DEVELOPING AN EVIDENCE-BASED PRACTICESc hool10
THE NIGHTINGALE LEGACY
CHILD HEALTH 2000
International Pediatric Nursing Conference
Friday, June 2, 1995
Heather F. Clarke, RN, PhD
Nursing Research Consultant
Registered Nurses Association of British Columbia,
Vancouver, B.C., Canada
"The time has come the walrus said to talk of many things, of sailing ships and sealing
wax and cabbages and kings". Indeed the time has come - and its a time of reform - not just a
tinkering around the edges - but of rule breaking; not just reducing/maintaining costs but of
reengineering - doing more with less; not just developing new technologies but of their creative
use. Albert Einstein's wisdom is as relevant today as it was decades ago "The significant
problems we face cannot be solved at the same level of thinking we were at when we created
The clues that it is a time for calling in the chits include: - evidence-based practice is "in"
- ritual and intuition are "out" - inappropriate/ineffective diagnostic and therapeutic interventions
are not being tolerated - evidence-based tools for decision-making in practice (e.g. CPGs, Care
Maps, Critical Paths) are proliferating and being made widely accessible (e.g. on-line, internet) -
accountability for outcomes is demanded of each and every health care profession - the "lone
ranger" practitioner is neither effective nor tolerated - "collaborative" practice is taking on many
shapes and sizes - consumer participation in decision making is not an option - the medical
model (paradigm) has been replaced (by many if not most) by the consumer model (paradigm) -
In this era of shared responsibility and cost-consciousness, patient preferences are a key element
of health care decisions and should be considered in the development of practice guidelines.
How come it is taking us so long to recognize these clues - to re-conceptualize our world
of professional nursing - to clearly demonstrate how nursing care makes a difference - how
health care resources and therapeutic nursing interventions are effectively and efficiently utilized
to improve the health status of clients of our health care system? Clearly, there is a need to
improve the research and evidence bases of our practice. This is the Nightingale Legacy -
Research and Practice. In Nightingale's view, nursing should be a search for truth. She held that
the ability to collect accurate information and make correct observations is essential. "If you
cannot get the habit of observation one way or other, you had better give up being a nurse, for it
is not your calling, however kind and anxious you might be"(1)
However, promoting and implementing research-based practice is not a simple task; nor
is it solely reliant upon nurses in clinical practice. There are forces affecting the advancement of
research-based practice within both the health care and nursing systems.
I know Dr. Ritchie is going to address this as well, so I am going to focus more on some
"how come" questions related to research-based nursing practice and discuss two interrelated
processes which must be attended to if the "how come" questions are to be turned into "why not"
questions - or "just do it" approaches. And I am going to address this with particular emphasis on
How come there is a gap between knowledge generation and application? Is it that
research is not seen to be relevant to practice? If so, how come we aren't getting the relevant
research done? Are we not asking the right or relevant questions? We know nurs es have
questions - consider those generated through the provincial Agency Challenge and agency
dinosaur and sacred cow challenges. There are relevant questions. So - How come they are not
being explored? Are researchers not listening to those questions? And even if they are to some
extent - How come clinicians are not more engaged in answering those questions? Furthermore
sometimes there are answers to the practice relevant questions. How come we're not using the
Example: Internet - IM Injection Sites
In the clinical arena the challenges of promoting research-based practice require a
different view of our world - they require us to create a new future. How we shape our future will
depend to great extent on how we perceive the clues I mentioned earlier - do we see them as
threats? or opportunities? do we see this as a loss? or a gain?
I believe it is time to turn our nursing system upside down:
From one that is currently-
difficult for responsive decision-making
inappropriate for knowledge diffusion and distillation (promotes evaporation instead)
not strategically situated to meet today's challenges
to one that is -
firmly grounded on evidence and research-based knowledge
encourages diffusion and distillation of knowledge
maximizes the potential of each resource (clinicians, educators, administrators and
Let's go back to one of the "how come" questions.
How come we're not using the research-based knowledge that we have in our practice?
are we unaware of the difference it would make - or do we either not believe the research
findings - or not believe that we have "permission" to use them?
Nurses tend to be perfectionists, looking for absolute proof of all facts before a piece of
research is deemed usable(2)
do we not value this aspect of our responsibilities?
do we lack the infrastructure and/or competencies to support such activity?
is there a lack of incentive to do so?
are we unaware of frameworks available to assist us in the process?
In this section of the presentation I will focus on two processes - diffusion and adoption
of innovations and use of research utilization models/frameworks - processes that have the
potential to facilitate the use of research in nursing. I will tell you a couple of success stories to
illustrate my point.
We know that neither the mere existence or dissemination of knowledge nor enforced
behavior change ensure that attitudes, values and behaviors will change (3). Using research
findings in nursing practice can be thought of as adoption of an innovation - a complex process
which involves several stages.
Rogers'(4) (1983) theory of diffusion of innovations with its four successive stages is a
good place to start. The first stage - knowledge - occurs as nurses become aware of the
innovation. Next, in the persuasion stage, they form a favorable or unfavorable attitude toward
the innovation. Thirdly, nurses make decisions to adopt or reject the innovation, at least on a trial
basis. If a new practice is mandated without practitioners moving through these appropriate
stages, it is unlikely that the innovation w ill be implemented consistently or as intended.
Consistent application with evaluation occurs in the fourth confirmation stage - if progress has
been successful through the previous stages.
A number of researchers have found that the source for new knowledge influences the
rate at which individuals pass through the first stage. Print-media and interpersonal contacts
(research-oriented conferences and inservice programs and role models) are most influential in
solving clinical problems and adopting innovations (Brett(5), Coyle and Sokop(6), Means(7),
Salasin and Cedar(8), Stinson and Mueller(9)). Although educational programs are suggested as
important methods of research dissemination, few studies have examined the extent to which
research findings are incorporated into nursing curricula.
In 1995, Barta(10) reported on a study that investigated pediatric nurse educators'
inclusion of evidence-based pain management techniques in the curriculum. Practices most
highly diffused among pediatric nurse educators were use of pain scales, providing sensory
information and teaching self-comforting strategies. However, only the use of pain scales was in
the "include always" range. The least diffused innovation in this sample was the use of TENS
(transcutaneous electrical nerve stimulation). It's interesting to note that at the 1992 International
Pediatric Nursing Conference at Child Health 2000, Dr. Leora Kutner11 spoke about desirability
(in fact predicted) that physical methods to ease pain would become more commonplace -
including therapeutic touch, massage and TENS - and that this would reflect the growing
appreciation of the research that shows that pain can be shifted by means other than
pharmacological. However, sadly in a 1994 report from Alberta, Williams'12 study of nurse
educators in that province we learn that there is a significant lack of fundamental know-how
about the pharmacological management of acute pain - that little time is spent on pain
management in nursing curricula and that content is often spontaneous rather than planned. In
Barta's study the educators chose nursing journals, nursing texts and Cumulated Index of
Nursing Literature, as most useful sources of information for updating instruction of
baccalaureate degree students. One has to seriously question the currency of texts and their
appropriateness as a source of update!
Factors influencing nurses in the persuasion stage are agency policy, procedure manuals,
and the opinions of other professionals. Rather than actual agency policy about research-based
nursing practice, Brett(13) found that it was perceived policy that influenced innovation adoption
behavior among her sample of hospital nurses. In the last two innovation adoption stages, the
most common barriers identified by clinicians were organizational barriers. Nurses' perception
that they lack authority and support of administration to change nursing practice inhibits
Romano's (14) identified five attributes of the innovation, as perceived by potential users
that affect the rate of its adoption. Innovations which have an obvious advantage to the
patient/client; are compatible with nurses' values and experiences; are relatively simple to
understand and implement; can be tested and evaluated; and demonstrate results are likely to be
adopted relatively quickly - with nurses passing through each of the four stages quickly and
without much angst. However, problems are sure to arise when at least one of these attributes
differ and when attention is not paid to assisting nurses move through the four stages in a logical
and timely fashion.
In 1991 members of the RNABC Nursing Research Committee Network questioned why
their staff nurses were not using the Patient Controlled Analgesia approach, including the pump,
as intended and supported by research. Subsequently an 11 site research study w as carried out
by 13 nurse-investigators. The purpose of the study was to determine nurses' learning needs to
bring about effective and efficient implementation of a PCA approach within the complexity of
decision-making about pain management. We used Rogers'(15) innovation adoption framework,
paying special attention to two of the five attributes of PCA (the innovation) not previously
investigated - compatibility of PCA with nurses' existing values and experiences and complexity
of the approach.
We found that nurses' beliefs related to PCA changed in varying degrees depending upon
the accumulation of positive or negative forces in their agencies. Positive forces included
planned implementation, education/clinical experience and positive outcomes for most patients,
even the chemically dependent. Nurse-involvement in patient selection for PCA was another
positive force, as was the ease of pump use and safety features. The timing of learning and
clinical application of new information and skills was as important as the availability of
knowledgeable peer supported clinical experience. The positive forces enhanced nurses' ability to
adopt a new perception of the PCA approach and supported them in the transformation of their
pain management beliefs.
Negative forces were opposite of the positive forces and included increased workload
during early phases of PCA implementation. These negative forces inhibited the implementation
of PCA and changes in pain management beliefs.
Our findings support the need to systematically address five issues when embarking on
the innovation adoption process:
1. availability of research-based knowledge - Is it available in clinically focused journals,
conferences, or electronic communication systems?
2. acceptability and readability of that knowledge - is it worded in jargon that only a
researcher can understand?
3. credibility of the study - do nurses believe the findings, given their understanding of the
4. relevancy of the findings - how relevant are the findings to clinical practice, the
sociocultural context of practice and clients, and organizational structures?
5. support and reinforcement to adopt and maintain the innovation - are there supportive
persons and materials to assist nurses to adopt and practice innovations?
Why not change this how come into a "just do it"? What resources/processes are there to
assist moving through the innovation adoption process? One is a research utilization framework.
A research utilization framework can facilitate the research adoption process and the
resolution of some of the above mentioned issues. The four best-known frameworks are the
Western Interstate Commission for Higher Education in Nursing, also called WICHEN(16); the
Conduct and Utilization of Research in Nursing or CURN(17), NCAST(18) and
Stetler/Marram(19). WICHEN and CURN frameworks are both based on the concepts of
diffusion of innovation and planned change; NCAST focusses solely on diffusion of innovations;
and the refined Stetler/Marram framework is an interactive, staged model.
Based on the work of Stetler (20) and the expressed needs of nurses and health care
agencies in British Columbia, a decision-making model for utilization of research findings in
practice was developed and published in the workbook Nursing Research: From Question to
Funding(21). Application of this framework requires partnerships among nurses with clinical
expertise, research experience, and administrative responsibilities. Each of the four phases
requires particular nurses to be involved, decisions to be made, and resources to be accessed. The
framework can be modified by individual agencies, thus making it relevant to both staff needs
and the organizational structure. <PExample: Vancouver Health Department
The Vancouver Health Department Nursing Research Committee - a sub-committee of
their Nursing Council - decided that their focus would be on assisting staff nurses in research
utilization. Based on the work of RNABC an agency-specific research utilization framework was
developed and a supporting manual written. During this process the committee members
critiqued the RNABC model, identified their agency's needs and resources, articulated their
agency's culture, philosophy, and mission statement, and consulted with Nursing Council and the
Quality Improvement Program. The result - a widely accepted framework and manual that are
user-friendly and "owned" by each of the health units in the department.
How well a given framework will serve a situation or agency depends on the framework's
efficacy, the type of problem, and the congruence of the framework's theoretical based with
nurses' decision making22. As well, the framework must fit with the organization's structure,
philosophy of nursing practice, and available resources.
Each stage of the innovation adoption process is critical to appropriate implementation of
research-based nursing practice. Change is rarely easy, but can be facilitated by addressing
known organizational and individual factors and using a research utilization framework.
Other individuals and organizations have tackled the "how comes" head on - and turned
them into "why nots" - "why not do it?" or "just do it". The "why nots" have included:
1. Why not be explicit about the responsibilities and accountability of every nurse for
evidence-based practice - in job descriptions and performance appraisals, in agency
philosophy and mission statements, in educational courses and programs?
2. But the changes required to solve today's problems won't come about unless there is a
supportive Infrastructure - why not tackle the various elements to determine which can be
expanded, coordinated with others, or developed?
3. Why not create opportunities for staff nurses to participate in evidence-based practice?
Agency challenge in the workplace; interdisciplinary research-based projects;
nursing/agency research committees; utilization frameworks; etc.
4. Why not build on what we know about discouragers and facilitators?
o Discouragers - lack of time, lack of support from nursing administration, lack of
nursing staff support, lack of support from other disciplines
o Encourages - methods to keep informed about study findings, research
newsletters, research meetings, continuing education programs, computer
networks, research study guides
5. Why not focus on the positive rather than overlooking or ignoring it and focusing on the
negative? Why not give praise for small and large accomplishments - for taking on the
challenge? Praise is the oil that greases the wheels of performance. It helps us to see the
good, build on success, overcome difficulties and not feel defeated by failure.
Putting our efforts into mobilizing a supportive environment for quality nursing care -
care that uses research findings appropriately - can have far reaching effects in promoting the
health of children and their families - that's what we are all about.
Barta, K.M> (1995). Information-seeking, research utilization, and barriers to research utilization
of pediatric nurse educators. Journal of Professional Nursing, 11, 1, 49-57.
Brett, J.L. (1987). Use of nursing practice research findings. Nursing Research, 36, 6, 344-349.
Coyle, L.A. & Sokop, A.G. (1990). Innovation adoption behavior among nurses. Nursing
Research, 39, 3, 176-180.
Horsely, J., Crane, J. & Bingle, J. (1978). Research utilization as an organization process.
Journal of Nursing Administration, 8, 4-6.
King, D., Barnard, K., & Hoehn, R. (1981). Disseminating the results of nursing research.
Nursing Outlook, 3, 164-169.
Krueger, J., Nelson, A., & Wolanin, M. (1978). Nursing research: Development, collaboration,
and utilization. Germantown, MD: Aspen.
Kutner, L. (1992). Pain management at BC's Children's Hospital. In H.F. Clarke and B. Davies
(eds) Shaping the Future of Child Health: Challenges for Nurses. Vancouver, BC. p. 92-
Larson, E., Kent, L, & Larson, J.S. (1984). Effects of enforced behavior change on attitudes.
Journal of Continuing Education in Nursing, 15, 4, 143-145.
Means, R.P.(1979/1980). Information seeking behaviors of Michigan Family Physicians.
Unpublished doctoral dissertation. University of Illinois at Urbana-Champaign.
Nightingale, F. (1969). Notes on Nursing. New York: Dover Publications. (Original work
published 1860). p. 113
Registered Nurses Association of British Columbia (1990). Nursing research: From question to
funding. Vancouver: Author.
Rogers, E.M. (1983). Diffusion of Innovations (3rd ed.). New York: The Free Press.
Romano, C.A. (1991). Diffusion of technology innovation. Advances in Nursing Science, 13, 2,
11-21. 15. Rogers op cit
Salasin, J. & Cedar, T. (1985). Information-seeking behavior in an applied research/service
delivery setting. Journal of the American Society for Information Science, 36, 2, 94-102.
Stetler, C. (1983). Nurses and research: Responsibility and involvement. National Intravenous
Therapy Association, 6, 3, 207-212.
Stetler, C. (1985). Research utilization: Defining the concept. IMAGE: The Journal of Nursing
Scholarship, 17, 2, 40-44.
Stetler, C. (1994). Refinement of the Stetler/Marram Model for application of research findings
to practice. Nursing Outlook, 42, 1, 15-25.
Stinson, E.R. & Mueller, E. A. (1980). Survey of health professionals information habits and
needs. Journal of the American Medical Association, 243, 2, 140-143.
Williams, B. (1994). A painful lack of knowledge. Canadian Nurse, November, 19-20. 13. Brett
Wood, M. (1992). Shaping practice through research. Clinical Nursing Research, 1, 2, 123-126.