BIOLOGICAL October Roy / Dissemination 1999 RESEARCH and Utilization FOR NURSING of Nursing Vol. Literature 1, No. 2,

State of the Art: Dissemination and Utilization of Nursing Literature in Practice Callista Roy, PhD, RN, FAAN

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Building the case for the state of the art on the assigned topic begins with understanding the key

terms. In particular, we will look at state of the art, nursing knowledge, and dissemination and utilization. Art has been defined as the use of the imagination to make things of aesthetic significance or a sphere in which creative skill is used (New Webster’s 1992). Yet, state of the art is defined as the highest level of technology in a field at a given time (New Webster’s 1992). It seems that for the purposes of the important work before us, a synthesis of these key notions is useful. I will use the term state of the art to mean the highest level of imagination and creative skill used to outline a field of knowledge at a given time. Understanding of the term nursing knowledge is based on an understanding of the nature of knowledge. Nursing epistemology of the past few decades has been rich in looking at knowledge as problem solving, as created in the mind of the knower, as deduced from premises, as intuited in human experience. All of these approaches are useful in developing knowledge. I submit that knowledge is more than the additive totality of the diversity of these approaches. All of these ways of knowing, and others yet to be designed, form a view of knowledge as a universal cosmic imperative (Roy 1997). Such knowledge is characterized by unity, purposefulness, and promise. The possibility of a universal truth has moved in and out of vogue in the study of knowledge. Nurse scholars in particular have made great efforts to steer clear of any position that hints at there being a truth to be discovered. Still, I believe that providing a new understanding of universal truth provides a grounding for the art and science of genetic nursing. This view, which I term the universal cosmic imperative, brings together scientific and philosophical assumptions that provide a new conceptual structure.

BIOLOGICAL RESEARCH FOR NURSING, Vol. 1, No. 2, October 1999, 147-155 Copyright © 1999 Sage Publications, Inc.

Callista Roy, PhD, RN, FAAN, is a professor and nurse theorist at Boston College School of Nursing.

t is indeed a pleasure to address this significant conference on the State of the Art and Science of Genetic Nursing: A Knowledge Development Conference. For several years now, I have ended a number of presentations about nursing knowledge with the analogy that just as the scientists of the Human Genome Project would be mapping every amino acid sequence expressed in the human genetic code, so too would nurse scientists be making progress with the even more daunting task of mapping nursing knowledge, that is, understanding holistic persons in their cosmic environments and the processes whereby nurses help them promote and maintain health. One particular joy of this conference for me is to be a small part of revisioning the intersection of these two momentous challenges. The conference planners have wisely focused our attention on both the art and science of genetic nursing. With the stunning biotechnology involved in genome mapping, it is not difficult to become almost exclusively focused on knowledge from an emperic science perspective. I submit that it is our understanding of the nature of nursing knowledge and knowledge for practice that can keep us broadly focused on the significant contributions being made and to be made by genetic nursing. My task for this short time is to explore the significance, process, and key issues in knowledge dissemination and utilization in this developing field of nursing and to provide some links among theory development, standards of practice, and educational programming.

Understanding Key Terms

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The reenvisioned conceptual structure identifies nursing’s view of person and environment within the challenges of modern science and the values of the discipline. I have articulated this position in greater detail elsewhere (Roy 1997), but I can summarize the key points briefly. First, the unity of knowledge is supported by both philosophical argument and scientific evidence. Let me provide a contemporary image of Aristotle’s famous line that “All knowledge is of the universal.” Young (1993) provides a comparison of two photographs: the North Sky about the Pole Star with an 8-hour exposure compared with a photograph of a sundial shell (see Figure 1). The likeness between the photographs is striking. As to the purposefulness of knowledge, Young notes the irony that scientific thought at times denies meaning or purpose in the cosmos; yet at the same time, more remarkable facts have been emerging from cosmology, geology, and the study of life that seem to point to a purposeful and ordered universe. The image used to illustrate this point is a computer graphics-generated axial view of a DNA molecule, compared with a photograph of a rose window in Washington Cathedral depicting the first chapter of Genesis (see Figure 2). Again, the images tell the story of unity. E. O. Wilson (1998) supports these notions in his soon to be classic work, titled Consilience: The Unity of Knowledge. One of the world’s greatest living scientists, Wilson argues for the fundamental unity of all knowledge and the need to search for consilience—the proof that everything in our world is organized in terms of a small number of principles underlying every branch of learning. Unity and purposefulness of knowledge evoke great promise for the future. We can face the new millennium with hope, as we participate in effective human and environment transformations. Zohar (1990) emphasizes that human consciousness, the thinking and feeling person, is at the heart of the emerging universe, as knower and known and as creator. In the next major epoch of the earth, together people will decide what kind of a universe we will inhabit. Nursing knowledge, then, is composed of scientific and philosophical assumptions, conceptions of person and environment life processes, and the transformations that promote health. The assumptions and understanding of life processes, I label as basic nursing science. Transformations promoting health, then, are clinical nursing science.

Figure 1. Images of Unity of Knowledge in Nature, from Young, L. (1993). The Unfinished Universe. New York: Simon & Schuster, Inc. pp. 32-33. (above) North Sky about the Pole Star: Eight hour exposure (Lick Observatory Photograph). (below) Sundial shell (Photograph c. 1985 by Andreas Feininger).

Strategies for knowledge development include explication of assumptions and values, model construction, theory development—with the familiar

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Figure 2. Images of a Purposeful and Ordered Universe, from Young, L. (1993). The Unifinished Universe. New York: Simon & Schuster, Inc. pp. 128-129. (above) Computer Graphics-generated axial view of a DNA molecule (Courtesy of Computer Graphics Laboratory, University of California). (below) Rose window in Washington Cathedral Depicting the First Chapter of Genisis (Photograph by John Grupenhoff, courtesy of Science).

steps of concept analysis, synthesis, and derivation of propositions, and research, both qualitative and quantitative. Nursing literature relevant for knowledge includes a range of philosophic, theoretical, experiential and interpretive works, as well as empirical works.

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We have seen examples of these various approaches summarized in the review by Anderson (Anderson 1998). The scientific and philosophical assumptions that I have deemed most relevant to developing nursing knowledge for the 21st century are listed in Tables 1 and 2. In a field such as genetics, nurse scholars will need to identify the most significant life processes for nursing knowledge, for example, valuing, deciding, supporting, coping, believing, and hoping. If nurses in genetics spend time on the foundational strategies for knowledge development, then they can more easily identify which of the wealth of qualitative and quantitative research methods will answer the most pressing questions. The last two terms to define are dissemination and utilization. After reading a fair amount of literature about research dissemination and utilization in nursing, I decided to begin with dictionary definitions. According to the New Webster’s (1992), dissemination stems from the Latin word meaning sowing seeds and has come to mean to spread wisdom and beliefs. Utilization means using something for its understood purpose, or making something perform its function. The purpose of knowledge in nursing is clinical practice and specifically helping people to promote health. A related definition comes from LoBiondo-Wood and Haber (1986) writing on research utilization. The authors refer to utilization as a systematic method of implementing sound, research-based (in a broader sense, knowledge-based) innovation in clinical practice, evaluating outcomes, and sharing knowledge. Understanding the term utilization can be expanded by reviewing the steps for research utilization described by Fitzsimmons and others (1995) and translating the steps to utilization of nursing literature in genetics practice. As in any problem-solving approach, nurses in genetics begin with identifying the clinical problem. This provides the focus for the next step in which the scholar in practice assesses the research, and philosophical and other literature, relevant to the problem. Derived from this knowledge, the nurse in genetics designs an innovation for practice. With genetic nursing on the cutting edge of knowledge, utilization projects all tend to be innovative. As with any innovation, the innovative approach is submitted to a clinical trial. A crucial step, then, is to evaluate the innovation and modify it as needed. The outcome is a far-reaching

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Table 1.

Scientific Assumptions for the 21st Century

Table 2.

Philisophic Assumptions for the 21st Century

Þ Systems of matter and energy progress to higher levels of

Þ Persons have mutual relationships with the world and with a

Þ Conciousness and meaning are constitutive of person and en-

Þ Human meaning is rooted in an omega point convergence of

Þ Awareness of self and environment is rooted in thinking and

Þ God is intimately revealed in the diversity of creation and is

Þ Human decisions are accountable for the integration of crea-

Þ Persons use human creative abilities of awareness, enlighten-

Þ Thinking and feeling mediate human action. Þ System relationships include acceptance, protection, and fos-

Þ Persons are accountable for the processes of deriving, sustain-

complex self organization.

vironment integration. feeling.

tive processes.

God-figure.

the universe.

the common destiny of creation. ment, and faith.

ing, and transforming the universe.

tering of interdependence.

Þ Persons and the earth have common patterns and integral relationships.

Þ Persons and environment transformations are created in human conciousness.

Þ Integration of human and environment meanings results in adaptation.

clinical decision to adopt, alter, or reject the innovation. Finally, the heart of research utilization lies in the last step of developing ways to extend and sustain innovative practice. As the field of genetic nursing expands in numbers and expertise, there will be experts in handling these different steps, but it will be the combined expertise in managing the entire process that is needed for dissemination and utilization of the growing knowledge base.

Significance and Process of Transferring Knowledge The second point, the significance of transferring knowledge to practice, need not be belabored since the entire conference has highlighted the crucial importance of this process. Put simply, “Knowledge without the culture, interest, and support to promote, act upon, and implement change remains a sterile asset” (Peters 1992, p 68). The significance of transferring knowledge to practice is highlighted by the number of professional organizations that have made formal statements and/or developed guidelines on transferring knowledge to practice. These include the ANA Council on Nursing Research, Sigma Theta Tau International, American Association of Critical Care Nurses, Cardiovascular Nurses, and as heard at this

conference, the 125 member organizations of the Coalition for Health Professional Education in Genetics. Two groups of professionals with particular commitment to transferring knowledge to practice are nurse researchers and nurse theorists. From the perspective of nurse researchers, current trends include a strong focus on outcomes research (Hill 1998). A journal has recently been established on evidence-based nursing practice, and nurses play a key role in the Agency for Health Care Policy and Research (AHCPR), which emphasizes guidelines for practice. Speaking for theorists, I can say that without exception, all articulate that they are describing and explaining nursing as a scholarly practice discipline. There is no “we and they” here; practice is the ground where all meet in our efforts to promote health. From the point of view of protecting patients, we have accrediting bodies such as the Joint Commission on Accreditation of Health Care Organizations requiring evidence that patient care is research based. It has been asserted that 40% of medical practice is research based. Whether this figure is true, it offers nurses a challenge to aim for the ideal of 100% knowledgebased practice. For genetic knowledge, we can argue that once the knowledge is available, we are accountable for it, and our patients deserve no less. Being committed to transferring knowledge to practice is not enough; we strive also to implement effective processes for transferring knowledge. One perspective that can add to our understanding of the process of transferring knowledge to practice is to recognize its immense complexity. Such complexity derives from the fact that transferring knowledge is a human activity that involves change on multiple levels.

Roy / Dissemination and Utilization of Nursing Literature Table 3.

Process of Transferring Knowledge to Practice at Different Levels

Individual cognitive-educational models Institutional organizational change models Societal and cosmic models, a new public vision

Each of these levels, individual, institutional, and societal-cosmic, requires a different level of analysis and differing knowledge bases to deal with change (see Table 3). We can articulate further the challenge we face by describing the three levels at which utilization of knowledge for nursing and in particular genetics takes place. At the individual level, nurses interact with patients and their families and nurse faculty with students. At this level, cognitive and educational models of knowledge utilization and change are required. As a postdoctoral fellow in neuroscience nursing, I had the opportunity to explore the field of cognitive processing. From literature review and clinical experience, a nursing model for cognitive processing was derived that has been useful for understanding some of the complexities involved and for organizing knowledge for practice (see Figure 3). The inner circle lists the basic internal processes, first of cognitive input, arousal and attention, sensation and perception; then the central processes of coding and concept formation, memory and language; finally, cognitive output processes are named as planning and motor response. The major functions of each of the processes is identified in Table 4. One example of how this knowledge is useful for practice is the principle the model highlights, that to help someone use new knowledge requires first that we get his or her attention. They will learn if we can entice and excite, use creativity and enthusiasm. Second, for example, pattern recognition is an important part of sensation and perception. This was demonstrated by Lashley’s (1998) remarks on the panel that part of what we do in education is to help others to know what they already know. The second level of analysis related to the process of transferring knowledge to practice is the institutional level. This approach involves organizational change models. Certainly when we consider that there are 125 organizations in the Coalition for Health

Table 4.

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Nursing Model for Cognitive Processing

I. Input Processes A. Arousal and attention 1. Selective attention 2. Speed of processing 3. Alertness B. Sensation-Perception 1. Primary sense processing 2. Pattern recognition 3. Naming and associating II. Central Processing A. Coding 1. Registration 2. Consolidation 3. Synthesis B. Concept formation 1. Integrated recognition 2. Abstraction and flexibility 3. Calculation C. Memory 1. Simultaneous 2. Successive D. Language III. Output Processes A. Planning B. Motor response 1. Motor planning 2. Initiating action 3. Regulating action

Professional Education in Genetics, we recognize that highly complex processes are involved. One author of a text on group processes and structures (Kimberly 1997) offers models of an integrated theory of change for both primary and secondary groups. Each model contains 28 concepts that are organized within four stages, that is, development, stability, orderly change, and disintegration. For both models, examples of concepts included in social-psychological processes are application of individual values and, related to structural process, group goals and norms. In an effort to provide a manageable model for organizational change, Roy and Andrews (1999) have redesigned the interdependence adaptive mode. In this nursing model for organizational change (see Figure 4), knowledge of context, or stimuli, infrastructure, or adaptation levels, and people or coping abilities are interlocked. Members of groups such as the International Society of Nurses in Genetics are addressing the process of transferring knowledge to practice at the institutional level.

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Figure 4. Nursing Model for Organizational Change.

Figure 3.

Nursing Model for Cognitive Processing.

The work of major societal institutions moves into Level 3 in which societal and cosmic perspectives are the focus for change. Let me challenge you a little further to consider your impact at the societal and cosmic level to create a new public vision. The direction of thinking is in the quantum world of Bose-Einstein condensate whose parts have both order and unity—quantum in the sense that “bits” can get inside each other or relate internally (Zohar 1990). Zohar and Marshall (1994) discuss the Quantum Self and the Quantum Society. The latter allows for a community of communities model of pluralism; boundaries overlap through shared potentialities. A visual image of this notion can be seen by showing a slide of the architecture of the arches from St. Peters in Rome and a slide of major structures in the same architectural style in St. Petersburg in Russia. The following quote provides insight into the notion of a community of communities. We have to learn to speak to those we do not wish to convert, but with whom we wish to live. . . . In a society of plurality and change there may be no detailed moral consensus that can be engraved on tablets of stone. But there can and must be a continuing conversation, joined by as many voices as possible, on what makes our society a collec-

tive enterprise; a community that embraces many communities. (Zohar and Marshall 1994, p. 193) We are then to use the highest level of imagination and creative skill to outline the process of transferring knowledge to practice at individual, institutional, and societal cosmic levels. In her book, Choosing to Lead, Buchanan (1996) points out that women are particularly suited to reconceiving the public agenda and creating a new public vision. We have an example of creating a public agenda in the Agency for Health Care Policy Research. The agency was created by the U.S. Congress in 1989 and as early as 1992 published the first Clinical Practice Guidelines. These were related to Acute Pain Management. Since that time, 10 additional sets of guidelines were developed between 1992 and 1995. Panels working to create the guidelines are multidisciplinary and include health experts and consumers. Each expert panel has 9 to 15 members, who work for a year using the following process for development of clinical practice guidelines: (1) National Library of Medicine conducts literature search, (2) the panel receives 5,000 to 10,000 abstracts, (3) articles are selected by the panel, (4) evidence tables are prepared, (5) open forums are held to solicit comments, (6) peer and pilot reviews are conducted, (7) revisions and final version is submitted, and finally (8) guidelines are widely publicized by direct mail and a clearinghouse. In the private arena, one example of efforts to reconceive the public agenda is the health system

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change research organization that is funded by the Robert Wood Johnson Foundation. This organization seeks to provide objective, incisive analyses that inform sound policy and management decisions, with the ultimate goal of improving the health of the American people. For example, their studies tract community practices to find out whether managed care provides competition, as argued by proponents (Long and Marquis 1998).

Issues Related to Dissemination and Utilization Major issues related to dissemination and utilization can be identified by describing barriers and facilitators to this highly significant stage of the knowledge cycle. Summarized from the literature, some commonly identified barriers can be organized and described as follows: • • • • •

culture—values, aims, and language nurse factors—knowledge, values, skill, and awareness organization—authority, administration, and awareness innovation—content and methods communication—accessibility and relevance

It is not difficult to describe examples of each barrier that makes it more difficult to use nursing literature in practice. If these barriers are true for knowledge in general, how much more true are they of knowledge in genetic nursing? Commenting briefly on nurse factors in the literature from the United Kingdom, an anti-intellectualism among their nurses was identified. This barrier was not identified in the journals from the United States that were reviewed. However, given an era of more intense focus on holism and humanism, nurses may have an antiscience and antitechnology bias that is a barrier. Such an attitude becomes particularly relevant in disseminating knowledge in genetic nursing, which needs both science and technology, as well as holism and humanism. Considering the barrier of communication, it seems ironic that as communication technologies increase, issues of accessibility and relevance also increase. Will a nurse in prenatal care be able to get information

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on a given genetic defect in a timely way, the first time she faces this issue? Will the nurse find the information at the level of her current knowledge, and will this be relevant to the family’s needs? Each of these barriers to knowledge dissemination and utilization seems to be amplified in applying them to the unique situation of genetic nursing knowledge. Similarly, the facilitators of knowledge implementation can be organized and described as follows: • • • •

creating environments—onsite, invisible colleges synthesizing knowledge—need for knowledge brokers providing access—broaden channels, open dialogue developing specific models of knowledge utilization—creative approaches

When we consider creating environments for effective dissemination and utilization of knowledge, it means that each nurse involved in genetic nursing is accountable. Wherever one practices, in hospitals, schools of nursing, and a variety of outpatient settings, each nurse contributes to an environment that creates and uses knowledge. Furthermore, we need to find ways to link our efforts so that such environments are not bounded by the walls of our institutions. Rather, they are interdependent in a way that provides support and encouragement for timely utilization. Journal editors have a special obligation to provide dissemination of newly developing and foundational knowledge in genetic nursing. The use of sidebars in journals to highlight recent developments is to be encouraged. Editors can issue calls for manuscripts that are peer reviewed and prominently and promptly featured.

Links among Theory Development, Standards of Clinical Practice, and Educational Programs Finally, I want to address the links among theory development, standards for clinical practice, and educational programming. The points that I want to make are derived from what I have said and what others at this conference have said. In a field as significant as emerging genetic nursing, specifying values and assumptions is clear and imperative. Our view of

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Figure 6. Global Effect of Links for Action. Figure 5.

Dynamism of Facilitating Knowledge Utilization.

persons, the environment, and the social good must be clear and compelling. Standards that are already developed likely imply our values and assumptions, but further explication and links can be made. Second, dissemination and utilization of knowledge for genetic nursing demands an inclusive metaparadigm. By this, I mean that any view of nursing must have room for all dimensions of knowledge for genetic nursing. Each conceptual view of nursing will be examined for how knowledge relevant to genetic nursing fits within the conceptualization. Furthermore, the conceptual models for nursing can be used to further holistic views of the person to enrich knowledge for genetic nursing practice. As Sue Donaldson (1998) noted, “family” is a key concept, and there are others. If each of us here wrote a letter to the editor each time we identified a noninclusive metaparadigm, I think the message would begin to take root. With specified values and inclusive metaparadigms, we can develop action plans for standards of clinical practice as guides. Participants at this conference have discussed action plans related to education as a path for change. Again, we can continue to link these to our values and assumptions, to our knowledge base, and to our models for individual, organizational, societal, and cosmic change.

Conclusion There are two images and a quote that can summarize the thinking I have shared. First, taking the facilitators of knowledge utilization, I have inserted the

worldwide dynamism such as evidenced by the dynamism such as evidenced by the International Society of Nurses in Genetics (see Figure 5). I feel that this group gives us reason to hope for great growth in the years to come. Second, I believe some of links for action suggested throughout the conference also can have a global effect (see Figure 6). After all, we are dealing with the future of humanity on earth. Since our work is so forward thinking, I want to quote Hillman on revisioning. Ideas remain impractical when we have not grasped or been grasped by them. When we do not get an idea, we ask “how” to put it into practice, thereby trying to turn the insights of the soul into actions of the ego. But when an insight or idea has sunk in, practice invisibly changes. The idea has opened the eye of the soul. By seeing differently, we do differently. (Hillman 1977) I congratulate nursing in genetics on your grasp of such significant ideas and your commitment of soul by which all of nursing will be seeing things differently.

References Anderson G. 1998. The state of the science: Social/psychological/ethical nursing research in genetics, presented at State of the art and science of genetic nursing: A knowledge development conference, September 19, 1998, Baltimore, MD. Buchanan CH. 1996. Choosing to lead: Women and the crisis of American values. Boston: Beacon. Donaldson S. 1998. State of the art genetic nursing knowledge in the discipline: Past and future, presented at State of the art and

Roy / Dissemination and Utilization of Nursing Literature science of genetic nursing: A knowledge development conference, September 18, 1998, Baltimore, MD. Fitzsimmons L, Shively M, Verderber A. 1995. Research connections: Focus on research utilization. J Cardio Nurs 9(2):87-94. Hill M. 1998. State of the science: Biological/behavioral nursing research in genetics, presented at State of the art and science of genetic nursing: A knowledge development conference, September 19, 1998, Baltimore, MD. Hillman J. 1977. Re-visioning psychology. New York: Harper Colophon. Kimberly JC. 1997. Group processes and structures: A theoretical integration. Lanham, MD: University Press of America. Lashley F. 1998. Genetic Content in Undergraduate Nursing Programs, presented at State of the art and science of genetic nursing: A knowledge development conference, September 18, 1998, Baltimore, MD. LoBiondo-Wood G, Haber J. 1986. Nursing research: Critical appraisal and utilization. St. Louis: C. V. Mosby. Long SH, Marquis, MS. 1998. How widespread is managed competition? Data Bull 12:1-2.

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Peters DA. 1992. Implementation of research findings. Health Bull 50(1):68-77. Roy C. 1997. Knowledge as universal cosmic imperative, In Proceedings Nursing Knowledge Impact Conference 1996: Exploring linkages of philosophy, theory, and research as the basis of outcomes for practice. Chestnut Hill, MA: BC Press. p 95-118. Roy C, Andrews H. 1999. The Roy adaptation model (2nd ed.). Stamford, CT: Appleton & Lange. Wilson EO. 1998. Consilience: The unity of knowledge. New York: Alfred A. Knopf. Young LB. 1993. The unfinished universe. New York: Simon and Schuster. Zohar D. 1990. The quantum self: Human nature and consciousness defined by the new physics. New York: Quill/William Morrow. Zohar D, Marshall I. 1994. The quantum society: Mind, physics, and a new social vision. New York: Quill/William Morrow.