Original Article

Research Awareness: An Important Factor for Evidence-Based Practice? Robert McSherry, RGN, DipN(Lon), BSc(Hons), MSc, PGCE, Angela Artley, RGN, BSc(Hons), DipN, ENB 219, Jan Holloran, SRN, SCM. DipN, BSc(Hons), MSc

ABSTRACT Background: Despite the growing body of literature, the reality of getting evidence into practice remains problematic. Objective: The purpose of this study was to establish levels of research awareness amongst registered health care professionals (RHCPs) and the influence of research awareness on evidence-based practice activities. Design and Methods: This was a descriptive quantitative study. A convenience sample of 2,126 registered RHCPs working in a large acute hospital in Northeast England, the United Kingdom was used. A self-completion Research Awareness Questionnaire (RAQ) was directed towards measuring RHCP: attitudes towards research, understanding of research and the research process, and associations with practising using an evidence base. Data were entered into a Statistical Package for Social Science (SPSS) database and descriptive and inferential statistics were used. Findings: A total of 843 questionnaires were returned. Seven hundred and thirty-three (91%) RHCPs overwhelmingly agreed with the principle that evidence-based practice has a large part to play in improving patient care. This point was reinforced by 86% (n = 701) of respondents strongly agreeing or agreeing with the idea that evidence-based practice is the way forward to change clinical practice. Significant associations were noted between levels of confidence to undertake a piece of research and whether the individual had received adequate information about the research process, had basic knowledge and understanding of the research process, or had research awareness education or training. Conclusions: The study shows that RHCPs, regardless of position or grade, have a positive attitude towards research but face many obstacles. The key obstacles are lack of time, support, knowledge, and confidence. To address these obstacles, it is imperative that the organisation adopts a structured and coordinated approach to enable and empower individuals to practice using an evidence base. Worldviews on Evidence-Based Nursing 2006; 3(3):103–115. Copyright © 2006 Sigma Theta Tau International KEY WORDS

evidence-based practice, research awareness, attitudes, knowledge, confidence, support,

resources

INTRODUCTION

T

he United Kingdom (U.K.) National Health Service (NHS) has experienced significant policy changes placing a strong emphasis on encouraging the integration

Robert McSherry, Principal Lecturer, Practice Development, School of Health and Social Care, Practice Development Team, University of Teesside, Middlesbrough, UK. Angela Artley, Lead Nurse, Division of Medicine, James Cook University Hospital, Middlesbrough, UK. Jan Holloran, Senior Research Midwife, Obstetric Directorate, James Cook University Hospital, Middlesbrough, UK. Address correspondence to Robert McSherry, School of Health and Social Care, University of Teesside, Practice Development Team, Parkside West, Middlesborough, Tees Valley TS1 3BA, UK; [email protected] Accepted 11 April 2006. Copyright ©2006 Sigma Theta Tau International 1545-102X1/06

of appropriate evidence into the practice of all registered health care professionals (RHCPs; Department of Health [DoH] 1993; 1995; 1996a; 1996b; 1997; 1999; 2000; 2002). This move towards evidence-based practice is a move away from care or treatment based on a knowledge base which is unmethodical, towards care based on rigorous observation, clear decision making, and appropriate action for individual patients. It is no longer acceptable for RHCPs to base care on tradition. They must be able to substantiate the decisions they have made on a foundation of professional expertise which clearly includes using relevant evidence to inform practice. The U.K. government’s reforms indicate that RHCPs must increase their research competence and involvement Worldviews on Evidence-Based Nursing r Third Quarter 2006 103

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in order for practice to be driven by empirically derived findings (DoH 1993; 1995; 1996a; 1996b; 1997; 1999; 2000; 2002). An inherent belief is that for this to be realised individuals require a positive regard, and the knowledge, understanding, competence, and skills to critically review research. Additionally, RHCPs need to be able to consider the relevance of research to practice. It is evident that RHCPs do not always act upon evidence and that in reality many practices continue to be based on assumptions and tradition rather than driven by empirical evidence (Closs & Cheater 1994). Investigators have identified what factors inhibit the use of evidence-based practice from the perspective of a single professional group (Hicks 1995; Pearcey 1995; Breggen 1996; McSherry 1997; Taylor 1997; Parahoo 1998; Gee 1999; Greenhalgh 2000). Limited attempts have been made to understand what enables the use of research across professional groups, and whether these issues are similar. The overall aims of this study were to establish the levels of research awareness amongst RHCPs and establish whether there was an association between research awareness and use of an evidence base. To achieve these aims, a series of objectives were established: r Ascertain and measure RHCPs’ perceptions towards,

r r r r

understanding of, and barriers to, research awareness, and its implications for engaging in evidence-based practice. Administer an RAQ to assess RHCPs’ attitudes towards, confidence in, and understanding of, research, and the support offered to develop skills in research awareness. Use quantitative data to establish levels of research awareness and implications for engaging in evidencebased practice. Test the strength of correlation between RHCPs’ attitudes towards and understanding of research, and their confidence in delivering evidence-based health care. Establish a level of research awareness commensurate with practice using an evidence base.

Literature Review An initial literature search was conducted via CINAHL using the key term “evidence-based practice” that showed 6,816 articles. This was limited to 155 by focusing on: r articles published in 1987–2005 r research studies r articles containing abstracts and citations, and r those making direct reference to evidence-based practice in the title. The term evidence-based practice has been characterised and defined many times, with over 14 definitions in the medical discourse alone (French 2000). Similarly, 104 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

nursing and allied health professionals have witnessed an upsurge in use in various forms including evidence-based nursing, practice, and health care (Taylor 1997; Closs & Cheater 1999; Goding & Edwards 2002). Sackett et al. (1997, p. 2) describe evidence-based practice as: The conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. This external information is blended with clinical expertise in order to decide if and how this evidence may relate to the individual patient. The aim is to inform practice and see if the treatments that are used are the most powerful, accurate, effective and safest options.

Viewed in this way, evidence-based practice becomes more than a number of steps in which individuals read, interpret, and utilise research material in practice. If evidence-based practice is to become a reality, individuals require a positive regard, the knowledge, understanding, competence, and skills to critically review research and assess its relevance to practice. Authors have recognised the complexity of integrating research findings into practice (e.g., Enkin et al. 1995; Page 1997; Bjorkstrom & Hamin 2001). According to French (2000), evidence-based practice is a complex concept, which makes it difficult to define and implement because of an association with other important elements, such as decision making (Thompson 2004), research and development (DoH 1993), and resources (Cullum et al. 1998). McSherry (1997), Estabrooks (1999), and Jolley (2002) report that for evidence-based practice to occur RHCPs need to be “research aware.” Being research aware means RHCPs have a positive regard for research, which is gained through possessing the knowledge, skills, confidence, ability to think critically, and have access to the appropriate support. Access to high-quality evidence is not enough; a positive research culture is also necessary. Researchers suggest that practicing using an evidence base is dependent on three primary factors: attitudes, understanding and confidence, and support (McSherry 1997; Estabrooks 1999; Figure 1). Although McSherry (1997) and Estabrooks (1999) raise important points, the reality of making this happen in practice is somewhat complex and difficult. A wealth of research literature exists in which authors describe the poor utilisation of research findings because of numerous obstacles such as lack of time and insufficient resources (Funk et al. 1991; Glacken & Chaney 2002). Arguably to ensure effective implementation of research evidence, more knowledge is required about how RHCPs think about research, the value they place on it, and how they envisage that it may help or hinder them in their everyday working lives. Studies that have identified attitudes to research often do so from the perspective of a single professional group

Research Awareness

Cheater 1994; Mead 1996; Gee 1999). McSherry (1997), Estabrooks (1999), and Glacken (2002) highlight several barriers associated with integrating evidence into practice, including: r Lack of time to access and review the evidence. r Lack of skills to read, critique, and understand the evidence. r Lack of knowledge and understanding of the research

Figure 1. Prerequisites to achieving evidence-based practice. (Pearcey 1995; Breggen 1996; Taylor 1997; Parahoo 1998; Gee 1999; Greenhalgh 2000). There appears to be a gap in understanding from a multi-professional perspective about what enables the use of research in practice. Attitude Research into RHCP attitudes towards research has been informed by the work of Young and Rice (1983), Bostrom et al. (1989), Marsh and Brown (1992), McSherry (1997), and Estabrooks (1999). Various studies across all RHCP groups (Gee 1999; Humphries 1999; Greenhalgh 2000) have reported positive attitudes about the role of research and enactment of evidence-based practice. However, the beliefs and values held by some RHCPs appear to be threatened by research. This view is supported by Pout et al. (2003, p. 398), who wrote: [A] justification for the negative attitude towards evidence-based practice is that opinions, attitudes, beliefs, and values are all characteristics that shape personal knowledge.

The current persuasive power of evidence-based practice appears to be based on a belief that it is a viable construct. However, early research indicates that attitudes of RHCPs, in particular scepticism about the benefits of research findings, act as potential barriers to the implementation of evidence (Hunt 1981). French (2000) suggests that there is more belief associated with the concept of evidencebased practice than there is empirical research evidence to substantiate its claims. Thompson (2004), like French (2000), suggests that too much faith has been placed in the assumption that the availability of new information will automatically lead to change in clinical practice. Understanding and Confidence Several investigators report that lack of knowledge and understanding of the research process are main reasons for RHCPs’ lack of involvement in research activities (e.g., Hunt 1981; Harrison et al. 1991; Hicks 1993; Closs &

process. r Limited access to research. r Perceived cultural divide making it difficult to apply research evidence in practice. There is a presumption that all RHCPs can read and evaluate research. In reality, many are unfamiliar with much of the specific terminology and the often-impenetrable academic style that characterises some research articles (McSherry 1997). Hunt (1981) suggests that the inability to understand the vocabulary has caused many problems with regards to use of research in practice. Authors have indicated that it is imperative that at the point of care RHCPs are able to evaluate their contribution to the care processes and be aware of the consequence of their actions and decisions in practice (Burrow & McLeish 1995; Pearcy 1995; Kitson et al. 1998; Hundley et al. 2000). Some have suggested that for RHCPs to be able to provide evidence-based practice, their knowledge and skills of critical appraisal need to be developed (Cullum et al. 1998). This, according to Sackett et al. (1997), is essential in order to decide whether research findings may be of use. This is a skill that may well be beyond the scope of many RHCPs’ abilities (Hicks 1995; Breggen 1996; Cullum et al. 1998). According to Cullum et al. (1998), acquiring the knowledge and skills to critically appraise research evidence requires support.

Support Many factors that influence the implementation of evidence-based practice are organisational in nature. The uptake and dissemination of evidence alone is insufficient to achieve wide-spread evidence-based practice. Managerial support is important if the process, which facilitates the integration of evidence into practice, is to be effective (Stocking 1993). Without the cooperation and support of managers, it is unlikely that RHCPs will be able to introduce evidence-based changes into practice. Humphries (1999) suggests that an individual cannot adopt a new idea until the organisation has previously adopted it. The amount of support required is, however, likely to be dependent upon the grade of staff, with more junior staff needing more support. Arguably, the attitudes of management and the level Worldviews on Evidence-Based Nursing r Third Quarter 2006 105

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of managerial support are deemed more influential than is peer support for implementing research (Wickham 1999). The successful organisation shows a “unity of purpose” between employers and RHCPs. The culture of the organisation will be determined by what managers are perceived to be paying attention to. The workforce will form attitudes and opinions based on what they believe these leaders see as important. This point is supported by the findings of a study conducted by Humphries (1999), which indicted that conditions within an organisation are perceived as having an effect upon the encouragement or discouragement of the use of research evidence. The study findings showed an interesting view of “the Trust” (i.e., hospital) as something separate from them; almost an external entity to which they felt little sense of connection. This sense of separation was also evident in the way that clinicians perceived the Trust not taking action should they not address the issue of implementing evidence. McSherry (1997), Estabrooks (1999), Humphries (1999), and Wickham (1999) suggest that to deliver and make evidence-based practice a reality, the presence of three variables are essential: positive attitude, understanding and confidence, and support. For these variables to be enhanced, RHCPs need greater access to high-quality research. However, to be able to do this effectively, they need the ability to appraise the evidence and decide whether to put it into practice. They also need to be in a position to implement change with support from managers and peers. Arguably, without exploring and raising awareness of the importance of these three variables, evidence-based practice will not become a reality.

its association with practicing using an evidence base. A quantitative method enabled a structured approach to data collection enabling the use of a large sample and thus enhancing the generalisability of the findings.

METHODS

The Likert scale format is applied to questions 1–15. Each statement for these questions on the questionnaire runs from “strongly agree” to “strongly disagree” with the five positions given a weighting of 1 to 5. A high score indicates a favourable attitude and a low score an unfavourable attitude. To reduce the likelihood of a responseset bias, questions 1–10 are presented in a mixture of positive (strongly agree to strongly disagree) and negative (strongly disagree to strongly agree) responses. The attitude measurement scale was finalised by totalling respondents’ scores for the ordinal and nominal attitudinal scale questions 1, 2, 3, 4, 5, 15, and 16. The ordinal questions 1–5 (Figure 2, Box 1) were scored 1 for strongly disagree and 5 for strongly agree. The nominal questions 15 and 16 were scored 1 for an incorrect, and 5 for a correct answer (Figure 2, Box 2). The respondent’s scores for the seven questions were totalled where a minimum of 7 and maximum of 35 points for their overall attitude towards research could be achieved. To accommodate the wide diversity of respondents’ attitudes towards research, it was necessary

This study aimed to build on the work of Artley (1994), McSherry (1997), Gee (1999), and Holloran (2004) by exploring whether there is an association between level of research awareness and practicing using an evidence base. The purpose of this work was to explore the attitudes of eight professional groups: nurses, midwives, doctors, physiotherapists, occupational therapists, pharmacists, radiographers, and dieticians. These groups represent the majority of the U.K.’s NHS workforce delivering direct clinical care. Research Design A quantitative research approach was used in which the RAQ was administered. The RAQ resulted from combining the work of Artley (1994), McSherry (1997), and Holloran (2004). The questionnaire was specifically adapted towards measuring RHCPs’ attitudes towards research, their understanding of research and the research process, and 106 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

Method Design: Survey Approach The RAQ, previously reported by McSherry (1997), was developed using Oppenheim’s (1992) recommendations about survey design. In adapting McSherry’s (1997) RAQ for the purposes of this study, changes were focused on enhancing the order, wording, and presentation of questions. Previous studies by Artley (1994), McSherry (1997), Gee (1999), and Holloran (2004) all describe good internal consistency of the RAQ. Following the adaptations, no reassessment of validity was carried out because no changes were made to the number of questions or scales of measurement used within the questionnaire. The questionnaire was checked for internal consistency, which is reported in the reliability and validity section of this paper. The RAQ was self-administered to RHCP working in their clinical settings. Research Awareness Rating Scale The RAQ contains three independent measurement scales that are focused on eliciting information associated with RHCPs’ attitudes towards: r research, questions 1, 2, 3, 4, 5, 15, and 16; r understanding and confidence about research and the research process, questions 8, 9, 17, 18, 19a, and 19b; r the support available for research utilisation, questions 6 and 7.

Research Awareness Box 1 Example: Question 3

Box 2 Example: Question 15

Box 3 Original Attitude Rating Scale

Original codes / responses and re-coded responses

Original codes / responses and re-coded responses

(Sum of re-coded responses)

1 = Strongly Agree 2 = Agree 3 = Can't Decide 4 = Disagree 5 = Strongly Disagree

1 = Strongly Agree 2 = Agree 3 = Can't Decide 4 = Disagree 5 = Strongly Disagree

=5 =4 =3 =2 =1

= 5 correct = 5 correct = 1 incorrect = 1 incorrect = 1 incorrect

0 - 7 = Very Poor = 1 (n=0) 8 - 14 = Poor = 2 (n=3) 15 - 22 = Fair = 3 (n=43) 23 - 30 = Good = 4 (n=93) 31 - 35 = Excellent = 5 (n=0)

Figure 2. Attitudinal measurement rating scale. to recode the responses into categories to ensure accurate statistical testing (Figure 2, Box 3). The confidence and understanding rating scale consisted of totalling the scores for the ordinal and nominal questions 8, 9, 17, 18, 19a, and 19b. The ordinal questions 8 and 9 were scored 1 for strongly disagree and 5 for strongly agree. The participants’ responses to the nominal questions 17–19b were again recoded into new variables that represented a correct or incorrect answer. A score of 1 was given for an incorrect and 5 for a correct answer (Figure 3, Box 1). The respondents’ scores for the six questions were totalled where a minimum of 6 and maximum of 30 points could be achieved, representing the overall level of confidence and understanding of research, and the research process. To accommodate and demonstrate the range and diversity of the respondents’ confidence and understanding of research, and the research process, it was necessary to recode the responses into categories (Figure 3, Box 2). The support rating scale comprises questions 6 and 7. By applying the same process to questions 6 and 7 (Figure 4, Box 1) as for the attitudinal rating scale, a minimum score of 2 and maximum of 10 could be achieved for the support rating scale. To accommodate and demonstrate the range and diversity of the respondents’ perceived level of support, it was necessary to recode the responses into categories (Figure 4. Box 2). The RAQ comprises three subscales associated with attitude, confidence and understanding , and support, which formed the overall Research Awareness Rating (RAR) Scale. The score of the RAR Scale was calculated by totalling respondents’ scores for the three subscales: attitude, confiBox 1 Example: Question 17 Original codes / responses and re-coded responses 1 = Strongly Agree 2 = Agree 3 = Can't Decide 4 = Disagree 5 = Strongly Disagree

= 5 correct = 5 correct = 1 incorrect = 1 incorrect = 1 incorrect

Box 2 Confidence and Understanding Rating Scale

dence and understanding, and support. The respondents could achieve a minimum score of 15 and maximum score of 75. The RAR Scale total scores were categorised to group respondents’ scores rather than treating them as individual scores. Sample A convenience sample was used, which included all RHCPs working both full- and part-time within a large acute care hospital in Northeast England. The total sample size was 2,126 participants. Those not professionally registered, on long-term sickness leave, maternity leave, or suffering from bereavement were excluded from the study. Reliability and Validity of the RAQ The RAQ’s reliability and validity has been tested in earlier research studies (Artley 1994; McSherry 1997; Gee 1999; Holloran 2004). It was presumed unnecessary to test the questionnaire for reliability, because the above studies have all indicated internal consistency of the measurement scales akin to attitude, understanding and confidence, and support. However, the questionnaire was subjected to statistical tests to indicate the level of internal consistency. Internal consistency was tested by Chronbach’s alpha, for which the average of all possible split-half reliability coefficients was calculated. It is generally accepted that the results should be .8 or above (Hicks 1996). The tests for inter-rater reliability showed the research questionnaire as having a reliability coefficient score of .65, which is in the .6–.7 range as recommended by Polit and Hungler (1995). Box 1 Example: Question 6 Original codes / responses and re-coded responses

(Sum of re-coded responses) 0 - 5 = Very Poor = 1 (n=0) 6 - 11 = Poor = 2 (n=26) 12 - 17 = Fair = 3 (n=59) 18 - 23 = Good = 4 (n=25) 24 - 30 = Excellent = 5 (n=28)

Figure 3. Confidence and understanding rating scale.

Box 2 Support Rating Scale (Sum of re-coded responses)

0 - 2 = Very Low (1) 1 = Strongly Agree 2 = Agree 3 = Can't Decide 4 = Disagree 5 = Strongly Disagree

=5 =4 =3 =2 =1

3 - 4 = Low (2) 5 - 3 = Fair (3) 6 - 7 = Good (4) 8 - 10 = Very Good (5)

Figure 4. Support rating scale. Worldviews on Evidence-Based Nursing r Third Quarter 2006 107

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Ethics The Local Research Ethics Committees (LREC), following clearance by the Local Research Scrutiny Committee, approved the research study. Furthermore, approval was also given by the local university’s research ethics committee, Trust’s executives, and senior management. Data Analysis Quantitative data were analysed with the aid of the Statistical Package for Social Science (SPSS) Version 10. A combination of descriptive statistics: summaries, frequencies, and averages (mean and median scores), and inferential statistics: chi–square and Spearman correlations, were used. The results reported here are focused on the quantitative findings of the RAQ using chart and tabular formats.

RESULTS Of 2,126 questionnaires distributed to RHCPs working within a large acute care hospital in Northeast England, a total of 843 were returned of which 12 were incomplete and 21 were returned after the cut-off date. This resulted in a total sample of 825 questionnaires; a response rate of 40%. The response rate and percentages by RHCP groups are shown in Table 1. Responses to questions 1–22 relating to individual RHCP’s attitudes, support, and confidence and understanding are shown in Table 2. The remaining results summarise the respondents’ response to the RAQ by focusing on explaining how attitudes towards research, understanding of research, and confidence and support influence the use of research in practice. Attitudes Towards Evidence-Based Practice Ninety-one percent (n = 733) of RHCPs overwhelmingly agreed with the principle that evidence-based practice has a large part to play in improving patient care. This is rein-

forced by 86% (n = 701) of respondents strongly agreeing or agreeing with the idea that evidence-based practice is the way forward to change clinical practice. Only 30% (n = 285) of staff had instigated a change in practice (Q18) together with providing minimal detail to substantiate their claims (Q19). Furthermore, 87% (n = 707) of RHCPs perceived evidence-based practice to be an integral part of their role where 85% (n = 686) recognised the personal gains of engaging in evidence-based practice activities. Perhaps more significant was the finding that 90% (n = 727) of RHCPs perceived evidence-based practice as a means of benefiting quality of service through changing practice and working environment. This is supported by responses to question 5 (Evidence-based practice can have a benefit in changing practice in the working environment) demonstrating a significant effect (Spearman correlation rho) on questions 1–4. These include, for example, evidence-based practice has a large part to play in improving quality (Q1) (rho = .533, p = .01) and is regarded as an integral part of their professional role (Q2) (rho = .501, p = .01). Furthermore, in using evidence, staff see a benefit for themselves (Q3) (rho = .571, p = .01) and a mean to change clinical practice (Q4) (rho = . 700, p = .01). Across all professional groups, attitudes towards evidence-based practice were not influenced by position, grade, or whether the respondent reads journals regularly (Q20). Sixty-nine percent (n = 567) of RHCPs read professional journals weekly (Q21) with 44% (n = 357) reporting they visit the library (Q23) to access Internet databases such as Ovid at least 1–4 times a month (Q24). Understanding and Confidence RHCPs were asked if they felt confident to undertake a piece of research. More than half of the respondents reported not feeling confident to undertake a piece of research (65%, n = 526). A significant association was found between being confident to undertake a piece of research

TABLE 1 Response Rate by Health Care Professional Group HEALTH CARE PROFESSIONAL GROUP

TARGET POPULATION

RESPONSE BY QUESTIONNAIRE RETURNED

GROUP RESPONSE AS % OF TOTAL RESPONSES

Doctors Nurses Midwives Radiographers Occupational therapists Pharmacists Dieticians Physiotherapists

401 1,316 108 138 42 30 14 77

172 (42%) 383 (29%) 86 (80%) 43 (31%) 31 (74%) 26 (87%) 10 (71%) 45 (58%)

(21%) (47%) (11%) (5%) (4%) (3%) (1%) (6%)

Note. These figures were based on information received from the Directorate of Human Resources and verified as an accurate record when the study was undertaken. These figures have been rounded to the nearest decimal place.

108 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

13 Research provides information regarding feelings and attitudes related to clinical practice (n = 811)

1 Evidence-based practice has a large part to play in improving patient care (n = 811) 2 Evidence-based practice is part of my role (n = 811) 3 In using evidence to support my practice I see benefit for myself (n = 811) 4 Evidence-based practice is the way forward to change clinical practice (n = 811) 5 Evidence-based practice can have a benefit in changing practice in the working environment (n = 811) 6 I have sufficient support and encouragement from peers and professionals to engage in research activities (n = 809) 7 I have sufficient support from the management within my directorate/clinical area to engage in research activities (n = 811) 8 I am confident to undertake a piece of research (n = 811) 9 In my training, I received adequate information about the research process (n = 811) 10 I have a basic knowledge and understanding of the research process (n = 811) 11 Have you had any research awareness, education or training? (n = 811)

SCALE/QUESTION (ITEM)

TABLE 2 Summary of the Research Awareness Questionnaire

139 (17%)

294 (36%) 89 (11%) 265 (33%)

499 (62%) 285 (35%)

78 (10%)

171 (21%) 160 (20%)

150 (19%)

155 (19%)

12 (1.5%)

17 (2%)

17 (2%) 16 (2%)

8 (1%)

DISAGREE

No

199 (25%)

250 (31%) 189 (23%)

272 (34%)

273 (34%)

66 (8%)

87 (11%)

79 (10%) 102 (13%)

59 (7%)

CAN NOT DECIDE

Yes

290 (36%)

196 (24%)

103 (13%)

221 (27%)

314 (39%)

413 (51%)

190 (23%) 182 (22%)

284 (35%)

417 (51%)

95 (12%) 125 (15%)

295 (36%) 306 (38%)

412 (51%) 380 (47%)

202 (25%)

239 (30%)

494 (61%)

94 (12%)

AGREE

STRONGLY AGREE

(continued )

23 (3%)

23 (3%)

105 (13%) 153 (19%)

92 (11%)

80 (10%)

5 (1%)

4 (.5%)

6 (1%) 5 (1%)

10 (1%)

STRONGLY DISAGREE

Research Awareness

Worldviews on Evidence-Based Nursing r Third Quarter 2006 109

110 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

a Percentages based on total positive responses.

14 Research provides information regarding figures and numbers relating to clinical practice (n = 810) 15, 16 Which of the following is associated/concerned with Causes and association What individuals understand and think about the world Do not know None of the above Both 17a If you were about to carry out a research project what 17b Having carried out the first stage of your research what Identify practical problem needing addressing Do a literature search Formulate a research question Devise a method of how to study the problem Perform the research Write up and present research Do not know Ticked more than one box 22 Why do you read professional journals?a Because colleagues do To keep up-to-date with new practices Job advertisements Read about current research Pressure from unit management Self education Other

SCALE/QUESTION (ITEM)

TABLE 2 (Continued )

21 (3%) 626 (77%) 217 (27%) 460 (57%) 15 (2%) 642 (79%) 56 (7%)

29 (4%) 4 (.57) 463 (57%) 198 (24%) 72 (9%) 7 (1%) 20 (2.5%) 16 (2%)

Qualitative research (n = 811) 135 (17%) 446 (55%) 103 (13%) 47 (6%) 73 (9%) Would you do first? (n = 811)

227 (28%)

STRONGLY AGREE 390 (48%)

AGREE

Would you do next? (n = 811) 36 (4%) 15 (2%) 341 (42%) 42 (5%) 232 (29%) 122 (15%) 5 (5%) 13 (2%)

Quantitative research (n = 811) 482 (59%) 58 (7%) 109 (13%) 105 (13%) 36 (4%)

161 (20%)

CAN NOT DECIDE

16 (2%)

DISAGREE

5 (1%)

STRONGLY DISAGREE

Research Awareness

Research Awareness

and whether the individual had received adequate information about the research process (rho = .535, p = .01). Additionally, there was a significant relationship between having a basic knowledge and an understanding of the research process, and having research awareness education or training (rho = .594, p = .01). Forty-five percent (n = 358) of respondents did not understand the term qualitative research. Similarly, 41% (n = 308) of respondents did not know what quantitative research was. Surprisingly, only 4% (n = 29) of respondents could correctly identify the first step in carrying out a piece of research. Support A significant association between peer (rho = −.219, p = .01) and managerial (rho = −.250, p = .01) support, and the effect on an individual’s understanding and confidence to engage with evidence-based practice was found. Sixtytwo percent (n = 508) of RHCPs reported that they had insufficient support and encouragement from peers and professionals to engage in research activities. This figure rose to 74% (n = 606) in relation to insufficient support from the management within their directorate or clinical setting to engage in research activities. Research Awareness Rating Scale As described earlier, the RAQ comprises three subscales associated with attitude, understanding and confidence, and support, which formed the overall RAR Scale. The RAR Scale scores were totalled to give an overall individual score, and level of research awareness. The scale scores ranged from a minimum of 13 to a maximum of 85. These were then grouped together to produce five distinctive classifications, which indicated the respondent’s level of research awareness (Figure 5). To avoid bias within the RAR Scale, high positive scores for attitude having the poLevela 1

2

3

Category of research awareness Introductory

Confidence and competency

Advanced competencies in research awareness

4

Expert practice

5

Authority

tential to skew the final scores, the subscale scores were percentage weighted. Significant correlations were found indicating the interdependency of the three subscales; attitude, understanding and confidence, and support, illustrating how these confirm the existence of the RAR Scale. Furthermore, the study is believed to be the first to highlight differences in the levels of research awareness amongst the professional disciplines (Table 3). Findings indicate a fair to good level of research awareness amongst all professional disciplines. Further exploration of the overall RAR Scale scores showed that this was only influenced by hours worked (rho = .89, p = .05). Grade of RHCPs (rho = .062, p = .089), year the professional qualified (rho = .64, p = .079), and professional position (rho = .063, p = .083) had no statistical significance. There was a tendency to score higher on the RAR Scale score for those respondents who qualified after 1986. To identify the barriers that discourage the use of research, question 25 asked respondents to rank the three greatest barriers affecting their use of research evidence. From the original set of returned questionnaires and for convenience (in order to meet deadlines for completing the research) a random sample of questionnaires were reviewed (n = 535, 63%). The key barriers to research use are indicated in Table 4. Findings indicate that there is an important association between attitudes, understanding and confidence, and support and the ability to use research evidence in practice. Several conditions have been found that might support or hinder the engagement and application of evidence into practice. Limitations The nature of this descriptive study makes any generalisations and transferability of the findings other than to those

Rationale for research awareness category Should focus on raising individual’s attitudes towards research awareness by focusing on what research is, why it is needed and the importance it plays in the delivery of evidence-based care This is about enhancing the individual’s understandings of research methodologies and how the appropriate research approach should be commensurate with addressing the problem under review. Active engagement in problem solving should be encouraged so that the skills of critical appraisal are developed along with outlining strategies for putting research into practice. This is about ensuring that individuals have the underpinning knowledge, skills, understanding and confidence to critique, implement and evaluate evidence where changes in practices occur as a direct result of engagement in the research process. Should focus on leading, directing and continually advancing research awareness at a divisional and organisational level. Associated with developing a clear corporate, strategic and organisation approach to raising, maintaining and evaluating research awareness amongst all health care professionals within the organisation.

Research Awareness Scores indicative to category 13-27

28-42

43-57

58-72 73-85

a

The level of engagement in and involvement with research should be commensurate to the individual’s role and responsibilities outlined in the job description (DoH 2004).

Figure 5. Levels of research awareness based on research awareness rating scores. Worldviews on Evidence-Based Nursing r Third Quarter 2006 111

Research Awareness TABLE 3 Professional Positions and the Research Awareness Rating Scale Scores

POSITION

NUMBER QUESTIONNAIRE RETURNED

RESEARCH AWARENESS RATING SCALE SCORES 1

Doctor Hospital midwife Community midwife Nurse Occupational therapist Physiotherapist Radiographer Pharmacist Orthoptist Dietitian Sonographer Totals

172 86 383 31 45 43 26 1 8 4

2 1 1

2

21

1 1

1 4 4

3

33

3 34 9 4 57 3 9 10 6 1

133

TOTALS

4 75 22 4 108 10 17 21 7

5 54 29 11 160 16 16 7 5

4 4 272

4 302

164 61 19 348 29 42 43 23 1 8 4 742

Table 3 findings indicate a fair to good level of research awareness amongst all professional disciplines. This is a very good finding because only 7 cases were excluded from the total response due to missing data.

RHCPs who participated in the study difficult. However, the NHS organisation in which the study was undertaken was a typical hospital making the findings relevant to similar organisations. Response rates could have been improved by giving staff more time to complete the questionnaire and by sending out a reminding letter. Greater use of qualitative data could have complemented quantitative findings.

DISCUSSION Research awareness, according to this study’s findings, is an important factor influencing RHCPs’ perceived ability to engage with, and apply evidence to support their practice. Research awareness, within the context of this study, can be defined as a “positive regard for research through having the knowledge, skills, confidence, and support to think critically and to be able to appraise research so that it is TABLE 4 Barriers to Research

BARRIER Time Lack of knowledge Reluctance to change/power Lack of resources Lack of support from management Lack of support from colleagues Lack of education and training in research

NUMBER OF RESPONDENTS (N = 535) PERCENTAGE 523 156 118 111 97 86 72

98 29 22 21 19 16 13

112 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

incorporated into everyday clinical practice.” For evidencebased practice to occur, all RHCPs need an acquired level of research awareness to able to: r Define what health care research is. r Understand why health care research is needed. r Know how health care research can be applied in practice. r Identify what conditions prevent health care research utilisation. r Demonstrate how the implementation of health care research can be evaluated. The strength of this study, in contrast to other studies associated with research awareness in health care (Young & Rice 1983; Bostrom et al. 1989; Marsh & Brown 1992), is that a complete or holistic approach to studying research awareness was taken. The limitation of previous studies is that the focus was on only one or two elements of research awareness, such as attitudes, understanding, or barriers to research appreciation and utilisation. Within the context of this study, we have discovered that for evidence-based practice to work efficiently and effectively at an individual level, all factors associated with research awareness need addressing. In order for RHCPs to become proficient and effectively research aware to practice using evidence, they need to be aware of three factors: attitude, support, and confidence and understanding. Factor One: Attitude Towards Research This factor, similar to findings in previous studies (Hicks 1993, 1995, 1996; Artley 1994; McSherry 1997; Holloran 2004), provides insight into the importance attitude

Research Awareness

plays in encouraging RHCPs to become sufficiently research aware to engage in, and apply evidence in practice. The phrase “evidence based” was viewed positively by almost all of those who completed the RAQ. Respondents appear to be convinced that research plays an important part in improving standards and changing practice. Despite the finding that the majority of RHCPs viewed research positively, a few had negative attitudes towards research. The arguments put forward to support these attitudes were mainly because of the staff having insufficient time to access, review, and implement findings from research. Three quarters of respondents believed that research did add value and was an integral part of their role. Despite these positive responses, confusion continues to exist across all professional groups with regard to the meaning, purpose, and value of research evidence, suggesting that the quest for an agreed definition remains both challenging and difficult. The majority of the respondents believed that evidence-based practice was a medium for changing professional and clinical practice, but to do so successfully required time, support from peers and managers, and sufficient resources. Some caution in interpreting these positive results should be taken. The possibility of socially desirable answers may be high in today’s climate. It is likely that respondents would have found it difficult to express an opinion that is contrary to the current trend for evidence-based practice and, therefore, gave desirable responses in order to create a good impression. While attitude is not an obvious barrier to evidence-based practice, a positive attitude does not necessarily translate to research evidence being used in practice.

Factor Two: Support to Utilise Research This factor indicated that support from peers, colleagues, and managers to utilise research was necessary, a finding which is not new, but again, confirmatory of the literature (Stocking 1993). Over half of the respondents believed that they had insufficient support from peers. Almost three quarters felt unsupported by managers. Furthermore, having insufficient time and lack of resources were also reported as supporting issues. Despite the perceived trend that staff members do not receive enough support, some staff did feel supported by both peers and managers. These findings support the results of other’s studies (e.g., Young & Rice 1983; Artley 1994; Lacey 1994; McSherry 1997; Gee 1999; Holloran 2004), which found a lack of time and support as the largest condition preventing the use of research in practice. Arguably, pressure from within the organisation appears to result in an environment that was not viewed as enabling.

Factor Three: Confidence and Understanding Confidence and understanding are dependent on one another. The detection of the close relationship between confidence and understanding has not been reported in the literature before. What emerges from this study is that lack of understanding of research was ranked lowest on the list of barriers, along with the respondent’s agreement that they had received formal education in research methods. When asked to identify the “traditional” research process, only half of the respondents correctly identified the first stage of the research process. Less than half of respondents could correctly identify the second stage. Respondents appeared to have no common construct of research or appeared to know what constituted the research process. This could be attributed to a lack of confidence, as demonstrated in the overall confidence scale. Relatively few RHCPs become involved in research activities and without the opportunity to practice skills taught in universities, those skills may be lost. The need to appear congruent with current thinking regarding evidence-based practice may well have affected replies, whereas the categories indicating knowledge of the research process may genuinely reflect the conscious views and opinions of the respondents. From these perspectives, it may be safe to assume that in this study the confidence scores were more indicative of the respondents’ true perspective of their use of research. The finding that respondents’ value evidence-based practice but few had implemented a change in practice lends further support to this suggestion. Application of Research Knowledge: Conditions Supporting or Hindering Research Utilisation Findings indicated that evidence-based practice can only be achieved through RHCPs having equal access to robust education and training programmes. The development, application, and evaluation of efficient and effective education and training programmes are essential to help ensure services provided are delivered by appropriately skilled, knowledgeable, and competent practitioners. RHCPs need to be actively supported to further develop, apply, and evaluate the skills provided with the aim of improving the quality and standards of care. For RHCPs to become evidence based, they require support in practice so that they are proactively encouraged to develop skills in research awareness, apply the skills in practice, and evaluate the effectiveness of their decisions, actions, and/or interventions. The latter requires investment, time, and access to ongoing professional development. The findings from this research study indicate five distinct levels of research awareness (Figure 3). This is founded on the basis that all RHCPs should be confident and competent in reading and interpreting research articles. Worldviews on Evidence-Based Nursing r Third Quarter 2006 113

Research Awareness

The findings generated as part of the RAR Scale scores seem to suggest that the five distinct levels of research awareness could be based on a continuum of progression and expectation commensurate to the individual’s role and responsibilities and job description (DoH 2004). Recommendations Any changes in practice need to be targeted towards alleviating the anxiety and fears around “research.” RHCPs and their employers need to be realistic in the level of research awareness expected from RHCPs working in busy and stressful working environments. The recommendations for future practice are presented to reflect the changes that need to occur at an organisational and individual level. For example: r The development of an organisational approach to research and development should be realistic, straightforward, and truly representative of all RHCPs in the organisation. r The level of research awareness should be commensurate with the job description, roles, and responsibilities for which an individual is employed (Knowledge & Skills Framework [KSF], DoH 2004). In the United Kingdom, the level of research awareness should be aligned to the KSF and mapped against current training provision. r The provision of a range of flexible and realistic education and training approaches should be focused on ensuring that all RHCPs become evidence-informed through the development of research awareness, including skills of critical appraisal.

CONCLUSIONS The findings from this study indicate that the relationship research awareness plays in the application of evidencebased practice and how RHCPs use evidence to support actions or decisions in practice may be critical. Evidencebased practice is dependent on the level of research awareness acquired by RHCPs. Research awareness in this study refers to having a positive regard for research through having the knowledge, skills, confidence, support, and ability to think critically so individuals are able to retrieve and appraise research and as a result incorporate it into everyday clinical practice (where appropriate). Findings from this study indicate that research awareness is significantly promoted or inhibited by three factors: attitude, confidence and understanding, and support. Evidence-based practice is only likely to become a reality when local institutions and in-service education programmes promote, support, and provide resources for its development in practice. 114 Third Quarter 2006 r Worldviews on Evidence-Based Nursing

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