The Organizational Environment and Evidence-Based Nursing
The Province-Wide Nursing Project (PWNP) was designed to remove some of the structural barriers that can impede the ability of nurses in selected health care settings to assess, implement and evaluate best nursing practice. Literature on capacity building and research utilization suggests that the organization is the most important factor in promoting best nursing practice. Therefore, managers and nursing leaders need to encourage the creation of optimum work environments. A survey undertaken by the PWNP Research Centre team assessed the extent to which the 23 agencies in the 4 Participating Complexes provided supportive environments for evidence-based practice. The Characteristics of Agencies in Participating Complexes: Demographics and Resources questionnaire investigated the resources available to help nurses improve their standards of practice in agencies participating in the project. Larger agencies, especially those associated with academic centres, had considerably more resources than agencies in smaller towns. Participation in the Province-Wide Nursing Project enabled agencies to develop strategies to improve the use of evidence in nursing practice.
The Organizational Environment and Evidence-Based Nursing
The Province-Wide Nursing Project (PWNP) was a three-year project in Ontario, Canada whose goal was to promote best nursing practice. Four Participating Complexes took part in the project: Cornwall, London, Ottawa and Sioux Lookout. Each complex included at least one acute care hospital, long term care agency, and community agency. The Research Centre was established to evaluate the project (PWNP Research Centre, 1999). This article describes a survey undertaken by the Research Centre team to assess the resources available in the participating agencies to facilitate evidence-based practice.
Capacity building usually refers to "a process of individual and institutional development which leads to higher levels of skill and greater ability to perform useful research" (Throstle, 1992, p. 1321). While the term has most frequently been applied to enterprises funded by donors in less-developed countries, it is equally applicable to situations in developed societies. The Province-Wide Nursing Project can be appropriately referred to as an exercise in capacity building.
Much of the literature relevant to an understanding of factors favouring or preventing the development of "best nursing practice" focuses on research dissemination and utilization. Dissemination is the process through which target groups and individuals become aware of, receive, accept, and utilize information (Jennet & Premkumar, 1996). Research utilization fills the gap between the dissemination of information and its use in decision making or clinical practice (Dobbins, Ciliska, & DiCenso, 1998). The study of research utilization grew out of a more general concern with the diffusion of innovation in the health sciences professions, particularly in medicine. Dissemination research has been influenced by both diffusion of innovation and research utilization studies.
A systematic review of studies on research utilization and dissemination showed that both acknowledge the importance of the individual, organization, and environment in influencing research use (Dobbins et al., 1998). While dissemination studies mostly focus on strategies targeting the individual, studies on research utilization place more emphasis on the organization and the environment.
Most research utilization studies focus on barriers and facilitators to research use. Some recent examples include surveys of nurses (Brett, 1989; Carroll et al., 1997; Funk, Champagne, Weise, & Tornquist, 1991; Funk, Tornquist, & Champagne, 1995; Lacey, 1995; Peacey, 1995; Walczak, McGuire, Haisfield, & Beezley, 1994). The current consensus is that organizational factors are more important than either individual or environmental factors. Eight of the top ten barriers identified by Funk et al., (1991) related to the setting. Steelman (1996) identified the need to address organizational barriers in order to successfully implement clinical practice guidelines. Blythe and Royle (1993) found that the organizational environments in which nurses work have not always been conducive to accessing and retrieving research information. A survey of 71 hospitals in Central West and Northwest Ontario (Royle, Blythe, DiCenso, Baumann, & Fitzgerald, 1997) found differences between large and small hospitals in their access to resources and training in research utilization. Organizational characteristics significantly associated with research utilization include size, centralization of decision making, administrative support, and research climate (Dobbins et al., 1998).
Environmental factors that affect research utilization have been identified in the literature but have not been studied in the same depth as organizational factors. There is some evidence that urban hospitals have more facilities for research utilization than rural ones and that some agencies are embedded in more productive networks than others (Dobbins et al., 1998; Royle et al., 1997).
Given the influence that organizational factors have on research utilization, evidence-based practice must be made an integral part of organizational policy at all levels if it is to be adopted successfully (McGuire, 1990). As a strategy for public accountability and justification for the use of resources, evidence-based health care can serve as motivation for policy makers to encourage research utilization in their organizations. There is a greater awareness of the potential of science to produce benefits when its findings are appropriately applied. Information technology is making research evidence more accessible. The Iowa model, which includes members of all health care professions at every level in the process of critically applying research to practice, is one example of an attempt to change the organization to optimize patient outcomes (Titler, Kleiber, & Steelman, 1994).
Sample and settings
The four Participating Complexes in the project were located in Cornwall, a small town community; London and Ottawa, large urban centres; and SiouxLookout, a northern community, Agencies in the Ottawa and London Participating Complexes were affiliated with academic centres. Survey questionnaires were completed by representatives from all 23 agencies that took part in the Province-Wide Nursing Project.
The purpose of the questionnaire was to investigate the extent to which agencies in the Participating Complexes provided environments that facilitated evidence-based practice. Relevant questions were asked about the availability of
- Resources for research utilization, including library facilities, agency-wide computerized resources, and program/unit/office-based resources
- People with research expertise
- Research-oriented committees
- Continuing education
- Policies on research utilization.
The questionnaire was adapted from Mitchell, Janzen, Pask, and Southwell (1995) and Royle et al., (1997) for this project. It was pilot tested before administration.
The survey was carried out before project interventions were implemented. Questionnaires were sent to the project coordinators, RNs hired by each Participating Complex to coordinate the project. The project coordinators distributed them to the representative from each agency who served on the project management committee. The project coordinators were also responsible for ensuring their return to the Research Centre. The questionnaires were completed during Spring 1997 and Spring and Summer 1998 for a total of 23 (100%) questionnaires.
Because the sample was small and the purpose was to describe and compare data from the agencies rather than to make broad generalizations, analysis was confined to simple descriptive statistics, such as counts, percentages, ranges, means, and medians. Data were analysed by Participating Complex and by type of agency (i.e., acute, chronic, community, and long term care).
Representatives from all 23 agencies (100%) completed questionnaires: 6 agencies were located in the north (Sioux Lookout), 4 were rural (Cornwall), and 13 were affiliated with academic settings (7 from London, 6 from Ottawa). Seven were acute care agencies, 3 chronic care, 6 community, 5 long term care and 2 were outpost stations.
Resources for research utilization
Library resources. Several questionnaire items asked for information on available resources for research utilization. Of the 23 respondents, 18 indicated that their agency had a library accessible by both RNs and RPNs (LPNs). These respondents were asked for information on the types of resources available in their libraries. In decreasing order, 14 had interlibrary loans, 13 had links to community college or university libraries, 9 had a librarian, 9 had electronic bibliographic databases, and 10 had membership in a health sciences library network. Library resources were most plentiful in the academic settings. While none of the northern agencies had librarians, that community had more connections for accessing resources beyond their region than the rural site. Hospitals, both acute and chronic, had more resources than other types of agencies while community care agencies and nursing stations had very few resources.
Agency-wide computerized resources. Items asking whether nurses had access to computerized resources in their workplace revealed that access to resources, other than word processing, was minimal. Nurses had access to word processing (14 of 23 respondents), workload measurement tools (8), electronic mail/notice board (9), other computerized resources (6), bibliographic databases (4), laboratory results (3), the Internet (3), patient records (2), and policies and procedures (2). Only one respondent indicated having access to clinical nursing information resources. Agencies in academic settings had the most computerized resources while those in the rural setting had the least (see Table 1).
Work-site information resources. Respondents were asked whether nurses had access to clinical resources in their immediate practice environment. Eighteen indicated having access to nursing texts and reference books published within the last five years and 15 reported having access to current nursing journals. Only one respondent indicated having access to computerized clinical information resources.
Nursing research resources. In response to items asking for information on research, 11 respondents indicated that research was carried out at their agencies. These included 1 of the 4 Cornwall agencies, 4 of the 7 London agencies, and all 6 from Ottawa. Nursing research was not carried out at any of the Sioux Lookout agencies. Research was nursing specific at one Cornwall agency, one Ottawa agency, and one London agency. At 6 agencies, 1 in London and 5 in Ottawa, research was both agency-wide and specific to nursing. In the two remaining London agencies, research was agency-wide.
Six respondents, 5 from Ottawa, indicated that a nursing research position, such as a research director or coordinator, was available at their institution. Four of which, 3 from Ottawa and 1 from London, were full-time positions (see Table 2 on previous page). While research was carried out in all types of agencies except nursing stations, hospitals had more supportive mechanisms for carrying out research.
Access to research expertise
Thirteen respondents, including 2 from Cornwall, 4 from London, 4 from Ottawa, and 3 from Sioux Lookout, felt that they had access to nurses with expertise in research in their agency. However, only 6 respondents, 3 in Ottawa and 3 in London, stated having access to nursing faculty for research collaboration. Access to nurses with research expertise was available in 5 acute care hospitals, 2 chronic care hospitals, 2 community agencies, 3 long term care facilities, and 1 nursing station. Access to faculty was available in 2 acute and 2 chronic care hospitals, 1 community agency, and 1 long term care agency.
Respondents suggested that nursing personnel involved in research included staff nurses (11), followed by nursing administrators (6), clinical nurse specialists (6), nursing faculty (4), students (3), and others (2).
Ten respondents, 2 at Cornwall, 3 at London, 4 at Ottawa, and 1 at Sioux Lookout, felt that there was sufficient support for nursing research in their institution. One community agency noted that nurses had little time to be involved in research and did it as a favour to graduate students rather than as part of their responsibilities to the agency.
Five respondents identified having clinical nurse specialists (CNSs) at their agencies: 1 at Cornwall, 2 at London, and 2 at Ottawa. There was a range of one to five CNSs at these agencies. Specialties mentioned more than once included geriatrics, incontinence, and enterosomal therapy. One acute care, 1 chronic care, 2 community, and 1 long term care agencies employed CNSs. Two agencies in London noted that they did not have CNSs but that they did have nurse specialists. Both nursing stations mentioned having nurses specializing in outpost nursing.
Table 3 displays the availability of research-oriented committees across the four centres. The committees consisted of Nursing Quality Assurance/Improvement (15 respondents), Nursing Education (10), Library Committee with nursing representation (7), Nursing Research (7), Nursing Practice (7), and Agency-wide Research Committee with nursing representation (5). There was considerable variability among the Participating Complexes. All 6 of the Ottawa agencies had a Nursing Education Committee and 5 had a Nursing Practice Committee. London had fewer research-oriented committees than Ottawa. None of the Cornwall or Sioux Lookout agencies had Nursing Education, Nursing Research, or Nursing Practice Committees.
Five respondents reported that their agency had implemented programs to help nurses participate in clinical research and 6 reported that their agency had implemented programs in research utilization. Four of the 5 research courses reported were at agencies in Ottawa and the other was in London. Of the research utilization courses, 3 had been implemented in Ottawa, 2 in London, and 1 in Cornwall. No courses related to research or research utilization were available to nurses in Sioux Lookout.
Table 4 shows courses relevant to research utilization that were available at various centres. Library orientation courses (11) and basic computer literacy courses, such as keyboarding (10), were most frequently available and had been offered by one or more agencies in each of the Participating Complexes. Courses on critical appraisal and electronic literature searching had been offered only at Ottawa and London agencies and courses on the hospital/agency information system only at one agency in Ottawa and one in Cornwall.
Respondents were also asked about the availability of educational or health care institutions in their regions where nurses can take courses on information management, research utilization or research methods, and critical appraisal of research literature. Most respondents listed at least one institution where such courses were offered.
Policy on research utilization
Twelve respondents indicated that research was used as a basis for implementing change at their agency. In Ottawa, all agencies used research to implement change and in London, 5 of the 7 agencies did so. In Cornwall, only 1 agency used research as a basis for change while none in Sioux Lookout did. Four acute hospitals, 2 chronic care hospitals, 3 community agencies, and 3 long term care agencies said that research was used to change practice. It was not always clear from the responses if research evidence was used in any consistent way.
During the Province-Wide Nursing Project, each participating complex worked independently to improve the environment for evidence-based practice. An important facilitator was the commitment of management at all participating complexes to the objectives of the project. Members of committees representing the participating agencies developed strategies to increase the use of research and encourage evidence-based practice. They faced considerable challenges in developing and implementing these strategies. For example, restructuring occurred in agencies at all sites. However, much was accomplished. Commonly employed strategies included holding workshops and inservices for nurses on evidence-based practice and research use, sharing resources among agencies and across communities, drawing on the expertise of participants from other participating complexes and academic centres. Other strategies included making use of externally available resources and services available via the Internet or from the PWNP Research Centre. One agency set up a committee for evidence-based nursing. Most importantly, nurses in all participating complexes were made aware that evidence-based practice was an integral part of nursing that would be rewarded by the organization.
Of the four centres studied, Ottawa is the most urbanized. The London complex included both rural and urban agencies. Both the Cornwall and Sioux Lookout complexes were in small towns and served large rural regions. Sioux Lookout in Northern Ontario was the most remote. The two urban sites in academic settings, Ottawa and London, had the largest institutions and possessed the most resources, research capacity, access to research expertise, and opportunities for continuing education. Ottawa had a particularly strong research orientation, but London also had access to sources of research expertise. Agencies in the rural Participating Complex of Cornwall and in the north, Sioux Lookout, rarely engaged in research and had fewer resources of all kinds. The smaller sites differed from one another in that nurses in Cornwall had occasional involvement in research and more access to research expertise. Nonetheless, nurses in Sioux Lookout had more resources for evidence-based practice. Although they did not have any librarians, they had links to libraries and access to interlibrary loans, including one agency having access to health sciences databases.
A review of the literature suggests that while individual and environmental factors affect the ability of nurses to develop evidence-based practice, the influence of the organization is most important. A questionnaire was designed to investigate the extent to which agencies in the Province-Wide Nursing Project provided environments that facilitated evidence-based practice. Further research is required to discover whether evidence-based practice is most successfully achieved in environments where resources and expertise are available and where organizational structures, such as research-oriented committees, exist. It is noteworthy that eleven of the twelve sites that used research evidence as a basis for changing practice were in the two urban academic settings where these advantages were available. Differences in resources were evident in different types of health care settings. Nursing outposts had very few resources and other community settings were also disadvantaged in comparison to both acute and chronic care hospitals.
Participation in the Province-Wide Nursing Project enabled managers and nurses to develop strategies for evidence-based nursing. Their experiences suggested that nurses in small, northern or rural settings could improve their use of evidence if management was committed to this goal and if they fully exploited both local and external resources.
[Please note that graphics such as tables are not available in this online version.]
About the Author(s)
Joan A. Royle, RN, MScN, is Associate Professor, School of Nursing, McMaster University, Hamilton, ON.
Jennifer Blythe, Phd, MLS, is Assistant Professor, School of Nursing, McMaster University, Hamilton, ON.
Donna Ciliska, RN, PhD, is Associate Professor, School of Nursing, McMaster University, Hamilton, ON.
Dominique Ing, BA, is a BScN student, McMaster University, Hamilton, ON.
AcknowledgmentThe Province-Wide Nursing Project was funded by the Ontario Ministry of Health.
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