CLINICAL METHODS
B A R R I E R S : The Barriers to R e s e a r c h Utilization Scale
Sandra G. Funk, Mary T. Champagne, Ruth A. Wiese, and Elizabeth M. Tornquist
HE MODELS OF Rogers (1983) and others (e.g., Dracup & Breu, 1977; Horsley, Crane, Crabtree, & Wood, 1983; Stetler, 1985) delineate the process by which new information or innovations are diffused and used. Rogers identifies four main elements in the diffusion process: (a) the innovation--the idea, practice or object that is new to the potential adopter; (b) the communication channel--the means by which one individual shares an innovation with another; (c) time-the time it takes an individual to move from first knowledge of an innovation to its adoption or rejection; and (d) the social systenv--the set of interrelated units that are engaged in joint problem solving to accomplish a common goal. In essence, says Rogers, "diffusion is the process by which (a) an innovation (b) is communicated through certain channels (c) over time (d) among the members of a social system" (p. 11). Decisions to adopt or reject innovations do not occur spontaneously. Research suggests that a potential adopter passes through sequential stages of a decision process that include knowledge, persuasion, decision, implementation, and confirmation. Knowledge occurs when the individual becomes aware of and gains some understanding of the innovation. Persuasion occurs when the individual forms a favorable or unfavorable attitude toward the new finding or idea through interactions with colleagues or with someone perceived to be more knowledgeable about the topic. Decision occurs when the individual decides to try out or experiment with the innovation, which then leads to a choice to adopt or reject it. Implementation occurs when an individual puts an innovation into use, frequently altering the innovation slightly. Finally, confirmation occurs when the individual seeks reinforcement of the innovation decision already made. Characteristics of the individual, the organization, the communication channels, and the innovation itself are among the factors influencing the extent to which an innovation is adopted (Rogers, 1983).
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39
Despite the insights into the diffusion/utilization process, the use of research results in nursing practice has remained at relatively low levels for over a decade. In 1975, a study examining nurse practitioners' practices in determining oral temperatures concluded that "the practitioner either was totally unaware of the research literature relative to her practice, or if she was aware of it, was unable to relate to it or utilize i t " (Ketefian, p. 91). In 1981, Stokes reported that 64% of staff nurses sampled from 23 hospitals across the United States believed that findings resulting from nursing research were not reflected in patient care at their institutions; of those who did think research findings were being used, "half thought it was only to a small degree. A year later, Kirchhoff (1982) reported that only 24% to 35% of the critical care nurses in her study were aware of research that would affect commonly practiced coronary care precautions. In 1987, in a study of the use of 14 well researched nursing innovations, Brett reported that, on the average, only 28% of nurses surveyed "always" used them; with 33% using them "some of the time." The majority of the innovations were "always" used by less than one fourth of the sample. A recent replication of the Brett study (Coyle & Sokop, 1990) indicated that these percentages have remained largely unchanged. Thus, while the gap between research and practice has narrowed somewhat, much remains to be done. The literature is replete with suggested reasons for the research-practice gap. These barriers to research use closely parallel the concepts in Rogers' model and include, among others, the way in which research is communicated, the accessibility of the research findings, the quality and relevance of the research, the research values and skills of the practitioners, time to read and implement research, and organizational and workplace limitations (Bohannon & LeVeau, 1986; Buckwalter, 1985; King, Bamard, & Hoehn, 1981; Hefferin, Horsley, & Ventura, 1982; Kirchhoff, 1983; Levin, 1986; Phillips, 1986). Although the views of researchers and administrators are represented in this literature, rarely have the potential adopters themselves, the clinicians, been asked what they perceive to be the barriers to using research in practice. While Stokes (1981) included a few items on barriers in his study, only Miller and Messenger (1978) have reported a formal survey of practicing
40
CLINICAL METHODS
nurses' perceptions of the frequency with which they encountered problems related to using research findings. The most frequently reported bartier was inability to obtain research findings in the area of interest. The remaining seven barriers about which subjects were queried (time constraints, cost, resistance, relevance, rewards, understanding, and agreement with conclusions of the research) were not reported to occur with great frequency. The overall low level of perceived bartiers to use reported in this study is somewhat surprising, given the concurrently low levels of use reported in the literature. Perhaps the individuals surveYed had not tried to implement research findings and, thus, had not yet encountered such bartiers. Additionally, the survey instrument was both brief and relatively global and may not have tapped the true extent of barriers to utilization. If we are to increase the utilization of research findings, as we must if we are to improve practice (Bamard, 1986; Crane, 1985; Cronenwett, 1987; Mercer, 1984), it is important to determine clinicians' perceptions of the barriers to utilization. The views of clinicians (the potential adopters) are critical because they influence adoption behavior. Only when specific barriers are identified can we effectively intervene to reduce or eliminate diem or to alter clinicians' perceptions of them. Further, we have no information on how clinicians' views differ from those of administrators and academicians-individuals who shape the utilization environment, the research-based innovations to be implemented, and, in part, clinicians' attitudes and knowledge about research. Only when the perspec•tive of each is understood by the others can academicians, clinicians, and administrators effectively collaborate on strategies for implementation. Therefore, the purpose of this study was to develop an instrument for the assessment of clinicians', administrators', and academicians perceptions of bartiers to the utilization of research findings in practice.
METHOD Item Development Items for the instrument were developed from the literature on research utilization, from the Conduct and Utilization o f Research in Nursing (CURN) Project Research Utilization Questionnaire (with permission)(Crane, Pelz, & Horsley, 1977), and from informal data gathered from
nurses. Extensive lists of potential items were generated, their wording was edited and clarified, and expert input was obtained from research utilization consultants, nursing researchers, practicing nurses, and a psychometrician. Items for which a consensus about face and content validity was obtained were retained, and the resulting instrument was pilot-tested with graduate nursing students, most of whom were clinically employed. Written and group-discussion feedback from the pilot subjects resulted in the inclusion of two additional items and minor rewording of several others. The resulting 29 items were randomly ordered to form the BARRIERS Scale used in this study. Each item is rated on a scale from 1 to 4, reflecting the degree to which the item is perceived to be a barrier (1 = to no extent; 2 = to a little extent; 3 = to a moderate extent; 4 = to a great extent). In addition, a " n o opinion" response is allowed.
Procedure A stratified random sample of 5,000 individuals was drawn from the 1987 American Nursing Association (ANA) membership roster. Subjects were selected from those 22 states for which the roster is preapproved for public distribution. Only RNs employed full time in nursing were included in the sample. No exclusions were made based on sex, age, or other demographic characteristics. One thousand individuals were randomly selected from each of five educational strata based on the highest degree earned (diploma, associate, baccalaureate, master's, or doctorate).* Each individual selected by the procedure outlined above was mailed a five-page BARRIERS questionnaire that included the 29 barriers items, * This stratificationplan was used to allow stable estimation of population parameterswithin each of the educational strata for future descriptive analyses. Because the resulting sample was not representativeof the population, psychometricanalyses were performedin two ways. For the first set of analyses, each subject respondingto the survey served as one observation.For the second set of analyses, the data for each subject were weighted by a reciprocalfunctionof the subject'sprobabilityof selection. When the weighting procedureswere used, the educational distribution of the sample matched that of the original ANA population (diploma, 10.6%; associate degree, 25.7%; bachelors, 34.0%; masters, 26.2%; and doctorate, 3.5%). Results of the two sets of psychometricanalysescloselyparalleled one another, so for purposesof simplicity, only the ftrst set are reported in this article.
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space for the respondent to add and rate additional barriers, a question requesting specification of the three greatest barriers, a question requesting information on things perceived to facilitate research utilization, and a series of 18 personal, educational, employment, and research background questions. An individual packet of coffee was attached to each questionnaire, and subjects were encouraged in a cover letter to take a few moments to relax and fill out the questionnaire. The research protocol was approved by a federally approved Institutional Review Board for the protection of human subjects. Participation in the study was voluntary and indicated by return of the questionnaire. Anonymity was assured because the subject's identity was not solicited on the questionnaire or retained from the original mailing for tracking purposes. RESULTS
Questionnaires were returned from 1,989 individuals, a 40% response rate. On 41 questionnaires, the individual indicated that she or he was retired, was no longer employed full time in nursing, or did not wish to complete the questionnaire, resulting in a final sample of 1,948. Although questionnaires were received from subjects in 44 states and 2 foreign countries, over 95% were living in the 22 states from which the sample was originally selected. The majority (95.5%) were female, their average age was 43.1 years, and, on the average, the individuals in the sample had been licensed for almost 20 years (19.6 years) and had received their last degree approximately 9 years ago (8.9 years). Bachelor's (23.1%), master's (28.5%), and doctoral (26.7%) degrees were somewhat overrepresented, and associate degree (11.1%) and diploma graduates (10.6%) were somewhat underrepresented.
PsychometricAnalyses Factor analytic procedures were used to identify underlying dimensions or factors of the items on the BARRIERS instrument. For these analyses, the sample was randomly divided in two so the analysis could be performed on the first half of the sample and then again on the second half to see if the Same factors would be identified. The number of subjects in each group was 974, which surpasses Nunally's (1978) criterion of 10 subjects per variable. The analysis on the first half of the sample
identified four factors accounting for 43.4% of the variance in the data. t Factor loadings were then examined to determine which items belonged o'n each factor. When the factors are uncorrelated, as they were in this analysis, the loadings represent the correlations between each item and the factors. The greater the loading, the more strongly correlated the item and the factor. Only items with loadings greater than .40 were retained on a factor. Using this criterion, only one item ("the amount of research information is overwhelming") did not load on any of the four factors and was dropped from the instrument. Table 1 presents the four factors and the items on each. Factor 1, which includes eight items with loadings of .40 to .78, deals with the characteristics of the potential adopter of the research the nurse's research values, skills, and awareness. Items include not seeing the value of research for practice, being unwilling to change and try new ideas, not perceiving benefits of implementation, having no documented need to change practice, feeling incapable of evaluating the quality Of the research, feeling isolated from colleagues, and being unaware of the research. The second factor, with eight items loading .41 to .80~ deals with the characteristics of the organization in which the research will be used--the barriers and limitations perceived in the setting. Administration not allowing implementation, lack of support from physicians and other staff, insufficient time to read and implement research, lack of authority to make changes, inadequate facilities, and perceived lack of generalizability of the research to the setting are the items forming this factor. Factor 3 is formed from six items (loadings of .41 to .77) reflecting the characteristics of the in-
* Two methods of factor extraction (principal components analysis and principal axis factoring) were used. The principal components analysis, with varimax rotation, identified seven factors with eigenvalues greater than one. A scree test indicated that the variance accounted for by the factors leveled off between four and five factors. Varying factor solutions for two through seven factors were examined for interpretability, simplicity of structure, magnitude of the loadings, and absence of trivial factors. Based on these criteria, a four-factor solution was selected and is presented here. Since the analyses were exploratory in nature, principal axis factoring with both orthogonal and oblique rotations were also performed. These analyses did not result in any gain in interpretability, variance accounted for, or structural integrity.
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T a b l e 1. B A R R I E R S S c a l e F a c t o r s a n d F a c t o r L o a d i n g s Factors
1 Questionnaire Items
$1
2 S2
Sl
3 $2
$1
4 $2
Sl
$2
.65 .60 .59 .58 .41 .40
.74 .59 .48 .61 .36 .50
FACTOR 1. CHARACTERISTICS OF THE ADOPTER: The nurse's research values, skills, and awareness The nurse does not see the value of research for practice. The nurse sees little benefit for self. The nurse is unwilling to change/try new ideas. There is not a documented need to change practice. The nurse feels the benefits of changing practice will be minimal. The nurse does not feel capable of evaluating the quality of the research. The nurse is isolated from knowledgeable colleagues with whom to discuss the research. The nurse is unaware of the research.
.78 .66 .63 .60
.81 .72 .76 .53
.59
.49
.56
.67
.48 .40
.52 .43
FACTOR 2. CHARACTERISTICS OF THE ORGANIZATION: Setting barriers and limitations Administration will not allow implementation. Physicians will not cooperate with implementation. There is insufficient time on the job to implement new ideas. Other staff are not supportive of implementation. The facilities are inadequate for implementation. The nurse does not feel she/he has enough authority to change patient care procedures. The nurse does not have time to read research. The nurse feels results are not generalizable to own setting.
,80 .80
.73 .70
.65 .62 .61
.50 .51 .56
.56 .49
.56 .43
.41
.44
FACTOR 3. CHARACTERISTICS OF THE INNOVATION: Qualities of the research The research has methodological inadequacies. The conclusions drawn from the research are not justified. The research has not been replicated. The literature reports conflicting results. The nurse is uncertain whether to believe the results of the research. Research reports/articles are not published fast enough.
.77
.79
.70 .61 .60
.74 .58 .64
.55
.56
.41
.46
FACTOR 4. CHARACTERISTICS OF THE COMMUNICATION: Presentation and accessibility of the research Implications for practice are not made clear. Research reports/articles are not readily available. The research is not reported clearly and readably. Statistical analyses are not understandable. The relevant literature is not compiled in one place. The research is not relevant to the nurse's practice.
The first column for each factor ($1) presents the factor Ioadings for the randomly selected first half of the sample; the second column ($2) presents the factor Ioadings for the second half of the sampte. In analyses such as these, where the factors are independent of one another, the Ioadings can range from - 1.00 to 1.00 and represent the correlations between the factor and the item. A commonly accepted rule of thumb is to identify an item as belonging to or "loading" on a factor if the loading is greater than .40 or .30.
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CLINICAL METHODS
novation or research--its methodological inade-
quacies, inappropriateness of the conclusions drawn from the research, lack of replication of the research, conflicting results in the literature, the nurse's uncertainty regarding whether to believe the results of the research, and the slowness of publication of those results. The final factor focuses on the characteristics of the communication of the research--its presentation and accessibility. The six items on this factor (loadings of .40 to .65), include lack of readability and clarity of implications for practice, lack of availability of research reports, incomprehensible statistical analyses, the scattered nature of the relevant literature, and failure to communicate the research in a way that demonstrates its relevance to the nurse's practice. After the factors were derived from analyses of the first half of the sample, the second half of the sample was analyzed in the same way..~gain, a four-factor solution accounting for approximately the same percentage of variance (44.9%) was identified. The four factors were identical to those identified in the first analysis and the loadings were of the same magnitude (see Table 1), with one exception: one item on the fourth factor ("the relevant literature is not compiled in one place") had a loading below .40 (.36) and loaded equally well on both the third and fourth factors. As in the first analysis, the item concerning the overwhelming amount of research information did not load on any factor. A final factor analysis on the full sample again replicated the original analysis. Taken together, these analyses indicate that the BARRIERS tool has a stable structure that closely parallels critical factors in Rogers' model. Respondents were asked to specify and rate any additional barriers they believed might be missing from the tool. These data were analyzed to further assess the comprehensiveness or content validity of the instrument. Responses were categorized and coded into 21 categories. Most of the categories were found to overlap with existing items on the tool, probably because respondents chose to reiterate a barrier with phrasing that added personal meaning for them or to emphasize the importance of the barrier to them. None of the additional bartiers were cited by more than 10% of the sample, and only two were cited by more than 5%. These two were lack of administrative support for implementation and the nurse's lack of knowledge about
research. Both of these concepts are represented in somewhat different forms on the tool (e.g., "administration will not allow implementation"). The lack of specification of additional major barriers lends added support to the content validity of the BARRIERS tool. The respondents' differential or personal phrasing of the barriers, however, does point to the need to retain this open-ended portion of the instrument. Using the entire sample, indexes of internal consistency reliability, Cronbach's alphas, were calculated for each of the four factors. The alpha coefficients for the nurse, setting, and research factors (Factors 1, 2, and 3) were .80, .80, and .72, respectively, indicating good reliability. Itemtotal correlations for these factors ranged from .32 to .65. The alpha for the fourth factor, presentation of the research, was somewhat lower (.65); however, the item-total correlations were all in an acceptable range (.30 to .53), and the deletion of any item would have resulted in a substantial decrement in the alpha coefficient. Therefore, all four factors were retained in the form identified by the principal components analysis. Scale scores were calculated for each factor by averaging the individual's scores on the items for that factor. Table 2 presents descriptive information on the four scales. T h e full range of possible scores was obtained for each scale, the means varied closely about the midpoint of the scale (ranging from 2.35 to 2.87), and the standard deviations were modest. The kurtosis and skew were also modest, indicating well-behaved and normal distributions for each of the scales. To obtain preliminary estimates of the test-retest reliability of the scales, an additional study was conducted on 17 master's level graduate students who were concurrently employed in clinical settings. The 17 students completed the BARRIERS questionnaire on two occasions, 1 week apart. Pearson correlations between the two sets of measures ranged from .68 to .83, indicating adequate temporal stability of the instrument's scales over this relatively short time interval. DISCUSSION
The growth in nursing research in recent years has not been paralleled by a comparable growth in the use of research findings in practice (Phillips, 1986), Though a number of authors have speculated about the reasons for this (e.g., Bohannon &
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Table 2. Descriptive Data on BARRIERS Scales BARRIERS Scales Descriptive Statistics
Nurse
Setting
Research
Presentation
Number of items Range of possible scores"
8 1.00-4.00
8 1.00-4.00
6 i 1.00-4.00
6 1.00-4.00
Observed range Mean
1.00-4.00 2.78
1.00-4.00 2.87
1.00-4.00 2.35
1.00-4.00 2.74
Standard deviation Skew Kurtosis
.61
.58
.55
.53
-.40 - .34
-.31 - .44
.07 - .20
-.32 - .10
8 Average scores are used for each scale to generate comparable scoring across scales.
LeVeau, 1986; Brett, 1987; Levin, 1986, Phillips, 1986), few have assessed the views of the potential users of the research, the clinicians, or compared their views with those of administrators and academicians. This is perhaps in part because of the lack of an available, appropriately specific, sound instrument with which to assess these ~'iews. The BARRIERS tool presented here is soundly based, having been derived from the literature. The tool is sufficiently specific to identify areas needing intervention, is easy to administer, and takes only about 15 minutes to complete. Face and content validity of the tool have been established by a panel of judges, and factor analyses performed and replicated on randomly chosen halves of the sample lend preliminary support for the tool's construct validity. The factor structure was the same for the two samples and the full weighted and unweighted samples. On the average, the magnitude of the loadings for the factors was also similar across the samples. Indexes of reliability for the factors are adequate, and the distributional properties of each scale are normal, with little evidence of skew or kurtosis. The factors identified within the BARRIERS tool closely parallel four of the major concepts in Rogers' model of innovation diffusion: characteristics of the adopter, the organization, the innovation, and the communication. When focused on the application of nursing research findings to practice, the factors translate into characteristics of the nurse, the setting, the research, and its presentation and accessibility. For each of these, the BARRIERS tool identifies from six to eight areas that may be perceived as problematic by the potential adopter. Whether they have actually been experienced by the individual or are only perceived to be a problem, these barriers could hinder at-
tempts to put innovations into practice or keep the potential adopter from even initiati0g the adoption process. Use of the BARRIERS tool to delineate these specific areas in varied clinical settings and in different subgroups of practicing nurses could enhance research on the utilization process, guide the development and evaluatiod of education and intervention programs, and se.rve as the basis for dialogue between clinicians, researchers, and administrators so that we can begin to close the gap between research and its application. ACKNOWLEDGMENT
The authors thank Betsy Perry for her contribution to the project as research assistant; Drs. J. Crane, D. Pelz, and J.A. Horsley for permission to adapt selected items from the CURN Project Research Utilization Questionnaire for use in the BARRIERS Scale; and Drs. C. Williams, L. Cronenwett, N. Lang, and O. Strickland for providing expert review of the BARRIERS tool. REFERENCES Bamard, K.E. (1986). Research utilization: The researcher's responsibilities. Maternal Child Nursing, 11, 150. Bohannon, R.W., & LeVeau, B.F. (1986). Clinicians' use of research findings: A review of literature with implicationsfor physical therapists. Physical Therapy, 66, 45-50. Brett, J.L. (1987). Use of nursing practice research findings. Nursing Research, 36, 344-349. Buckwalter, K.C. (1985). Is nursing research used in practice? In J.C. McCloskey & H.K. Grace (Eds.), Current issues in nursing (2nd ed., pp. 110-123). London: Blackwell Scientific Publishers. Coyle, L.A., & Sokop, A.G. (1990). Innovation adoption behavior among nurses. Nursing Research, 39, 176-180. Crane, J. (1985). Research utilization: Theoretical perspectives. WesternJournal of Nursing Research, 7, 261-268. Crane, J., Pelz, D., & Horsley, J.A. (1977). CURNproject research utilization questionnaire. Ann Arbor, MI: Conduct and Utilization of Research in Nursing Project, School of Nursing, University of Michigan. Cronenwett, L.R. (1987). Research utilization in a practice setting. Journal of Nursing Administration, 17(7,8), 9-10.
CLINICAL METHODS
Dracup, K.A., & Breu, C.S. (1977). Strengthening practice through research utilization. In M. Batey (Ed.), Communicating nursing research 10 (p. 341). Boulder, CO: Western Interstate Commission for Higher Education. Hefferin, E.A., Horsley, J.A:, & Ventura, M.R. (1982). Promoting research-based nursing: The nurse administrator's role. Journal of Nursing Administration, 12(5), 34-41. Horsley, J.A., Crane, J., Crabtree, M.K., & Wood, D.J. (1983). Using research to improve nursing practice: A guide (CURN project). Philadelphia: Grune & Stratton. Ketefian, S. (1975). Application of selected nursing research findings into nursing practice: A pilot study. NursingResearch, 24, 89-92. King, D., Batnard, K.E., & Hoehn, R. (1981). Disseminating the results of nursing research. Nursing Outlook, 29, 164169. Kirchhoff, K.T. (1982). A diffusion survey of coronary precautions. Nursing Research, 31, 196-201. Kirchhoff, K.T. (1983). Using research in practice: Should staff nurses be expected to use research? Western Journal of Nursing Research, 5, 245-247. Levin, R.F. (1986). Utilizing nursing research. In G. Lobiondo-Wood, & J. Haber (Eds.), Nursing research: Critical appraisal and utilization (pp. 294-312). St. Louis: Mosby. Mercer, R.T. (1984). Nursing research: The bridge to excellence in practice. Image, 16, 47-51. Miller, J.R., & Messenger, S.R. (1978). Obstacles to applying nursing research findings. American Journal of Nursing, 78, 632-634. Nunally, J.C. (1978). Psychometric theory. New York: McGraw-Hill. Phillips, L.R. (1986). A clinician's guide to the critique and
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utilization of nursing research. Norwalk, CT: AppletonCentury Crofts. Rogers, E.M. (1983). Diffusion of innovations. New York: The Free Press. Stetler, C.B. (1985). Research utilization. Del'ming the concept. Image, 17, 40-44. Stokes, J.E. (1981). Utilization of research findings by staff nurses. In S.D. Krampitz & N. Pavlovich (Eds.), Readingsfor nursing research (pp. 227-234). St. Louis: Mosby.
From the School of Nursing, University of North Carolina, Chapel Hill, NC, and the School of Nursing, Duke University, Durham, NC. Sandra G. Funk, PhD: Professor, University of North Carolina at Chapel Hill School of Nursing; Mary T. Champagne, PhD, RN: Associate Professor and Dean, Duke University School of Nursing; Ruth A. Wiese, MSN, RN: Research Instructor, Universityof North Carolina at ChapelHill School of Nursing; Elizabeth M. Tornquist, MA: Lecturer, University of North Carolina at Chapel Hill School of Nursing. Supported in part by Grant No. RlS-NRO1357from the National Centerfor Nursing Research, the National Institutes of Health, Bethesda, MD; and GrantNo. DlO-NU24318from the Division of Nursing, HRSA, Rocl~'ille, MD. Address reprint requests to Sandra G. Funk, PhD, Professor and Director, Research Support Center, School of Nursing, CB#7460 Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460. Copyright © 1991 by W.B. Saunders Company 0897-189719110401-001055.00/0
B A R R I E R S : The Barriers to R e s e a r c h Utilization Scale
Sandra G. Funk, Mary T. Champagne, Ruth A. Wiese, and Elizabeth M. Tornquist
HE MODELS OF Rogers (1983) and others (e.g., Dracup & Breu, 1977; Horsley, Crane, Crabtree, & Wood, 1983; Stetler, 1985) delineate the process by which new information or innovations are diffused and used. Rogers identifies four main elements in the diffusion process: (a) the innovation--the idea, practice or object that is new to the potential adopter; (b) the communication channel--the means by which one individual shares an innovation with another; (c) time-the time it takes an individual to move from first knowledge of an innovation to its adoption or rejection; and (d) the social systenv--the set of interrelated units that are engaged in joint problem solving to accomplish a common goal. In essence, says Rogers, "diffusion is the process by which (a) an innovation (b) is communicated through certain channels (c) over time (d) among the members of a social system" (p. 11). Decisions to adopt or reject innovations do not occur spontaneously. Research suggests that a potential adopter passes through sequential stages of a decision process that include knowledge, persuasion, decision, implementation, and confirmation. Knowledge occurs when the individual becomes aware of and gains some understanding of the innovation. Persuasion occurs when the individual forms a favorable or unfavorable attitude toward the new finding or idea through interactions with colleagues or with someone perceived to be more knowledgeable about the topic. Decision occurs when the individual decides to try out or experiment with the innovation, which then leads to a choice to adopt or reject it. Implementation occurs when an individual puts an innovation into use, frequently altering the innovation slightly. Finally, confirmation occurs when the individual seeks reinforcement of the innovation decision already made. Characteristics of the individual, the organization, the communication channels, and the innovation itself are among the factors influencing the extent to which an innovation is adopted (Rogers, 1983).
T
39
Despite the insights into the diffusion/utilization process, the use of research results in nursing practice has remained at relatively low levels for over a decade. In 1975, a study examining nurse practitioners' practices in determining oral temperatures concluded that "the practitioner either was totally unaware of the research literature relative to her practice, or if she was aware of it, was unable to relate to it or utilize i t " (Ketefian, p. 91). In 1981, Stokes reported that 64% of staff nurses sampled from 23 hospitals across the United States believed that findings resulting from nursing research were not reflected in patient care at their institutions; of those who did think research findings were being used, "half thought it was only to a small degree. A year later, Kirchhoff (1982) reported that only 24% to 35% of the critical care nurses in her study were aware of research that would affect commonly practiced coronary care precautions. In 1987, in a study of the use of 14 well researched nursing innovations, Brett reported that, on the average, only 28% of nurses surveyed "always" used them; with 33% using them "some of the time." The majority of the innovations were "always" used by less than one fourth of the sample. A recent replication of the Brett study (Coyle & Sokop, 1990) indicated that these percentages have remained largely unchanged. Thus, while the gap between research and practice has narrowed somewhat, much remains to be done. The literature is replete with suggested reasons for the research-practice gap. These barriers to research use closely parallel the concepts in Rogers' model and include, among others, the way in which research is communicated, the accessibility of the research findings, the quality and relevance of the research, the research values and skills of the practitioners, time to read and implement research, and organizational and workplace limitations (Bohannon & LeVeau, 1986; Buckwalter, 1985; King, Bamard, & Hoehn, 1981; Hefferin, Horsley, & Ventura, 1982; Kirchhoff, 1983; Levin, 1986; Phillips, 1986). Although the views of researchers and administrators are represented in this literature, rarely have the potential adopters themselves, the clinicians, been asked what they perceive to be the barriers to using research in practice. While Stokes (1981) included a few items on barriers in his study, only Miller and Messenger (1978) have reported a formal survey of practicing
40
CLINICAL METHODS
nurses' perceptions of the frequency with which they encountered problems related to using research findings. The most frequently reported bartier was inability to obtain research findings in the area of interest. The remaining seven barriers about which subjects were queried (time constraints, cost, resistance, relevance, rewards, understanding, and agreement with conclusions of the research) were not reported to occur with great frequency. The overall low level of perceived bartiers to use reported in this study is somewhat surprising, given the concurrently low levels of use reported in the literature. Perhaps the individuals surveYed had not tried to implement research findings and, thus, had not yet encountered such bartiers. Additionally, the survey instrument was both brief and relatively global and may not have tapped the true extent of barriers to utilization. If we are to increase the utilization of research findings, as we must if we are to improve practice (Bamard, 1986; Crane, 1985; Cronenwett, 1987; Mercer, 1984), it is important to determine clinicians' perceptions of the barriers to utilization. The views of clinicians (the potential adopters) are critical because they influence adoption behavior. Only when specific barriers are identified can we effectively intervene to reduce or eliminate diem or to alter clinicians' perceptions of them. Further, we have no information on how clinicians' views differ from those of administrators and academicians-individuals who shape the utilization environment, the research-based innovations to be implemented, and, in part, clinicians' attitudes and knowledge about research. Only when the perspec•tive of each is understood by the others can academicians, clinicians, and administrators effectively collaborate on strategies for implementation. Therefore, the purpose of this study was to develop an instrument for the assessment of clinicians', administrators', and academicians perceptions of bartiers to the utilization of research findings in practice.
METHOD Item Development Items for the instrument were developed from the literature on research utilization, from the Conduct and Utilization o f Research in Nursing (CURN) Project Research Utilization Questionnaire (with permission)(Crane, Pelz, & Horsley, 1977), and from informal data gathered from
nurses. Extensive lists of potential items were generated, their wording was edited and clarified, and expert input was obtained from research utilization consultants, nursing researchers, practicing nurses, and a psychometrician. Items for which a consensus about face and content validity was obtained were retained, and the resulting instrument was pilot-tested with graduate nursing students, most of whom were clinically employed. Written and group-discussion feedback from the pilot subjects resulted in the inclusion of two additional items and minor rewording of several others. The resulting 29 items were randomly ordered to form the BARRIERS Scale used in this study. Each item is rated on a scale from 1 to 4, reflecting the degree to which the item is perceived to be a barrier (1 = to no extent; 2 = to a little extent; 3 = to a moderate extent; 4 = to a great extent). In addition, a " n o opinion" response is allowed.
Procedure A stratified random sample of 5,000 individuals was drawn from the 1987 American Nursing Association (ANA) membership roster. Subjects were selected from those 22 states for which the roster is preapproved for public distribution. Only RNs employed full time in nursing were included in the sample. No exclusions were made based on sex, age, or other demographic characteristics. One thousand individuals were randomly selected from each of five educational strata based on the highest degree earned (diploma, associate, baccalaureate, master's, or doctorate).* Each individual selected by the procedure outlined above was mailed a five-page BARRIERS questionnaire that included the 29 barriers items, * This stratificationplan was used to allow stable estimation of population parameterswithin each of the educational strata for future descriptive analyses. Because the resulting sample was not representativeof the population, psychometricanalyses were performedin two ways. For the first set of analyses, each subject respondingto the survey served as one observation.For the second set of analyses, the data for each subject were weighted by a reciprocalfunctionof the subject'sprobabilityof selection. When the weighting procedureswere used, the educational distribution of the sample matched that of the original ANA population (diploma, 10.6%; associate degree, 25.7%; bachelors, 34.0%; masters, 26.2%; and doctorate, 3.5%). Results of the two sets of psychometricanalysescloselyparalleled one another, so for purposesof simplicity, only the ftrst set are reported in this article.
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space for the respondent to add and rate additional barriers, a question requesting specification of the three greatest barriers, a question requesting information on things perceived to facilitate research utilization, and a series of 18 personal, educational, employment, and research background questions. An individual packet of coffee was attached to each questionnaire, and subjects were encouraged in a cover letter to take a few moments to relax and fill out the questionnaire. The research protocol was approved by a federally approved Institutional Review Board for the protection of human subjects. Participation in the study was voluntary and indicated by return of the questionnaire. Anonymity was assured because the subject's identity was not solicited on the questionnaire or retained from the original mailing for tracking purposes. RESULTS
Questionnaires were returned from 1,989 individuals, a 40% response rate. On 41 questionnaires, the individual indicated that she or he was retired, was no longer employed full time in nursing, or did not wish to complete the questionnaire, resulting in a final sample of 1,948. Although questionnaires were received from subjects in 44 states and 2 foreign countries, over 95% were living in the 22 states from which the sample was originally selected. The majority (95.5%) were female, their average age was 43.1 years, and, on the average, the individuals in the sample had been licensed for almost 20 years (19.6 years) and had received their last degree approximately 9 years ago (8.9 years). Bachelor's (23.1%), master's (28.5%), and doctoral (26.7%) degrees were somewhat overrepresented, and associate degree (11.1%) and diploma graduates (10.6%) were somewhat underrepresented.
PsychometricAnalyses Factor analytic procedures were used to identify underlying dimensions or factors of the items on the BARRIERS instrument. For these analyses, the sample was randomly divided in two so the analysis could be performed on the first half of the sample and then again on the second half to see if the Same factors would be identified. The number of subjects in each group was 974, which surpasses Nunally's (1978) criterion of 10 subjects per variable. The analysis on the first half of the sample
identified four factors accounting for 43.4% of the variance in the data. t Factor loadings were then examined to determine which items belonged o'n each factor. When the factors are uncorrelated, as they were in this analysis, the loadings represent the correlations between each item and the factors. The greater the loading, the more strongly correlated the item and the factor. Only items with loadings greater than .40 were retained on a factor. Using this criterion, only one item ("the amount of research information is overwhelming") did not load on any of the four factors and was dropped from the instrument. Table 1 presents the four factors and the items on each. Factor 1, which includes eight items with loadings of .40 to .78, deals with the characteristics of the potential adopter of the research the nurse's research values, skills, and awareness. Items include not seeing the value of research for practice, being unwilling to change and try new ideas, not perceiving benefits of implementation, having no documented need to change practice, feeling incapable of evaluating the quality Of the research, feeling isolated from colleagues, and being unaware of the research. The second factor, with eight items loading .41 to .80~ deals with the characteristics of the organization in which the research will be used--the barriers and limitations perceived in the setting. Administration not allowing implementation, lack of support from physicians and other staff, insufficient time to read and implement research, lack of authority to make changes, inadequate facilities, and perceived lack of generalizability of the research to the setting are the items forming this factor. Factor 3 is formed from six items (loadings of .41 to .77) reflecting the characteristics of the in-
* Two methods of factor extraction (principal components analysis and principal axis factoring) were used. The principal components analysis, with varimax rotation, identified seven factors with eigenvalues greater than one. A scree test indicated that the variance accounted for by the factors leveled off between four and five factors. Varying factor solutions for two through seven factors were examined for interpretability, simplicity of structure, magnitude of the loadings, and absence of trivial factors. Based on these criteria, a four-factor solution was selected and is presented here. Since the analyses were exploratory in nature, principal axis factoring with both orthogonal and oblique rotations were also performed. These analyses did not result in any gain in interpretability, variance accounted for, or structural integrity.
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T a b l e 1. B A R R I E R S S c a l e F a c t o r s a n d F a c t o r L o a d i n g s Factors
1 Questionnaire Items
$1
2 S2
Sl
3 $2
$1
4 $2
Sl
$2
.65 .60 .59 .58 .41 .40
.74 .59 .48 .61 .36 .50
FACTOR 1. CHARACTERISTICS OF THE ADOPTER: The nurse's research values, skills, and awareness The nurse does not see the value of research for practice. The nurse sees little benefit for self. The nurse is unwilling to change/try new ideas. There is not a documented need to change practice. The nurse feels the benefits of changing practice will be minimal. The nurse does not feel capable of evaluating the quality of the research. The nurse is isolated from knowledgeable colleagues with whom to discuss the research. The nurse is unaware of the research.
.78 .66 .63 .60
.81 .72 .76 .53
.59
.49
.56
.67
.48 .40
.52 .43
FACTOR 2. CHARACTERISTICS OF THE ORGANIZATION: Setting barriers and limitations Administration will not allow implementation. Physicians will not cooperate with implementation. There is insufficient time on the job to implement new ideas. Other staff are not supportive of implementation. The facilities are inadequate for implementation. The nurse does not feel she/he has enough authority to change patient care procedures. The nurse does not have time to read research. The nurse feels results are not generalizable to own setting.
,80 .80
.73 .70
.65 .62 .61
.50 .51 .56
.56 .49
.56 .43
.41
.44
FACTOR 3. CHARACTERISTICS OF THE INNOVATION: Qualities of the research The research has methodological inadequacies. The conclusions drawn from the research are not justified. The research has not been replicated. The literature reports conflicting results. The nurse is uncertain whether to believe the results of the research. Research reports/articles are not published fast enough.
.77
.79
.70 .61 .60
.74 .58 .64
.55
.56
.41
.46
FACTOR 4. CHARACTERISTICS OF THE COMMUNICATION: Presentation and accessibility of the research Implications for practice are not made clear. Research reports/articles are not readily available. The research is not reported clearly and readably. Statistical analyses are not understandable. The relevant literature is not compiled in one place. The research is not relevant to the nurse's practice.
The first column for each factor ($1) presents the factor Ioadings for the randomly selected first half of the sample; the second column ($2) presents the factor Ioadings for the second half of the sampte. In analyses such as these, where the factors are independent of one another, the Ioadings can range from - 1.00 to 1.00 and represent the correlations between the factor and the item. A commonly accepted rule of thumb is to identify an item as belonging to or "loading" on a factor if the loading is greater than .40 or .30.
43
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novation or research--its methodological inade-
quacies, inappropriateness of the conclusions drawn from the research, lack of replication of the research, conflicting results in the literature, the nurse's uncertainty regarding whether to believe the results of the research, and the slowness of publication of those results. The final factor focuses on the characteristics of the communication of the research--its presentation and accessibility. The six items on this factor (loadings of .40 to .65), include lack of readability and clarity of implications for practice, lack of availability of research reports, incomprehensible statistical analyses, the scattered nature of the relevant literature, and failure to communicate the research in a way that demonstrates its relevance to the nurse's practice. After the factors were derived from analyses of the first half of the sample, the second half of the sample was analyzed in the same way..~gain, a four-factor solution accounting for approximately the same percentage of variance (44.9%) was identified. The four factors were identical to those identified in the first analysis and the loadings were of the same magnitude (see Table 1), with one exception: one item on the fourth factor ("the relevant literature is not compiled in one place") had a loading below .40 (.36) and loaded equally well on both the third and fourth factors. As in the first analysis, the item concerning the overwhelming amount of research information did not load on any factor. A final factor analysis on the full sample again replicated the original analysis. Taken together, these analyses indicate that the BARRIERS tool has a stable structure that closely parallels critical factors in Rogers' model. Respondents were asked to specify and rate any additional barriers they believed might be missing from the tool. These data were analyzed to further assess the comprehensiveness or content validity of the instrument. Responses were categorized and coded into 21 categories. Most of the categories were found to overlap with existing items on the tool, probably because respondents chose to reiterate a barrier with phrasing that added personal meaning for them or to emphasize the importance of the barrier to them. None of the additional bartiers were cited by more than 10% of the sample, and only two were cited by more than 5%. These two were lack of administrative support for implementation and the nurse's lack of knowledge about
research. Both of these concepts are represented in somewhat different forms on the tool (e.g., "administration will not allow implementation"). The lack of specification of additional major barriers lends added support to the content validity of the BARRIERS tool. The respondents' differential or personal phrasing of the barriers, however, does point to the need to retain this open-ended portion of the instrument. Using the entire sample, indexes of internal consistency reliability, Cronbach's alphas, were calculated for each of the four factors. The alpha coefficients for the nurse, setting, and research factors (Factors 1, 2, and 3) were .80, .80, and .72, respectively, indicating good reliability. Itemtotal correlations for these factors ranged from .32 to .65. The alpha for the fourth factor, presentation of the research, was somewhat lower (.65); however, the item-total correlations were all in an acceptable range (.30 to .53), and the deletion of any item would have resulted in a substantial decrement in the alpha coefficient. Therefore, all four factors were retained in the form identified by the principal components analysis. Scale scores were calculated for each factor by averaging the individual's scores on the items for that factor. Table 2 presents descriptive information on the four scales. T h e full range of possible scores was obtained for each scale, the means varied closely about the midpoint of the scale (ranging from 2.35 to 2.87), and the standard deviations were modest. The kurtosis and skew were also modest, indicating well-behaved and normal distributions for each of the scales. To obtain preliminary estimates of the test-retest reliability of the scales, an additional study was conducted on 17 master's level graduate students who were concurrently employed in clinical settings. The 17 students completed the BARRIERS questionnaire on two occasions, 1 week apart. Pearson correlations between the two sets of measures ranged from .68 to .83, indicating adequate temporal stability of the instrument's scales over this relatively short time interval. DISCUSSION
The growth in nursing research in recent years has not been paralleled by a comparable growth in the use of research findings in practice (Phillips, 1986), Though a number of authors have speculated about the reasons for this (e.g., Bohannon &
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Table 2. Descriptive Data on BARRIERS Scales BARRIERS Scales Descriptive Statistics
Nurse
Setting
Research
Presentation
Number of items Range of possible scores"
8 1.00-4.00
8 1.00-4.00
6 i 1.00-4.00
6 1.00-4.00
Observed range Mean
1.00-4.00 2.78
1.00-4.00 2.87
1.00-4.00 2.35
1.00-4.00 2.74
Standard deviation Skew Kurtosis
.61
.58
.55
.53
-.40 - .34
-.31 - .44
.07 - .20
-.32 - .10
8 Average scores are used for each scale to generate comparable scoring across scales.
LeVeau, 1986; Brett, 1987; Levin, 1986, Phillips, 1986), few have assessed the views of the potential users of the research, the clinicians, or compared their views with those of administrators and academicians. This is perhaps in part because of the lack of an available, appropriately specific, sound instrument with which to assess these ~'iews. The BARRIERS tool presented here is soundly based, having been derived from the literature. The tool is sufficiently specific to identify areas needing intervention, is easy to administer, and takes only about 15 minutes to complete. Face and content validity of the tool have been established by a panel of judges, and factor analyses performed and replicated on randomly chosen halves of the sample lend preliminary support for the tool's construct validity. The factor structure was the same for the two samples and the full weighted and unweighted samples. On the average, the magnitude of the loadings for the factors was also similar across the samples. Indexes of reliability for the factors are adequate, and the distributional properties of each scale are normal, with little evidence of skew or kurtosis. The factors identified within the BARRIERS tool closely parallel four of the major concepts in Rogers' model of innovation diffusion: characteristics of the adopter, the organization, the innovation, and the communication. When focused on the application of nursing research findings to practice, the factors translate into characteristics of the nurse, the setting, the research, and its presentation and accessibility. For each of these, the BARRIERS tool identifies from six to eight areas that may be perceived as problematic by the potential adopter. Whether they have actually been experienced by the individual or are only perceived to be a problem, these barriers could hinder at-
tempts to put innovations into practice or keep the potential adopter from even initiati0g the adoption process. Use of the BARRIERS tool to delineate these specific areas in varied clinical settings and in different subgroups of practicing nurses could enhance research on the utilization process, guide the development and evaluatiod of education and intervention programs, and se.rve as the basis for dialogue between clinicians, researchers, and administrators so that we can begin to close the gap between research and its application. ACKNOWLEDGMENT
The authors thank Betsy Perry for her contribution to the project as research assistant; Drs. J. Crane, D. Pelz, and J.A. Horsley for permission to adapt selected items from the CURN Project Research Utilization Questionnaire for use in the BARRIERS Scale; and Drs. C. Williams, L. Cronenwett, N. Lang, and O. Strickland for providing expert review of the BARRIERS tool. REFERENCES Bamard, K.E. (1986). Research utilization: The researcher's responsibilities. Maternal Child Nursing, 11, 150. Bohannon, R.W., & LeVeau, B.F. (1986). Clinicians' use of research findings: A review of literature with implicationsfor physical therapists. Physical Therapy, 66, 45-50. Brett, J.L. (1987). Use of nursing practice research findings. Nursing Research, 36, 344-349. Buckwalter, K.C. (1985). Is nursing research used in practice? In J.C. McCloskey & H.K. Grace (Eds.), Current issues in nursing (2nd ed., pp. 110-123). London: Blackwell Scientific Publishers. Coyle, L.A., & Sokop, A.G. (1990). Innovation adoption behavior among nurses. Nursing Research, 39, 176-180. Crane, J. (1985). Research utilization: Theoretical perspectives. WesternJournal of Nursing Research, 7, 261-268. Crane, J., Pelz, D., & Horsley, J.A. (1977). CURNproject research utilization questionnaire. Ann Arbor, MI: Conduct and Utilization of Research in Nursing Project, School of Nursing, University of Michigan. Cronenwett, L.R. (1987). Research utilization in a practice setting. Journal of Nursing Administration, 17(7,8), 9-10.
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Dracup, K.A., & Breu, C.S. (1977). Strengthening practice through research utilization. In M. Batey (Ed.), Communicating nursing research 10 (p. 341). Boulder, CO: Western Interstate Commission for Higher Education. Hefferin, E.A., Horsley, J.A:, & Ventura, M.R. (1982). Promoting research-based nursing: The nurse administrator's role. Journal of Nursing Administration, 12(5), 34-41. Horsley, J.A., Crane, J., Crabtree, M.K., & Wood, D.J. (1983). Using research to improve nursing practice: A guide (CURN project). Philadelphia: Grune & Stratton. Ketefian, S. (1975). Application of selected nursing research findings into nursing practice: A pilot study. NursingResearch, 24, 89-92. King, D., Batnard, K.E., & Hoehn, R. (1981). Disseminating the results of nursing research. Nursing Outlook, 29, 164169. Kirchhoff, K.T. (1982). A diffusion survey of coronary precautions. Nursing Research, 31, 196-201. Kirchhoff, K.T. (1983). Using research in practice: Should staff nurses be expected to use research? Western Journal of Nursing Research, 5, 245-247. Levin, R.F. (1986). Utilizing nursing research. In G. Lobiondo-Wood, & J. Haber (Eds.), Nursing research: Critical appraisal and utilization (pp. 294-312). St. Louis: Mosby. Mercer, R.T. (1984). Nursing research: The bridge to excellence in practice. Image, 16, 47-51. Miller, J.R., & Messenger, S.R. (1978). Obstacles to applying nursing research findings. American Journal of Nursing, 78, 632-634. Nunally, J.C. (1978). Psychometric theory. New York: McGraw-Hill. Phillips, L.R. (1986). A clinician's guide to the critique and
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utilization of nursing research. Norwalk, CT: AppletonCentury Crofts. Rogers, E.M. (1983). Diffusion of innovations. New York: The Free Press. Stetler, C.B. (1985). Research utilization. Del'ming the concept. Image, 17, 40-44. Stokes, J.E. (1981). Utilization of research findings by staff nurses. In S.D. Krampitz & N. Pavlovich (Eds.), Readingsfor nursing research (pp. 227-234). St. Louis: Mosby.
From the School of Nursing, University of North Carolina, Chapel Hill, NC, and the School of Nursing, Duke University, Durham, NC. Sandra G. Funk, PhD: Professor, University of North Carolina at Chapel Hill School of Nursing; Mary T. Champagne, PhD, RN: Associate Professor and Dean, Duke University School of Nursing; Ruth A. Wiese, MSN, RN: Research Instructor, Universityof North Carolina at ChapelHill School of Nursing; Elizabeth M. Tornquist, MA: Lecturer, University of North Carolina at Chapel Hill School of Nursing. Supported in part by Grant No. RlS-NRO1357from the National Centerfor Nursing Research, the National Institutes of Health, Bethesda, MD; and GrantNo. DlO-NU24318from the Division of Nursing, HRSA, Rocl~'ille, MD. Address reprint requests to Sandra G. Funk, PhD, Professor and Director, Research Support Center, School of Nursing, CB#7460 Carrington Hall, University of North Carolina, Chapel Hill, NC 27599-7460. Copyright © 1991 by W.B. Saunders Company 0897-189719110401-001055.00/0
