three were by invitation (Cabrini Hospital in Melbourne, Flinders Medical Centre in Adelaide and the Women and Children’s Hospital in Wellington).

Not surprisingly, the perspectives of the nurse managers and clinical staff had a different emphasis to that of the academics. Most managers and clinicians were aware of the need to introduce more research-based practice.

They were keen that it was integrated into other initiatives such as care pathways, computerized nursing records and quality improvement initiatives. Consistent issues emerged across the practice areas.These were governance systems, that is, how can nursing be organized in such a way that practice issues drive everything else. Many hospitals were looking at the concept of shared governance and saw this as a way of modernizing the quality assurance and policy and procedure committees that often lacked focus and direction.30,31

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Another area was that of new clinical roles and new ways of working. Those hospitals that had begun to look at evidence-based practice were realizing that they needed to identify local champions or change agents. The CNCs and educational support staff were ideal candidates but a major awareness-raising development programme needed to be undertaken before these roles would be sufficiently prepared to take on new challenges.

Another area that was raised on several occasions was how the evidence-based practice movement could link up with clinical decision-support systems. In the Royal Adelaide Hospital, staff from JBIEBNM worked with clinical review teams to ensure that clinical practice instructions conformed to the most up-to-date evidence.

Analysis of information Using the four key questions described earlier, a number of patterns can be detected from the activity about research implementation in nursing in Australia and New Zealand.

Who generates the knowledge and how is its quality assured?

The spread of research implementation ideas would seem to be following a classic model of research and development, very much influenced by the evidence-based practice (medicine) movement. Characteristics of this model are the generation of research evidence by external experts, the construction of systems to test the rigour of the information (systematic review processes) and the subsequent translation of the research into acceptable guidelines.

Variants of this process were observed in every academic and practice unit visited. There was some dialogue around the role of clinicians in selecting topics for review (New Children’s Hospital, Sydney and JBIEBNM network) but the process of generating the evidence was seen as a specialist (and time-consuming) activity. Nurses leading these initiatives were faced with two major challenges. One was to generate sufficient expertise to generate the evidence, and the other was to prepare the organization for its subsequent acceptance and use. Units that were based in hospitals seconded practitioners to work with researchers on developing evidence-based guidelines. However, these were still perceived by the majority of nurses to be outside of their everyday experience and there was still work to be done about the ownership of guidelines.

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Academics, researchers and clinicians involved in knowledge generation recognized the problems about ownership and were beginning to explore how more clinical nurses could feel more involved. There were some initial examples of problem-based models or linkage models.

What are the systems like?

The majority of interviewees were aware of the challenges facing them in trying to get evidence-based guidelines/ research into practice.The perception was that energy had been focused on this first stage of the cycle (i.e. generating the evidence) and now teams were beginning to be aware of the next set of challenges.

There was a general awareness of the need to promote greater ownership at local level and a developing sense of processes and tactics to use to achieve this. Approaches that had been considered were restructuring the nursing committee process whereby new nursing practice committees could begin to review hospital policies and replace them with evidence-based guidelines.A number of former quality assurance coordinator posts had been used in one hospital (Auckland Healthcare) to implement and evaluate the introduction of new guidelines. Also, at an associate hospital in Auckland, clinical nurse consultant (CNC) and clinical nurse specialist roles had been targeted as being used as possible change agent roles to promote more interest in this work.

However, the general view was that nursing, like every other group in health care, was resistant to the evidencebased practice movement. It was still at the stage of being championed by a few enthusiasts and there was still relatively little penetration into the prevailing culture of the organization. Some evidence-based practice teams had reached a point where they knew that the next step was to involve clinicians in a much more direct way and they were beginning to look around for methodologies that would help them.

Few nurses saw quality improvement (particularly quality assurance) as a natural solution and few had any direct involvement in some of the wider policy discussions about how such initiatives as the Breakthrough series could be utilized.

How to engage the individual There were some excellent examples of one-to-one mentoring and coaching of individual clinical nurses in promoting a greater appreciation and understanding of

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the research process. There were also good examples of opinion leaders championing the new message of evidence-based practice. Consistently, strong leaders were identified at Director of Nursing (DON) and at professorial levels who understood the importance of including nursing in the policy shift towards evidence-based practice. Organizations who had both Directors of Nursing and academic leaders working together on this agenda were in an even stronger position.

The strength of vision created by this partnership enabled the development of many other roles at the clinical level. Support posts such as CNCs, CNS ward-based education support posts and quality improvement posts were being developed to embrace some of the central messages of the evidence-based practice movement.These innovations were still at an early stage of development in the majority of units visited and structural approaches were yet to be developed.

Implementation and evaluation Nurses in Australia and New Zealand have pioneered some exciting approaches to the generation and presentation of evidence for practice. It was evident from the visit that they have now reached a point where the next challenge is to understand more clearly how this research evidence can be introduced into practice.

Having adopted a more classic top-down approach, the challenge now is how to generate ownership and interest at clinical level. While some attempt has been made to involve clinicians in problem identification and topic selection (for the area of evidence generation), it was clear that the prevailing culture in nursing was still one of resistance to such approaches.

Many personal strategies of targeting potential change agents at local level were observed, and in discussing future plans with colleagues, it was clear that everyone recognized the need for a more coordinated approach to implementing the evidence. A number of implementation studies had been undertaken (particularly in JBIEBNM in Adelaide and Auckland) that confirmed the need for a more systematic approach to implementation. How these implementation studies take account of the evidence already available will be an interesting question. There is growing acknowledgement that successful interventions must deploy multiple strategies targeting aspects of the individual, the organization, its culture and characteristics of the message simultaneously. We should also bear in mind Estabrooks’ observation that we still know relatively

little about the underlying conceptual construction of effective research utilization.20

LESSONS TO BE LEARNT One must always be cautious about drawing conclusions from a study tour because of the impressionistic nature of the evidence collected. Attempts were made to ensure that the criteria used for the selection of sites were transparent and consistent. No doubt, many areas that are undertaking similar activity were omitted. However, trends that emerged from the sites visited turned out to be consistent with the literature on research implementation and with the experience of nursing teams in the UK. It must also be noted that this study focused on nursing rather than taking a multidisciplinary perspective, and its orientation was towards process rather than looking for evidence of effective strategies.

Within these parameters, the most consistent themes to emerge are as follows.

1. Strategies developed by health policy makers in Australia and New Zealand to introduce evidence into practice are consistent with approaches used in the USA, Canada and in the UK. 2. The classical model of research utilization characterized by outside experts generating knowledge that is then given to clinicians still dominates peoples’ thinking.

This has been translated into the evidence-based practice movement where techniques such as guideline development and specific implementation strategies such as educational support, critical appraisal skill training and use of audit and feedback for quality improvement techniques are used to speed the uptake of the evidence.There is little theoretical debate about the strengths or weaknesses of certain approaches such as using a problem-based (adult learning) approach or a variant of the linkage model.

Some approaches have moved more to a linkage model with research teams explicitly engaging clinicians for the beginning.

3. Nursing needs to ensure that it positions itself firmly in the centre of the wider health policy developments.

Leading edge initiatives such as those at the Joanna Briggs Institute for Evidence-based Nursing and Midwifery, the University of Melbourne and at New Children’s Hospital, Sydney, need to be mainstreamed into the wider evidencebased movement in order to ensure that nursing is influencing the wider policy debate and that unnecessary duplication is minimized.

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4. A number of centres in Australia and New Zealand are leading on the generation of evidence-based practice for nursing. They are recognizing that they have reached a stage where they need to look at systematic techniques to implement such research into practice. Positive factors include strong leadership, joint appointments between evidence-based units and clinical practice, potential roles that could be developed for this purpose and networks into the wider evidence-based practice movement. Areas that need to be addressed are the need to increase ownership and involvement in developing evidence, possible tensions between national and federal policies and the relationship between academia and practice.

5. There is real potential for collaboration between Australia, New Zealand, the UK and North America in the area of research utilization/implementation. It appears that similar models have influenced the policy agenda and consequently funding patterns that support a classic model of knowledge generation and implementation. The limitations of this model at the implementation stage are well documented and include problems with acceptance and ownership, and the need to involve clinicians early on in the decision-making process.

Work in the UK has evolved more around the testing of problem-based and linkage models of research utilization.21,23,32 There may be great benefits to sharing these experiences and working towards a more integrated model that combines the best elements of a variety of approaches.

Also, it must be recognized that evidence for clinical practice is not locally constrained. National and international clinical guidelines could be developed and many teams around the world could be involved in the ongoing review of evidence to ensure that guidelines are kept upto-date. The JBIEBNM already has an international role and it might now be time to extend this to include more Cochrane collaboration and involving colleagues from North America, Europe and the UK.

nature of the system the knowledge is introduced into, how individuals are involved in the process, and the methods used to implement and evaluate the knowledge.

Clear answers to these questions will enable us to understand the underlying theories we use to achieve effective research utilization and will teach us how to use them more effectively. There is also a role for an international organization (possibly JBIEBNM, Cochrane Collaboration, a charity such as the Florence Nightingale Foundation or for a consortium of National Nursing Associations or a combination of the above) to coordinate the production and ongoing review of clinical guidelines and to ensure their effective dissemination.

The purpose of the study tour was to investigate how nurses were implementing research into practice. It was clear that the wider political agenda was working on health policy choices and that nursing was responding to these wider trends in a variety of ways.A consistent theme was the impact of the classic model of knowledge generation and dissemination. Nurses were responding to the clinical guideline initiative but are now moving to a point where they know how they need to address some of the wider implementation issues more systematically. Users of research evidence were similar to users in other countries: if they had not been involved in the selection of the topic or in the development of the evidence, then they were not inclined to accept it. Acknowledging the centrality of issues, such as ownership and involvement, must be some of the most important lessons to be learnt and the challenge to all of us who wish to promote evidencebased practice. Yet, despite the growing evidence about the importance of local involvement, be it from the original studies conducted by Rogers33 to those looking at the effectiveness of quality improvement strategies, there is little scientific understanding of how we promote greater local ownership to achieve change.28,34–37

RECOMMENDATIONS AND CONCLUSIONS

I would like to thank all of the nursing, medical and health policy colleagues in Australia and New Zealand who agreed to be interviewed and who made my visit so rewarding. I would also like to thank the Florence Nightingale Foundation and, particularly, the Edith Cavell Scholarship, for sponsoring the study tour. Finally, a big thank you to Tracey Rogers who helped to coordinate the travel arrangements.

ACKNOWLEDGEMENTS There is much to be learnt from international comparisons. Trends in the area of research utilization are consistent between events in the UK, Australia and New Zealand. Four key questions guide our work in this area. These are understanding the consequence of who generates the knowledge and how it is quality assured, the

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