Original Article

Developing Nursing and Midwifery Research Priorities: A Health Service Executive (HSE) North West Study Randal Parlour, PhD, MSc, BSc (Hons), RGN, RMN • Paul Slater, PhD, MSc, BSc (Hons)

ABSTRACT Keywords research utilization, research methods, nursing/midwifery practice, survey methodology/data collection, Delphi technique

Aim: The primary purpose of this study was to identify research priorities for nurses and midwives across the Health Service Executive (HSE) North West region. The rationale for the study was underlined during meetings of HSE North West Directors of Nursing and Midwifery in January 2011. It was agreed that a more strategic approach to generating synergy among nursing and midwifery research, evaluation, and evidence-based practice should be developed through the Nursing and Midwifery Planning and Development Unit. Methods: The research design was founded upon collaborative processes for consensus building that included the Delphi technique and nominal group technique. The study sample included a panel of experts. Data were collected between March 2011 and December 2011. Findings: Findings from this study validate the efficacy of the research methodology in enabling the effective identification of priority areas for research. These include: (a) an evaluation of the impact of postgraduate nursing and midwifery education programs focusing upon patient, professional, and organizational outcomes; (b) development and evaluation of an effective culture of nurse- and midwife-led audit across all services within a Regional Health Trust in Ireland; (c) an examination of the efficacy of approaches to clinical supervision within the context of the Irish health system; (d) an evaluation of the impact of an Advanced Nurse Practitioner role in supporting the effective management of long-term conditions within the context of Regional Health Trust primary care settings in Ireland; and (e) Supporting and developing an ethical framework for nursing and midwifery research within a Regional Health Trust in Ireland. Linking Evidence to Action: It is anticipated that future work, outlined within this paper, will lead to important improvements in patient care and outcomes. Furthermore, this study provides evidence that a strong nursing and midwifery research agenda can be established upon genuine collaborations and partnerships across varying levels of research knowledge and skills, but with a shared purpose and shared values.

INTRODUCTION The rights of individuals to safe, effective, and high-quality health and social care permeate all policy documents that have emerged within the Irish health system during the past decade (Department of Health & Children, 2010), and this report comes at a time of ongoing and significant reconfiguration and reform. There are increasing demands for greater productivity and for challenging more traditional models of service delivery (Health Service Executive [HSE], 2012). A recurring theme is how to improve quality in service provision while at the same time cutting costs (National Economic and Social Council [NESC], 2012). The impact of these measures is confounded by continuing reductions in health expenditure and the numbers of staff employed within the health services. The impact of the political and economic crisis within Ireland adds

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further pressures that challenge both the personal and professional values of nursing practitioners and other care workers.

CONTEXT It has been acknowledged (Department of Health & Children, 2003) that nurses and midwives play a pivotal role in the delivery of effective health care. Considering that nurses and midwives comprise almost 40% of the healthcare workforce, the care that they deliver has a significant impact upon patient outcomes (Estabrooks, Midodzi, Cummings, Ricker, & Giovanetti, 2005; National Council for Professional Development of Nursing and Midwifery [NCNM], 2009). However, scholars involved in the study of research utilization have repeatedly voiced concerns about whether nurses and midwives use the best available evidence to guide their clinical practice

Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

Original Article (Hughes, 2008; Veeramah, 2004). A lack of research use by nurses and midwives has potentially damaging consequences, with up to 30–40% of patients not receiving appropriate care (Squires, Estabrooks, Gustavsson, & Wallin, 2011). Patients and service users need to know that the nursing and midwifery care they receive is founded upon “best practice” and is of the highest quality, thus protecting them from harm and maintaining their dignity at all times. This can be best achieved by ensuring that nurses and midwives are skilled at using the best available evidence while carrying out their dayto-day practice. This requires support at various levels to enable nurses and midwives to access and use research data. However, evidence suggests that organizational structures, governance, and cultures impact the ability of nurses and midwives to conduct and use research in their practice (Royal College of Nursing, 2007). Collaboration and commitment are essential at all organizational levels in establishing a supportive environment where research initiatives are conducted and assimilated into practice to enhance the delivery of nursing and midwifery care. Within the current literature, which has focused on the themes of research and evidence-based practice (EBP), the critical role of context (Greenhalgh et al., 2004; Rubenstein & Pugh, 2006) has been routinely identified (Stetler, Ritchie, Rycroft-Malone, Schultz, & Charns, 2007) as both a barrier and a factor that can help explicate potential solutions. In a study of aspects that impact upon senior and junior clinical nurses in using research evidence in practice, Gerrish, Ashworth, Lacey, and Bailey (2008) suggest that nursing culture may act as a constraining influence upon junior nurses, with the result that they lack the capacity to independently activate evidence-based measures in practice. Nursing and midwifery research must be insightful toward these contextual factors and adopt appropriate methodologies that capture the influence exerted upon approaches to research utilization. Reported research is often flawed in this regard, as the reader is presented with little evidence with which to judge the quality or value of the chosen methodology and its impact on the study (Parlour & McCormack, 2012). At a meeting of HSE North West Directors of Nursing in 2011, it was agreed that a more strategic approach to generating synergy among nursing and midwifery research, evaluation, and EBP should be developed through the Nursing and Midwifery Planning and Development Unit (NMPDU). As further interest in the study was expressed by colleagues across the HSE West area, it was agreed that the study remit would be expanded to include nurses and midwives from across the region.

PURPOSE The purpose of this study is to further develop and expand a framework for research and EBP that enables delivery of the best standards of care, and ensures an optimum patient experience. This purpose is undertaken collaboratively with Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

Directors of Nursing and Midwifery, and is vital to creating a culture where nurses and midwives provide robust evidence that “best practice” standards are being attained.

RESEARCH QUESTIONS Research questions were: (a) What are the general short-term and medium-term research priorities related to clinical, managerial, and educational issues for nurses and midwives across the HSE North West region? and (b) What is the existing evidence base for the highest priority issues identified?

METHODS Study Design The methodology for this research was founded upon collaborative processes for consensus building that included the Delphi technique and nominal group technique. In the first instance, the Delphi technique was initiated to determine if there were emerging patterns or consensus on nursing and midwifery research priorities within a panel of experts across the HSE West region. The Delphi technique is a method for “systematic solicitation and collation of judgments on a particular topic through a set of carefully designed sequential questionnaires interspersed with summarized information and feedback of opinions derived from earlier responses” (Delbecq, Van de Ven, & Gustafson, 1975, p. 10). In the past, this methodology has attracted criticism from certain scholars (Keeney, Hasson, & McKenna, 2001; Williams & Webb, 1994), as it was seen as open to a variety of methodological approaches. Nonetheless, Delphi’s utility as a tool for setting healthcare research priorities across varying contexts, including nursing (Cohen, Harle, Woll, Despa, & Munsell, 2004; B¨ack-Pettersson, Hermansson, Sernert, & Bjorkelund, 2008; Gordon & Barry, 2006; Wiener, Chacko, Brown, Cron, & Cohen, 2009), mental health care (Owens et al. 2008), community health care (Downie, Henderson, Juliff, Munns, & Wichmann, 2006), and parenting and child health (Hauck, Kelly, & Fenwick, 2007; Wilson, Ramelet, & Zuiderduyn, 2010) has been more recently recognized. Findings from these studies articulate and support the efficacy of Delphi as an approach for achieving consensus, highlighting deficits in research knowledge, and providing information to guide and construct a future research agenda. Similar to Delphi, the nominal group technique has seen more widespread use in healthcare contexts during the past decade. It is viewed as valuable in setting research priorities, especially when there is a paucity of definitive empirical data (Shortt, Guillemette, Duncan, & Kirby, 2010). Consistent with the Delphi approach, the nominal group technique enables researchers to collect data from a panel of experts, while facilitating more creative problem solving through judgmental decision making in situations where standard responses are unsatisfactory (Stolper et al., 2010). As a result of this, it is possible to mold opinions and establish a research agenda. McCance, Fitzsimmons, Keeney, Hasson, and McKenna (2007) have

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previously advocated the combined use of the Delphi technique and the nominal group technique as a suitable method for ensuring the inclusion of all stakeholders in group discussion and decision-making processes.

SAMPLE Sample representativeness within this research was guided by the principles of collaboration, inclusion, and participation, which in turn are closely associated with the themes of enlightenment, empowerment, and emancipation that reflect the tenets of critical social science (Fay, 1987). Guided by this, the decision was taken to include all registered nurse and midwife groups within the HSE West as nominated by Directors of Nursing and Midwifery across the region. These nominees populated the panel of experts. Consistent with Gordon and Barry (2006), the intent was to acknowledge collective practice expertise and knowledge, and to develop a sense of ownership toward the developing research agenda.

ETHICAL CONSIDERATIONS There were a number of ethical considerations that required attention within the study. Issues included: informed consent as an ongoing process for all concerned; safeguards to ensure no harm comes to the participants; aspects relating to respect for persons that incorporates the right to withdraw and assurance of confidentially and anonymity. Participant information leaflets incorporating written consent were provided to all participants to address these requirements.

DATA COLLECTION AND ANALYSIS Prior to implementation of the study, a participant information leaflet, questionnaire, and demographic data sheet were forwarded by electronic mail to the panel of experts. Reminders also were sent to the same population at 3–4 weeks after the initial request. Delphi participants were asked to give consideration to the following, and to indicate the importance of undertaking research in these areas:

r What questions in relation to clinical practice, edu-

Delphi participants were requested to rank statements provided to establish preliminary priorities among them. Following a process of content analysis, participant responses (n = 187) were entered into a database and coded to categories established in the NCNM (2005) study. Data were then further analyzed using the statistical package for social sciences (SPSS version 14; SPSS Inc., Chicago, IL, USA) to compute the mean value and frequency of responses. Data from this round were then analyzed, collated, and redistributed to participants by electronic mail. Round two consisted of bringing together groups of participants from round one, who had been nominated by Directors of Nursing and Midwifery and had consented to engage in this process. This was a structured approach, facilitated by the research team, and presented an opportunity for participants to re-evaluate considered opinions established during the previous round and, following dialogue with colleagues, reach an overall consensus. Similar to Tuffrey-Wijne, Bernal, Butler, Hollins, and Curfs (2007), this consisted of four phases: generating ideas, structured discussion of ideas, evaluation, and a group decision phase on priorities. Two separate groups were facilitated in round two, including participants from across the HSE North West. Participants were requested to consider the priority areas identified during round one and engage in round table discussions. The aim was to refine the data from round one down to three identified priorities relating to nursing and midwifery practice, education, and management. The results from this process were collated by the research team and then, in an iterative manner, fed into round three. A similar approach to populating the groups was adopted in round three, and the discussion was facilitated once again by the research team. As in round two, participants were asked to consider the statements made and to rank, if possible, this data in a priority statement for nursing and midwifery practice, education, and management. These three statements were further ranked in terms of overall importance. The findings from these processes are presented in the following section. Responses provided within the entire study were treated with complete confidentiality by the research team.

cation, and management do we need better answers to?

r What gaps are there in the knowledge that we need for clinical practice, education, and management?

r What information do we need to enhance our clinical practice, education, and management? This questionnaire was adapted from a previous study (NCNM, 2005) that examined Nursing and Midwifery Research Priorities for Ireland. Kerlinger (1973) previously suggested it is appropriate to employ a modified Delphi process if basic information concerning the designated topic is available and usable.

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FINDINGS Round One A total of 187 responses were returned in round one. Quality assurance reduced this figure by 15 due to insufficient or incomplete responses, and these were excluded from data analysis (total usable sample n = 172). These figures reflected a range of relevant clinical services or specialties: Acute Services 73.3%; Mental Health Services 8.0%; Older People Services 9.6%; Intellectual Disability Services 1.1%; and Community Services 8.0%. As previously stated, respondents were requested to indicate the importance of undertaking research in areas related Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

Original Article

Figure 1. Categorization of responses according to three broad themes. to nursing and midwifery clinical practice, education, and management (Figure 1). Table 1 provides a breakdown of the themes that emerged from the NCNM (2005) research. These themes were used as a foundation template upon which to refine and code the statements provided by respondents within round one of this study. Table 1 also indicates the frequency with which specific themes were referred to, and also the level of priority that respondents attached to these themes. Higher scores indicate a greater sense of importance to that particular theme. Mean scores were also calculated for each theme.

Summary Findings from round one demonstrate both similarities and variations from previous priorities identified by NCNM (2005). Although specific responses from round one may also reflect areas of general concern to nurses and midwives, as opposed to areas requiring further research, the findings afford an insight into the current nursing and midwifery context within the HSE. Round two and three provided participants with an opportunity to further clarify their judgments or statements and their relative importance. It was anticipated that this would attain a greater level of consensus on areas for prioritization. The revised list of priorities was compiled and redistributed to participants during the third and final phase of the study, providing a final opportunity for those involved to mold their opinions and sanction a list of issues, concerns, or priorities for action.

Round two At the outset of round two, those who responded to the questionnaire (or a nominee) were requested to engage in structured Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

consultation groups to offer an informed opinion on themes summarized by the research team during the previous round, and to review and revise their judgments and the order of priority attached. As outlined previously, two focus groups were facilitated with respondents in two sites (site 1 n = 16; site 2 n = 11). All of the responses that had been provided during the first cycle of data collection were disseminated to group participants. Table 2 provides a summary of the key issues identified by the group members having had the opportunity to review responses and consider, in order of importance, local or national priorities, wider impact of the proposed work upon patient outcomes, and relevance of the issues across service boundaries. These outcomes were also disseminated for review by respondents from across the wider HSE West area.

Round three During the third and final round, the themes on which there was consensus in round two were distributed to the same respondent groups who had participated previously. This presented a final opportunity for participants to revise judgments made during previous rounds and reconsider opinions formed following dialogue with colleagues based upon the priority criteria discussed at round two. The aim at this juncture was to achieve consensus on a definitive set of priorities (Table 3) that would become the focus of work within the developing program of nursing and midwifery research across the HSE North West. Subsequently, the research team convened a group of staff from the NMPDU and Centre for Nursing and Midwifery Education (CNME) to consider research questions that may address the priority issues identified. This group proposed that research be undertaken as follows:

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Table 1. Frequency of Themes and Perceived Importance of Themes

Statement No.

Freq (%)

1*

2*

3*

Mean

Outcomes of care delivery

17

18.7

1

8

7

2.4

Staffing issues in practice

15

16.5

0

7

7

2.5

5

5.5

0

3

2

2.4

Quality assurance in practice

21

23.1

0

7

14

2.7

Nursing practice roles

12

13.2

0

2

9

2.8

Psychological care concerns

2

2.2

0

2

0

2.0

Ethical concerns

4

4.4

1

1

2

2.3

Specialist and advanced practice roles

7

7.7

1

3

3

2.3

Physical care concerns

4

4.4

0

2

2

2.5

Nurses attitudes to specific patients/clients

4

4.4

0

2

2

2.5

3

37

48

2.51

Practice themes

Communication in clinical practice

Totals

91

100

Management themes Recruitment and evidence-based practice

1

3.7

0

1

0

2.0

Nursing input into health policy and decision making

6

22.2

0

2

2

2.5

12

44.4

1

1

8

2.7

8

29.6

1

2

4

2.4

2

6

14

2.54

Role of nurse managers Quality assurance and standards of care Totals

27

100

Education themes Research and evidence-based practice

6

11.1

1

1

4

2.5

Career planning and professional or educational development

9

16.7

2

5

1

1.9

Outcomes and effectiveness of education

6

11.1

0

1

4

2.8

Undergraduate/pre-registration clinical learning

7

13.0

0

2

4

2.7

Clinical education links between service and academic organizations

1

1.9

0

0

1

3.0

Education needs analysis

5

9.3

2

2

1

1.8

15

27.8

1

5

9

2.5

5

9.3

1

1

13

2.4

7

17

27

2.39

Professional appraisal and staff development Models of course delivery Totals

54

100

Note. *= 1 – moderate importance; 2 – very important; 3 – extremely important.

r An evaluation of the impact of postgraduate nursing

r An examination of the efficacy of approaches to clin-

and midwifery education programs focusing upon patient, professional, and organizational outcomes.

ical supervision within the context of the Irish health system.

r Development and evaluation of an effective culture of

r An evaluation of the impact of an Advanced Nurse

nurse and midwife led audit across all services within a Regional Health Trust in Ireland.

Practitioner role in supporting the effective management of long-term conditions within the context

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Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

Original Article Table 2. Main Themes Identified and Rank Ordering from NGT Focus Groups

Focus group 1

Focus group 2

Nursing midwifery: Practice issues 1

Ethical issues in practice

Evidence-based practice, standards and audit

2

Issues of audit and clinical competence

Practitioner accountability

3

Use and understanding of therapeutic activities and integration within a plan of care

Caseload management

Nursing midwifery: Education issues 1

Clinical supervision and practitioner competence

Clinical supervision/appraisal

2

Appropriate utilization of learning from postgraduate and continuing education programs for nurses and midwives

Competence in practice

Nursing midwifery: Management issues 1

The future role of the Director of Nursing in the Irish Health system

Influencing practice change through expanded roles.

2

New approaches to facilitating mandatory staff training

New approaches to facilitating mandatory staff training

3

Appropriate utilization of learning from postgraduate and continuing education programs for nurses and midwives

Table 3. Agreed Priorities

Focus group 1

Focus group 2

Nursing midwifery: Agreed priorities 1

Ethical issues in practice

Evidence-based practice, standards and audit

2

Clinical supervision and practitioner competence

Clinical supervision/appraisal

3

Appropriate utilization of learning from postgraduate and continuing education programs for nurses and midwives

Influencing practice change through expanded roles

of Regional Health Trust primary care settings in Ireland.

r Supporting and developing an ethical framework for nursing and midwifery research within a Regional Health Trust in Ireland.

DISCUSSION AND IMPLICATIONS The significance of context as a factor influencing the approval or adoption of research evidence has been raised in other studies (Estabrooks et al., 2004; Greenhalgh et al., 2004). However, if research evidence is going to be effectively implemented, it requires ownership. The framework upon which this study was built offers a process of ownership to nurses and midwives throughout the organizations, and focuses on needs and Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

priorities at a local and regional level. Consequently, this has a positive impact and increases the likelihood of uptake (Meijers et al., 2006; Parlour & McCormack, 2012). A review of the research foci identified above indicates consistency with the key priority areas that were established by the panel of experts during the 12-month period of study implementation. This will provide the cornerstone for developing this region as an important hub for innovative nursing and midwifery research in the future. The methods adopted within this study were based upon a framework of collaboration, inclusion, and participation. This approach has allowed for systematic investigation of opinions of a geographically dispersed group of nurses and midwives with a diverse range of expertise. The findings reflect specific implications for both practice and future research

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implementation that include (a) the potential within this approach to develop a research agenda that is founded upon shared values, (b) partnership across nursing and midwifery stakeholder groups, and (c) knowledge translation based upon consensus. This study demonstrates how concrete projects can emerge from an iterative process of consultation, and asserts itself within a number of key areas.

r The use of the Delphi and nominal group techniques has validated the effective identification of priority areas for research that are important to the delivery of nursing and midwifery care.

r Future work, outlined within this study, can enable significant care and outcomes.

improvements

to

patient

r A strong nursing and midwifery research agenda can be established upon genuine collaborations and partnerships across varying levels of research knowledge and skills, but with a shared purpose and shared values.

r There exists an opportunity to raise the profile of nursing and midwifery research and practice within the HSE North West from this study.

r The methodology adopted in this study can serve as a means of achieving consensus across different professional groupings and geographical locations.

LIMITATIONS As noted by Downie et al. (2006), there is a need for caution in interpreting research findings generated from use of the Delphi technique. Although efforts were made to encourage a representative cohort of registered nurses and midwives from across the HSE North West and HSE West regions to participate in the initial survey, there is always the potential of bias, as the priorities may be overly influenced by one particular section of the nurse and midwife population. Additionally, as a number of the responses were not conceptually definitive it was a challenge to relate these to identified research needs. Although it has been noted that respondents from the HSE West area were unable to participate beyond round one, the use of nominal group technique thereafter allowed for valid exploration of research priorities for different stakeholder groups within nursing and midwifery across the HSE North West. This was an innovative approach as, with McCance et al. (2007), it allowed for inclusion of senior policy makers and strategists who were eager to be involved during rounds two and three.

CONCLUSIONS Building capacity is the key requirement to position research as a legitimate activity that can influence nursing and midwifery professional practice (McCance et al., 2007). This requires engaging strong and visible leadership from Directors of Nursing

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and Midwifery while developing the research expertise of registered nurses and midwives to deliver programs of research at all levels of clinical practice. This has remained an explicit intention underpinning the approach adopted throughout this process. It is furthermore the intention to facilitate the attainment of the specified research programs through blending research collaborations between the NMPDU and the Institute of Nursing Research within the University of Ulster. WVN

ACKNOWLEDGMENTS We would like to express our thanks and appreciation to the study participants and to the Health Service Executive for their support in conducting this study. We also thank and appreciation the National Council for the Professional Development of Nursing and Midwifery. No conflict of interest has been declared by the authors.

LINKING EVIDENCE TO ACTION • Nursing and Midwifery practice, management, and education must be built on the best available research evidence. • Nurses and midwives must be skilled in finding, evaluating, and using research evidence to improve nursing and midwifery practice, management, and education, and to provide the optimum patient experience. • Nursing and midwifery leadership must be actively engaged in supporting nursing and midwifery research, evaluation, and EBP at unit, service, and organizational levels. A coherent and consensus-based program of research, evaluation, and EBP is essential to creating and sustaining a culture of nursing and midwifery excellence.

Author information Randal Parlour, Assistant Director, Nursing and Midwifery Planning and Development, Health Service Executive, Ballyshannon, Ireland, and Honorary Fellow, University of Ulster, Derry, Northern Ireland; Paul Slater, Lecturer in Statistics, University of Ulster, Belfast, Northern Ireland, and Nursing and Midwifery Planning and Development, Health Service Executive, Ballyshannon, Ireland. Address correspondence to Dr. Randal Parlour, Assistant Director, Nursing and Midwifery Planning and Development Unit, Health Service Executive, Ballyshannon, Ireland; [email protected] Accepted 9 December 2013 C 2014, Sigma Theta Tau International Copyright  Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

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doi 10.1111/wvn.12035 WVN 2014;11:200–208

Worldviews on Evidence-Based Nursing, 2014; 11:3, 200–208.  C 2014 Sigma Theta Tau International

Developing nursing and midwifery research priorities: a Health Service Executive (HSE) North West study.

The primary purpose of this study was to identify research priorities for nurses and midwives across the Health Service Executive (HSE) North West reg...
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