Research Utilization: An Overview
1994; Elsevier BV; Volume: 23; Issue: 4 Linguagem: Inglês
10.1111/j.1552-6909.1994.tb01882.x
ISSN1552-6909
Autores Tópico(s)Infant Development and Preterm Care
ResumoNursing practice needs to be research based, not only to provide the best possible care to patients but also to ensure that nursing as a profession continues to grow. Criteria to help nurses determine how and when to implement research‐based practice changes are presented. Forces that facilitate research utilization are discussed, as are barriers to research utilization. Areas of research that are ready to be implemented in women's health, obstetric, and neonatal nursing are presented. Nursing practice needs to be research based, not only to provide the best possible care to patients but also to ensure that nursing as a profession continues to grow. Criteria to help nurses determine how and when to implement research‐based practice changes are presented. Forces that facilitate research utilization are discussed, as are barriers to research utilization. Areas of research that are ready to be implemented in women's health, obstetric, and neonatal nursing are presented. The care nurses give to women and infants has changed dramatically during the past few decades, thanks in large part to the solid research base of women's health, obstetric, and neonatal nursing. Nurses have learned how to help laboring women manage pain (Geden et al., 1986Geden E.A. Beck N.A. Anderson J.S. Kennish M.E. Mueller‐Henize M. Effects of cognitive and pharmacologic strategies on analogued labor pain.Nursing Research. 1986; 33: 301-306Google Scholar; Duchene, 1989Duchene P. Effects of biofeedback on childbirth pain.Journal of Pain and Symptom Management. 1989; 4 (123): 717Abstract Full Text PDF Scopus (18) Google Scholar; Geden et al., 1989Geden E. Lower M. Beattie S. Beck N. Effects of music and imagery on physiologic and self‐report of analogued labor pain.Nursing Research. 1989; 38: 37-41Crossref PubMed Scopus (29) Google Scholar, and how to help lactating mothers feed their infants (Carvalho et al., 1983Carvalho M. Roberson S. Friedman A. Klaus M. Effect of frequent breastfeeding on early milk production and infant weight gain.Pediatrics. 1983; 72: 307-311PubMed Google Scholar; Slaven and Harvey, 1981Slaven S. Harvey D. Unlimited suckling time improves breastfeeding.Lancet. 1981; 1: 392-393Abstract PubMed Scopus (26) Google Scholar; Freeman and Lowe, 1993Freeman C.K. Lowe N.K. Breastfeeding care in Ohio hospitals: A gap between research and practice.JOGNN. 1993; 22: 447-454Abstract Full Text Full Text PDF Scopus (8) Google Scholar. Research has helped nurses to improve the care given to the smallest and sickest infants (Anderson et al., 1983Anderson G.C. Burroughs A.K. Measel C.P. Non‐nutritive sucking opportunities: A safe and effective treatment for premature infants.in: Field T. Sostek A. Infants born at risk: Physiological, perceptual and cognitive processes. Grune & Stratton, 1983Google Scholar; Hodge, 1991Hodge D. Endotracheal suctioning and the infant: A nursing care protocol to decrease complications.Neonatal Network. 1991; 9: 7-15PubMed Google Scholar, and nurses have learned howto help women be more involved in preventative health care, such as breast self-examination (Champion, 1992Champion V. Relationship of age to factors influencing breast self‐examination practice.Health Cure of Women International. 1992; 13: 1-9Crossref PubMed Scopus (30) Google Scholar; Long, 1993Long E. Breast cancer in African‐American women: Review of the literature.Cancer Nursing. 1993; 16: 1-24Crossref PubMed Google Scholar. These are only some of the many areas in which nursing research has made an impact on nursing practice. Nurses have changed practice by eliminating what they do that does not work (such as having women prepare their breasts antenatally for breastfeeding) (Brown and Hurlock, 1975Brown M.S. Hurlock J. Preparation of the breast for breastfeeding.Nursing Research. 1975; 42: 448-451Crossref Scopus (28) Google Scholar, and they have instituted new ways to care for women that work better than old ways (such as providing structured preoperative teaching) (Devine and Cook, 1983Devine E.C. Cook T.D. A meta‐analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay.Nursing Research. 1983; 35: 267-274Google Scholar. However, as the research base increases, it becomes difficult to keep up with all of the new information. In addition, as more sophisticated and complex studies are conducted and more sophisticated data analysis techniques are used, it sometimes is difficult to determine when research is ready to be translated into practice. However, the largest barrier the faced by women's health, obstetric, and neonatal nurses in terms of research utilization is that such nurses are not always interested in incorporating research into practice. Collectively, this group of nurses cares for women or infants every day of the year. They provide care to many people at a period in their lives when they are particularly vulnerable. Is there a better way of knowing how to care for these patients and clients than through research? Nursing practice could be based on on what others say is the best way to practice, and probably all nurses have based some of their practice on the words of authorities. However, even if these authorities are trusted and admired experts, this is not the most efficient way to practice. By necessity, practice based on the word of others is limited by the expertise and knowledge of one small set of experts. Another basis of practice could be the nurse's past experience. Each nurse could carefully recall what has worked in the past and use that expertise to try the same kind of techniques in the future. This process works but is limited by the nurse's previous experience or the experience of those around the nurse. In this rapidly changing world with increasingly complex technology, surely combining the collective knowledge and expertise is the most efficient way to ensure that a sound base is provided for the care given. Research is the scientific vehicle that allows nurses to objectively determine if answers to clinical problems hold true with the test of time and if they hold true in more than one practice setting. Research provides the most objective information upon which to make decisions about how nurses should practice. Research utilization is the process by which research knowledge is moved into the clinical arena, and it can happen in many different ways. Research utilization does not always mean implementing research findings in practice. Research can be used in education, to spark additional research, or to help nurses better understand clinical situations, even if practice changes do not occur (Bircumshaw, 1990Bircumshaw D. The utilization of research findings in clinical nursing practice.Journa1 of Advanced Nursing. 1990; 15: 1272-1280Crossref PubMed Scopus (38) Google Scholar. However, research utilization usually means changing practice or validating that current practice is appropriate and does not require change. Research utilization may be as simple as one nurse changing how she or he gives care, may involve developing or updating protocols for nursing care based on available research, or may be a more involved process, in which a research-based protocol is evaluated to see whether it is being implemented as expected and whether it is producing the predicted results (Goode et al., 1987Goode C. Lovett M. Hayes J. Butcher L. Use of research based knowledge in clinical practice.Journal of Nursing Administration. 1987; 17: 11-18PubMed Google Scholar. This more formal evaluation process usually is necessary only when there is some barrier to implementation. For example, the research-based practice change may be costly, may have some degree of potential risk to the patient, or may be a change that is meeting resistance from staff. In each of these situations, the evaluation process is necessary. Whatever the process, the ultimate goal of research utilization is to improve patient care. Using research in practice not only benefits patients but also strengthens nursing as a profession. If nursing is truly a profession, and not just a job or an occupation, nurses have to be able to continually evaluate the care they give and be accountable for providing the best possible care. Evaluating nursing care means that nurses also have to evaluate nursing research and determine if there is a better way to provide care. It is difficult to realize that a long-practiced nursing intervention does not help improve the quality of care and to change that intervention. For example, although there are excellent data to show that suctioning infants below the carina causes mucosal damage (Bailey et al., 1988Bailey C. Kattwinkel J. Teja K. Buckley T. Shallow versus deep suctioning in young rabbits: Pathologic effects on tracheobronchial wall.Pediatrics. 1988; 82: 746-751PubMed Google Scholar, nurses who pride themselves on the thoroughness of their suctioning technique may misguidedly find it difficult to control the depth of suctioning. It also is difficult to begin to use research-based practices that are new and have not been a part of nursing care. For example, research on breastfeeding makes it clear that insufficient milk volume or other kinds of breastfeeding failure are more common when mothers and infants are separated, when there are delays in initiating breastfeeding, and when duration of breastfeeding is limited (Carvalho et al., 1983Carvalho M. Roberson S. Friedman A. Klaus M. Effect of frequent breastfeeding on early milk production and infant weight gain.Pediatrics. 1983; 72: 307-311PubMed Google Scholar; Slaven and Harvey, 1981Slaven S. Harvey D. Unlimited suckling time improves breastfeeding.Lancet. 1981; 1: 392-393Abstract PubMed Scopus (26) Google Scholar; Freeman and Lowe, 1993Freeman C.K. Lowe N.K. Breastfeeding care in Ohio hospitals: A gap between research and practice.JOGNN. 1993; 22: 447-454Abstract Full Text Full Text PDF Scopus (8) Google Scholar. However, nursing practices that incorporate keeping mothers and their infants together have not been uniformly instituted (Freeman and Lowe, 1993Freeman C.K. Lowe N.K. Breastfeeding care in Ohio hospitals: A gap between research and practice.JOGNN. 1993; 22: 447-454Abstract Full Text Full Text PDF Scopus (8) Google Scholar. By updating nursing practice, keeping interventions that work and eliminating those that do not, the profession is strengthened. Research utilization helps ensure that the care nurses give is standardized and efficacious and helps to demonstrate that nursing as a profession improves patient outcomes. Not all problems encountered in clinical practice require research-based answers. Some problems require immediate answers and are unique to a particular institution at a particular time. Hinshaw and Smeltzer, 1987Hinshaw A. Smeltzer C. Research challenges and programs for practice settings.Journal of Nursing Administration. 1987; 17: 20-26PubMed Google Scholar suggest that clinical problems for which researchable answers need to be identified are problems that are repetitive, occur in multiple clinical settings, are testable (and not about philosophic stances such as what "should" or "ought" to be done), and that represent long-term practices or policies for which accurate data would help in decision making. Clearly, there are many administrative and clinical problems that do not require scientific rigor and for which problem-solving skills are adequate. However, questions about how best to give care that improves the quality of patient outcomes and transcends the institution are likely to be questions for which research is needed to provide accurate and objective answers. All research is not ready for implementation into practice. Nurses need to be able to understand research and critique research to determine when research findings are ready for implementation into practice. This process of evaluating research findings is one critical step in research utilization and in being accountable for nursing care. The basic questions that each nurse needs to ask to determine if research is ready to be used in practice are:How alike are the study samples to the patients for whom I care?Do the findings and conclusions of this research make sense to me?Would implementing the changes the research suggests improve the care I give to my patients? If the answer to any of the questions is "I'm not sure," the nurse evaluating the research base can consult with other nurses and use their collective expertise in evaluating the research base. Criteria for evaluating the potential of research findings for application to practice were developed by Haller et al., 1979Haller K.B. Reynolds M.A. Horsley J.A. Developing research‐based innovation protocols: Process criteria, and issues.Research in Nursing & Health. 1979; 2: 45-51Crossref PubMed Scopus (50) Google Scholar and include having more than one study in a research base, examination of each study's scientific merit, and determination of any potential risks to patients. In evaluating available research, it is important to realize that perfect research does not exist and that every day nurses provide care to patients. The nurse who is accountable for the care she or he gives will no doubt choose to give research-based care if more than one well-executed study has the same findings, the studies appear to be sound, and implementing these findings does not cause undue risk to patients. However, even when the research base is clear and changing practice appears to be beneficial to patients, additional steps sometimes are needed before change can be implemented. For change to occur, the practice that needs to be changed must be under the control of nursing practice or collaboration needs to occur between nursing and other disciplines involved in giving care (Haller et al., 1979Haller K.B. Reynolds M.A. Horsley J.A. Developing research‐based innovation protocols: Process criteria, and issues.Research in Nursing & Health. 1979; 2: 45-51Crossref PubMed Scopus (50) Google Scholar. For example, implementation of findings supporting changing position during labor or promoting exhalation pushing during second stage may well require careful collaboration with obstetricians before they can successfully be implemented. In addition, in this era of cost containment in health care, it is important that we examine the cost of implementing change and the cost savings that might result from change. A research-based practice change might not be implemented because it is not feasible in a particular practice setting. Because of problems with personnel, space, or time, it might not be possible to implement practice changes. To determine how well a research-based change is occurring in practice, there has to be the ability to evaluate the clinical change. The clinical evaluation of a research-based change can be informal or formal. In more formal evaluations, a pre- and postimplementation design often is used, and the patient outcomes are compared before and after the change is made. Alternatively, change may be implemented on one unit and compared concurrently to routine practice on another unit to determine if the change improves patient care. A postimplementation design alone also may be implemented (as is true in the research-utilization project presented in this issue of JOGNN, for which the protocol for weaning preterm infants from isolettes into open cribs was changed and the change evaluated). Sometimes the differences between "research" and "research utilization" can be confusing. Haller et al., 1979Haller K.B. Reynolds M.A. Horsley J.A. Developing research‐based innovation protocols: Process criteria, and issues.Research in Nursing & Health. 1979; 2: 45-51Crossref PubMed Scopus (50) Google Scholar, p. 46) clearly differentiate the two as "the conduct of research is directed toward the production of knowledge that is generalizable beyond the population directly studied. The process of research utilization, on the other hand is directed toward transferring specific research-based knowledge into actual practice." If changing practice has no cost to an institution and does not appear to be likely to harm a patient, there is no need for a time-consuming and formal evaluation process. When change has minimal risk, there is no need for specific evaluation, and nurses can rely on their existent quality-assurance mechanisms to let them know how care has improved. However, when there is risk or cost involved, it becomes important that the change be evaluated for its effectiveness. It is possible that research performed under strict controls and with additional personnel does not have the same results in the less controlled and less well staffed realities of clinical practice. Nurses may not be sure of the risk involved and thus may choose to be conservative and evaluate change. Often the research base does not provide answers that will allow documentation of every step of a protocol, and nurses use other kinds of knowledge to complete the protocol. Nurses may wish to evaluate how appropriately they were able to "fill the gaps" in which actual research did not exist. For example, if one were to devise a research-based protocol on infant suctioning (a topic for which there is much research), questions still would be raised about specific steps in the protocol, such as the size of catheters that should be used. In the absence of research on every step of the protocol, inferences need to be made based on physiology and clinical knowledge. Depending on the number and kinds of these inferences that are made as a research-based protocol is developed, evaluation may seem warranted. Formal evaluation also may be used to help build group consensus. When nurses cannot agree to change practice, they sometimes can agree to try something for a limited period of time in one or two areas to see how well it works. This evaluation might not teach anything new about the procedure but may teach many things about nurses' resistance to change, and nurses might come to realize that the "new way" is much better than was anticipated. Many significant changes in practice have occurred based on research that has not been found to be true during a period of time. For example, Klaus and Kennell, 1976Klaus M. Kennell J. Maternal infant bonding. C. V. Mosby, 1976Google Scholar work on maternal-infant bonding has not been found to be valid with replication. However, many valuable family-centered changes in the provision of care were instituted that probably would not have been acceptable if it were not for the research base. Thus, evaluation in clinical practice may not support the research findings of particular studies but may prove to be beneficial anyway. Research is not available to answer every practice problem nurses face. Nurses need to use the research base that exists and to promote the development of research answers for important clinical questions when a research base is not available. Research utilization and the generation of research knowledge are an interactive process by which, when it is discovered the research needed to change practice does not exist, nurses help researchers in conducting the studies needed to improve patient care. One way of helping to bridge the gap between practice and research is to establish mechanisms by which researchers and clinical nursing staff work together (Campbell and Dowd, 1991Campbell D. Dowd T. Promoting clinical research through collegial relationships.Nursing Connections. 1991; 4: 39-45PubMed Google Scholar. Many hospitals and other health-care institutions have hired clinical nurse researchers to help bridge the gap (Schutsenhofer, 1991Schutsenhofer K. Scholarly pursuit in the clinical setting: An obligation of professional nursing.Journa1 of professional Nursing. 1991; 7: 10-15Abstract Full Text PDF PubMed Scopus (10) Google Scholar, and these clinical researchers have demonstrated a wide range of activities that promote practice-based research (Knafl et al., 1987Knafl K. Bevis M. Kirchoff K. Research activities of clinical nurse researchers.Nursing Research. 1987; 36: 249-252Crossref PubMed Scopus (17) Google Scholar. Cost-effective models for the sharing of resources or research consortium also have been developed (Zalar et al., 1985Zalar M. Welches L. Walker D. Nursing consortium approach to increase research in service settings.The Journal of Nursing Administrations. 1985; 15: 36-41Crossref PubMed Scopus (15) Google Scholar. Programs have been evaluated in which local health-care institutions join forces with local universities to encourage clinicians and researchers to change practice collaboratively (Riesch and Mitchell, 1989Riesch S. Mitchell E. A model for research implementation.Dimensions in Critical Care Nursing. 1989; 8: 356-363Crossref PubMed Scopus (3) Google Scholar. Indeed, in some institutions clinicians and researchers may be the same person. In an institution in which a mechanism has not been adopted to help translate clinical problems into research, it is important for nurses in leadership positions to identify research resources. Often there are researchers who need access to clinical sites and who would value a collaboration with staff nurses or clinical nurse specialists interested in helping to define and solve a significant clinical problem. However, this process takes time, and one of the frustrations involved in research utilization is that sometimes practice cannot be changed on the basis of scientific evidence because such evidence does not exist. Research utilization, to be successful, requires nurses who are committed to providing the highest quality of patient care and to changing care as needed to ensure quality. Several major projects have increased nursing's understanding of the research-utilization process. In 1971, one of the first major attempts to foster the use of research in practice was initiated by the Western Interstate Commission for Higher Education (WICHE) in the Regional Nursing Research Development project. In 1975, the Conduct and Utilization of Research in Nursing (CURN) (Horsley et al., 1988Horsley J. Crane J. Crabtree M. Wood D. Using research to improve nursing practice: A guide. Grune & Stratton, 1988Google Scholar project of the Michigan Nurses Association was begun. Both efforts were aimed at translating research into clinical knowledge for use in practice settings and helping to define the research-utilization process. Other programs also have helped foster research utilization, and research utilization has support from several different kinds of institutions. For example, the Division of Nursing is sponsoring the Orange County Research Utilization in Nursing Project, in which 25 organizations in California are identifying strategies to collaborate on research-utilization projects. Many specialty organizations have research utilization as a focus. The commitment of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) to research utilization was expanded in 1990, when the Research Committee convened a panel of nurse experts in obstetric, neonatal, and women's health nursing to identify areas of nursing research ready for implementation (see Table 1). The transition of low-birth-weight infants from isolettes to open cribs was one area that was identified in which a research-based protocol could be developed. Other areas that were identified appear in Table 1, but because the research base is constantly growing, this is not a complete list. AWHONN also supports research utilization with a small grant program awarded to individuals; this program was begun in 1992. AWHONN plans to conduct another multisite research-utilization project based on research utilization that is occurring on a regional level. District IX of AWHONN has coordinated and is implementing a research-utilization project to evaluate a research-based protocol on pushing during the second stage of labor (Mayberry et al., 1993Mayberry L. Wood S. Held N. Second stage labor management: Why can't we make progress [oral presentation].Challenges Beyond Limits. Association of Women's Health, Obstetric and Neonatal Nurses, 1993Google Scholar. Other organizations also support research utilization. For example, the American Association of Critical Care Nurses has a research-utilization grants program and Sigma Theta Tau sponsors research-utilization workshops around the United States to promote an understanding of the research-utilization process.Table 1Research Utilization Project AreasMaternity Nursing1.Identification of abused women through the routine use of screening questions.2.Promotion of breastfeeding by modeling the home experience in the hospital.3.Use of upright versus recumbent position during second-stage labor to reduce fetal compromise and maternal pain.4.Exhalatory versus sustained bearing down during second stage labor to reduce abnormal FHR patterns and low Apgar scores.5.Use of antacids and dietary fiber in pregnancy.6.Decreased use of pharmacologic analgesia in childbirth7.Reducing smoking during pregnancy through patient education programs.8.Improving parental knowledge and skills about behavioral capabilities of newborn infants.9.Reduction of depression and anxiety in bereaved parents through enhanced care strategies.10.Practices to abandon, including:Leaving women unattended in laborFailure to include women in decision-makingRoutine episiotomyAdvising restriction of weight gainWomens Health Nursing1.Motivating women to initiate and maintain regular breast self-examination in conjunction with a regular program of clinical examination and mammography.2.Promotion of pelvic muscle strengthening for mild and moderate stress urinary incontinence.3.Preparation of mother-daughter dyads for menarche.4.Preparation of women for menopause as a normal and healthy transition.5.Use of both psychologic and physical examination components to routinely screen women for emotional, sexual, or physical abuse.Neonatal Nursing1.Use of comfort measures such as non-nutritive sucking during or in anticipation of stressful procedures.2.Removal of barriers to successful breastfeeding; improving breastfeeding success in preterm infants.3.Improving skin integrity of low-birth-weight premature infants.4.Improving thermoregulation of infants.5.Reducing physiologic sequelae of infant suctioning.7.Use of findings that infants do feel pain.8.Use of telephone follow-up services, especially for high-risk infants and families.These topics were identified by NAACOG's Research Utilization Task Force (1990) as areas in which a sufficient base exists to guide implementation and evaluation of changes in clinical practice. Topics for research utilization projects are not limited to those on this list. Open table in a new tab These topics were identified by NAACOG's Research Utilization Task Force (1990) as areas in which a sufficient base exists to guide implementation and evaluation of changes in clinical practice. Topics for research utilization projects are not limited to those on this list. How research is taught in schools of nursing also influences how nurses use research in practice. Larson, 1989Larson E. Using the CURN project to teach research utilization in a baccalaureate program.Western Journal of Nursing Research. 1989; 11: 593-599Crossref PubMed Scopus (10) Google Scholar proposes an innovative method that not only teaches research utilization but also encourages students to evaluate research and make judgments about how ready it is for use in practice (Hinshaw, 1988Hinshaw A. The National Center for Nursing Research: Challenges and initiatives.Nursing Outlook. 1988; 36: 54-56PubMed Google Scholar. These first steps in research utilization are shared with practice sites. This method of teaching results in students having a positive attitude about nursing research and has an immediate impact on clinical practice. There also are national forces that help promote research utilization. The National Institute for Nursing Research has demonstrated interest in promoting the dissemination and utilization of nursing research in practice. Another federal agency, the Agency for Health Care Policy and Research, has facilitated the use of nursing research in practice by gathering experts together to develop practice guidelines that are available free of charge to practitioners. Clinical practice guidelines that maybe of special interest to women's health, obstetric, and neonatal nurses include "Acute Pain Management: Operative or Medical Procedures and Trauma," "Acute Pain Management in Infants, Children, and Adolescents: Operative and Medical Procedures," "Urinary Incontinence in Adults," and 'Sickle Cell Disease: Comprehensive Screening and Management in Newborns and Infants." Guidelines can be obtained by calling 1-800-358-9295. These guidelines are interdisciplinary but have been developed with major input from nurse experts. Each set of guidelines has three separate publications: a clinical practice guide, a quick reference guide, and a patient guide. Evidence that research utilization is very much a part of nursing care is provided by Brett, 1987Brett J. Use of nursing practice research findings.Nursing Research. 1987; 36: 344-349PubMed Google Scholar, who studied 216 nurses in small, medium, and large hospitals. Brett found that most nurses were aware of 14 research-based practice innovations. Not only were nurses aware of the research that had been done, but most of the nurses also were persuaded that the practice innovation should be implemented. In addition, most of the nurses reported using research-based innovations in practice at least some of the time. Coyle and Sokop, 1990Coyle L.A. Sokop A.G. Innovation adoption behavior among nurses.Nursing Research. 1990; 39: 176-180C
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