Registered nurses (RN) deliver care to patients by applying validated interventions. In a Bachelor of Science in Nursing (BSN) program, nurses learn about evidence-based practice (EBP), which aids them in pinpointing care strategies that can help their patients. In recent decades, EBP has become a key component of exceptional patient care. Show What Is EBP in Nursing?EBP in nursing is an integration of research evidence, clinical expertise and a patient’s preferences. This problem-solving approach to clinical practice encourages nurses to provide individualized patient care. How Is EBP Incorporated in Nursing?EBP helps nurses determine an effective course of action for care delivery. According to NSW Government’s Clinical Information Access Portal (CIAP), EBP involves the following five steps:
 Learn more about our RN to BSN online. Learn more about our RN to BSN online. What Kind of Research Is Used in EBP?The U.S. Army Medical Center of Excellence’s Stimson Library offers a good overview of the types of research utilized in EBP, visualized as two sections of a pyramid. The top section is described as “filtered information” and consists of the following three categories:
The bottom section of the “evidence pyramid” is described as “unfiltered information,” being the research performed. This section consists of the following four categories:
The above four categories are listed in descending order from most credible to less reliable. How Does EBP Benefit Nurses and Patients?The inclusion of EBP in nursing provides nurses with the scientific research that — in combination with real-time, data-driven insight — is used to make well-founded decisions. Through EBP, nurses can stay updated about new medical protocols for patient care. By searching for documented interventions that fit the profiles of their patients, nurses can increase their patients’ chances for recovery. EBP enables nurses to evaluate research so they understand the risks or effectiveness of a diagnostic test or treatments. The application of EBP enables nurses to include patients in their care plan. This allows patients to have a proactive role in their own healthcare since they can voice concerns, share their values and preferences and make suggestions on how they want to proceed. What Is the Advantage of EBP for Healthcare Organizations?With the application of EBP comes better patient outcomes, which can decrease the demand for healthcare resources. Thus, healthcare organizations can reduce expenses. For example, outdated practices may have included supplies, equipment or products that are no longer necessary for certain procedures or techniques. What Is the History of EBP?Florence Nightingale is credited with improving patient care in the 1800s when she noted that unsanitary conditions and restricted ventilation could adversely affect the health of patients. She went on to record medical statistics using patient demographics to ascertain the number of deaths in hospitals and the mortality rate connected to different illnesses and injuries. Archie Cochrane introduced the concept of applying randomized controlled trials (RTC) and other types of research to the nursing practice in 1972. Before Cochrane’s contribution to healthcare, medical care centered on unfounded assumptions without consideration for the individual patient. Cochrane proposed that healthcare systems have limited resources so they should only use treatments that are proven to be effective. He believed that RTCs were the most verified form of evidence, and his assertion created the foundation for the EBP movement. In the 1990s, medical pioneers like David Sackett and Gordon Guyatt furthered the conceptual development and practice of what was then known as evidence-based medicine. Unlike Cochrane, Sackett felt that EBP should not only focus on research but should also merge evidence, clinical experience and patient values. As other healthcare professions began adopting this concept for patient care, it was renamed evidenced-based practice. EBP is an essential component of safe, quality patient care. Nurses must be aware of current practices in order to provide care to patients with complicated and debilitating conditions. Nursing students in an RN to BSN program learn the role of research in the nursing practice. These programs cover the design, methodologies, process and ethical principles of research. In addition, nursing students use critical-thinking skills to evaluate and critique research studies in order to apply the findings to their nursing practice. Learn more about our RN to BSN online. Learn more about our RN to BSN online. Learn more about the Eastern Illinois University online RN to BSN program. To describe the importance of, and methods for, successfully conducting and translating research into clinical practice. There is universal acknowledgement that the clinical care provided to individuals should be informed on the best available evidence. Knowledge and evidence derived from robust scholarly methods should drive our clinical practice, decisions and change to improve the way we deliver care. Translating research evidence to clinical practice is essential to safe, transparent, effective and efficient healthcare provision and meeting the expectations of patients, families and society. Despite its importance, translating research into clinical practice is challenging. There are more nurses in the frontline of health care than any other healthcare profession. As such, nurse‐led research is increasingly recognised as a critical pathway to practical and effective ways of improving patient outcomes. However, there are well‐established barriers to the conduct and translation of research evidence into practice. This clinical practice discussion paper interprets the knowledge translation literature for clinicians interested in translating research into practice. This paper is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We provide practical, evidence‐informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse‐led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are presented in conjunction with supporting evidence. Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician/consumer behaviour change and it is critical that implementation strategy includes this. Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central. Keywords: behaviour change, clinical practice, evidence based, evidence informed, implementation science, knowledge translation, nursing, research, trauma What does this paper contribute to the wider global clinical community?
The importance of robust scholarly research for quality, safe, effective and efficient care of patients and their families is well established (Australian Commission on Safety and Quality in Health Care 2009). Although research evidence is being produced at an increasing rate, change in clinical practice to reflect this evidence has lagged behind (Kitson 2008, Benner et al. 2010). For example, in Australia, clinician compliance with providing appropriate care for 22 conditions in large nationwide cross‐sectional study ranged from 32–86% (Runciman et al. 2012). In the United States, it is reported that <20% of what physicians do has solid research to support it (Kumar & Nash 2011). With more nurses in the frontline of health care than any other healthcare profession, nurse‐led research is increasingly recognised as a critical pathway to practical, effective and cost‐effective ways of reducing hospital errors, cutting down on unnecessary costs and improving patient outcomes (World Health Organization 2012). This practice paper aims to describe the importance of, and considerations for nurses to successfully disseminate and translate research into clinical practice. This is a practice paper that interprets the knowledge translation literature for clinicians interested in conducting translational research and translating robust research evidence into clinical practice. The discussion is informed by the scientific literature around knowledge translation, implementation science and clinician behaviour change, and presented from the nurse clinician perspective. We discuss the importance of disseminating research and explain the definition and role of knowledge translation within the knowledge‐to‐action cycle. This is followed by practical, evidence‐informed suggestions to overcome the barriers and facilitate enablers of knowledge translation. Examples of nurse‐led research incorporating the principles of knowledge translation in their study design that have resulted in improvements in patient outcomes are provided. These examples are supported by a discussion of the supporting theories and evidence to maximise the opportunities and traction of the uptake of the evidence into practice. Central to nurse‐led research and knowledge translation is dissemination. A research study is not complete until the study findings have been disseminated via presentations at professional forums and published in a peer‐reviewed journal and where appropriate recommendations regarding how the research findings could be translated into clinical practice are made. Research involves considerable intellectual, time and financial commitments by researchers, participants and funding organisations. It is often conducted using public funds under the guise of the common good. Consequently, researchers are obliged and required to share the findings of their project with others, regardless of the results. Moreover, the World Health Organization (WHO), in its position on Interventional Clinical Trial Results, states that it is unethical to conduct human research without publication and dissemination of the results of that research, as withholding results may subject future volunteers to unnecessary risk (Matosin et al. 2014). While there is a clear bias towards publication of positive response (Matosin et al. 2014), it is equally important to publish studies with negative or equivocal results for this reason. Furthermore, the WHO states that clinical trial results be submitted for publication in a peer‐reviewed journal within 12 months of study completion (Moorthy et al. 2015). Fortunately, there are many opportunities for sharing new knowledge, not only by writing for journals or books, but also by using social media, speaking at conferences and other events about the research outcomes. When planning research, it is critical to consider prospectively how findings will be disseminated and to be cognisant of this throughout the research process. Successful dissemination and uptake of research evidence requires identifying the appropriate audience and tailoring messages via appropriate mediums. When analysing study data and interpreting the results, researchers must address the study aims and answer the research question(s) in view of the background research problem and its significance. The conduct of the research should also consider how the study findings should or could influence clinical practice, education, policy or future research. Such recommendations should inform dissemination activities. Targeted dissemination activities can include summaries for stakeholders, educational sessions with clinicians and/or policymakers, development and implementation of clinical guidelines and media engagement (Canadian Institutes of Health Research (CIHR) 2014; Table 1). At the heart of dissemination of research findings is knowledge translation. Choosing dissemination forums for research findings
Knowledge translation is the process through which research knowledge is created, circulated and adopted into clinical practice. Synonymous terms are used by researchers around the world. A study involving 33 research funding agencies across nine different countries identified 29 different terms referring to knowledge translation (Graham et al. 2005). For example, similar processes are called research utilisation in the UK and Europe, research dissemination, diffusion or knowledge uptake in the USA, and knowledge translation and knowledge‐to‐action in Australia and Canada (Strauss & Corbin 1990, Graham et al. 2006). The Canadian Institute of Heath Research (CIHR) definition of knowledge translation is widely accepted and commonly cited in healthcare literature (Graham et al. 2006, Lang et al. 2007, Bjørk et al. 2013; Box 1). Knowledge translation is not simply a linear procedure but involves many processes, systems and interactions of the researcher and knowledge users. The level at which these interactions take place varies depending on the situation and application of knowledge. Definition of Knowledge Translation‘knowledge translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically‐sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user’ (Canadian Institutes of Health Research (CIHR) 2014 ). While all research should be disseminated, not all research is readily translatable. The design, applicability and strength of the research should be assessed, and the evidence for translation determined to be relevant and sound. This process is rarely simple, and the increasing volume of research evidence being produced, access to new evidence, the skills to appraise the quality of the evidence, time to locate and read evidence, and the capacity to apply evidence (Gravel et al. 2006) are some of the major barriers to dissemination and translation. Strategies to promote the use of research in practice by clinicians continue to be devised as the complexity of the application of evidence into practice has been recognised. One strategy now commonly used is knowledge distillation, that is the synthesis of findings from the most rigorous research available on a specific topic into systematic reviews and guidelines (Straus et al. 2009). The synthesis can then be presented to clinicians as practice guidelines or fact sheets (see, for instance, www.nhmrc.gov.au/guidelines/titles_guidelines.htm or www.clinicalguidelines.gov.au for two Australian organisations providing practice guidelines, https://www.nice.org.uk/guidance in the UK, http://www.ilcor.org/home/ for resuscitation, https://www.cma.ca/En/Pages/clinical-practice-guidelines.aspx in Canada). While sourcing sufficient evidence to base practice on is an ongoing challenge, so too is identifying established evidence and translating it into practice (Titler 2008). The lapse between the publication of evidence and its implementation into practice is referred to as an evidence–practice gap (National Institute of Clinical Studies 2003). Addressing this gap requires knowledge translation. Knowledge translation forms part of the knowledge‐to‐action cycle (Fig. 1) (Graham et al. 2006). The knowledge‐to‐action cycle details the sequence and steps involved in achieving the transfer of research knowledge into clinical practice consisting of two phases. The initial creation phase consists of synthesising knowledge as part of producing new tools, such as clinical guidelines in response to an identified clinical problem. This step ensures knowledge is founded on the best available evidence prior to progressing to the action component, which is the process of implementing and evaluating new knowledge in clinical practice (Graham et al. 2006). The action cycle comprises seven phases: (1) identify problem and relevant research; (2) adapt research to local context; (3) assess barriers to using the knowledge; (4) select, tailor and implement interventions; (5) monitor knowledge use; (6) evaluate outcomes; and (7) sustain knowledge use. Despite the importance of research knowledge translation, barriers to understanding, conducting, and evaluating evidence impede nurses’ uptake of research at an individual, unit and organisational level (Leasure et al. 2008). This was confirmed in a survey conducted by the Emergency Nurses Association (ENA) in the United States (Chan et al. 2011). Nine hundred and seventy‐eight ENA members completed a survey which assessed nurse's involvement and uptake in research and perceived barriers to research. At an individual level, it was found that nurses lacked knowledge about appraising research preventing them from implementing research knowledge in their clinical practice. At a unit level, barriers included lack of assistance from managers and colleagues in beginning a project or having the authority to implement change. Insufficient time provided by the organisation was also found to be an impeding factor failing to provide nurses with the support and time required to conduct research and change practice (Chan et al. 2011). Other studies have also identified that the attitudes and beliefs of nurses as obstacles to research being translated into nursing practice (MacDonald 2002, Brown & McCormack 2005, Davies et al. 2007, Newhouse 2007). The process through which individual attitudes and beliefs are formed, interest of administrators at a unit and organisational level must be addressed to promote research translation into clinical practice. There are many well‐documented enablers of successful knowledge translation. Translation of findings should be considered in initial study design and should be a major consideration when developing the study aim(s). When planning research, by prospectively thinking about how findings will be translated to clinical practice, key considerations may be what clinicians will need to change their behaviour and what resources the organisation will require to permanently maintain (sustain) the intervention. Further, it is essential to consider the ongoing monitoring and evaluation of the intervention to enable refinement and determination of impact (be that negative or positive). This process will ensure that data will be collected as part of the research to inform the implementation of the research findings if appropriate, for example times of day where problems occur or staff opinion about the proposed intervention. If applying for funding to conduct research, it is important to budget for implementation and evaluation of the proposed work. The success of any implementing practice change is heavily reliant on senior clinician support (Bennetts et al. 2012), those that will be impacted by the intervention and those that will be required to act on the intervention (the end users). It is critical to involve end users throughout the research process. In our complex and multidisciplinary healthcare system, aside from our patients, who are at the centre of care, those impacted are likely to include multiple services and medical specialties from outside of the instigating department. This could include the hospital switch board, pathology, radiology, allied health, as well as hospital executive. Some suggestions for this multidisciplinary type implementation are establishment of a working party of key stakeholders to develop a consensus plan to streamline successful implementation. This process is likely to be facilitated if the instigator is an employee or has close links with staff at the target site. The key principles around incorporating translation into research design are summarised in Table 2 and an example in Table 3. Key principles to building knowledge translation into research design
Nurse‐led translational research example 1: Improving the emotional well‐being of major trauma patients (Wiseman et al. 2015, 2016)
There are also many well‐documented barriers to research translation. Multiple factors influence the uptake of research into practice. It is challenging to introduce and sustain evidence and evidence‐informed protocols in the context of competing priorities in health care. Despite high‐level recommendations to improve implementation of evidence‐based practice, implementation is variable. Numerous organisational and individual factors impact implementation and uptake, including clinician behaviour, lack of time, difficulties in developing evidence‐based or informed guidelines, a lack of continuing education and an unsupportive organisational culture (Haynes & Haines 1998, Wallis 2012), the availability and dissemination of evidence, individual motivation and the culture of specific healthcare practices (McKenna et al. 2004). Central to successful implementation of research evidence into clinical practice is changing human behaviour. Any attempt to improve the quality of care for patients by translating research must incorporate a clear understanding of the associated barriers to, and facilitators of, behaviour change. Understanding these is also fundamental to the development of a feasible, successful and sustainable implementation strategy. A variety of models and theories have been developed in attempt to conceptualise the multifaceted process of knowledge translation. The transformation learning theory developed by Mezirow (Mezirow 1978, 2000, 2004) assists the process of knowledge translation through acknowledging the role and impact of attitudes and beliefs, which are constantly cited as barriers to research utilisation (MacDonald 2002, Brown & McCormack 2005, Davies et al. 2007, Newhouse 2007). To successfully engage clinicians and change their behaviours based on sound research knowledge, their attitudes and beliefs towards the proposed new knowledge must be learned, shaped and transformed (Matthew‐Maich et al. 2010). The clinicians existing thoughts and stances must be unlearned, and the new way of approach adopted. One such way to achieve this is to use tools to design implementation interventions using the theoretical domains framework (French et al. 2012) or the behaviour change wheel (Michie et al. 2011) discussed below. Further, knowledge translation requires design and implementation of interventions. Implementation is a science and can be encompassed within the normalisation process theory, which characterises implementation as a social process of collective action (May 2013). The intent of implementation science is to investigate and address major contextual factors (e.g. social, behavioural, economic, management) that hinder successful implementation, test new approaches and determine causal relationships (Fogarty International Center 2013). The Consolidated Framework for Implementation Research (CFIR) published in 2009 provides a pragmatic structure to promote verification about what works where and why across multiple contexts and includes five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and the process of implementation (Damschroder et al. 2009). This work provides a foundation for researchers implementing and evaluating knowledge translation to build the implementation knowledge base across multiple settings (Damschroder et al. 2009). As with all research, and to truly validate the CFIR and other research frameworks, descriptions must be precise enough to enable measurement and reproducibility (Proctor et al. 2013). When publishing research, researchers should clearly explain how they justified the selection of specific framework constructs, integrated the framework throughout the research process (in study design, data collection, and analysis) and link determinants of implementation to outcomes to contribute to this emerging field of research (Kirk et al. 2016). Implementing evidence by translating knowledge needs planning and strategy that address the complexity of healthcare systems, individual practitioners, managers (Titler 2008) and strong organisational support and patronage (Bate et al. 2008). There are multiple models available on which to develop and plan an implementation strategy (Schaffer et al. 2013). Perhaps the most well known in health is the Promoting Action on Research Implementation in Health Services Framework, or PARIHS Framework (Rycroft‐Malone 2004), which is a conceptual framework that suggests fundamental and interrelating elements that influence effective implementation of interventions. There is a need for this and other implementation models to undergo more robust evaluation of their effectiveness in use in implementation projects (Helfrich et al. 2010, Proctor et al. 2013). Using a systematic four‐step approach as the principal framework to inform intervention development process is ideal. The four steps consist of questions to direct the choice of the most appropriate components of an implementation intervention (French et al. 2012) and can be iteratively adjusted and refined to suit other contexts. For example, the following steps recommended by French et al. (2012) in conjunction with the theoretical domains framework (Cane et al. 2012) have been evaluated as effective. It is also practical and pragmatic:
There are myriad templates available online to then guide the finer details of implementation plans, which all have common components. Many health services have a health redesign or implementation unit which may assist in the process, beginning by outlining the project purpose and justification (i.e. what will be used to introduce the plan to others). Many of these actions will have been made much smoother if the key stakeholders have been engaged in the process. It is also important to conduct a stakeholder needs analysis to identify the key stakeholders and their expectations and needs with respect to the project outcomes. The responsibilities for each person should then be established, alongside a communication strategy, and decisions on the interventions to be used to implement your evidence and timeline (Centre for Healthcare Redesign 2014). There is a vast array of intervention techniques available to translate research‐based evidence into practice, for example visual cues (such as signs in the clinical area), audit, educational seminars, prompts, clinical guidelines, protocol and leadership involvement (Wuchner 2014). Interventions with the most likelihood of sustainable success are generally multimodal. To decide how to best to implement change depends on what you are trying to change. Changing behaviour is not simple, but is most effective if interventions are based on the principles of behaviour change, and knowing what it is exactly that you need to change. Three validated tools to use either in isolation or together are the theoretical domains framework (Cane et al. 2012), the behaviour change wheel (Michie et al. 2011) and the behaviour change technique taxonomy (BCTT; Michie et al. 2013), which are the specific behaviour change techniques to use in interventions focused on behaviour change. Once it is determined who is going to need to change their behaviours, the theoretical domains framework (Cane et al. 2012) helps you to consider each of possible influences on behaviour in 14 domains including ‘knowledge’, ‘skills’, ‘beliefs about capabilities’, ‘optimism’, ‘beliefs about consequences’, ‘reinforcement’, ‘intentions’, attention and decision processes’, ‘environmental context and resources’, ‘social influences’ and ‘behavioural regulation’. For example, to determine what may need to be addressed to change clinician behaviour, a staff survey could be conducted with questions mapped to each of the domains. For example, ‘Do you think that the X protocol improves patient care?’ would be mapped to ‘beliefs about consequences’. If the majority of staff do not think that the protocol will deliver improved care, they may not make it a priority to change their behaviour, and you now know that this is an area that you need to address. But how to do it? The behaviour change wheel and the BCTT are linked to the theoretical domains framework and will guide choice of interventions and techniques. For example, to address beliefs about consequence, the interventions known to do this are education, modelling and persuasion. There are multiple ways to educate, model and persuade. The BCTT provides a range to choose which would be suitable for the target site, staff and context. For example, a technique known to be effective in persuasion is having a senior, well‐respected clinician repeatedly model the behaviour you want the rest of the team to do. Using behaviour change techniques outlined in the BCTT also adds strength to your work because it means your work will be observable (people will know what you have done) and replicable. Research utilisation implies not only the implementation of evidence into practice, but also the evaluation of consequent changes in practice (Jones 2000). It is no longer acceptable to implement a change in clinical care and not evaluate the impact of that change. That is, if the research evidence is applied in a given context, the resulting change should be evaluated in terms of the outcomes, considering patients, consumers, clinicians and the organisation. It is crucial to build implementation evaluation into study design by ensuring collection of data that will be able to be used to determine how well the intervention has been adopted, For example, Do all staff comply with the introduced protocol all the time? If they do (or do not), Why and what difference does this make? An example of this is demonstrated in Table 4. A summary of key knowledge translation terms is provided in Table 5. Nurse‐led translational research example 2 – Changing State‐wide Stroke Practice: The QASC Implementation Project (Middleton et al. 2011, 2015)
Key knowledge translation terms
Translating best research evidence can make for a more transparent and sustainable healthcare service, to which nurses are central. More importantly, the translation of evidence can bring about cultural, behavioural and practice change reducing the research–practice gap. Through the translation of evidence, patient safety and care responses can be recalibrated to optimise outcomes for patients and staff. Strong evidence must be translated into practice. Translation should be considered in research design, including the end users and an evaluation of the research implementation. The success of research implementation in health care is dependent on clinician or consumer behaviour change and it is critical that implementation strategy includes this. KC led the development, writing and preparation of the manuscript. MF, RS and JC contributed, critically reviewed and prepared the manuscript for publication. Professor Curtis was supported by an NHMRC Translation of Research into Practice Fellowship (GNT 1067639).
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What statement explains how research is establishing the credibility of nursing as a profession?
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